Breast Flashcards
Describe the ways in which breast cancer may present
- Discolouration
- Oedema
- Peau d’orange (skin puckering from local invasion)
- Pagets disease (eczematous rash, bloody discharge)
- Nipple retraction
- Discharge
- Assymetry
What are the RF for breast cancer?
- Family hx (first degree relative with bilateral disease)
- Oestrogen exposure including COCP
- Previous benign breast disease
- Smoking/alcohol/obesity
When is USS helpful for breast cancer diagnosis?
Can distinguish between solid and cystic, especially if the lesion is non-palpable
When is MRI helpful for breast cancer diagnosis?
Patients who already have fibroadenomas or excessive lumpiness, in which palpation is very difficult
Used especially in high risk or younger patients (not routine)
When is breast biopsy indicated? Describe the two types
If FNA shows blood, or unsure about diagnosis
- Excisional biopsy - removes entire abnormal area
- Wire excision biopsy
Which tumour marker can be done in breast cancer?
CA-153 - low specificity and sensitivity so not suitable for screening/diagnosis but can be good for risk of recurrence. Also raised in gynae cancers.
Where is the most common location for breast cancer?
Left breast
Upper outer quadrant and retroareolar region
Describe the two non-invasive breast cancers (in situ) and their management
DUCTAL (DCIS) - Premalignant changes, seen as micro calcification on mammography. Manage with breast-conserving surgery eg. lumpectomy (without SLNB) or mastectomy (with SLNB). Offer annual mammography.
LOBULAR - Premalignant, rarer, multifocal
Describe the two invasive breast cancer types
Ductal (70%)
Lobular (10-15%)
Medullary in young patients, colloid/mucoid in elderly
What percentage of breast cancers are oestrogen receptor positive?
60-70% - this implies better prognosis
What percentage of breast cancers overexposes HER2 (growth factor receptor gene)?
30% - this implies more aggressive disease and worse prognosis
What are BRCA1/2? What are the characteristics?
Tumour suppressor genes that have ‘loss of function’ mutations in familial breast cancer. More common in Azhekansi Jews.
- Younger age of onset
- Frequent bilateral occurence
- Worse histological features (aneuploidy, higher grade, proliferation)
These patients get annual screening from age 30
Describe the ER status of BRCA1/2 and what this means?
BRCA1 - ER negative, cant use tamoxifen
BRCA2 - ER positive, can use tamoxifen
How do you determine HER status ?
FISH testing
How do you treat HER positive cancer?
Herceptin
Describe the staging of breast cancer
TNM
or
Stage 1 - confined to breast, mobile
Stage 2 - Confined to breast, ipsilateral lymph nodes
Stage 3 - tumour fixed to muscle, ipsilateral lymph nodes, skin involvement
Stage 4 - tumour fixed to chest wall, distant mets
What investigations should be done:
a) in all patients
b) if suspected mets
a) CXR, USS, bone scan, ER/PR/HER2 status
b) CT, MRI
Where does breast cancer metastasize?
- Bones - do radioisotope scan (main cause of spinal cord compression)
- Brain - do CT/PET (second most common after lung cancer)
- Liver
- Lung
When should patients get a 2WW referral?
Aged 30 and over and have an unexplained breast lump with or without pain or
Aged 50 and over with any of the following symptoms in one nipple only:
- discharge
- retraction
- other changes of concern.
What are the components of the 2WW screening for breast cancer?
- Clinical exam
- Mammography (or MRI/USS)
- FNA/core biopsy
Describe the breast cancer screening programme in the UK
Mammogram offered from all women from age 50-75 years, every 3 years
How is breast cancer treated?
SURGICAL (ALL PATIENTS):
- Removal of tumour by wide local excision OR masectomy +- breast reconstruction
- Prior to this do USS +/- sentinel lymph nodes biopsy to check in pts with no lymph node involvement on scan
Masectomy - multifocal, central tumour ,large lesion, DCIS >4cm
WLE - solitary, peripheral, small lesion, DCIS<4cm
RADIOTHERAPY:
- Recommended for all patients with invasive cancer after WLE or post mastectomy if T3/T4
- Used axillary therapy if lymph node involvement
CHEMOTHERAPY:
- Used as an adjuvant eg. epirubicin +CMF
ENDOCRINE:
- Tamoxifen (pre-peri menopausal)
- Herceptin (trastuzamab) cant use if cardiac hx
- Aromatase inhibitors eg. letrozole, anastrozole (post menopausal)
OTHER:
- Bisphosphonates if node positive/bony mets
What are some complications of breast cancer?
Lymphoedema
Pleural effusion
Mets (bone, brain, liver, lung)
Early menopause
Neutropenic sepsis
What is the PREDICT tool?
An online tool that helps patients and clinicians see how different treatments for early invasive breast cancer might improve survival rates after surgery
What are the side effects of bisphosphonates?
- Osteonecrosis of the jaw
- Atypical femoral fractures
During treatment of breast cancer, which patients should be offered a DEXA scan?
Invasive cancer, not receiving bisphosphonates and:
- starting aromatase inhibitor
- have treatment induced menopause
- starting ovarian ablation therapy
What is Paget’s disease?
A rare form of breast cancer in which cancer cells collect in and around the nipple - causes eczematous like changes
How is breast cancer followed up?
Annual mammography until they enter the screening program aged 50.
If already over 50, should have annual mammography for 5 years.
What is a sentinel node biopsy?
A method of decreasing needless axillary clearance in lymph node NEGATIVE patients. It involves:
- Blue dye injected into tumour
- Probe used to identify sentinel node
- Node removed/biopsied, sent for histology and IHC
- This allows axillary staging of cancer
- If the SLN does not have mets, axillary lymph node dissection is not needed
NB - the sentinel node is the ‘first’ lymph node draining a cancer
What index is used in breast cancer prognosis?
NOTTINGHAM PROGNOSTIC INDEX
0.2 x tumour size (cm) + histological grade + nodal status
What is a fibroadenoma?
Benign overgrowth of collagenous mesenchyme of breast nodule.
Firm, smooth, MOBILE
<35 yo
Manage with observation and reassurance unless >3cm, then excise
What is a breast cyst?
Benign fluid-filled rounded lymph.
Not tethered to tissue. Painful if infected.
>35yo
Aspirate to confirm diagnosis
What is a breast abscess/mastitis?
Infection of the mammary duct often associated with lactation and S. aureus
What is the first line treatment in postmenopausal women with hormone-dependent advanced breast cancer?
Letrozole
It is an aromatase inhibitor that blocks oestrogen production therefore can only be used in ER positive breast cancers
What is the Allred score?
A scoring system looking at the percentage of cells that test positive for hormone receptors, and how well the receptors show up after staining.
ie ER 7/8 - lots of receptors found and easily stained
What is clipping?
A small metal clip may be inserted into the breast to mark the site of biopsy in case the tissue proves to be cancerous and additional surgery is required. This clip is left inside the breast and is not harmful to the body. If the biopsy leads to more surgery, the clip will be removed at that time.
What is neoadjuvant therapy?
The administration of therapeutic agents before the main treatment
eg. letrozole (if ER+) before masectomy
What is mammary duct ectasia?
Occurs when a milk duct beneath the nipple becomes wider (dilated) and filled with fluid. The milk duct can then become blocked or clogged with a thick, sticky substance. Common in menopause
Presents with a tender lump around the areola and green discharge
How does fat necrosis present?
More common in obese women with large breasts
May follow trivial or unnoticed trauma
Initial inflammatory response, the lesion is typical firm and round but may develop into a hard, irregular breast lump
Rare and may mimic breast cancer so further investigation is always warranted
What is a duct papilloma?
Local areas of epithelial proliferation in large mammary ducts
Hyperplastic lesions rather than malignant or premalignant
May present with blood stained discharge
What is recommended after wide-local excision ?
Whole breast radiotherapy
When is biological therapy used in breast cancer?
Biological therapy is used in patients who are HER2-positive and is effective in only 20-25% of the tumours. Trastuzumab (Herceptin) is the most common type that is used.
When do you use wide local excision vs mastectomy?
Mastectomy:
Multifocal tumour
Central tumour
Large lesion in small breast
DCIS >4cm
Wide local excision:
Solitary tumour
Peripheral tumour
Small lesion in large breast
DCIS <4cm
How does the presence of axillary lymphadenopathy pre-surgery influence management?
Women with no palpable axillary lymphadenopathy at presentation should have a pre-operative axillary ultrasound before their primary surgery. If positive then they should have a sentinel node biopsy to assess the nodal burden
In patients with breast cancer who present with clinically palpable lymphadenopathy, axillary node clearance is indicated at primary surgery. This may lead to arm lymphedema and functional arm impairment
What are the side effects of tamoxifen?
Increased risk of endometrial cancer
VTE - must stop 6 weeks before surgery
Menopausal symptoms (no 1 is hot flushes)
What is a CI for trastumab (Herceptin)?
History of heart disorder
What are the side effects of aromatase inhibitors (eg. anastrozole)
Osteoporosis - patients should have a DEXA scan before starting treatment
Hot flushes
Arthralgia
Insomnia
