Breast cancer Flashcards
Carcinoma in situ
- neoplasms that are contained within the breast ducts and have not spread into the surrounding breast tissue
- represent a precursor to invasive breast cancer
- two main types are ductal carcinoma in situ and lobular carcinoma in situ
DCIS
Most common type of non-invasive breast malignancy
Malignancy of the ductal tissue of the breast that is contained within the basement membrane
Five major types - comedo, cribriform, micropapillary, papillary & solid types
Investigations
- DCIS is often detected through screening with diagnosis then subsequently confirmed via biopsy
Management
- surgical excision - done with breast conserving surgery (wide local excision) or (in cases of widespread or multifocal DCIS) with mastectomy
LCIS
Non-invasive lesion of the secretory lobules of the breast that is contained within the basement membrane
Much rarer than DCIS, but increased risk of invasive breast malignancy
Investigations
- LCIS is usually asymptomatic, however not associated with microcalcifications → diagnosed as an incidental finding during biopsy of the breast
Management
- depends on extent of disease
- low grade LCIS → monitoring rather than excision
- bilateral prophylactic mastectomy can be potentially indicated if individuals possess the BRCA1/BRCA2 genes
Invasive breast cancer classification
Invasive ductal carcinoma is the most common type & microscopically composed of nests and cords of tumour cells with associated gland formation
Invasive lobular carcinoma is the second most common type & more common in older women → characterised by a diffuse pattern of spread that makes detection more difficult
Invasive breast cancer risk factors
Female sex
Increasing age
Family history of breast cancer
BRCA1 & BRCA2
Exposure to unopposed oestrogens → early menarche, late menopause, nulliparity & long term use of HRT
Previous benign breast disease
Obesity
Alcohol consumption
Smoking
Geographic variation (more common in developed countries)
Invasive breast cancer clinical features
Can present symptomatically or asymptomatically via screening
Breast/axillary lump
Asymmetry or swelling
Abnormal nipple discharge
Nipple retraction
Skin changes - dimpling/peau d’orange or Paget’s)
Mastalgia
Invasive breast cancer Ix & Mx
Gold standard for diagnosis - triple assessment → examination, imaging with mammography or USS and biopsy
Determined by a MDT
Treatment options are comprised of surgery, radiotherapy, chemotherapy, hormonal therapy and/or antibody therapy
Breast cancer screening
Invites women aged 50-71 years to have a mammogram every three years
Paget’s disease of the nipple
- rare condition, presenting as a persistent roughening, scaling, ulcerating or eczematous change to the nipple
- vast majority will also have an underlying breast neoplasm
- microscopically → involvement of the epidermis by malignant intraepithelial adenocarcinoma cells within the nipple epidermis
Paget’s disease of the nipple clinical presentation
Itching or redness in the nipple and/or areola, with flaking and thickened skin on/around the nipple
Painful & sensitive
Flattened nipple with or without yellowish/bloody discharge → may also be indicative
Paget’s disease of the nipple ddx
Dermatitis
Eczema
Paget’s disease of the nipple ix & mx
Biopsy is needed to confirm diagnosis
Complete breast & axilla examination
Imaging may be warranted
1st line management → operative: nipple & areola will need to be removed
Breast cancer endocrine treatment
In ER+ breast cancers → tumour growth can be driven by oestrogen binding at the oestrogen receptor
- SERMs eg. tamoxifen
- aromatase inhibitors eg. letrozole
Selection is generally based upon patients’ menopausal status
- ER+ pre-menopausal breast cancer patients → tamoxifen
- ER+ post-menopausal breast cancer patients → aromatase inhibitors
Can be given adjuvant or alone
Breast cancer immunotherapy
A range of monoclonal antibody treatments designed to target specific receptors/proteins that certain cancer cells produce
Drugs slow cancer cell growth and/or generate host immune responses against the cancer cells
HER2 receptor - herceptin: monoclonal antibody that binds to HER2 receptor which acts to halt the cell cycle
Breast cancer chemotherapy
Localised or advanced breast cancer → found to reduce breast cancer recurrence risk & mortality
Chemotherapy is more beneficial in younger patients, in larger tumours, high grade disease, & in disease with local or distant spread
Decision to offer chemotherapy is often complex
Can be considered prior to surgery to reduce tumour size & to assess tumour response to treatment
