Breast And Endocrine Flashcards
DCIS vs LCIS
Both are non-invasive, and are characterised by absence of stromal invasion
Ductal carcinoma in situ
25% of all newly dx breast ca
Usually unifocal
Frequently has a pattern of grouped microcalcifications
High risk of subsequent invasive carcinoma (ipsilateral)
VS
Lobular Carcinoma in Situ
0.5-1.5% of benign breast biopsies
Usually multi focal
Microcalcifications are rare
Not a true premalignant condition, if left untreated won’t progress to invasive
It is a marker of risk
High risk of subsequent invasive ca both breasts equally predisposed (but not limited to area of LCIS
IDC vs ILC
Invasive ductal carcinoma
70-80% of all invasive breast carcinoma
Unilateral localisation
Unifocal
More aggressive
Invasive lobular carcinoma
10-15% of all invasive br ca
Bilateral or unilateral
Multi focal
Less aggressive than ductal
Slower metastasis than ductal
Treatment of noninvasive breast carcinoma
DCIS:
-Breast conserving therapy or Mastecomy
-If BCT not feasible, do Mastectomy and Sentinel lymph node biopsy
LCIS
-Life long surveillance and chemoprevention with hormone therapy TAMOXIFEN
-surgery only if unsure of dx
-noninvasive doesn’t require systemic tx but radiotherapy might be indicated
Management of Invasive breast carcinoma
Stage 1&2
1. Surgery: breast conserving therapy followed by radiation therapy
2. Mastecomy for pt unable to undergo BCT or requests aggressive mx
3. Intra-Op lymph node evaluation (SLNB) to assess potential lymph node spread of ca cells to a axillary lymph node (indicated for all pt with neg preOp axillary LN.
-Axillary LN clearance for pt clinically positive preOp Axillary LN
Adjuvant systemic therapy
-Hormone and targeted biological therapy in all ER/PR+ (estrogen or progesterone receptor) or HER2+ patients
-Chemo in high risk pt
Stage 3 ca management
1. Neoadjuvant (before surgery) systemic therapy+ surgical resection (BCT or mastectomy) + Axillary LN resection
2. Followed by adjuvant therapy +/- radiation
Indications for chemotherapy
Metastatic LN
Aggressive tumour
Histology: HER2 positive or triple negative breast cancer
Locally advanced br ca (stage 3 I think)
Agents : Anthracycline and Taxane regimens
Side effects and contraindications of Chemo
Alopecia
Myelosuppresion
Hypersensitivity
Cardiotoxicity
Contraindicated in 1st trimester of pregnancy
Indications for hormone therapy (which agents to use)
Oestrogen receptor positive tumours
Premenopause:
1st line: Tamoxifen (serum estrogen receptor modulator), estrogen receptor antagonist, acts as agonist on uterus and bone. Often used in conjunction with ovarian suppression or ablation
Post menopausal
Aromatise inhibitors eg Arimidex (Anastrozole)
Side effects of hormone therapy in breast cancer tx
Page 211 lol
Side effects of hormone therapy in breast cancer tx
Page 211 lol
Complications of breast cancer
- Metastatic disease : bone metastasis
- Recurrence
- Paraneoplastic syndrome (hypercalcemia of malignancy)
Tx ass/complications
1. Endometrial ca promoted by Tamoxifen
2. Cardiotoxicity by certain chemo drugs
3. Anaphylactic reaction by certain drygs
4. Lymphadema or the arm
5. Angiosarcoma of the breast (or lymphangiosarcoma or hemangiosarcoma)
6. Skin changes and sensitivity from radiotherapy (post rad mastitis, joint stiffness, damage to underlying joint tissue)
What are the prognostic factors on breast cancer
Axillary lymph node status (most important)
Tumour size
Patient age
Receptor status (ER/PR neg, HER 2 pos and triple negative ass w worse prognosis)
Histological grade and subtype
HER2 positive ass/w aggressive tumour growth and high recurrence therefore poor prognosis
Since tx with trastuzumab prognosis has improved
What is the survival rate for pt with breast cancer
Early disease without LN involvement : 10y survival rate is 70%
Node positive disease: Hugh risk of recurrence without radiotherapy
Metastatic disease: 3 year survival rate of 48-71%
Differentials for a breast discharge
Introduction papilloma
Ductal actasia
Breast ca
Lactation or pregnancy
Medication
Causes of bilateral gynaecomastia
Drugs: spironolactone, steroids, HAART (efavirenz), diazepam, TCAs, cimetidine, digoxin, ca channel blockers
Liver/ renal failure
Recreational: Alcohol, marijuana, heroin, amphetamine
Testicular carcinoma
Causes of unilateral gynaecomastia
Breast cancer
Benign breast lump
+ all causes of bilateral as below
Drugs: spironolactone, steroids, HAART (efavirenz), diazepam, TCAs, cimetidine, digoxin, ca channel blockers
Liver/ renal failure
Recreational: Alcohol, marijuana, heroin, amphetamine
Testicular carcinoma
Differentials for a breast lump
- Benign: fibroadenoma, fat necrosis, cyst, galactocoele, lipoma, abscess, granulomatous inflammation
- Malignant: invasive carcinoma, ductal carcinoma in-situ, phyllodes tumour, metastases, lymphoma, sarcoma
• Fibroadenomas:
o Benign lumps that arise from the lobular component
o Typically affects women aged 15-25
o Firm, well-circumscribed, <3cm, hypoechoic on U/S
o Patients over 20 may need a U/S to confirm. Patients over 25 may need U/S and core biopsy to confirm
o Any mass that feels like a fibroadenoma but is associated with skin/nipple changes, discharge, rapid growth etc. warrants further investigation
o Surgical excision only warranted if: large (>5cm), patient request, patient over 30, diagnostic uncertainty
• Fat necrosis: occurs at any age following trauma. May require triple assessment with U/S +/- mammogram, and biopsy
• Breast cysts: common in 40’s-50’s. Caused by blockage on terminal ducts. Anechoic on U/S. Treated with aspiration of straw-coloured fluid and biopsy of remaining mass. Blood-stained aspirate may indicate papillary cystic carcinoma
• Galactocoele: occurs in a woman who is lactating or lactated recently. Caused by obstruction of the lactiferous duct. Aspiration of milky contents confirms diagnosis. May need oral antibiotics if secondarily infected
• Abscess: (lactational) treat with flucloxacillin and drainage. (non-lactational) treat with augmentin and drainage with biopsy to rule out inflammatory carcinoma
• Granulomatous inflammation: typically presents with a unilateral, firm, discrete breast mass with inflammation of overlying skin +/- nipple retraction. Treat with corticosteroids +/- wide local excision if required
Risk factors for breast cancer
Personal hx of breast cancer
Increase oestrogen exposure
-nulliparous
-wide window- early mernache late menopause
-high number of menstrual cycles
-first pregnancy after 35
-exogenous oestrogen (eg HRT)
BRCA1/2 gene mutations
Positive family hx
Prev radiation
Lifestyle: smoking, obesity, alcohol,low fibre high fat diet
Genetic disorders associated with breast cancer
- Li-fraumeni syndrome
-Autosomal dominant inherited mutation of the p53 tumour suppressor gene
Multiple malignancies at early age
-breast cancer, osteosarcoma, leukaemia, lymphoma, brain tumour, adrenocortical carcinoma - Peutz-Jeghers syndrome
Signs of breast cancer
Palpable lump on breast
Skin dimpling
Skin redness
Nipple discharge (blood)
Nipple changes/inversion
Signs of benign vs malignant breast mass on mammogram
Benign:
-well defined circumscribed mass
-halo sign (radiolucent ring surroundings)
-diffuse microcalcifications or course calcifications
Malignant
-focal mass with poorly designed margins
-speculated margins
-clustered microcalcifications
-skin thickening or dimpling
-abnormal LN
Signs of breast cancer on U/S (benign vs malignant)
Benign
Well defined, circumscribed mass
Wider than tall
Malignant:
Hypoechoic lesion
Irregular margins
Taller than wide
Posterior shadowing
What are Desmond tumours
Desmond tumours are aggressive or deep fibromatosis, they are not sarcomas but represent neoplasms of fibroblastic tissue that lacks ability to metastasise.
Complications of Desmond tumours
Local recurrence even after complete excision
Capacity to cause local morbidity
Death
Risk factors for Desmoids (who is it common in)
Pregnancy (mostly Postpartum)
Familial Adenomatous Polyposis (FAP) in the mesenteric route
