Breast Cancer Flashcards
Clinical
• Breast lump
− Hard
− Irregular surface
− Indistinct borders
• Supportive tissue involvement
− Tethering/dimpling (infiltration of coopers ligaments)
− Nipple retration
• Skin changes (T4)
− Peau d’orange (infiltration of lymphatics of the dermis)
− Ulceration
− inflammatory Ca (usually ductal carcinoma) -> EMERGENCY CHEMO
⎫ Skin edema
⎫ Warm
⎫ Swollen
• Nipple + areolar
− Paget’s disease: red, oedema, crust of nipple and areolar (spread in ductal epithelium – i.e. ductal carcinoma; ON TOP epidermis, not infiltrated))
− Discharge (10% of blood discharge = cancer – unprovoked, unilateral)
• Lymphadenopathy
− Axillary
− Supra/infraclavicular
• Metastasis
− CNS neurological symptoms
− Liver enlargement
− Lungs pleural effusion
− Bone pain
− Ovaries
− Pouch of Douglas
Epidemiology
- Rare before 25 years old
- 80% > 40 years old
- Peaks: 50 years
Risk Factors
Major
• Advancing age
• Female (average risk 8-10%)
• Family history: direct family member…
− 1 x > 50 years = 12%
− 2 x > 50 years = 16%
− 1 x < 50 years: 22%
− 2 x < 50 years: 40%
• Genes
− BRCA 1; BRCA 2
⎫ 80% risk of breast Ca; develop cancer earlier: 40 years
⎫ Associated Ca
♣ Woman
¬ Ovarian 60%
¬ Colon 29%
¬ Stomach 25%
♣ Men
¬ Prostate
• History of breast cancer
• Carcinoma in-situ
Minor
• Hormones
− Menarche – younger
− Oral contraception
− Parity: age at first birth, number of full births
− Lactation?, at what age, for whole long?
− Menopause- older
− > 5 years HRT
− Obesity
• Other
− Smoking
− Alcohol
− Radiation (mammogram associated with 0.5% risk – benefits outweigh risks)
Pathology
Epithelial :originating in the duct lobular unit first spread by lymphatics
1. Non-invasive (hasn’t penetrated basement membrane) pre-malignant
− DCIS develop into ductal Ca
⎫ Often multifocal
⎫ 80% non-palpable; detected by screening mammogram
⎫ 35% multicentric
⎫ Risk: up to 35% in 10 years
− LCIS develop into ductal or lobular Ca
⎫ No palpable mass, no mammographic findings, usually incidental finding on breast biopsy for another indication
⎫ 60-80% multicentric and bilateral
2. Invasive
− Common
⎫ IDC (70-80%)
♣ Always develop from DCIS
⎫ ILC (5-10%)
♣ Can be sporadic; not always from LCIS
♣ 20% multicentric and/or bilateral
− Uncommon
⎫ Medullary (better prognosis than IDC)
⎫ Tubular
⎫ Papillary
⎫ Mucinous
Non-epithelial (from supporting stroma) aka sarcoma first spread by haem • Malignant phylloides tumour • Liposarcoma • Fibrosarcoma • Angiosarcoma
Investigations
- Clinical
- Imaging
− <35 years: u/s )as breast too dense)
− >35 years: mammogram
⎫ Objective
♣ Extent of infiltration
♣ Assess other breast
♣ Before biopsy can bleed = haematoma = distortion
⎫ Findings of Ca
♣ Hypodense mass
¬ Poorly defined mass
¬ Radiating spicules (border)
¬ Microcalcifications
♣ Lymph node involvement
¬ Normal: oval, small, fatty hilum; cancerous: round, > 1cm; no fatty hilum
♣ Invasion: muscle, skin - Sampling
− Fine needle biopsy = cytology (cells) when you don’t think its malignant
⎫ Green needle. 20ml syringe (better suction)
⎫ No local: to painful to infiltrate; cause double pain with FNA
⎫ Representative biopsy: going in and out at different angles 3 times
⎫ Smear on glass
− Core needle biopsy/true cut biopsy (u/s guided) = Histology (piece of tissue) when you suspect malignancy
⎫ Local: skin, not parenchyma
⎫ Incise skin
Multiple biopsies: 3-4 (ideal if sinks in formalin = ca)
− Incisional biopsy when true cut biopsies repeatedly come back negative
− Excisional biopsy if too small to biopsy
Spread
• Local invasion
• Lymphatic spread
• Haematogenous spread
− Brain
− Lung
− Liver
− Ovaries
− Pouch of douglas (Blumer’s shelf)
− Bone: to bone marrow (in adults = flat bones)
*bone > lungs > pleura > liver > brain
Staging
Approach
- Local (T staging)
− Ultrasound/mammagram - Nodes
− Palpation
− Sentinel biopsy - Metastases
− Brain
⎫ Clinical: headache, seizures, neurological fallout, signs of raised intracranial pressure
⎫ CT
− Lung
⎫ Examination: pleural effusion
⎫ Chest x-ray: pleural effusions; cannonball lesions
⎫ CT chest
− Liver
⎫ Palpate: hepatomegaly
⎫ LFT: ALP
⎫ Ultrasound/CT abdomen
− Ovaries
⎫ PV
⎫ Ultrasound/CT abdomen
− Pouch of douglas (Blumer’s shelf)
⎫ Rectal examination
⎫ Ultrasound/CT abdomen
− Bone
⎫ Examination: palpate bones
⎫ Chest x-ray (sternum, ribs, vertebrae); pelvic x-ray (pelvis)
⎫ LFT: ALP; calcium levels
⎫ If no evidence on chest-x-ray but clinical signs bone scan
Staging
TNM
• T
− is: carcinoma insitu
− 1: < 2cm
− 2: 2-5cm
− 3: > 5cm
− 4:
A. Chest wall
B. Skin
C. Both 4A + 4B
D. Inflammatory Ca
• N
− 1: mobile, ipsilateral axillary
− 2: immobile, ipsilateral axillary
− 3:
A. Ipsilateral infraclavicular
B. ipsilateral internal mammary lymph nodes
C. ipsilateral supraclavicular lymph nodes
• M
− 1: mets
Stages
• Stage 1:
A. T1
B. T2
• Stage 2
A. T1,N1
B. T2,N1 or T3
• Stage 3
A. T3, N1 or T1-3, N2
B. T4, N0-2 or T1-4 , N3
• Stage 4: M1Management
Non-invasive
LCIS
• Neoadjuvant
Tamoxifen + follow-up
DCIS
• Surgery
− Tumour
⎫ Lumpectomy
⎫ Masectomy
• Adjuvant
⎫ Radiotherapy (if indicated)
⎫ Tamoxifen
Management
Invasive
Curative: T1,2,3; Any N (resectable)
- Surgery
− Tumour
⎫ Lumpectomy/breast conserving surgery: wide local incision of 2cm
♣ Provided there are sufficient margins not more than 15-20% of breast (size of tumour in relation to the breast) AND < 5cm
♣ Objective: cosmesis
⎫ Mastectomy +- reconstruction (when above not possible)
♣ Radical: breast tissue, skin, pectoralis major and all lymph nodes
♣ Modified: breast tissue, skin, lymph nodes up to stage 2
− Axillary LN’s
⎫ Lumpectomy/breast conserving surgery
♣ Sentinel LN biopsy (SLNB) histology
¬ Use of blue dye (isosulphan blue, methylene blue) or radioactive isotope (Tc-99 sulphur colloid or colloidal albumin) injected in the area of the breast 24 hours before surgery concentrates in the first lymph node (sentinel node) that drains the breast
¬ During the op, look for the SLN by colour, or using a Geiger-Muller counter to detect the node with highest radioactivity
¬ Send node for frozen section
♣ If positive: axillary lymph node dissection (ALND) histology
⎫ Mastectomy
♣ Axillary lymph node dissection (ALND) histology - Adjuvant
− Radiotherapy (to prevent recurrence)
⎫ Consists of 25 to 30 cycles in total, 1 cycle per day from Monday to Friday over five to six weeks
♣ Lumpectomy: always radiotherapy
♣ Mastectomy indication
¬ If >4 nodes positive
¬ Tumour >5 cm
¬ Margins not clear
¬ High grade
− Chemotherapy, hormones (to destroy systemic micrometastases)
⎫ Tumour
♣ T> 2cm always
♣ T: 1cm-2cm N0 only if high histological grade
♣ T< 1cm not given
⎫ Any N
Management
Invasive
Curative: T4, Any N (non-resectable)
- Neoadjuvant (for 6 months)
− Chemotherapy
− Hormones
2. Surgery(once reduced in size)
− Tumour
⎫ Mastectomy
− Axillary LN’s
⎫ Axillary lymph node dissection (ALND) histology
- Adjuvant radiotherapy
− Always (to prevent recurrence; not fix poor surgery)
Management
Invasive
Palliative: M1
- Symptomatic
− Breast: palliative (toilet mastectomy – leave axillary LNs) improve quality of life risk of ulceration + smell etc.)
− Brain: radiation (chemo doesn’t cross blood brain barrier)
− Lungs (pleural effusions) sclerotherapy: tetracycline, talc, neomycin
− Bone: if neurological fallout radiation
Management
Receptors
Oestrogen Progesterone HER KI67
Luminal A + + - < 20% Hormones
Luminal B +/- +/- - >20% Chemotherapy + hormones
HER +/- +/- + Any Chemo or hormonal + herceptin
Triple negative - - - Any Chemotherapy
Basaloid - - - Any Chemotherapy
Management
Chemotherapy
• FAC (cardiotoxic echo first!)
− 5-fluorouracil (5FU), doxorubicin (Adriamycin, A), and cyclophosphamide (Cytoxan, C)
− 6 cycles (1 cycle = 3 weeks; IV chemo on day one only)
• AC and T
− doxorubicin (Adriamycin), and cyclophosphamide (Cytoxan). Paclitaxel (Taxol)/ docetaxel (Taxotere)
− 8 cycles (1 cycle = 3 weeks; IV chemo on day one only)
⎫ First four: AC
⎫ Next four: T
• CMF
− cyclophosphamide (Cytoxan, C), methotrexate, 5-fluorouracil (5FU),
