Breast Cancer Flashcards
how is each lobule of glandular tissue in the breast delineated?
by suspensory ligaments (Cooper’s ligaments)=CT septa extending from the skin into the deep fascia, help to support lobes and lobules of mammary gland.
*note, tethering of these ligaments due to a Ca causes skin dimpling, which is more readily noticed by asking the pt on breast exam. to put their arms behind their head.
why is the breast mobile?
due to the retromammary space= a potential space between the breast and the pectoral fascia.
where is the breast located anatomically?
extends from the lateral border of the sternum to the mid-axillary line and vertically overlies the 2nd to 6th ribs.
arterial supply of the breast?
medial mammary branches of perforating branches and anterior intercostal branches of the internal thoracic artery, from SCA.
lateral thoracic and thoracoacromial from the axillary
posterior intercostal arteries from throacic aorta, in the 2nd, 3rd and 4th IC spaces.
venous drainage mainly to axillary vein, some to ITV.
describe the lymphatic drainage of the breast
lymph 1st passes into the subareolar plexus of sappey, then more than 75%, espec. from lateral breast, goes to axillary LNs-most anterior or pectoral initially. then to clavicular LNs, then to subclavian lymphatic trunk.
that part. from the medial breast drains to parasternal LNs or to the other breast, that from inferior may drain deeply to abdo LNs (subdiaphragmatic inferior phrenic LNs). parasternal to bronchomediastinal lymphatic trunks.
what is meant by a sentinel node?**
the 1st draining LN of the breast
sentinel LN biopsy used for early Ca axillary staging, but would instead do axiallry clearance if axillary node involvement suspected clinically or on USS.
use to stage axilla in early invasive breast Ca and no evidence of LN involvement on US or -ve US-guided needle biopsy
use isotope and blue dye
which quadrant of the breast is the site of most breast tumours and why?
the superolateral quadrant as this contains the most glandular tissue, largely due to an extension toward or into the axilla (axillary process).
why is screening not recommended with use of mammogram for younger patients?
difficult interpretation of mammogram in younger patients due to more glandular tissue making the breasts dense.
what can an USS of the breast tell us in the presentation of a breast lump?
whether it is cystic
the size of the lump
what may cause inaccuracies in the mammogram taken for older women?
if women use HRT as this can make the breasts denser than would be expected for their age.
what type of breast Ca causes the overlying skin to become erythematous and warm?
inflammtory carcinoma-responsible for less than 3% of breast Cas
px-rapidly growing, sometimes painful mass enlarging the breast, may be diffuse infiltration of the tumour.
lifetime risk of females developing breast Ca in the UK?
1 in 8
breast Ca RFs?
FH
increasing age-peak reached between 45 and 55
gene MUTATIONS-BRCA 1-80-85% lifetime risk, also 55% more likely to get ovarian Ca, BRCA 2-25% more likely to develop ovarian cancer, TP53, PTEN, also other common genes with faults assoc. with breast Ca that genetic tests not yet available for e.g.FGFR2
higher duration of exposure to oestrogens: early menarche, use of COCP, nulliparity, not having a full-term pregnancy, 1st child born after age 30, lower number of pregnancies, never breastfeeding, late menopause, use of HRT after menopause-combined oestrogen and progesterone=higher risk
previous breast Ca
previous Ca e.g. CLL
radiation to the chest e.g. for Hodkin’s lymhoma treatment-risk depends on age had tment, dose of radiotherapy, amount of time that has gone by and women’s age now.
benign breast disease-proliferative without atypia, and proliferative with atypia-atypia with hyerplasia-3X average risk of breast Ca
high alcohol intake
AI thyroiditis-3X risk in women
men-klinefelter’s syndrome (47,XXY), and other causes of gynaecomastia e.g. hormonal therapy-anti-androgen in treatment of prostate Ca.
who is the UK breast screening programme open to?
all women aged between 50 and 70yrs, 3 yearly screening
some areas open to those from 47 to 73 as part of a study to decide if these ages should be included.
NICE guidelines on r/f needed from GP to secondary care in relation to FH of breast Ca?
1 1st degree female relative diagnosed under the age of 40
1 1st degree male relative diagnosed at any age
1 1st degree relative with bilateral breast Ca, where 1st Ca diagnosed under age of 50
2 1st degree relative, or 1 1st and 1 2nd diagnosed at any age
1 1st degree or 2nd degree diagnosed at any age AND 1 1st or 2nd diagnosed with ovarian at any age (1 should be a 1st)
3 1st or 2nd diagnosed at any age
1 1st degree or 2nd diagnosed over 40 plus 1 of:
bilateral
male
ovarian Ca
jewish ancestry
sarcoma in relative under 45
glioma or childhood adrenal cortical tumours
complicated patterns of multiple Cas diagnosed at any age
2 or more relatives with breast Ca in father’s side of the family.
breast Ca presenting features?
breast lump-80% painless, may alternatively present with lump under the arm or in other regional LNs nipple changes(10%)-inversion skin contour changes(5%)-dimpling nipple discharge(3%) e.g. bloody in DCIS breast pain
bone pain, pathological fractures if mets
key questions to ask in presentation of a breast lump?
lump-duration, changes in size over this time, and other changes e.g. nipple inversion, pain
exposure to oestrogen-menarche, COCP, pregnancies, BF, menopause, HRT
menstrual hx-if premenopausal ?last period, note any changes through menstrual cycle
FH-breast Ca, other Cas, other conditions
when is MRI indicated in investigating breast Ca?
usually in difficult cases such as dense breast tissue espec. younger women, familial breast Ca assoc. with BRCA mutations, silicone gel implants, +ve axillary LN status with occult breast primary or where multiple tumour foci suspected.
NICE recommend pre-op MRI to be offered to those with invasive breast Ca if:
discrepency regarding disease extent from exam. mammogram and US
breast density inhibits accurate mammographic asses.
assess tumour size if breast conserving surgery being considered for invasive lobular Ca.
breast Ca grading?
Bloom-Richardson:
graded 1-3: 1=well differentiated=95% 5 year survivial, 3=poorly differentiated=50% 5 year survival
based on adding up scores 1-3 for each of tubule formation, nuclear pleomorhism and number of abnormal mitoses
breast Ca staging?
staged 0-4
0=CIS, not invasive
1=tumour less than 2cm in diameter, no LN involvement or mets
2= between 2 and 5cm in diameter, and/or spread to axillary LNs on same side and nodes not adherent
3=A and B, A=tumour more than 5cm or nodes adherent, B=invasive to involve breast skin, chest wall or internal mammary LNs and includes inflammatory breast Ca with peau d’orange-due to lymphoedema.
4=mets-may be supraclavicular nodes, bone, liver, lung or brain.
why might mastectomy be preferred to wide local excision plus radiotherapy?
due to large tumour size (4 cm or greater) so can’t be sure a wide local excision would remove all of the tumour cells, or if multifocal tumour.
why might immediate breast reconstruction following mastectomy not be adviseable in some women?
those with planned radiotherapy as this might delay wound healing
indications for bilateral prophylactic mastectomy?
BRCA1 or 2 carriers
types of adjuvant hormonal therapy in breast Ca treatment for women with oestrogen receptor positive breast Ca?
- SERMs for oestrogen receptor (E receptor) +ve breast Ca e.g. tamoxifen-given for 5 years, increased risk of endometrial Ca avoid in post menopausal women
- aromatase inhibitors e.g. anastrozole, letrozole. for post-menopausal women.
- LHRH analogues e.g. goserelin (zoladex), for pre-menopausal or peri-menopausal women.
when can herceptin be used in breast Ca treatment?
(trastuzumab)-anti-HER-2
in those breast Cas that overexpress HER2 gene (HER2 gene amplification in breast Ca cells)
tment is a monoclonal Ab which lowers recurrence risk bu 25-50% and risk of death by about 17-33%
can be combined with a taxane and is well tolerated, but cardiotoxic if combined with doxorubicin (anthracycline).
HER-2 strong expression by tumour assoc. with poorer survival-tumours are more aggressive, grow quickly
treatment of ductal CIS?**
can do conservation surgery if clear resection margins can be acheived (must be at least greater than 2mm)
followed by adjuvant whole breast irradiation which reduces recurrence risk but no effect on survival.
