- screen high risk women e.g. strong FHx - assess size and features of tumour

Breast cancer Flashcards by Kristin L Bryce

What is the second most common cause of death from cancer in the UK?

Breast cancer

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Risk factors for breast cancer

(1) Female - 99%
(2) Increased oestrogen exposure
- -> early period, late menopause
- -> COCP, HRT (combined)
- -> nuliparity or late 1st pregnancy
(3) Family history (1st degree)
(4) Obesity
(5) Smoking + alcohol
(6) Caucasian

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1) What chromosome is BRCA1 gene found on?
2) What % will develop breast cancer by 80 years?
3) What % will develop ovarian cancer?

1) chromosome 17
2) 70%
3) 50%

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What other cancers are associated with faulty BRCA1 gene?

bowel & prostate

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Is the risk of breast cancer and ovarian cancer higher or lower with a faulty BRCA2 gene in comparison to a faulty BRCA1 gene?

Lower

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Most common form of breast tumour?

Ductal carcinoma –> if basement membrane isn’t breached = ductal carcinoma in situ (DCIS)

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What aged women are offered breast screening?

50-70

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What does breast screening involve?

Mammogram (X-ray) every 3 years

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Potential downsides of screening?

exposure to radiation
missed (false negatives) leading to false reassurance
false positives leading to emotional distress and unnecessary tests

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Benefits of breast screening?

early detection of cancer
20% reduction in relative risk of death from breast cancer
peace-of-mind

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Which patients should be referred along the URGENT cancer referral pathway (2 week wait) for breast cancer?

1) unexplained breast lump in 30+ year old

2) unilateral nipple changes in 50+ (discharge, retraction etc)

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Which patients should be considered for referral along the URGENT cancer referral pathway (2 week wait) for breast cancer?

1) unexplained axilla lump in 30+ year old

2) Skin changes suggestive of cancer

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Who would you consider non-urgent referral for?

unexplained breast lump in <30 year old

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What’s the triple assessment?

1) clinical (history/exam)
2) imaging (US or mammography)
3) biopsy (fine needle aspiration OR core biopsy)

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What imaging is used for patients under 30? why?

US - good at distinguishing solid from cystic lumps

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What imaging is used for patients older women? why?

Mammogram - can pick up calcifications

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When would you MRI?

screen high risk women e.g. strong FHx

- assess size and features of tumour

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What other scans would you perform after diagnosing breast cancer?

US axilla + US-guided biopsy

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What imaging may be used during breast surgery to detect abnormal lymph nodes?

Sentinel Lymph node biopsy –> contrast and dye travels to the sentinal lymph node (1st lymph node)

Clinical features suggesting breast cancer?

(1) Lumps are hard, irregular, painless or fixed in place
(2) Lumps are tethered to skin or chest wall
(3) Nipple retraction
(4) Peau d’orange - skin dimpling or oedema
(5) Assoc. lymphadenopathy (axilla)

Main types of breast tumours?

Ductal carcinoma (in-situ or invasive) 75% of invasive
Lobular carcinoma (in-situ or invasive) 10% of invasive
Inflammatory breast cancer
Paget’s disease of the Nipple

Rare types of breast cancer?

Medullary breast cancer (common w/ BRCA1)
Phyllodes Tumour
Mucinous breast cancer
Tubular breast cancer

If strong family history patients are referred for genetic tests, what to do prior to this?

genetic counselling

- pre-test counselling

What is offered to women with increased risk?

(1) Annual mammogram
(2) Chemoprevetion
- -> Tamoxifen if premenopausal
- -> Anastrozole if postmenopausal
(3) Risk-reducing surgery
- -> bilateral mastectomy
- -> bilateral oophorectomy

When is anastrozole contraindicated?

Severe osteoporosis

3 types of receptors?

(1) Oestrogen receptors (ER) (2) Progesterone receptors (PR) (3) Human epidermal growth factor (HER2)

What is triple negative breast cancer

breast cancer cells don't express any of the 3 receptors and carries worse prognosis.

Who does NICE recommend receives gene expression profiling?

Early breast cancer that are: ER +ve but HER2 and lymph node -ve

Where can breast cancer mets?

Anywhere but commonly: (1) Lungs (2) Liver (3) Bones (4) Brain

How would you stage breast cancer?

TNM System: - Tumour size --> assess with imaging + histology biopsy - Node spread --> exam, sentinal lymph node biopsy - Mets --> US liver, CT thorax, abdo and pelvis, isotope scan for bony mets

Surgical options for tumour removal?

(1) Breast-conserving surgery = e.g. wide local excision, coupled with RT (2) Mastectomy = removal of whole breast tissue, coupled with reconstruction

Risk of lymph node removal?

Chronic lymphoedema

Why would you avoid cannulating arm w/ previous breast cancer/lymph node removal?

Higher risk of infection due to impaired lymphatic drainage

Conservative management of lymphoedema?

- massage techniques (manual lymphatic drainage) - compression bandage - weight loss if overweight - specific exercises

Common radiotherapy side effects?

- fatigue - skin changes --> irritation, colour change (darkens) - tissue changes - fibrosis, shrinking, swelling

3 options for chemotherapy?

(1) Neoadjuvant - shrinks tumour BEFORE surgery (2) Adjuvant - given after surgery to reduce recurrence (3) Treatment - if metastatic OR recurrent

Which hormone receptor would indicate chemotherapy?

HER2 over-expression

Who is offered biological therapy? Name?

Trastuzumab (Herceptin) offered to HER2 positive

What monitoring is required for Herceptin?

Monitor heart function (inital and during) due to side-effects: - cardiac dysfunction (HF) - teratogenecity

Hormonal treatment options for ER receptor positive breast cancer?

(1) Anastrazole (aromatase inhibitor) if post-menopausal | (2) Tamoxifen (SERM) if pre-menopausal

Mechanism of action of tamoxifen?

- A selective oestrogen receptor modulator (SERM) - Blocks in breast tissue - Stimulates in uterus (increased risk endometrial cancer) - Stimulates in bones (reduced risk osteoporosis)

How long are ER patients given tamoxifen or anastrazole?

5-10 years

Reconstruction options following breast-conserving surgery?

(1) Partial reconstruction (fat/flap tissue replaces gap) | (2) Reduction + reshaping

Reconstruction options following mastectomy?

(1) Breast implants | (2) Flap reconstruction

Benefits of implants? Disadvantages?

``` Minimal scarring & acceptable appearance Feels unnatural (cold, less mobile) & long-term problems (hardening, leakage, shape change) ```

What flaps are available for flap reconstruction?

(1) Latissimus dorsi --> pedicled OR free flap (2) Transverse rectus abdominus (TRAM) --> pedicled OR free, hernia risk (3) Deep inferior epigastric perforator (DIEP) --> free flap.

What vessels are involved with a DIEP flap reconstruction?

Deep inferior epigastric artery in transplanted into breast. attached to the internal mammary artery and vein.