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MET3B > Breast cancer > Flashcards

Breast cancer Flashcards

1
Q

List the main causes of breast cancer

A
  1. Increased Exposure to oestrogen (too much induces breast cancer)
    - Early menarche - Early age (<12)
    - Late menopause - late age (>55)
    - Nulliparity (No pregnancy beyond 20 weeks)
    - First pregnancy after age 30
    - Hormone replacement therapy
  2. Ionizing Radiation - before age 40
  3. Genetic (BRCA1 and BRCA2) and Li Fraumeni syndrome (TP53 mutation)

Prior benign or premalignant breast changes
– In situ cancer
– Atypical hyperplasia
– Radial scar

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2
Q

List 7 risk factors for breast cancer

A
  • > 40 years
  • Personal or family history
  • Obesity (fat stores oestrogen)
  • Hypertension
  • Diabetes
  • Chronic stress
  • White race or Jewish lineage
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3
Q

Describe 4 high risk families of breast cancer

A

4 or more relatives with breast/ovary ca

3 relatives under the age of 60

2 relatives under the age of 40

1 relative with both or bilateral breast ca.

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4
Q

List 4 lifestyle risk reduction strategies for cancer

A 
Early child birth <30
Exercise 3-5 hours weekly
Maintain normal weight
Avoid smoking/alcohol
Avoid prolonged hormone replacement
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5
Q

What are the signs and symptoms of breast cancer?

A

Breast lump/ mass

  • Ill defined
  • Fixed mass (especially if attached to chest wall)
  • Overlying skin changes ( dimpling, Erythema. oedema)

Obvious breast cancer

  • Skin dimpling
  • Fixed firm axillary nodes
  • Large breast mass
  • Orange peeling (associated with inflammatory breast cancer)
  • Nipple retraction (unusual)
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6
Q

Describe the breast cancer screening program

A

Screens conducted with a mammogram

Use MRI in premenopausal women

  • Those with a family history or moderate – high risk- yearly screening every year from 40 years
  • Yearly screen starts age 20 for women with a TP53 mutation
  • Yearly screen starts age 30 for women with a BRCA1 or BRCA2 mutation

All women aged between 50 and 70 (69) for screening every 3 years

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7
Q

What is the best screening method for breast cancer? When is it used?

A

MRI

Used in pre-menopausal women and those who are really high risk e.g PT53 gene

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8
Q

In a normal screening program, what is conducted after a mammogram if cancer is suspected?

A

Core biopsy

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9
Q

Describe the process of diagnosing a patient under 30 with breast cancer

A

First -
Wait 2-3mestrural cycles. If it goes away = benign lesion

If persistent – get an ultrasound - helps differentiate between a mass or cyst

If under 30 with a cyst → FNA (fine-needle aspiration)

  • If bloody (probably cancer)
  • Puss (abbesses)- Treat with infection
  • Fluid (benign cyst)- Drain

If under 30Y and cyst resolves- Diagnosis complete

If bloody cyst or cyst recurrence, there is a high chance of malignancy

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10
Q

Name the 2 types of non invasive breast cancers

A

Ductal Carcinoma in situ

Lobular Carcinoma in situ

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11
Q

Name the 2 types of invasive breast cancers

A

Infiltrating Ductal Carcinoma

Infiltrating Lobular Carcinoma

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12
Q

What is the difference between a non invasive an invasive breast cancer?

A

Invasive breast cancers Invade the basement membrane

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13
Q

How is an invasive breast cancer differentiated between a non invasive breast cancer?

A

Determined by biopsy

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14
Q

Describe what a ductal carcinoma in situ is? What is the risk of this cancer type developing into an invasive cancer

A

Carcinoma confined to ductal tissue
1% progress to invasive cancer per year
Usually unilateral

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15
Q

How is ductal carcinoma in situ treated?

A

Lumpectomy plus radiation (breast conservation)

ALT -

Modified Radical mastectomy

Survival rate for both is equal

Chemotherapy is not necessary for in situ carcinoma (but women still have it)

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16
Q

Describe what a Lobular Carcinoma in situ is?

A 
- Carcinoma confined to Lobular Tissue 
Most often found incidentally 
 - Most likely to calcify 
 - So likely to be felt as a mass
More likely to affect other breast (bilateral carcinoma)
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17
Q

How is Lobular Carcinoma in situ treated?

A

Treatment is the same for ductal carcinoma

If mastectomy chosen - prophylactic Bilateral mastectomy should be considered

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18
Q

Describe what a Infiltrating Ductal Carcinoma is?

A

Carcinoma of ductal breast with invasion of basement membrane
There is an increased possibility of metastasis

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19
Q

How is Infiltrating Ductal Carcinoma treated?

A

First -
In addition to Core Biopsy (to confirm cancer type)
- Chest X- ray (identify lung metastasis)
- CT liver (Liver metastasis)
- Liver function test (metastasis that may not show on CT)
- Bone scan

Treatment -

  • Surgery (Exception, inflammatory breast cancer)
  • Lumpectomy and sentinel node biopsy + radiation
  • Modified Radical Mastectomy
  • Radical mastectomy- if there is invasion of pec major muscles

Chemotherapy
- If there is spread to nodes or else where
- Cyclophosphamide, Adriamycin, 5-Fluorouracil
Or
Replace Adriamycin with methotrexate

Hormonal therapy
when tumour is oestrogen or progesterone receptor positive
- Oestrogen inhibitors- Tamoxifen, Raloxifen,
- Aromatase inhibitor- Anastrozole

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20
Q

Describe what a Infiltrating Lobular Carcinoma is?

A

Carcinoma of ductal cells with invasion of basement membrane

Strong tendency towards Bilaterality (20-29%)

21
Q

How is Infiltrating Lobular Carcinoma treated?

A

Initial work up the same as with ductal carcinoma (looking for metastasis)

The same as with infiltrative ductal carcinoma
- With modified radical mastectomy – consider prophylactic bilateral mastectomy

22
Q

What type of gene is the BRCA genes?

A

Tumour suppressor genes

23
Q

What is the inheritance pattern of BRCA 1 AND BRCA 2 genes?

A

autosomal dominant

24
Q

If a patient has a BRCA mutation, which other cancers are they at risk of getting?

A

ovarian cancer and pancreatic cancer

25
Q

Which gene mutation is a common cause of male breast cancer?

A

BRACA mutations

26
Q

What is the life time risk of cancer with the BRCA mutations, does it differ for BRCA 1 and 2?

A

breast cancer for both genes = 69-72%

27
Q

What is the difference in the cancers caused by BRCA 1 and BRCA 2 mutations?

A
  • BRCA 1 = Most are invasive ductal carcinomas, and triple negative (no ER,PR OR HER2 receptors
  • BRCA2- increased risk of melanoma
28
Q

Which tests are done to identify gene mutations for breast cancer?

A
  • Blood test

- Followed by DNA sequencing

29
Q

Which condition does mutation in the TP35 gene cause?

A

Li-Fraumeni Syndrome

30
Q

Describe key features of Li-Fraumeni Syndrome

A
  • Cancer is more likely to develop at a young age <30
  • Increased risk of multiple cancer diagnosis in a lifetime
  • Those with this mutation should avid radiation
31
Q

What type of mutation is HER 2?

A

Gain of function mutation

32
Q

Describe key features of HER2 receptor positive breast cancer

A
  • Cancer usually develops on one of the epithelial cells lining the collecting ducts
  • The mutation causes an increase in the number of HER2 receptors. More Human Epidermal growth factors bind onto the receptor
  • This causes an increase in pro-growth signalling hence cell division
33
Q

What is the difference between HER2 positive breast cancer and others?

A

HER2 positive breast cancer grows faster and is more life threatening than others

34
Q

How is HER2 receptor positive cancer diagnosed?

A 
IHC test (ImmunoHistoChemistry)
Chemical dye stains HER2 proteins 
- Score is given from 0-3+
- Score is an indication of the amount of HER2 proteins located on cells in a breast cancer tissue sample
- 0-1+ = HER2 negative 
- 2+ = Borderline (FISH test conducted)
- 3+ = HER2 positive

FISH test (Fluorescence In Situ Hybridization)

  • Measures the copies of the HER2 gene within 1 cancer cell
  • 3 or more genes = Positive
  • Most accurate test
35
Q

How is HER2 positive breast cancer treated?

A
  • Surgery (mastectomy or lumpectomy)
  • Radiation

Chemotherapy
- Enhertu

Combination of compound similar to Herceptin, Herceptin + topoisomerase I inhibitor + deruxtecan (joins the first 2 together)

  • Herceptin (trastuzumab)
  • Attaches to HER2 receptors and blocks the cancer cells from receiving chemical signals that stimulate growth
36
Q

What is Inflammatory breast cancer?

A
  • Most are invasive ductal carcinomas
  • Rare and very aggressive
  • Cancer cells block lymph vessels in the skin
  • Breast often looks swollen and red
  • Tends to be diagnosed at a younger age
  • Often Hormone receptor negative
37
Q

What is a main risk factor for Inflammatory breast cancer?

A

Obesity

38
Q

In which demographic is Inflammatory breast cancer mode common?

A

More common in African American women than white women

39
Q

What are the symptoms of Inflammatory breast cancer?

A
  • peau d’orange
  • Swelling and redness which affect 1/3 or more of the breast
  • Rapid increase in breast size
  • heaviness, burning, or tenderness in the breast
  • Inverted nipple
40
Q

How is Inflammatory breast cancer treated?

A

Systemic chemotherapy (shrink tumour) + Modified Radical mastectomy + Radiation

41
Q

What is a modified radical mastectomy?

A

Removal of all breast tissue
Removal of nipple/Areolar complex
Reconstruction
Lymph node removal

42
Q

What is the most common cancer type?

A

Infiltrative Ductal carcinoma

43
Q

How is breast cancer staged?

A

TX Primary tumor cannot be assessed
• T0 No evidence of primary tumor
• Tis Carcinoma in situ: Intraductal carcinoma, lobular carcinoma in
situ, or Paget’s disease of the nipple with no tumor
• T1 Tumor 2 cm or less in greatest dimension
T1mic Microinvasion less than 0.1 cm
T1a Tumor more than 0.1 cm but not more than 0.5 cm
T1b Tumor more than 0.5 cm but not more than 1 cm
T1c Tumor more than 1 cm but not more than 2 cm
T2 Tumor more than 2 cm but not more than 5 cm in greatest
dimension
• T3 Tumor more than 5 cm in greatest dimension
• T4 Tumor of any size with direct extension to (a) chest wall or (b)
skin only as described below
T4a Extension to chest wall
T4b Edema (including peau d’orange) or ulceration of the skin of
the breast or satellite skin nodules confined to the same breast
T4c Both (T4a and T4b)
T4d Inflammatory carcinoma

44
Q

Which drug is used in the treatment of early breast cancer treated (before menopause)? What is its mode of action?

A

Tamoxifen -antiestrogens. It blocks the activity of estrogen (a female hormone) in the breast.

45
Q

Which drugs are used in the treatment of breast cancer (post menapause)

A

Tamoxifen or AI for five years

Disease free but not overall survival advantage has
been demonstrated for:

  • Anastrozole rather than Tamoxifen for 5 yrs
  • Tamoxifen for 2 yrs followed by Exemestane for 3yrs
  • Tamoxifen for 5 yrs followed by Letrozole for 3 yrs

• and Anastrozole=Letrozole= Exemestae

46
Q

List 4 chemotherapy drug combinations used in the treatment of breast cancer

A

cyclophosphamide, methotrexate, fluorouracil (CMF)

•
Fluorouracil, epirubicin, cyclophosphamide (FEC)

•
Docetaxel, doxorubicin, cyclophosphamide (TAC)

•
FEC – Docetaxel or AC - Paclitaxel weekly (FEC-T)

47
Q

Describe the use of endocrine therapy in Breast cancer

A

Used in the treatment of hormone receptor positive cancer
Premenopausal options
- Tamoxifen first line pre menopause
- Oophorectomy - removal of ovaries and usually fallopian tubes
- Goserilin , Leuproprelin - GnRH analogues. Supresses ovarian function. Used in ER positive patients
- Tamoxifen, Fulvestrant - selective estrogen receptor modulator

  • Medroxy Progesterone acetate
    inhibits gonadotropin-releasing hormone (GnRH) pulsatility and gonadotropin secretion; LH is much more suppressed than is FSH

Postmenopausal
- anastrozole, letrozole,
exemestane - Aromatase inhibitors
inhibits the peripheral conversion of androgens to oestrogens
Use these drugs first line post menopause
- Plus all of the above

48
Q

How is metastatic breast cancer treated?

A
  • Palliative treatment
  • Treatment used to induce
    remission and maintain quality of life

Endocrine treatment anti-oestrogen

Chemotherapy with one or two drug regimens

Targeted biologicals if receptor positive eg trastuzumab,
pertuzumab, lapatinib

Radiotherapy eg bones
• Surgery to chest wall
• Supportive care eg bisphosphonates (used to prevent bone pain and bone lesions and fractures)
• Psychological support eg art therapy

MET3B (17 decks)

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