Breast cancer Flashcards
1
Q
How do we name breast cancer?
A
- Most arise from duct tissue, followed by lobular tissue- described as ductal or lobular carcinoma respectively
- Then subdivided as to whether cancer has spread beyond local tissue ( carcinoma-in-situ) or has spread (invasive)
2
Q
Most common types of breast cancer incl?
A
- Invasive ductal carcinoma (this is now know as No Special Type)
- Ivasive lobular carcinoma
- Ducatal carcinoma in situ (DCIS)
- Lobular carcinoma in situ (LCIS)
3
Q
What are the ‘Special Types” of breast cancer
A
- Lobular carcinoma
- Medullary breast cancer
- Mucinous (mucoid or colloid) breast cancer
- Tubular breast cancer
- Adenoid cystic carcinoma of the breast
- Metaplastic breast cancer
- Lymphoma of the breast
- Basal type breast cancer
- Phyllodes or cystosarcoma phyllodes
- Papillary breast cancer
4
Q
What is Pagets Disease of the nipple?
A
- Eczematoid change of the nipple associated with an underlying breast malignancy
- In half of these pts its associated with an underlying mass lesion -90% of those pts with have an invasive carcinoma
- 30% without a mass lesion will still be found to have an underlying carcinoma
- The remainder will have carcinoma in situ
5
Q
What is inflammatory breast cancer?
A
- where cancerous cells block the lymph drainage resulting in an inflamed appearance of the breast. This accounts for around 1 in 10,000 cases of breast cancer.
6
Q
What is triple assessment?
A
- One stop shop for 2 ww
Involves: - History and examination
- Imaging
- Histology- core needle biopsy as fine needle is cytology only and core needle can differentiate between invasive and in situ carcinoma.
7
Q
What is an in situ carcinoma?
A
- Neoplastic population of cells limited to ducts and lobules by basement membrane (BM), myoepithelial cells are preserved.
- Does NOT invade into vessels and therefore cannot metastasise or kill the patient.
8
Q
What is the significance of peau d’orange?
What type of breast cancer is it more likely to be?
A
- Means lymphatic drainage of the skin of breast is involved
- More likely to be an invasive breast cancer as invades lymph nodes
9
Q
What factors affect the prognosis of breast cancer?
5
A
- Whether the malignant tumour is in-situ or invasive
- The stage- TNM
- Grade of the tumour
- Histology of the tumour
- Gene expression profile
10
Q
A patient presents with:
3cm highly mobile lesion on her breast
1) What is you top differential?
2) How do they present
3) What is the prognosis
4) When would you excise it?
A
- Fibroadenoma
- highly mobile lesions, well defined and rubbery, most are less than 5cm
- Low malignant potential and can be left in situ with routine follow ups over a 2 year period, up to 30% will get smaller
- Greater than 3cm in diameter or pt preference
11
Q
What is invasive breast cancer?
A
- Neoplastic population of cells NOT limited to ducts and lobules by basement membrane (BM), myoepithelial cells are preserved.
- Can invade into vessels and therefore can metastasise / kill the patient.
12
Q
RF for breast cancer?
A
- BRCA1, BRCA2 genes - 40% lifetime risk of breast/ovarian cancer
- 1st degree relative premenopausal relative with breast cancer (e.g. mother)
- nulliparity, 1st pregnancy > 30 yrs (twice risk of women having 1st child < 25 yrs)
- early menarche, late menopause
- combined hormone replacement therapy (relative risk increase * 1.023/year of use), combined oral contraceptive use
- past breast cancer
- not breastfeeding
- ionising radiation
- p53 gene mutations
- obesity
- previous surgery for benign disease (?more follow-up, scar hides lump)
13
Q
When do you refer a pt for suspected breast cancer?
A
- aged 30 and over and have an unexplained breast lump with or without pain or
- aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern
14
Q
When should you consider referral of someone via 2ww for breast cancer?
A
- with skin changes that suggest breast cancer or
- aged 30 and over with an unexplained lump in the axilla
15
Q
When should you consider non-urgent referral to breast clinic?
A
- under 30 with an unexplained breast lump with or without pain
16
Q
Outline breast screening programme?
A
- offered to women between ages of 50-70 years
- Mammogram every 3 years
- After age of 70 women may still have mammograms but ‘encouraged to make their own appointments’
17
Q
Who should be offered breast screening from a younger age?
ie. referred to breast clinic for further assessment on this
A
- one first-degree female relative diagnosed with breast cancer at younger than age 40 years, or
- one first-degree male relative diagnosed with breast cancer at any age, or
- one first-degree relative with bilateral breast cancer where the first primary was diagnosed at younger than age 50 years, or
- two first-degree relatives, or one first-degree and one second-degree relative, diagnosed with breast cancer at any age, or
- one first-degree or second-degree relative diagnosed with breast cancer at any age and one first-degree or second-degree relative diagnosed with ovarian cancer at any age (one of these should be a first-degree relative), or
- three first-degree or second-degree relatives diagnosed with breast cancer at any age
18
Q
What are the treatment options for breast ca?
A
- Masectomy
- Wide local excision
- Biological therapy
- Chemotherapy
- Radiotherapy
- Hormonal therapy
19
Q
Prior to surgery, how does the presence/absence of axillary nodes determine management?
A
- women with NO palpable axillary lymphadenopathy at presentaton should have PREOP axillary USS before primary surgery- if POSITIVE then have a sentinel node biopsy to assess nodal burden
- Patients who present with clinically palpable lymphadenopathy, axillary node clearance is indicated at primary surgery
20
Q
What are the complications of axillary node clearance?
A
- Arm lyphedema
- Functional arm impairment
21
Q
When is mastectomy usually offered?
as opposed to wide local excision
A
- Mutifocal tumour
- Central tumour
- Large lesion in small breast
- DCIS> 4cm
22
Q
When is wide local excision offered?
As opposed to mastestomy?
A
- Solitary lesion
- Peripheral tumour
- Small lesion in large breast
- DCIS< 4cm
23
Q
When is radiotherapy offered in breast ca?
A
- Whole breast radiotherapy is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence by around two-thirds.
- Women who’ve had a mastectomy, radiotherapy is offered for T3-T4 tumours and for those with four or more positive axillary nodes
24
Q
When do you offer adjuvant therapy is breast ca?
A
- If tumours are positive for hormone receptors
25
What hormonal therapy do you use for breast ca?
What is the regimen?
* Tamoxifen for pre and peri-menopausal women
* Aromatase inhibotrs e.g. anastrozole for post menopausal women
26
Side effects of tamoxifen?
* Increase risk of endometrial cancer
* VTE
* Menopausal symptoms
27
When is biological therapy used for breast ca?
Prognosis?
Contraindications?
* Trastuzumab (Herceptin)- for HER2 + tumours
* Only useful in 20-25% of tumours that are HER2 positive
* Cannot be used in pts with hx of heart disorders
28
When is chemotherapy used in breast ca?
* Neoadjuvant (prior to chemo) to downstage a primary lesion
* Adjuvant (after surgery) depending on stage of the tumour
29
Breast lumps ddx?
* Fibroadenoma-common under 30, discrete, non-tender and highly mobile
* Fibrocystic disease (fibroadenosis)- lumpy breast which may be painful, symptoms may be cyclical
* Breast cancer- classically hard and irregular lump with skin tethering, nipple inversion
* Mammary duct ectasia- tender lump around areola +/- green nipple discharge
* Fat necrosis- ususally obese women with large breast, following trivial or unnoticed trauma, initally firm but may develop into hard, irregular breast lump
* Breast abscess- more common in lactacting women, red hot tender swelling
30
What is the difference between a ductal carcinoma and lobular carcinoma of the breast (both non-invasive)?
Ductal - limited to the ducts by the basement membrane. Lobular - limited to the lobules by the basement membrane.
31
How does breast cancer present?
* hard, irregular breast lump with skin tethering
* non-flucuant
* nipple changes/inversion
* Pagets disease of the nipple
* breast discharge
32
Main risk of aromatase inhibitor e.g. Anastrazole?
* Increases risk of osteoporosis
33
Complications of breast cancer?
* Pain
* Bone mets causing hypercalcaemia, MSCC
* Lung mets
* Liver mets
* Brain mets
* Lymphedema
* Treatment complications
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