Breast cancer Flashcards
Types of breast cancer
DCIS
LCIS
Medullary
Peu de orange
Invasive Metastatic
What is DCIS
neoplastic proliferation atypical features contained by basement membrane
Epidemiology of DCIS, detection, presentation
- Age: 50-59
- Detection mammogram: microcalcifications, soft tissue densities
- Dense, irregular, lumpy area
Morphological types of DCIS
- Commedo carcinoma->central necrosis, fibrosis, calcifciations
- Non-commedo
Management of DCIS
- Excision/mastectomy
- Radiotherapy
- If receptor +ve->tamoxifen
Risk factors for DCIS
Strong
- FHx of breast cancer
- benign breast disease on prior biopsy
- hereditary breast ovarian cancer syndrome
- Li-Fraumeni syndrome Cowden’s syndrome Klinefelter’s syndrome
Weak
- older age at menopause
- older age at first full-term pregnancy
- nulliparity
- low physical activity
- high vitamin A intake
- ataxia telangiectasia
- Peutz-Jeghers syndrome
What is pagets disease
- Unilateral, erythematous, crusting, pruritic, eczema like
- Malignant cells from DCIS within ductal system to nipple skin via lactiferous ducts xcross BM
- Disrupt the barrier->EC fluid seeps onto skin= irritation
What is medullary type carcinoma
- Inflammatory Ca
- Less common More aggressive
Molecular testing and prognostic value in invasive carcinoma
- Luminal A: ER+ve HER2-ve
Most in post menopausal
- Luminal B: ER+ve HER2+ve
poor differentiation +metastasis
Respond to chemotherapy
- Basal like: Triple negative
Markers of myoepithelial= basal keratoms. Pcadherin, laminin +in BRCA1 Her2/neu +ve: Trastuzumab (clonal antibody against HER2/Neu Poor differentiation, ++proliferation
Prognostic factors
- Axillary node status
- Tumor size
- Histological grade
- Hormone receptor status
- Vascular invasion, menopausal, HER 2++ expression
Staging Manchester`
- Stage I
Tumour confined to the breast with skin involvement less than the size of the tumour
- Stage II Tumour confined to the breast with palpable mobile axillary lymph nodes
- Stage III Locally advanced breast cancer with skin fixation larger than the tumour. Cutaneous ulcers or fixity to pectoralis fascia may be present. Peau d’orange or satellite chest wall nodules. Fixed axillary nodes, supraclavicular nodal involvement
- Stage IV Distant metastases
What is peu de organge
- Malignant cells embolise to lymphatics: occlude causing lymphoedema retraction of skin= orange peel appearance
Screening with mammogram, outcomes
- for every 2000 women screened one will avoid dying of breast cancer
- 10 healthy women will be treated unnecessarily.
- >200 experience distress due to false positive findings.
Treatment options for breast Ca
- Surgical
- Adjuvant radiotherapy
- Adjuvant chemotherapy
- Hormone therapy
Surgical options
- Partial mastectomy
- Total mastectomy
Indications for partial mastectomy
- If can achieve good cosmetic result with clear margins
What is partial mastectomy usually followed by
Radiotherapy
Indications for total mastectomy
- Large tumor relative to Breast
- Involves overlying skin/ nipple
- Multifocal/extensive intraductal
- Prior breast irradiation
- Chooses this option
- Usually breast reconstruction follow
Risks of surgery
- Breast haematoma
- Wound infection
- Seroma of the skin flap
- Psychological effects on body image and self esteem
- Brachial plexus
- Lymphadema
When can radiotherapy generally be ommitted
- In elderly
- Low histologic grade ++abundant hormone receptors
Side effects of radiotherapy
Side effects of radiotherapy to the chest wall / axilla:
- Pneumonitis
- Rib fracture
- Pericarditis
- Lymphodema
- Brachial plexus injury
Options for ovarian ablation in pre-menopausal women
- Surgical oophrectomy
- Ovarian irradiation
- LHRH analogues- goserelin (reversible medical oophrectomy)
Commonly used chemotherapy regimens
- Adriamycin and cyclophosphamide
- Methotrexate and 5FU 6 months
Systemic therapy in node +ve
- Premenopausal–> Doxorubicin + cyclophosphamide 4 cycles
- Post-menopausal–> Receptor + tomoxifen 5 years
Receptor -ve Combo chemoT
Systemic therapy for node -ve
- Pre-menopausal–> chemotherapy if poor prognostic factors
- Post-menopausal–> Rec +ve Tamoxifen 5 years -ve same
Risk of endometrial Ca
Aberrations or normal development and involution in early reproductive years
- Lobar developement
Abberation= fibroadenoma Disease= giant fibroadenoma
- Stromal development
Aberration= teenage hypertrophy Disease=giantomastia
- Nipple eversion Abberration= Nipple inversion Disease= Subareolar abscess, mammary duct fistula
Aberrations or normal development and involution in mature reproductive years
- Epithelial hyperplasia of pregnancy
- Bloody nipple discharge
- Nodularity
- Phylloides tumor
- Cyclical changes of mensturation
- Cyclical mastalgia Incapacitating mastalgia
Involution
35-55
Lobar involution: A: Macrocysts, sclerosing lesions ,Ductal involution, dilation, sclerosis
A: duct ectasia D: periductal mastitis and abscess Nipple retraction Epithelial turnover
A: Hyperplasia D: Hyperplasia w/ atypia
Indications for surgery in fibroadenoma
- Triple test discordant S
- Symptomatic
- Rapid growth
- Patient request
TMN staging
Tumour categories
Tx Primary tumour cannot be assessed
Tis Carcinoma in situ
T1 Tumour size < 2cm
T2 Tumour size is 2-5 cm
T3 Tumour size is >5 cm
T4 Any tumour size with fixation to chest wall or skin
Nodal categories
Nx Regional lymph nodes cannot be assessed
N0 Axillary lymph nodes not involved
N1 Ipsilateral axillary nodal metastases (mobile)
N2 Ipsilateral axillary nodal metastases (fixed)
N3 Ipsilateral supraclavicular or internal mammary nodal metastases
Metastasis categories
Mx Presence of distant metastases cannot be assessed
M0 No distant metastases
M1 Distant metastases
Purpose of breast USS
- Dense breast
- Equivocal mammography
- Palpable mass
- Guide biopsy
Staging bloods
- full blood examination,
- urea and electrolytes,
- liver function tests,
- bone scan,
- liver ultrasound
- chest and abdomnial CT scan.
Is LCIS pre-malignant`
No
But has +risk for malignancy
Purpose of axillary dissection
- Remove metastatic deposits
- Assess receptor status for systemic therapy
- Assess nodal status for prognosis
Reduction in recurrence and death with adjuvant therapy with tamozifen
- Adjuvant systemic therapy with tamoxifen, with combination cytotoxic chemotherapy or, in premenopausal women, ovarian ablation, reduces the risk of recurrence and death after treatment for node-positive and node-negative breast cancer.
Benefits of chemotherapy increase
With decreasing age and increasing nodal status
Improvement in recurrence rate and death rate after ovarian ablation in pre-menopausal women
10% at 15 years in both recurrence-free and overall survival
Purpose of followup
- Detect local recurrence
- Detect distance recurrence
- Detect new primary
- Management of treatment toxicities
- Psychosocial supports
Most important prognostic factor for metastatic breast cancer
- disease-free interval after diagnosis of the primary breast cancer
Imaging in metastatic breast cancer
CXR CT abdomen/chest, brain if relevant symptoms Bone scan
Management of metastatic breast cancer: pre and post menopausal ER/PR +ve
- ER/PR +ve
Post-menopausal 1st line: aromatase inhibitor (anastrazole) or tamoxifen
adjunct: bisphosphonate or denosumab
adjunct: calcium and vitamin D
2. HER-2 +ve pertuzumab plus trastuzumab plus docetaxel
3. Pre-menopausal
1st line: tamoxifen plus monoclonal antibody if HER2 +ve plus: ovarian ablation (surgical or medical) plus monoclonal antibody plus: aromatase inhibitor adjunct: bisphosphonate or denosumab adjunct: calcium and vitamin D
Management of metastatic breast cancer: pre and post menopausal ER/PR -ve
HER2-negative 1st line: chemotherapy adjunct: bisphosphonate or denosumab adjunct: calcium and vitamin D adjunct: palliative therapy HER2-positive 1st line: pertuzumab plus trastuzumab plus docetaxel adjunct: bisphosphonate or denosumab adjunct: calcium and vitamin D
Treatment of choice in visceral mets
Chemotherapy
Treatment of cerebral mets
Radiotherapy
Follow up for breast cancer
- All patients should undergo a detailed history and physical examination by a doctor who is experienced in the surveillance of cancer patients and in breast examinations.
- Intervals between examinations should be 3 to 6 months for the first 3 years, 6 to 12 months for years 4 and 5, and yearly thereafter
