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Breast Surgery > Breast Cancer > Flashcards

Breast Cancer Flashcards

1
Q

Breast cancer is the … common malignancy affecting women in the UK.

A

Breast cancer is the most common malignancy affecting women in the UK.

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2
Q

Breast cancer is the most common malignancy in women - around 1 in … will develop it in their lifetime

A

Breast cancer is the most common malignancy in women - around 1 in 8 will develop it in their lifetime

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3
Q

A number of risk factors are associated with an increased risk of breast cancer.

A 
Female gender
Age
Family history
Personal history of breast cancer
Genetic predispositions (e.g. BRCA 1, BRCA 2)
Early menarche and late menopause
Nulliparity
Increased age of first pregnancy
Multiparity (risk increased in period after birth, then protective later in life)
Combined oral contraceptive (still debated, effect likely minimal if present)
Hormone replacement therapy
White ethnicity
Exposure to radiation
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4
Q

There are a number of hereditary syndromes that may predispose to breast cancer

A

BRCA 1: Caused by a mutation on chromosome 17 that predisposes patients to breast cancer amongst other malignancies. The lifetime risk of breast cancer is approximately 65-80% (compared to a baseline of around 12%) whilst the risk of ovarian cancer is 40-45% (compared to a baseline of around 1.3%).
BRCA 2: Caused by a mutation on chromosome 13 that predisposes patients to breast cancer amongst other malignancies. The lifetime risk of breast cancer is approximately 45-70% whilst the risk of ovarian cancer is 11-25%.

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5
Q

BRCA …: Caused by a mutation on chromosome 17 that predisposes patients to breast cancer amongst other malignancies. The lifetime risk of breast cancer is approximately 65-80% (compared to a baseline of around 12%) whilst the risk of ovarian cancer is 40-45% (compared to a baseline of around 1.3%).

A

BRCA 1: Caused by a mutation on chromosome 17 that predisposes patients to breast cancer amongst other malignancies. The lifetime risk of breast cancer is approximately 65-80% (compared to a baseline of around 12%) whilst the risk of ovarian cancer is 40-45% (compared to a baseline of around 1.3%).

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6
Q

BRCA …: Caused by a mutation on chromosome 13 that predisposes patients to breast cancer amongst other malignancies. The lifetime risk of breast cancer is approximately 45-70% whilst the risk of ovarian cancer is 11-25%.

A

BRCA 2: Caused by a mutation on chromosome 13 that predisposes patients to breast cancer amongst other malignancies. The lifetime risk of breast cancer is approximately 45-70% whilst the risk of ovarian cancer is 11-25%.

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7
Q

BRCA mutations also increase the risk of breast cancer in men. BRCA … appears to be more of a risk factor with approximately 8% of men affected developing breast cancer, compared to 1% with BRCA … (baseline - 0.1%).

A

BRCA mutations also increase the risk of breast cancer in men. BRCA 2 appears to be more of a risk factor with approximately 8% of men affected developing breast cancer, compared to 1% with BRCA 1 (baseline - 0.1%).

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8
Q

These mutations (primarily BRCA …) are also known to increase the risk of a number of other malignancies. This includes peritoneal, endometrial, fallopian, pancreatic and prostate cancer.

A

These mutations (primarily BRCA 2) are also known to increase the risk of a number of other malignancies. This includes peritoneal, endometrial, fallopian, pancreatic and prostate cancer.

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9
Q

The majority of breast malignancies are carcinomas, these are divided into either … or …

A

The majority of breast malignancies are carcinomas, these are divided into either ductal or lobular.

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10
Q

Ductal carcinoma in situ (DCIS)

A

DCIS refers to a heterogeneous group of non-invasive lesions. They may progress to invasive malignancy.

DCIS lesions may be categorised as high, intermediate and low grade. Comedo DCIS is a high-grade type that has an increased risk of invasion.

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11
Q

Invasive ductal carcinoma (IDC)

A

IDC composes around 70-80% of invasive breast cancer - it is the most common invasive breast cancer. It may be graded based upon how well or poorly differentiated the cells are. Grade 1 refers to well, grade 2 - moderately and grade 3 - poorly differentiated tumours.

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12
Q

Lobular carcinoma in situ (LCIS)

A

LCIS is a relatively uncommon finding that may be referred to as lobular neoplasia. It tends to be found incidentally on biopsy. Though its presence is indicative that a woman is at greater risk of invasive breast cancer, the direct relationship is unclear.

NB - The remainder of the management in this note will refer to invasive cancer, DCIS or both. Management of LCIS is not covered.

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13
Q

Invasive lobular carcinoma (ILC)

A

ILC is the second most common invasive breast cancer composing 5-10% of cases. There is growing evidence of a relationship with post-menopausal hormone therapy. The vast majority are oestrogen receptor-positive.

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14
Q

Invasive breast cancer can be categorised into one of four molecular subtypes based upon gene expression (receptor status of oestrogen receptors and progesterone receptors, HER2 and Ki-67).

A

Invasive breast cancer can be categorised into one of four molecular subtypes based upon gene expression (receptor status of oestrogen receptors and progesterone receptors, HER2 and Ki-67).

Luminal A
Luminal B
Basal
HER2

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15
Q

In England, breast cancer screening runs from the ages of … to ….

A

In England, breast cancer screening runs from the ages of 50 to 71. In some areas, an increased age range of 47 to 73 is being trialled.

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16
Q

Screening involves a mammogram conducted by a female mammographer. The images are then reviewed by a consultant radiologist with several possible results:

A

Satisfactory: no radiological evidence of breast cancer, approximately 96% will have a normal result
Abnormal: abnormality detected, further investigations needed. Around a quarter with an abnormal result will subsequently be found to have breast cancer.
Unclear: results or imaging unclear or inadequate. Further investigations required.

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17
Q

Breast cancer often presents with a … or … lump.

A

Breast cancer often presents with a breast or axillary lump.

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18
Q

Clinical features of breast cancer

A 
Breast and/or axillary lump:
Often irregular
Typically hard/firm
May be fixed to skin or muscle
Breast pain
Breast skin:
Change to normal appearance
Skin tethering
Oedema
Peau d’orange

Nipples:
Inversion
Discharge, especially if bloody
Dilated veins

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19
Q

Breast cancer - Features may also reflect metastatic spread. The bone (bone pain), liver (malaise, jaundice), lungs (shortness of breath, cough) and brain (confusion, seizures) are most commonly affected.

A

Breast cancer - Features may also reflect metastatic spread. The bone (bone pain), liver (malaise, jaundice), lungs (shortness of breath, cough) and brain (confusion, seizures) are most commonly affected.

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20
Q

Patients should be referred on a two-week wait suspected cancer pathway if:

… and over with an unexplained breast lump with or without pain or
… and over with any of the following symptoms in one nipple only:
Discharge
Retraction
Other changes of concern

A

30 and over with an unexplained breast lump with or without pain or
50 and over with any of the following symptoms in one nipple only:
Discharge
Retraction
Other changes of concern

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21
Q

NICE also recommend clinicians consider a two-week wait suspected cancer pathway for people:

With … changes that suggest breast cancer or
Aged 30 and over with an unexplained lump in the …

A

With skin changes that suggest breast cancer or

Aged 30 and over with an unexplained lump in the axilla

22
Q

Following referral for suspected breast cancer, patients will be reviewed in the …

A

Following referral for suspected breast cancer, patients will be reviewed in the ‘one-stop breast clinic’

23
Q

Imaging options for investigating potential breast cancer (2)

A

Mammogram: A mammogram utilises x-rays to image breast tissue. Findings suggestive of cancer include soft tissue masses and microcalcifications.

USS: Breast USS is the modality of choice in women under the age of 40. It is also used in older women, particularly when mammography and clinical findings do not align. High-resolution scanners meeting NHSBSP standards are used.

24
Q

When is USS used instead of mammogram for investigating potential breast cancer?

A

Breast USS is the modality of choice in women under the age of 40. It is also used in older women, particularly when mammography and clinical findings do not align. High-resolution scanners meeting NHSBSP standards are used.

25
Q

How is a tissue/cellular sample taken in breast cancer investigations?

A

This is usually in the form of a fine-needle aspiration (FNA), in which provisional results may be obtained the same-day or core biopsy, which often also provides provisional same-day results, but may have to wait up to a few days.

26
Q

Bloods for investigating potential breast cancer

A

FBC
Renal function
LFT
Bone profile

27
Q

Breast …: An additional investigation used infrequently utilising mammography to produce a 3-D representation of the breast.

A

Breast tomosynthesis: An additional investigation used infrequently utilising mammography to produce a 3-D representation of the breast.

28
Q

What other imaging may be used for investigating breast cancer further? (Exc USS/mammogram)

A

CXR
Breast tomosynthesis: An additional investigation used infrequently utilising mammography to produce a 3-D representation of the breast.
MRI breast: May be used as an adjunct, normally under the guidance of the Breast MDT. It is useful in certain settings, such as patients with high risk family history/genetics and those with occult primary tumours. NICE also recommends that it may be used in invasive cancer to guide treatment, assess tumour size if breast-conserving surgery is planned in patients with invasive lobular cancer, or if breast density prevents accurate assessment via other modalities.
CT chest, abdomen and pelvis: In patients with suspected advanced disease can be used to identify visceral metastasis.
CT brain: In symptomatic patients with suspected neurological spread.
Contrast-enhanced liver USS: May be used in those with suspected liver metastasis.
Bone scan: May be used to identify spread to bones.
PET/CT: Not routine, use guided by the Breast MDT. There are a number of complex indications, but in general, it is used in advanced disseminated disease to guide management or where the results of other imaging modalities are not clear.

29
Q

What two receptor status’ should be measured in breast cancer presentations?

A

Oestrogen receptor (ER) and progesterone receptor (PR) status should be measured. The hormones oestrogen and progesterone are known to impact the growth of breast cancers and the receptor status helps to identify patients who may benefit from endocrine therapy.

30
Q

… receptor status is also routinely measured in breast cancer patients, overexpression is seen in around 20% of patients. It indicates which patients will benefit from Herceptin (trastuzumab), a monoclonal antibody that blocks the … pathway.

A

Human epidermal growth receptor 2 (HER2) status is also routinely measured, overexpression is seen in around 20% of patients. It indicates which patients will benefit from Herceptin (trastuzumab), a monoclonal antibody that blocks the HER2 pathway.

31
Q

Triple-positive breast cancers refer to those that are positive for …, PR and …. At the other end of the spectrum are triple-negative tumours.

A

Triple-positive breast cancers refer to those that are positive for ER, PR and HER2. At the other end of the spectrum are triple-negative tumours.

32
Q

In patients with early invasive breast cancer, USS may be used to assess axillary lymph nodes. When abnormal lymph nodes are found, they may be sampled with ultrasound-guided needle sampling (FNA).

A

In patients with early invasive breast cancer, USS may be used to assess axillary lymph nodes. When abnormal lymph nodes are found, they may be sampled with ultrasound-guided needle sampling (FNA).

33
Q

Complications of breast surgery: (Anaesthetic)

A

Stroke
MI
Aspiration
Venothromboembolism

34
Q

Complications of breast surgery: (Surgical)

A 
Pain
Bleeding
Infection
Seroma
Displeasure with cosmetic outcome
35
Q

Complications of breast surgery: (axillary node clearance injury)

A

Lymphoedema
Damage to brachial plexus cords or nerves
Axillary artery/vein injury

36
Q

Consider offering …to patients newly diagnosed with bone metastases to prevent skeletal-related events and reduce pain

A

Consider offering bisphosphonates to patients newly diagnosed with bone metastases to prevent skeletal-related events and reduce p

37
Q

Offer … therapy as first-line treatment for the majority of patients with ER-positive advanced breast cancer.

A

Offer endocrine therapy as first-line treatment for the majority of patients with ER-positive advanced breast cancer.

38
Q

Offer … as first-line treatment for patients with ER positive advanced breast cancer whose disease is imminently life-threatening or requires early relief of symptoms because of significant visceral organ involvement, providing they understand and are prepared to accept the toxicity.

A

Offer chemotherapy as first-line treatment for patients with ER positive advanced breast cancer whose disease is imminently life-threatening or requires early relief of symptoms because of significant visceral organ involvement, providing they understand and are prepared to accept the toxicity.

39
Q

For patients with ER-positive advanced breast cancer who have been treated with chemotherapy as their first-line treatment, offer … therapy following the completion of chemotherapy

A

For patients with ER-positive advanced breast cancer who have been treated with chemotherapy as their first-line treatment, offer endocrine therapy following the completion of chemotherap

40
Q

Offer … as first-line treatment to men with ER-positive advanced breast cancer

A

Offer tamoxifen as first-line treatment to men with ER-positive advanced breast cancer

41
Q

Offer … and … suppression as first-line treatment to premenopausal and perimenopausal women with ER-positive advanced breast cancer not previously treated with ..

A

Offer tamoxifen and ovarian suppression as first-line treatment to premenopausal and perimenopausal women with ER-positive advanced breast cancer not previously treated with tamoxifen

42
Q

Offer … … to premenopausal and perimenopausal women who have previously been treated with tamoxifen and then experience disease progression.

A

Offer ovarian suppression to premenopausal and perimenopausal women who have previously been treated with tamoxifen and then experience disease progression.

43
Q

Neoadjuvant chemo for breast cancer

A

Given prior to surgery for those with large/advanced tumours - reduces recurrence and allows a smaller op (breast conservation instead of mastectomy)

44
Q

Adjuvant chemo for breast cancer

A

Given to those with nodes, high grade tumour or hormone negative

45
Q

Hormonal treatment for oestrogen +

A

Tamoxifen - oestrogen antagonist (usually 5 years)

46
Q

For post menopausal women with oestrogen + cancer, what hormonal treatment?

A

Aromatase inhibitors (letrozole, anastrozole) reduces peripheral conversion of androgens to oestrogens

47
Q

Herceptin in is used for..

A

HER2 receptor + breast cancer

48
Q

Radiotherapy - breast cancer

A

Offered to all with breast-conserving surgery and those with large, high-grade node positive tumours who have had a mastectomy

49
Q

Axillary surgery for breast cancer

A

Axillary node clearance - removes all nodes in levels 1-3% axilla. Extensive surgery, complications (paraesthesia, lymphoedema) axillary node 4 sampling
Sentinel node biopsy - less invasive - aims to identify the 1st nodes the tumour drains into through injecting dye and mapping the axilla

50
Q

Bloody nipple discharge =

A

Breast papilloma

51
Q

Phyllodes tumour?

A

Rare tumour of the connective tissue - large and fast growing
25% malignant

Breast Surgery (6 decks)

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