Breast Cancer Flashcards
Outline the normal anatomy of the breast.
- Breast is a sebaceous gland.
- Made of glandular and fatty tissue.
- 4 quadrants:
Upper outer quadrant (greatest bulk of mammary tissue). Benign and malignant tumours most common here. - Upper border is in 2nd IC space just below the clavicle.
- Lower border is at 6th IC space but clearly breast tissue can lie below this posterior attachment.
- Medial: inner sternum.
- Outer: anterior axillary line.
- Axillary tail (include in breast examination)
- Breast tissue changes in month due to menstruation and with pregnancy.
Epidemiology: 1 in how many women are diagnosed with breast cancer?
1 in 9
1,000 new diagnoses a year in NI
Discuss the risk factors for developing breast cancer.
- Increasing age
- Environmental factors > genetic
- Early first menarche (prolongs oestrogen exposure)
- Late menopause (prolongs oestrogen exposure)
- Age at first pregnancy (prolongs oestrogen exposure)
- Obesity (aromatase in adipocytes –> increases oestrogen exposure)
- Alcohol
- Diet
- Previous breast disease - CIS, atypical hyperplasia
- Exogenous oestrogen: HRT, oral contraceptives
- Genetics (BRCA-1, BRCA-2)
How does breast cancer normally present?
Typically: painless breast lump found on asymptomatic screening.
- Lump (most often)
- Through screening (mammography every 3 years 50-70 years)
Less often:
- Nipple discharge
- Nipple retraction
- Skin changes - rash, scaling, puckering
- RARELY, pain
- Family history - genetic component
Outline breast clinic assessment.
Triple assessment (examination/imaging/biopsy):
+ History
- Examination
- Mammography/USS
- MRI (if required)
- FNA/core biopsy
Which tumour marker may be used to monitor response of breast cancer to treatment or to surveil for recurrence?
- CA 15-3.
What are the classical characteristics of a palpable breast lump (cancer)?
- Single lesion
- Hard
- Immobile
- Irregular border
- Skin dimpling
- Skin > 2cm
Outline important characteristics of familial breast cancer (genetic).
- 5% of total
- Younger age of onset
- Often bilateral
- Autosomal dominant (maternal or paternal)
- BRCA-1/BRCA-2 (tumour suppressor gene) - risk of ovarian cancer as well
Outline NICE’s Suspected Cancer Referrals Pathway for breast cancer.
- Refer via the “Suspected Cancer Pathway”
– age >30 + unexplained breast lump +/- pain
– age >50 + unilateral nipple symptom - Consider referring via the “Suspected Cancer Pathway”
– skin changes that suggest breast cancer
– age >30 + axilla lump - Consider a routine surgery referral
– age <30 + unexplained lump +/- pain
List the differential diagnoses of a breast lump.
Most commonly:
- Fibroadenoma
- Fibrocystic change
- Intraductal papilloma
- Fat necrosis
- Breast abscess
- Invasive breast cancer
- Ductal carcinoma in-situ (DCIS)
Describe how the diagnosis of breast cancer is made (briefly).
- Clinical assessment (history + examination of both breasts)
- Imaging assessment (mammogram +/- USS)
- Tissue acquisition (FNA vs. core biopsy –> ductal vs. lobular)
Recall the TNM staging of breast cancer (give overview)
TNM covers pattern of spread T = local spread Size of largest (if multiple) Local extension (skin or chest wall) N = lymphatic spread Number of positive axillary nodes M = haematogenous spread Bone, lung, liver, brain
Recall the TNM staging of breast cancer (give specifics)
pT Stage T1 < 2cm T2 2-5 cm T3 ≥ 5 cm T4a chest wall T4b skin T4c both T4d inflammatory
pN Stage NX not assessable N0 no nodes N1 1–3 nodes N2 4–9 nodes N3 ≥10 nodes
M Stage
M0 no metastases
M1 metastases
Discuss tumour-related prognostic biomarkers.
• De novo metastatic disease • Nodal status • Primary tumour size & grade • T4 disease • Lymphovascular invasion • Receptor status: – ER & PR: positive is good – HER2: positive is poor
What is the surgical aim in the primary management of breast cancer?
Surgical Aim:
– Remove tumour: local control & possible cure
– obtain prognostic information (staging/node assessment)
- Restore anatomy
Outline the types of surgical intervention.
Types of Surgery
a. wide local excision
b. mastectomy +/- reconstruction
Outline axillary surgery in breast cancer management.
Axillary surgery:
Sentinel Node Biopsy (SNB)
– radioactive colloid & blue dye to peri-areolar area
– sentinel node located (Geiger counter & visualisation)
– ANC avoided if ≤1 node involved
• Axillary Clearance (ANC) – >1 node positive on SNB – N1–3 on examination/imaging – most patients have shoulder pain/stiffness – 15% get lymphoedema
Discuss the rational selection of adjuvant radiotherapy approaches.
- Whole breast radiotherapy = post-WLE. Reduces local relapse.
- Additional dose ‘boost’ to tumour bed = reserved for age <50, grade III, close margins, or “triple negative”
- Chest-wall radiotherapy = post-mastectomy for ≥T3 or ≥N2
- Ipsilateral supraclavicular fossa radiotherapy = ≥N2 disease
What is the rationale behind adjuvant systemic chemotherapy?
- Surgery often not ‘curative’
- Cancer may have spread prior to this intervention
- Micro-metastases a source of future relapse
- If these are eliminated, the patient has the potential for a cure
Discuss adjuvant hormonal therapy in breast cancer.
• 2/3 breast cancers are ER or PR positive
• Cells from these tumours are usually oestrogen–dependent
• Tamoxifen blocks the oestrogen receptors
• Aromatase inhibitors block oestrogen production in fat
– oestrogens arise from peripheral tissues due to the aromatase enzyme
– ovarian pathway available for oestrogen production pre-menopause
– hence AIs are effective in post-menopausal women only
What hormonal therapy regime is preferred in pre-menopausal women?
Tamoxifen 20 mg daily for 5-10 years
What hormonal therapy regime is preferred in post-menopausal women?
Tamoxifen 20 mg daily for 2 years then switch to aromatase inhibitors for 3-8 years OR aromatase inhibitors for 5-10 years (anastrozole/letrozole)
Outline some adverse effects of tamoxifen treatment.
- Menopausal symptoms
- VTE
- Low-grade uterine cancers
Outline some adverse effects of aromatase inhibitor treatment.
- Menopausal symptoms
- Osteoporosis (MCQs often have a stem where a post-menopausal woman falls and fractures her femur post-cancer treatment)
- Arthralgia
