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Surgery block > Breast Cancer > Flashcards

Breast Cancer Flashcards

1
Q

What is the basic breast anatomy?

A

Lobules are glands that produce milk
Duct are tubes that carry milk to the nipple
The connective tissue (interlobular stroma) consists of fibrous and fatty tissue surrounds and holds everything together.

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2
Q

How does the tissue make-up of the breast change with age?

A

Fibrous: fatty tissue
The proportion of fibrous tissue decreases with age, the breast becomes less dense.

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3
Q

What is the terminal lobule unit of the breast?

A

Most sensitive to hormone changes.
Conists of the terminal duct, associated ductules and acini within a lobule (the part furthest away from the nipple)
The most common site for cancerous and pre-cancerous changes.

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4
Q

What is the surface anatomy of the breast?

A

Sits over ribs 2-6
2/3 pec major, 1/3 seratus anterior
From lat sternum to mix axillary line
Divided into four quadrants.

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5
Q

What are the different portions of the breast?
Location wise

A

Upper inner
Upper outer
Lower outer
Lower inner
Axillary tail

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6
Q

What is the pattern of lymph node drainage from the beast?

A

75% - into axillary lymph nodes
25% into parasternal lymph nodes
1% inferior phrenic lymph nodes

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7
Q

What are the different axillary lymph nodes?

A
  1. Pectoral (anterior) - medial wall of the axilla - drain most breast and Ant thoracic wall
  2. Subscapula (posterior) - post thoracic wall and scapula region
  3. Humeral (lateral) - upper limb
  4. Central - drain all of the above
  5. Apical - drain central
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8
Q

What are some risk factors for breast cancer?

A

Female sex
Age (median age 62yrs)
Obesity
Smoking
Alcohol
Diabetes
FH - first degree - doubles relative risk
HRT
Contraceptive medication
Prolonged oestrogen exposure (early menarche, late menopause, low parity)
Previous breast cancer

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9
Q

What is the key epidemiology of breast cancer?

A

Most common cancer in the UK
Affects 1/7 women
Each year 56,000 women and 390 men diagnosed with breast cancer in the UK
150 people diagnosed a day.

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10
Q

How does the BRCA genes relate to cancer?

A

Are TSG - control cell division and repair damaged DNA
When they are defective (DUE TO MUTATION) more likely for a DNA mutation to occur, increase risk of breast and ovarian cancer
BRCA 1 found on chromosome 17
BRCA 2 found on chromosome 13.

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11
Q

What cancers are BRCA mutations associated with?

A

Breast
Ovarian
Pancreas
Prostate
Melanoma

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12
Q

What are the statistics relating BRCA genes to occurrence of cancer?

A

Mutations in
BRCA 1 - 70% develop breast cancer, 40% ovarian
BRCA 2 - 60% develop breast cancer, 20% ovarian

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13
Q

When is the best time in the menstrual cycle to self check the breast for cancer?

A

A few dyas after your period ends.

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14
Q

What changes in the breast can indicate breast cancer?

A

Feel a thick mass
Lump in breast or axilla
Indentation/inversion of the nipple or breast
Growing vein
Skin sores - Pagets disease
Retracted nipple
Erythema
New shape/size
Unusual or new fluid
Orange peel skin - Paue de orange
Dimpling
Hidden lump - hard and immovable
Is normally painless
Persistent/unchanged throughout the menstraul cycle

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15
Q

What thresholds qualify for a NICE urgent 2wwr for suspected breast cancer?

A

An unexplained breast/axilla lump in patients aged 30 or above
Unilateral nipple changes in patients aged 50 or above
Any skin changes suggestive of breast cancer.

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16
Q

What are the most frequent sub-types of breast cancer?

A

Ductal carcinoma = 80%
Lobular carcinoma = 15%
18 other subtypes = 5%

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17
Q

What is the difference between in-situ vs invasive cancer?

A

In situ - slower growing, more beign, in itself is harmless but has the potential to develop into invasive cancer.
Invasive cancer - more aggressive, fast growing and ability to metastasise/spread.

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18
Q

What is the most common classification of breast cancer?

A

Invasive ductal carcinoma

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19
Q

What is invasive ductal carcinoma of the breast?
What are some key features?

A

Most common type of breast cancer
Originates in cells from the breast ducts
Metastasis aggressively
Generally bad prognosis.

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20
Q

What is ductal carcinoma in situ?
What are some key features?

A

‘Early breast cancer’
Cancerous cells are contained at site of origin in the ducts
Fairly benign, but has potential to become invasive cancer is untreated
Generally good prognosis if caught early

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21
Q

Define neoplasia

A

Uncontrolled cell division, due to acquisition of genetic mutations.
Develops from dysplasia, when the whole tissue above the basement membrane is dysplastic

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22
Q

What is a neoplasm?

A

Any unusual mass of cells, forms when cells divide more often than they should or do not die when they should.
May also be called a tumour.

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23
Q

What is the key difference between benign and malignant tumour?

A

Malignant tumours metastasise and spread to other tissues e.g IDC
Benign tumours remain within the site of origin.

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24
Q

Define dysplasia

A

The presence of an abnormal cell development or differentiation.

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25
Q

What is invasive lobular carcinoma?
What are its key features?

A

Second most common type of breast cancer
Makes up around 10% of breast cancers
Cancer which originated in the cells of the breast lobules and has spread into the surrounding tissue.

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26
Q

What is lobular carcinoma in situ?
What are some common features?

A

Is a pre-cancerous condition
Cells inside the affected breast lobule have abnormal changes with the potential to develop into a malignant tumour.
However, no uncontrolled cell growth so not a neoplasm
Only a small risk of developing breast cancer.
Treated as cancer anyway to reduce risk.

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27
Q

What is meant by triple negative breast cancer?

A

Breast cancer cells which don’t have recepotrs for:
Oestrogen
Progesterone
HER2

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28
Q

What are the key clinical features of triple negative breast cancer?

A

More common in women under 40yrs
Tend to be more aggressive cancers
Not responsible to targeted therapies
Worse prognosis

29
Q

What is Pagets disease of the breast/nipple?

A

Very rare
Erythmatous, scaly rash of the nipple/areola
Suggestive of underlying invasive breast cancer.

30
Q

What are the most common sites of haematogenous spread of breast cancers?

A

Brain
Bone
Lung
Liver

31
Q

What is a key signs of lymphatic spread of breast cancer?

A

Commonly spreads to the axilla
Non-tender, firm, enlarged lymph nodes (>1cm)

32
Q

How/is that the axilla assessed in women with breast cancer?

A

Assessed in all women with breast cancers
Offered an USS of the axilla and USS guided biopsy of abnormal nodes
If USS does not show any abnormal nodes a sentinel lymph nodes biopsy will be carried out during breast cancer surgery.

33
Q

What is meant by the sentinel lymph node?

A

The lymph node to which cancer cells from a tumour are most likely to spread to first.

34
Q

What is a sentinel lymph node biopsy?

A

A radioactive dye injected into the tumour
Probe used to visualise LN close to tumour, typically using
LN removed during surgery to examine for cancer cells

35
Q

What makes up the triple assessment for Breast Cancer?

A
  1. Clinical - history and examination
  2. Imaging - ultrasound or mammography
  3. Pathology - fine needle aspiration (FNA) or core biospy
36
Q

What is a mammography?

A

An x-ray imaging modality
Not used in younger women ,35yrs due to density of breast (harder to interpret)
Easy to perform
Used for breast cancer screening.

37
Q

What is the use of ultrasound for imaging the breast?

A

Used for younger women under 35years
Helpful to distinguish solid lumps (fibroadenoma or cancer) from cystic lumps (fluid filled)
Safe and cheap
Not used for breast cancer screening

38
Q

What is a fine needle aspiration?

A

Uses a small needle to obtain a tissue sample (biopsy) from a mass/lymph node
Obtains a cluster of cells
The sample will then be analysed to check for cancer cells
Minimally invasive

39
Q

What is a core needle biopsy in terms of breast cancer?

A

Provides a larger tissue sample
Obtains an entire section of tissue
Enables differentiationbetween invasive and in situ carcinomas
Is the more accurate, gold standard, diagnostic test

40
Q

Why is the triple assessment in breast cancer relevant to clinical practice?

A

The positive predictive value of triple assessment in detecting breast cancer is near 100%
No need for open surgical biopsy
Highly cost effective and better for patients.

41
Q

What assessments/investigations may be included in order to stage breast cancer?

A

Lymph node biopsy
MRI breast and axilla
Liver USS for mets
CT-TAP for lung, abdominal and pelvic mets
Isotope bone scan for mets.

42
Q

What two systems tend to be used for staging breast cancer?

A

TMN staging
1-4 staging.

43
Q

What is the basic idea of TMN staging for breast cancer?

A

T - describe the size of the tumour
M - describes whether the cancer has spread beyond the lymph nodes
N - describe whether cancer has spread to the lymph nodes

44
Q

What is the simplified version of the Stage 1 to 4, staging pattern of Breast Cancer?

A

1 - generally small cancer - not spread beyond the breast
2 - general small cancer with some localised LN involvement
3 - larger cancer with multiple LN involvement
4- cancer has spread to other parts of the body e.g lungs, bones, brain.

45
Q

How does prognosis of 5 year survival rate relate to the stage of breast cancer?

A

Stage 1 - 98% survie for 5years or more
Stage 2 - 90% survive for 5 years or more
Stage 3 - 70% survive for 5 years or more
Stage 4 - 25% will survive for 5 years or more, the cancer is not curable, treatment is palliative, symptom controlling and aims to prolong life.

46
Q

What MDT tends to be involved in a breast cancer patient case?

A

Consultant breast surgeon +/- oncoplastic surgeon
Oncologist
Histopathologist
Radiologist
Breast cancer specialist nurses
MDT co-ordinator
Macmillan services.

47
Q

What is the typical patient management plan for a patient with metastatic breast cancer?

A

Determine extent of metastasies
Offer combination of: chemotherapy, radiotherapy, surgery, immunotherapy, hormonal therapy, palliative care.

48
Q

What is the typical patient management of a patient with localised breast cancer?

A

Is non-resectable tumour or inoperable patient offer radiotherapy +/- chemotherapy +/- hormonal/immunotherapy
If resectable and operable patient offer surgery with/without radiotherapy, chemotherapy, hormonal immunotherapy.

49
Q

What are the different types of surgical management for patients with breast cancer?

A

Breast conserving surgery
Mastectomy
Immediate/delayed reconstruction

50
Q

What are the different types of non-surgical treatment for breast cancer?

A

Targeted therapies
Adjuvant therapies
Neoadjuvant therapies

51
Q

What is the aim of breast conserving surgery?
How is it used within breast cancer treatment?

A

The aim is cosmetic
If cosmetic appearance cannot be achieved then perform a mastectomy
Usually coupled with radiotherapy to improve prognosis (adjuvant)

52
Q

What are the different techniques of breast cancer surgery?

A

Breast-conserving surgery:
Lumpectomy - remove the tumour and a small amount of surrounding tissue, just enough to make a negative margin
Wide excision - and a wide area of surrounding tissue
Quadrantectomy - remove the whole affected quadrant of the breast

Mastectomy - breast removal

53
Q

What is a mastectomy?
How is it relevant to the treatment of breast cancer?

A

Removal of the whole breast tissue and lymph nodes
May still need radiotherapy afterwards.

54
Q

What is a prophylatic mastectomy?

A

The removal of the breast tissue, often bilateral to reduce the risk of developing breast cancer.
Often offered to women with a strong family history of ovarian/breast cancer, will undergo genetic testing that comes back positive for BRCA 1 or BRCA 2 mutations.

55
Q

What is the purpose of breast reconstruction in the treatment of breast cancer?

A

Performed by plastics
Immediate - at the time of mastectomy
Delayed - months/years after mastectomy
Patient choice

56
Q

What is the purpose of axillary surgery/clearance for breast cancer patients?

A

Removal of all axillary lymph nodes for patients whose have cancer cells identified in the lymph nodes
30% of breast cancer patients will have nodal involvement
Should avoid taking blood from an arm is which corresponding axillary LN have been removed - as higher risk of infection due to impaired lymphatic drainage.

57
Q

What is the purpose of target treatments for breast cancer?

A

Target specific molecules or receptors on the surface of cancer cells, damaging to cancer cells whilst minimising the damage to healthy cells

58
Q

What treatment can be used for ER or PR positive breast cancers?

A

Tamoxifen - for pre-menopausal women
Aromatase inhibitors e.g letrozole (for post-menopausal women)
Both of these are hormonal treatments, typically given for 5-10 years.

59
Q

What treatment can be given for HER2 positive cancers?

A

Herceptin (trastuzumab) is a monoclonal antibody
Example of an immuntherapy.

60
Q

How can breast cancers be classified based on the molecules they have present on their surface?

A

ER positive - 50-65%, older women, men, BRCA2 mutation, tend to be detected by screening, mainly grade 1/2
PR positive -
A cancer that is PR+ and/or ER+ is considered HR+.
HER2 positive cancers - 20%, younger women, grade 2/3
Triple-negative cancers - 15%, young women, germline BRCA1, African American women, tend to be grade 3

61
Q

How can tamoxifen be used to treat breast cancer?

A

Used for chemoprevention and for treatment of ER+ BC in peri/premenopausal women.
Tamoxifen works as an anti-estrogen on cancer cells (competitive antagonist), and prevents proliferation of the cancer cells.
Cautions - can increase the risk of endometerial cancer.

62
Q

How can letrozole be used to treat breast cancer?

A

Used for post-menopausal women (as does not affect ovarian production of oestrogen)
Is an aromatase inhibitor - prevents the conversion of androgens to estrogen.
Used for hormone dependent cancers.

63
Q

How is trastuzumab used to treat breast cancer?

A

Clinical: HER2 positive breast cancer
Chem: humanized monoclonal antibody.
Pharm: non-competitive inhibitor of the extracellular domain of TKR Her2.
Physio: Prevent dimerisation and phosphorylation/cleavage of Her2.
Inhibits the Ras signalling pathway - no cell proliferation
inhibits the PI13 AKT pathway - no cell growth (Protein synthesis, lipid synthesis)
Reduces cancer cell growth

It also drives antibody-dependent cell-mediated cytotoxicity and Her2 endocytosis and degradation

64
Q

What is the purpose of adjuvant therapies in the treatment of breast cancer?

A

Adjuvant therapies are adminstered after surgery to kill any remaining cancer cells with the goal of reducing the chances of recurrence.
Examples - hormonal therapy (Letrozole or tamoxifen), immuntherapy (herceptin), chemotherapy and radiotherapy.

65
Q

What is the purpose of a neoadjuvant therapy?

A

Delivered before surgery with the goal of shrinking a tumour or stopping the spread of cancer to amek surgery less invasive and more effective.

66
Q

What tumour marker is important in breast cancer?

A

Tumour marker CA 15.3 - used to monitor response to treatment but is not a diagnostic test.
Is non specific and often absent in early onset disease.

67
Q

When might a person with breast cancer require genetic testing?

A

Breast cancer when <40yrs
Bilateral breast cancer when <50yrs
If BRCA positive genetic testing can be offered to your close relatives.

68
Q

What follow up will a breast cancer patient receive?

A

Surveillance mammograms yearly for 5 years - longer if not yet old enough for regular screening programme
Genetic testing
Potential for genetic testing of close relatives.

Surgery block (14 decks)

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