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breast surgery > Breast cancer > Flashcards

Breast cancer Flashcards

1
Q

What is the most common cancer in women?

A

Breast cancer

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2
Q

What is the 2nd most common cancer worldwide?

A

Breast cancer

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3
Q

How many new cases of breast cancer are diagnosed every year in the UK?

A

~ 50,000

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4
Q

What is the aetiology of breast cancers?

A

Multifactorial

Damaged DNA

AND

Genetic mutations
- BRCA1 and 2 (which code for tumour suppressor proteins when functioning normally i.e., anti-oncogenes)

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5
Q

What is the HER2 receptor?

A

Human epidermal growth factor receptor 2

Transmembrane glycoprotein

Plays a key role in cell survival, proliferation and differentiation

Important oncogene in breast cancer when overexpressed

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6
Q

Fill in the structures on this diagram

A
  1. Chest wall
  2. Pectoralis major
  3. Lobules - secretory units made up of many epithelial cells
  4. Nipple
  5. Areola
  6. Ducts
  7. Fat tissue
  8. Skin

https://en.wikipedia.org/wiki/Mammary_gland

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7
Q

What is the classification of breast cancer?

A

Non-invasive

Invasive

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8
Q

What are the two types of non-invasive breast cancer?

A

Ductal carcinoma in situ (DCIS) - from the epithelial cells lining the ducts. Usually unilateral

Lobular carcinoma in-situ (LCIS) - confined to the acini cells. Mainly occurs in pre-menopausal women and more often found in both breasts

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9
Q

What are the 4 subtypes of DCIS?

A

Papilary

Cribriform

Solid

Comedo

N.B. Knowing the subtype can help predict the rate of transformation to invasive cancer

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10
Q

What are the two types of invasive breast cancer?

A

Invasive ductal carcinoma - most common type of breast cancer

Invasive lobular carcinoma

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11
Q

Name the rare types of breast cancers

A

2 that is important for you to know are:
1. Inflammatory breast cancer

  1. Paget’s disease of the nipple

Others are:
- mucinous
- medullary
- papillary
- tubular
- phyllodes
- metaplastic
- basal-like
- primary breast lymphoma

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12
Q

What are the characteristics of inflammatory breast cancer?

A

Erythematous and oedematous breast

Often mistaken for an infection (i.e., mastitis) or breast abscess

Patients will NOT have fever, chills or elevated WCC

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13
Q

What are the characteristics of Paget’s disease of the nipple?

A

Rough, dry, erythematous and ulcerated skin around the nipple

Looks similar to eczema

Often associated with an underlying in-situ or invasive cancer

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14
Q

What is the difference between Paget’s disease of the breast and eczema of the breast?

A

Eczema tends to affect the areola more

https://www.researchgate.net/figure/Difference-between-Pagets-Disease-and-Eczema_tbl1_342077683

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15
Q

What is the more important and specific risk factors of breast cancer?

A

Increased exposure to oestrogen

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16
Q

Name factors that can increase exposure to oestrogen

A

Nulliparity and increasing age of 1st childbirth

Early menarche (i.e., < 12 years) - early exposure to oestrogen

Late menopause (> 55 years) - increases exposure length to oestrogen

HRT with oestrogen and progesterone

Obesity - more adipose tissues = increase aromatase expression and hence synthesis of oestrogen

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17
Q

Name other risk factors for breast cancer

A

Increasing age

Female

FHx - 1st degree relative

Previous breast cancer

Genetics - BRCA1 &2

Radiation to chest

Not breastfeeding

Lifestyle - excessive alcohol + fat intake

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18
Q

Name a protective factor against breast cancer

A

Breastfeeding

19
Q

What are the clinical features of breast cancer that can be deduced from the history?

A

Painless lump (breast or axilla)

Nipple discharge

Systemic symptoms (if patient presents late and metastasis has occurred) - e.g., weight loss, anorexia, bone pain, jaundice, fatigue and breathlessness

Breast pain (very rarely a symptom of breast cancer)

20
Q

Which type of nipple discharge is often benign and not associated with breast cancer?

A

Bilateral

Clear or milky

21
Q

Which type of nipple discharge is often abnormal and needs investigation for breast cancer?

A

Unilateral or bloody

22
Q

What are the clinical features of breast cancer that can be deduced on clinical examination?

A

Breast lumps - shape, size, consistency, tethering

Nipple changes

Skin changes

23
Q

Which breast lumps are usually associated with breast cancer?

A

Hard with a gritty texture

Ill-defined, irregular margins

Tethered (attached to surrounding breast tissue or skin) or fixed (attached to chest wall)

Usually in the upper outer quadrant of the breast

Lump in axilla = metastasis to lymph nodes

24
Q

Which nipple changes are usually associated with breast cancer?

A

Bleeding

Discharge

Inversion

Deviation

N.B. Paget’s disease can be misleading and often mistaken for cancer

25
Q

Which skin changes are usually associated with breast cancer?

A

Rough, dry, and ulcerated skin around the nipple - Paget’s disease

Dimpling or puckering of the skin

Peau d’orange - occurs when the lymphatic system that drains the breast is blocked by cancer cell; skin becomes oedematous. Can be easily misdiagnosed as an infection

26
Q

List the DDx for a breast lump?

A

Fibroadenoma

Cyst

Abscess

Fat necrosis

Intraductal papilloma

27
Q

Which investigation should be done for a suspected breast cancer?

A

TRIPLE ASSESSMENT
1. Clinical assessment (i.e., Hx + examination)

  1. Radiological imaging
  2. Core biopsy or fine needle aspiration
28
Q

Which type of imaging is used in women < 40? Why?

A

USS

Breast tissue is denser i.e., not undergone involution

Makes mammography less sensitive for breast cancer detection

29
Q

How many views are used in mammography? Why?

A

Mediolateral oblique

Craniocaudal

To see as much of the breast tissue as possible

Radiologist can see structures that would be superimposed in one view from another angle - less likely to miss smaller sinister masses

30
Q

How does denser tissue appear on mammography?

A

Whiter

Attenuate more X-rays compared to fat which appears grey

31
Q

What is FNA? When is it used?

A

Single fine needle - collects cells for cytology

For smaller more cystic lumps

Usually done under USS guidance

32
Q

How is core biopsy done?

A

Wider needle than FNA

Also under USS guidance

Takes core of tissue - provides more information about the cancer + its involvement with surrounding tissues

33
Q

Which is more diagnostic: FNA or core biopsy?

A

Core biopsy

34
Q

When does the breast cancer screening programme happen in the UK?

A

Women aged 50 - 70 years

Two-view mammography every 3 years

35
Q

Which two factors are used in diagnosis of breast cancer?

A

TNM

Receptor status

36
Q

What are the various receptors that breast cancer can be positive for?

A

ER

Progesterone

HER2

37
Q

What is triple negative breast cancer?

A

Negative for ER, progesterone and HER2

Limits treatment and has poor prognosis

38
Q

What is the medical Mx of breast cancer?

A

Endocrine - tamoxifen (in pre-menopausal), aromatase inhibitors (in post menopausal)

Biologics (for HER2) - e.g. trastuzumab

Chemotherapy - adjuvant, neoadjuvant

Radiotherapy - invasive cancer after wide local excision + bone mets

39
Q

Which score is used to determine whether adjuvant therapy is warranted?

A

Oncotype DX breast recurrence score assay

21 gene panel is used to analyse the cells and produces a score between 0 and 100

Higher score = higher chance of cancer recurring

Helps to avoid patients having chemotherapy that they may not benefit from

40
Q

What is the surgical Mx of breast cancer?

A

Wide local excision (breast conserving)
- removes the breast cancer with a margin of healthy tissue around the cancer
- for small cancers

Mastectomy
- entire breast removed + overlying skin
- for larger breast cancer (or for patients with small cancers but small breasts)
- patient dependent

Sentinel node sampling
- axillary node sampling
- aims to rule out lymphatic involvment

Breast reconstruction
- performed later or at same time as cancer removal

Ovarian ablation
- to stop oestrogen synthesis
- oophorectomy rarely done as oestrogen synthesis can be stopped with drugs or radiotherapy
- used in women with BRCA1/2 mutations (as also predisposes them to ovarian cancer)

41
Q

How is sentinel node sampling done?

A

Radioactive technetium injected to locate nodes

Travels up lymphatic vessel to the first lymph node

This is the sentinel lymph node

Sentinel lymph node is removed and sent to lab for analysis

If there is evidence of metastasis surgical clearance of axillary nodes is does

42
Q

What are the complication of breast cancer?

A

Metastases
- direct spread : into skin and muscles causing skin ulceration
- lymphatic spread : commonest site = axillary nodes
- haematogenous spread : blood-borne metastasis often to lungs, liver, brain and bones

Surgical complications
- axillary node clearance = brachial plexus damage, lymphoedema

43
Q

Sources

A

https://geekymedics.com/breast-cancer/

https://zerotofinals.com/surgery/breast/breastcancer/

https://en.wikipedia.org/wiki/Mammary_gland

breast surgery (3 decks)

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