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MBChB Surgery > Breast cancer > Flashcards

Breast cancer Flashcards

1
Q

What is the incidence of breast cancer?

A

8-10%

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2
Q

What is the peak age of breast cancer?

A

63yo

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3
Q

Name risk factors for breast cancer

A 
Non-modifiable:
Female 
Age 
Family history 
Genetics 
Early age at menarche
Older age at menopause
Race
Nulliparity 
Personal history 
Modifiable:
Obesity
Alcohol
Smoking
HRT
Parity
>30yo first live birth
Night shift work 
Histologic
Proliferative breast disease
Atypical ductal/lobular hyperplasia
Lobular carcinoma in situ 
Lack of breastfeeding
Hormonal use
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4
Q

How does family history affect breast cancer risk?

A

1 direct family member >50 = 12% risk
2 direct family members >50 = 18% risk
1 direct family member <50 = 22% risk
2 direct family members <50 = 40% risk

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5
Q

What is the BRCA gene risk for breast cancer?

A

80%

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6
Q

Why is imaging done before biopsy?

A

Tumour size assessment is important and biopsy causes bleeding that distorts the actual size

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7
Q

When can FNA be done for biopsy?

A

Clinical impression and imaging suggest that the lump is benign

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8
Q

What information should be provided by pathology?

A 
Benign vs malignant 
In situ vs invasive 
Ductal vs lobular 
Characteristics (mucinous, scirrhous) 
Elston Nottingham classification
Receptors
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9
Q

What is the Elston Nottingham classification?

A

It grades breast carcinomas by adding up scores for

  • tubule formation
  • nuclear pleomorphism
  • mitotic count
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10
Q

How is the Elston Nottingham classification graded?

A 
3-5 = well differentiated
6-7 = moderately differentiated
8-9 = poorly differentiated
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11
Q

How is tubule formation scored using the Elston Nottingham classification?

A

75% of tumour shows tubules (1)
10-75% of tumour shows tubules (2)
<10% of tumour shows tubules (3)

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12
Q

How is nuclear size scored using the Elston Nottingham classification?

A

Small, regular nuclei (1)
Intermediate size nuclei - 1.5/2x the size of normal nuclei (2)
Large nuclei - >2x the size of normal nuclei (3)

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13
Q

How is mitotic count scored using the Elston Nottingham classification?

A

0-7 mitoses/10HPF (1)
8-14 mitoses/10HPF (2)
>15 mitoses/10HPF (3)

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14
Q

Which score looks at the oestrogen and progesterone receptors?

A

Allred Quick Score

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15
Q

What is a positive predictor of effective anti-oestrogen treatment?

A

Progesterone receptor >30%

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16
Q

What is HER2?

A

Human epidermal growth factor receptor 2 - indicates high recurrence rates

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17
Q

What is Ki-67?

A

A nuclear protein that gives exact assessment of proliferation
Indicates % of cells in mitotic process

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18
Q

Name the sites of breast cancer metastases

A 
Lung
Liver
Pelvis
Ovaries
Bone
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19
Q

How is metastatic staging done in breast cancer?

A

Clinically
Radiologically
Blood tests

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20
Q

How do we look clinically for breast cancer metastases?

A 
Pleural effusion
Enlarged nodular liver 
Pouch of Douglas nodules 
Bone pain
Fractures
21
Q

Which imaging do we routinely do for TNM staging?

A

CXR
Abdominal U/S
Pelvic U/S

22
Q

When do we do CT/PET CT in TNM staging?

A

If there is doubt about findings

23
Q

Which blood tests should be done for TNM staging?

A

FBC
LFT
Calcium
Tumour markers (for baseline and treatment response)

24
Q

If you find an elevated calcium with no other signs of bone metastases, how do you proceed?

A

Rule out hyperparathyroidism before doing expensive bone scintigram

  • Repeat the calcium
  • Do a PTH assessment
25
Q

When should surgery of the primary breast tumour not be undertaken?

A

Tumour cannot be removed with clear surgical margins

Wound cannot be closed primarily

26
Q

How do we make the primary lesion operable?

A

Neo-adjuvant systemic therapy

  • chemotherapy
  • hormonal therapy
27
Q

What are the two surgical options?

A

Mastectomy

Breast conservation

28
Q

What must breast conservation therapy always be followed by and why?

A

Radiotherapy due to high local recurrence rate

29
Q

What is the only indication for breast conservation surgery?

A

Cosmesis

30
Q

How is the axilla managed in breast cancer?

A

Not involved - sentinel node biopsy

Involved - dissection of at least 1 level

31
Q

When is radiotherapy indicated after mastectomy?

A

> 4 involved nodes after axillary dissection

32
Q

When do we use radiotherapy for metastatic disease?

A
  1. Spinal cord compromise
    - symptoms of spinal cord compression need urgent MRI and radiotherapy to prevent paralysis
  2. Brain metastases
    - BBB prevents chemotherapeutic treatment
    - RT to stop increase in pressure
33
Q

When do we start systemic adjuvant treatment of breast cancer?

A

Within 3-4 weeks after surgery

>12w no benefit shown

34
Q

What is herceptin?

A

Monoclonal antibody

35
Q

Which chemotherapy agents are usually used for breast cancer?

A
  1. Monthly cycles for 6 months
    - 5-fluorouracil
    - cyclophosphamide
    - adriamycin
2. Newer regimen:
Monthly cycles for 4 months
- cyclophosphamide
- adriamycin 
Followed by taxane weekly for 12w
36
Q

What should you monitor if you give a patient adriamycin?

A

Cardiac function for cardiotoxicity

Poor function = methotrexate instead

37
Q

Which hormonal therapy do we use in premenopausal women?

A

SERMs (tamoxifen)

38
Q

Which hormonal therapy do we use in postmenopausal women?

A

Aromatase-inhibitors (anastrasole, letrosole)

39
Q

Discuss staging of the primary tumour (T)

A 
Tx - cannot be assessed
T0 - no evidence of tumour
Tis - carcinoma in situ
T1 - <20mm
T1mi - <1mm 
T1a - >1mm but <5mm 
T1b - >5mm but <10mm
T1c - >10mm but <20mm 
T2 - >20mm but <50mm
T3 - >50mm 
T4 - any size with extension to chest wall and/or skin
T4a - extension to chest wall 
T4b - ulceration and/or ipsilateral satellite nodules and/or skin edema 
T4c - both T4a and T4b 
T4d - inflammatory carcinoma
40
Q

Discuss staging of the regional lymph nodes (N)

A

Nx - cannot be assessed
N0 - no metastasis
N1 - 1-3 axillary nodes and/or in SLNB detected internal mammary nodes
N2 - 4-9 axillary nodes or in clinically detected internal mammary nodes
N3 - >9 axillary nodes or in infraclavicular or clinically detected internal mammary nodes w/ 1 or more axillary nodes

41
Q

Give the TNM stages for stage 0 breast cancer

A

Tis
N0
M0

42
Q

Give the TNM stages for stage 1a breast cancer

A

T1 N0

43
Q

Give the TNM stages for stage IB breast cancer

A

T0 N1
T1 N1
T2 N0

44
Q

Give the TNM stages for stage 2b breast cancer

A

T2 N1

T3 N0

45
Q

Give the TNM stages for stage 3a breast cancer

A 
T0 N2
T1 N2
T2 N2
T3 N1
T3 N2
46
Q

Give the TNM stages for stage 3b breast cancer

A

T4 N0
T4 N1
T4 N2

47
Q

Give the TNM stages for stage 3c breast cancer

A

Any T

N3

48
Q

Give the TNM stages for stage 4 breast cancer

A

M1

MBChB Surgery (38 decks)

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