Breast Flashcards
What are the two types of breast carcinomas?
- invasive ductal carcinoma
2. invasive lobular carcinoma
How often should women between 50-74 years old go to mammograms?
every 2 years
What are the aetiological factors of breast cancer?
- breast cancer in the contralateral breast
- increased oestrogen exposure-(early menarche and late menopause, nulliparity, having a baby after 35 years
- BRCA 1 and 2 gene mutations PREDISPOSES patients to 0% higher chance of breast and ovarian cancer
- Family History of first degree relatives
- obesity
- previous radiation
- previous history of benign breast conditions like fibroadenoma with atypical cellular involvement
What are the associated genetic conditions associated with breast cancer?
- P53 tumour suppressor gene mutataion
- Peutz-Jhegers syndrome
- Li-Fraumeni syndrome-SBLA-Sarcoma, breast, lymphoma, adrenal cancer syndrome
What type of cancer are breast cancers?
-adenocarcinoma
What are the characteristics of DCIS?
- unifocal
- pattern of grouped microcalcifications
- higher risk of invasive carcinoma(ipsilateral)
What are the characteristics of LCIS?
- microcalcifications are rare
- multifocal
- decreased chance of it becoming invasive carcinoma in both breasts
What are the characteristics of Invasive Ductal Carcinomas?
- most common(70-80%)
- unilateral localisation
- unifocal tumours
- most aggressive which easily cause Mets
What are the characteristics of Invasive lobular carcinoma?
- not as aggressive
- bilateral or unilateral
What is the third type of invasive breast carcinoma?
-inflammatory
What are the clinical features of breast cancer?
- asymmetrical breast size
- nipple changes-discharge or inverted nipple
- palpable mass-usually a single, non tender mass with poorly defined margins
- mostly in the upper outer quadrant(55%), then the inner upper quadrant(15%), nipple area(15%), lower inner area(10%), outer lower area(5%) - Lymph node involvement(axilla), more than 1 cm
- Skin changes: peau’ d orange (redness, edema and pitting of hair follicles)
What causes peau’ d orange?
-It is caused by blocked lympatic channels
What is Paget’s disease of the breast?
- a adenocarcinoma
- either in-situ or invasive ductal carcinoma that infiltrates the nipple and areolar
- it starts by affecting the nipple and then going out into the areolar
How does Paget’s disease present?
- it looks like eczema
- it usually has erythema, itching, crusting and rawness
How do you diagnose and treat Pagets disease?
- punch biopys
- a mastectomy is usually done
What is inflammatory breast cancer?
It is a advanced and invasive carcinoma associated with dermal lymphatic invasion of tumour cells
-it usually presents as a abscess or cellulitis
What are the clinical features of inflammatory breast cancer?
-25% have metastatic disease
-erythematous and oedematous (peau’ d orange) plaques appear over a rapidly growing mass
-tenderness
-axillary lympahdenopathy
-
What is the differential diagnosis for inflammatory breast cancer?
- pagets disease of the breast
- mastitis
- breast abscess
What should you do if a woman comes to you with a palpable breast mass and they are less than 30 years?
- low probability- clinically assess them 3-10 days after their menstrual period
- high probability-do ultrasound or FNA
What should you do if a woman comes to you with a palpable breast mass and they are above the age of 30?
- Mammogram
then do core needle biopsy
What are features of a benign breast mass on a mammogram?
- well defined margins
- Halo sign- radiolucent circle around the lesion
- diffuse and coarse microcalcifications
What are the features of a malignant breast mass on a mammogram?
- focal mass or density with ill-derfined margins
- spiculated margins
- clustered microcalfications
When do we do FNA’s?
We do fine needle aspirations when we have a low probability of a lesion being malignant
What is the preferred test?
Core needle biopsy because it can help distinguish between invasive and non-invasive carcinoma
In which instances would we excise the mass?
- inconclusive results on core needle biopsy
2. if we are unable to do core needle biopsy
What should we consider if there is axillary lymph node involvement?
- haematogenic spread has already ocured
What is the workup of a breast cancer patient?
- We start with receptor testing of the biopsy samples
- immunohistochemical testing of oestrogen and progesterone
- FISH staining of HER2 positive receptors-in 20% of the cases
What does triple negative mean?
- It is a high grade and aggressive form
- oestrogen negative, progesterone negative and HER 2 negative
What tests would you consider for checking mets?
- Bone mets- Contrast MRI scan to localise the pain, bone scan
- Liver mets- CT abdomen
- Lung mets- CXR and MRI of the lungs; thoracentesis is the case of pleural effusion
How do we make a diagnosis of breast cancer?
Triple assessment-clinical assessment, radiology and tissue biopsy and confirmation
What is a mammogram?
It is a special X-ray that can suggest but not make a diagnosis of breast cancer
-it is not useful in patients under 30 years because of the dense breast tissue that young people have
In which cases would we use an ultrasound?
- patients under the age of 30 because they have dense breast tissue
- to determine whether the mass is cystic or solid
Does an ultrasound help us determine whether the mass is benign or maligant?
No
What is a FNA test?
- cytological test that requires a 22 gauge needle and syringe
- aspirate the mass in different directions and place on the slides to stick together
- it is great to determine the type of cells but not enough to make a diagnosis of malignancy
What is a Trucut/core needle biopsy?
It is a biopsy of the mass/tissue that is the sent for histopathological assessment
-it can give us info on the tumour type,biology and hormone receptor status
What is the third and rare form of breast carcinoma?
mixed(both invasive and non-invasive)
-can include angiosarcomas and carcinosarcomas
What is the most common type of invasive ductal carcinoma?
-Infiltrating ductal carcinoma(it affects 50-70%)
What are some of the other invasive ductal carcinomas?
- medullary carcinoma
- mucinous carcinoma
- tubular carcinoma
- invasive cribriform carcinoma
- invasive papillary carcinoma
What do pathologists use to describe tumours?
- size
- grade
- blood vessel or lymphatic invasion
- PR(progsterone), ER(oestrogen), HER 2 receptors
What is the first thing to do when you have a positive breast cancer diagnosis?
- check for metastases:
- all patients must have CXR’s done, LFT’s done
- If the LFT’S are abnormal or T3 means that they also need an ultrasound of the liver
- patients must also have a bone scan done
What works for ER and PR positive patients?
-Endocrine maneoveres such as Tamoxifen
What seems to work for HER 2 positive patients?
Trastuzumab
Name the 5 treatment options for breast cancer patients?
- surgery
- radiotherapy
- chemotherapy
- biological treatments
- endocrine manipulation
What are the two surgical treatments for breast cancer?
- wide local excision
2. mastectomy
What 6 factors do patients have to fulfill before they are allowed to do a wide local excision?
- no multifocal lesions
- no family hx
- < 5 cm mass
- radiotherapy for 6 weeks
- outer quadrants
- large breast
What are the 2 surgical options for the axilla?
- sentinel lymph node biopsy
2. axillary nodal clearance
Which 3 factors deem a patient appropriate for sentinel lymph node biopsy?
- Stage T1/T2
- no lymph node involvement
- no previous axilla surgery, irradiation or chemotherapy
How is a sentinel lymph node biopsy done?
- it is a minimally invasive procedure that involves removal of the first draining lymph node
- The radioactive technetium is injected around the tumour 24 hours prior to surgery
- the sentinel lymph node uptake is then detected with gamma rays
- intraoperatively: they inject dye around the areolar around the same quadrant as the cancer
- the node is removed and put in a frozen section
- if cancerous: axillary node clearance is done
- if not cancerous then nothing is done to the axilla
Why do we need adjuvant therapy?
-We need it to ensure that we decrease the risk of women relapsing after 5 years
Name the different types of adjuvant therapy?
- radiotherapy
- chemotherapy(eg. adriamycin and taxanes)
- endocrine manipulation: entails changing the patients hormonal environment to cause tumour regression(progesterones and Tamoxifen)
- biological modifiers (Trastuzumab working on HER 2)
Name some of the hormonal or endocrine modifiers?
- premenopausal:
- tamoxifen works on ER
- progesterone
- LHRH agonist
- oopherectomy - post menopausal
- progesterone
- tamoxifen
- aromatase inhibitors
How is breast cancer staged?
stage 0 to 4
What is stage 0 and how do we treat it?
- carcinoma in situ
- if local: Wide local excision
- if multifocal: mastectomy with axillary node clearance
What is stage 1?
T1 without nodes
What is stage 2?
What is the treatment options?
T1 or T2 with nodes OR T3 without nodes
- the options include a total mastectomy with a sentinel lymph node biopsy or a wide local excision with a sentinel lymph node biopsy
- axillary node clearance is done when the sentinel lymph node biopsy is positive
- adjuvant therapy is needed
What is stage 3?
-How do we treat it?
Locally advanced tumour(T4) or locally advanced node(N2,3)
- Triple modality approach is needed: chemotherapy, surgery and radiotherapy
- neoadjuvant (chemotherapy before the surgery to downsize the tumour is necessary)
What is stage 4 and how do we treat it?
-metastatic disease
-palliation is the name of the game
Older, post-menopausal women-benefit from endocrine manipulation
younger women would benefit from chemotherapy
What is the management for men that present with breast cancer?
- mastectomy and axillary node clearance
- the incidence rate is 1%
What are some of the side effects of chemotherapy?
- cardiotoxicity
- alopecia
- myelosupression
- hypersensitivity
- contra-indicated in first trimester of pregnancy
What are he complications of breast cancer?
- metastatic disease: bone, liver, lung, brain mets
- recurrence: 40% in lymph nodes, chest wall
- paraneoplastic syndrome
- lymphedema of the arm is a side effect of treatment
What are some of the factors that can prevent breast cancer?
- mammograms every 2 years in women that are average risk between 50-74 years
- breast feeding
- early pregnancy
