Breast Cancer Flashcards
Triple assessment
- History/Examination
- Imaging: Mammography/ Ultrasound
- Biopsy: Core Biopsy/ Excision Biopsy
History
- Age of patient, age at menarche, age at meopause
- symptoms - lump, pain, nipple discharge, duration of symptoms, change in symptoms over time, previous history of breast lumps
- Family history of breast cancer/ ovarian cancer
- parity, breast fed children
- present or past use of HRT, oral contraceptives
Examination
Inspection
- proper exposure of both breasts + axillae
- inspection with patient lying down, sitting up, with arms up and with arms pressed onto hips
- Inspect skin contour, nipples, check for scars, pbvious deforimty, skin oedema (pea d’orange), skin puckering
Palpation
- ask about any painful areas first
- palpate with flat of hand entire breast. Examine nipple for discharge by squeezing gently
- Examine axillae. Take weight of paitents arm and examine with flat of hand
- examine supra-clavicular fossa
- remember to examine both sides
Skin changes
- Benigns skin lesions are common e.g sebacious cysts
- skin retraction/ puckering - sign of breast cancer
- red/hot skin is a sign of infection/abscess (may also be a presenation of an inflammatory cancer
- thickenened oedematous skin (peau d’oragne) may be caused by an inflamamtory breast cancer
Nipple/ Areolar changes
- Nipple inversion is common. More significant if a new symptoms
- eczema of nipple is often simple eczema but consider pagest disease of the nipple (caused by breast cancer)
- nipple discharge may be from a single duct or multiple ducts and may be unilater or bilater
- colour - Green/clear/yelllow, brown (usually benign), blood (mosttly benign but possibility of underlying cancer), white/milk (often physiologically but always exclude pituitary tumour)
- Extra nipples are not uncommon and may be mistaken for a skin mole
Breast lump
- Describe site in breast (upper outer quadrant)
- discrete lump or generalised lumpiness
- size in centimetres
- hard/soft, smooth/irregular
- mobile/fixed lump
Mammography
Mammography is used for patients with a new breast symptom over the age of 35. It is performed on both breasts
Note not performed in under 35 as density of breast is different, unclear pictures may be produced
Ultrasound
Used to look at specfic areas of clinical abnormality eg discrete breast lump. It is useful for distinguishing between solid and cystic lumps
Offer to women under 35
FNA
Cytologcal diagnosis but often difficult to get an adequate specimen but result can be given quickly. Also cysts can be aspirated to confirm the diagnosis
Core Biopsy
Histological diagnosis, more accurate but take more time to get
Excision biopsy
Needs surgery leaving a scar and any risks of anaesthetic. May be needed if other technqies cannot get a diagnosis and clinical supsicion persists
Causes of breast pain
- Muskuloskeletal
- Normal pre-menstrual cyclical pain
- FIbrocystic changes
- breast trauma
- infection
Causes of Nipple discharge
- [regnancy/previous breast feeding- physiological
- duct ectasia
- intra-duct papilloma
- breast cancer
- Galactorrhoea
Breast cancer epidemiology
1 in 11 women in UK
Breast cancer presentation
- Mostly present with a discrete lump in the breast
- bloody nipple discharge
- skin eryhtema, puckering
- nipple eczema (pagets)
- symptoms of metastatic disease e.g bone pain
Patients often detected when asymptomatic by the breast screenign programme
Staging of breast cancer
- is diseasle localised to breast or metastases present
- CXR
- CT chest/abdo/pelvis
- MRI scan
- Bone scan
Breast surgery options
- Masectomy (+/- breast reconstruction)
- Wide local excision (breast conservation)
Depends on tumour size, of tumour is multifocal, patient preference
Axilla Surgery options
- sentinel node bioopsy/ axillary node sample
- Axillary clearance - treatment of aximlla with involved nodes. Risk of lymphooedma
Decision depends on whether the axilla is thought to be involved with tumour at diagnosis. If it is proven that the nodes are positive then an axillary clearance is necessary
Radiotherapy
- to remaining breast tissue in those having a wide local ecision
- to chest wall in those having a mastectomy with higher risk of local recurrence i.e large or multifocal tumours or those close to the chest wall
Chemotherapy
For those at risk of developing metastastic disease ie large tumours, high grade tumours, involved axillary nodes or those with metastatic disease at diagnosis
Hormonal
Oestrogen receptor positive patients (about 80%)
- tamoxifen
- aromatase inhibitors (post-menopausal only) - arimidex, letrozole
- ovarian suppression
- Medical - zoladex
- surgical - oopherectomy
Monoclonal antibodies
Herceptic (tratuzumab) - blocks Her 2 receptors (growth factor type) which are associated with higher risk disease
Gynecomastia causes
- Physiological - pubertal
- chronic liver disease
- testicular failure - usually old age
- drugs e,g bendofluazide, digoxin, spironolactone, cannabis, anti-androgens
- andrenal tumour
Treatment of gynaecomastia
- physiological type often resolve spontaenously
- surgical
Male breast cancer
- Uncommon <1% of all BC
- older men
- later stage than in females
- treatment very similar to female BC
- Linked ot FH in female relatives
