Breast cancer Flashcards
What is the incidence of breast cancer?
8-10%
What is the peak age of breast cancer?
63yo
Name risk factors for breast cancer
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
How does family history affect breast cancer risk?
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
What is the BRCA gene risk for breast cancer?
80%
Why is imaging done before biopsy?
Tumour size assessment is important and biopsy causes bleeding that distorts the actual size
When can FNA be done for biopsy?
Clinical impression and imaging suggest that the lump is benign
What information should be provided by pathology?
Benign vs malignant In situ vs invasive Ductal vs lobular Characteristics (mucinous, scirrhous) Elston Nottingham classification Receptors
What is the Elston Nottingham classification?
It grades breast carcinomas by adding up scores for
- tubule formation
- nuclear pleomorphism
- mitotic count
How is the Elston Nottingham classification graded?
3-5 = well differentiated 6-7 = moderately differentiated 8-9 = poorly differentiated
How is tubule formation scored using the Elston Nottingham classification?
75% of tumour shows tubules (1)
10-75% of tumour shows tubules (2)
<10% of tumour shows tubules (3)
How is nuclear size scored using the Elston Nottingham classification?
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)
How is mitotic count scored using the Elston Nottingham classification?
0-7 mitoses/10HPF (1)
8-14 mitoses/10HPF (2)
>15 mitoses/10HPF (3)
Which score looks at the oestrogen and progesterone receptors?
Allred Quick Score
What is a positive predictor of effective anti-oestrogen treatment?
Progesterone receptor >30%
What is HER2?
Human epidermal growth factor receptor 2 - indicates high recurrence rates
What is Ki-67?
A nuclear protein that gives exact assessment of proliferation
Indicates % of cells in mitotic process
Name the sites of breast cancer metastases
Lung Liver Pelvis Ovaries Bone
How is metastatic staging done in breast cancer?
Clinically
Radiologically
Blood tests
How do we look clinically for breast cancer metastases?
Pleural effusion Enlarged nodular liver Pouch of Douglas nodules Bone pain Fractures
Which imaging do we routinely do for TNM staging?
CXR
Abdominal U/S
Pelvic U/S
When do we do CT/PET CT in TNM staging?
If there is doubt about findings
Which blood tests should be done for TNM staging?
FBC
LFT
Calcium
Tumour markers (for baseline and treatment response)
If you find an elevated calcium with no other signs of bone metastases, how do you proceed?
Rule out hyperparathyroidism before doing expensive bone scintigram
- Repeat the calcium
- Do a PTH assessment
When should surgery of the primary breast tumour not be undertaken?
Tumour cannot be removed with clear surgical margins
Wound cannot be closed primarily
How do we make the primary lesion operable?
Neo-adjuvant systemic therapy
- chemotherapy
- hormonal therapy
What are the two surgical options?
Mastectomy
Breast conservation
What must breast conservation therapy always be followed by and why?
Radiotherapy due to high local recurrence rate
What is the only indication for breast conservation surgery?
Cosmesis
How is the axilla managed in breast cancer?
Not involved - sentinel node biopsy
Involved - dissection of at least 1 level
When is radiotherapy indicated after mastectomy?
> 4 involved nodes after axillary dissection
When do we use radiotherapy for metastatic disease?
- Spinal cord compromise
- symptoms of spinal cord compression need urgent MRI and radiotherapy to prevent paralysis - Brain metastases
- BBB prevents chemotherapeutic treatment
- RT to stop increase in pressure
When do we start systemic adjuvant treatment of breast cancer?
Within 3-4 weeks after surgery
>12w no benefit shown
What is herceptin?
Monoclonal antibody
Which chemotherapy agents are usually used for breast cancer?
- 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
What should you monitor if you give a patient adriamycin?
Cardiac function for cardiotoxicity
Poor function = methotrexate instead
Which hormonal therapy do we use in premenopausal women?
SERMs (tamoxifen)
Which hormonal therapy do we use in postmenopausal women?
Aromatase-inhibitors (anastrasole, letrosole)
Discuss staging of the primary tumour (T)
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
Discuss staging of the regional lymph nodes (N)
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
Give the TNM stages for stage 0 breast cancer
Tis
N0
M0
Give the TNM stages for stage 1a breast cancer
T1 N0
Give the TNM stages for stage IB breast cancer
T0 N1
T1 N1
T2 N0
Give the TNM stages for stage 2b breast cancer
T2 N1
T3 N0
Give the TNM stages for stage 3a breast cancer
T0 N2 T1 N2 T2 N2 T3 N1 T3 N2
Give the TNM stages for stage 3b breast cancer
T4 N0
T4 N1
T4 N2
Give the TNM stages for stage 3c breast cancer
Any T
N3
Give the TNM stages for stage 4 breast cancer
M1