breast cancer Flashcards
development of breast buds
anatomy
both sexes 6-9th fetal life
fianl maturation during first pregnancy
regression following menopause
ER-VE>2CM
HER2+VE >2CM
<2CM SPREAD TO LYMPH NODES
2nd-6th rib Sternal edge to anterior axillary line 15-20 lobes Supported by Cooper’s suspensory ligaments
signs and symptoms of breast cancer
- lump or thickening in
breast. Often painless - discharge (20% DCIS intraductal papilloma, duct ectasia) or bleeding
- change in size or contours of breast
- change in colour or appearance or areola
- redness or pitting of skin over the breast, like orange
fibrocystic breast changes
20%+ of premenopausal women Discomfort/Cysts treatment rarely required • More likely to not detect a developing cancer
fibroadenoma
features
Most common benign breast tumor Young women Can be multiple Excision recommended if growing
firm and mobile
hormone dependent
breast cyst
Benign - middle aged - just before menopause - due to involutionary changes May be aspirated if large Usually multiple Commonly reoccurs following aspiration
epidemiology of breast
most common cancer in women in UK
1 in 8
Screening programme
50-71yrs 3 yearly
what is the triple assessment its what you get in the 2 week referral pathway
Clinical
Inspection
Palpation
Radiological
Mammograms - caudio-cranial, medio-lateral - reported by 2 independent radiologists
USS
MRI
Pathological FNA Cytology Core Biopsy VACB - vacuum assisted core biopsy of the breast Excisional biopsy
RFs of breast cancer
- early menarche
- late menopause
- late first pregnancy
- female
- not Breast Feeding long term
- current use HRT
- no children or fewer
previous Hx - atypical ductal or lobular hyperplasia
- FH of BRCA1, 2, p53
- obesity in post-menopausal women
- high consumption of alcohol
- previous Hx of cancer - as it increases in 5 years
what is triple negative
cells don’t have oestrogen or progesterone receptors
dotn profuce loads of HER2
high screening programmes
FH BRCA mutation
high risk FH
how to differentiate between pagets and eczema
eczema started from nipple or radially -> Pagets disease
oozing
destruction of nipple
if left neglected
areolar to nipple -> simple eczema
Hx of eczema
classification of breast cancer
invasive ductal carcinoma
lobular in situ - surveillance
classification of breast cancer
invasive ductal carcinoma - most common type
- Invasive lobular carcinoma - harder to detect as it has a diffuse multifocal pattern - large by the time its detected
- Ductal carcinoma-in-situ (DCIS)
- Lobular carcinoma-in-situ (LCIS)
lobular in situ - surveillance
her2 Mx
oestrogen
- HER2 - positive - promotes the growth of cancer cells - Trastuzumab - monoclonal AB blocks HER2 - CARDIAC TOXIC
- triple negative can metastasise early aggressive
recur after treatment localy or systemically
biologic types ER+ HER2 - commonest types easily treated ie tamoicen or letrizole p67 differentiating factor high staining luminal B
trNSUMAB her2 blocker if given with chemo efficacy is better
inflammatory breast cancer adjuvant reduce the size
T4 - involving pec muscle or
B- overlying skin or C- both or
D- inflammatory
post mastecomty radiotherapy
T3 >5cm
N2 4-9 LNs
R1 - positive margins
tamoxifen oestrogen receptor positive
Mx surgery
no palpable lymphadenopathy what do we do
palpable lymphadenopathy what do we do
WLE v MASTECTOMY
- > 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
breast
- wide local excision
- solitary lesion
- peripheral tumour
- small lesion in large breast
- DCIS <4cm - mastectomy
- multifocal tumour
- central tumour
- large lesion in small breast
- DCIS > 4cm
axilla
- sentinel LN biopsy/sample
- axillary dissection/clearance
Radiotherapy
- > after Wide Local Excision (WLE)
- to chest wall after mastectomy - T3/T4 tumours + four or more positive axillary nodes
SEs
acute
- skin reaction
- fatigue, chest wall pain
chronic
- fibrosis
- atrophy
- telangiectasia
- angiosarcoma
Mx Hormone therapy
offered if tumours are positive for hormone receptors
Oestrogen antagonists
- tamoxifen more premenopausal
- mixed agonist/antagonist at ER
- pre-menopausal and postmenopausal
- increased risk of DVT
- increased incidence of endometrial Ca
- bone protective
- hot clushes, weight gain, fatigue
Aromatose inhibitors used in post menopausal women if given in premenoposul suppress ovaries give olodex
- anastrozole/letrozole/exemestane
- blocks enzyme aromatase
- prevents oestrogne production in post menopausal women
- can only be used following menopause
- less risk of DVT
- increased risk of osteoporosis - bisphosphonates
- joint ache/bone thinning
we cant give aromatose unless we stop ovaries from working
pathologoical fractures
BOTH causes hot flushes and swelling
Prognosis of breast cancer
what scale predicts recurrence
NPI cancer size x 0.2 + grade (1-3) + node stage (1-3)
10 year survival
oncotype DX
what is paget’s disease
eczematoid change of the nipple associated with an underlying breast malignancy
bone disrupts the normal cycle of bone renewal, causing bones to become weakened and possibly deformed.
Sx
- constant, dull bone pain
- joint pain, stiffness and swelling
- a shooting pain that travels along or across the body, numbness and tingling, or loss of movement in part of the body
Mx
- bisphosphonates - help bone regeneration
- painkillers
- supportive therapies - PT, OT
- surgery
complications
- broken bones -> sudden severe pain, swelling or tenderness, bleeding
- bone deformities
- hearing loss
- Sx of hypercalcaemia
- heart failure
what is adjuvant chemo
after another definitive treatment, such as surgery or radiotherapy to improve survival of the patient and reduce the risk of recurrence of the cancer.
given before another treatment such as surgery, aiming to shrink the cancer and kill micro-metastases (small areas of cancer cells). This would be used in breast cancer to try and shrink a larger tumour and mean a patient could have breast conserving surgery (wide local excision) instead of a mastectomy.
aim to decrease symptoms, increase survival of the patient and improve QoL
what FH RFs will be needed to be referred
age of diagnosis < 40 years
bilateral breast cancer
male breast cancer
ovarian cancer
Jewish ancestry
sarcoma in a relative younger than age 45 years
glioma or childhood adrenal cortical carcinomas
complicated patterns of multiple cancers at a young age
paternal history of breast cancer (two or more relatives on the father’s side of the family)
when will one be referred via 2 weeks pathway
- 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.
Biological Mx of
HER2 - positive - promotes the growth of cancer cells - Trastuzumab - monoclonal AB blocks HER2 - CARDIAC TOXIC - check left ventricular ejection
problem give ACEi and beta blocker
doesnt get to the brain
lymphangitis - SOB
why neoadjuvant before
improves outcomes
shrink it
see if Mx works
CHEMO DRUG anthracyclines - cardiac toxicity - cardiomyopathy - peripheral neuropathy
common SEs N/V immunosuppression fatigue hair loss mucositis allergic reactions premature menopause infertility
ER+VE HER2-ve go to brain
treatment
premenoapusal zoldex
HER2+VE chemo and herceptin
triple negative test for PDL1 predictor to immunotherapy
immunotherapy SEs
colitis hepatits pneumonitis thyroid prob addison cushing
