Breast cancer Flashcards
1
Q
Main cause of breast cancer
A
Oestrogen exposure
2
Q
protective factors against breast cancer
A
breastfeeding
3
Q
features of family history risk for breast cancer
A
- 10% Ca breast is familial
- One 1st degree relative = 2x risk - 5% assoc. with BRCA mutations
- BRCA1 (17q) → 80% breast Ca, 40% + ov Ca
- BRCA2 (13q) → 80% breast Ca
4
Q
Conditions with increased oestrogen exposure
A
- Early menarche, late menopause
- HRT, OCP (Million Women Study)
- First child >35yrs
- Obesity
5
Q
types of breast cancer
A
- ductal carcinoma in situ/lobular carcinoma in situ
- invasive ductal carcinoma
- invasive lobular (~20% of cancers)
- medullary (affects younger pts, feels soft)
- colloid/mucinous (occurs in elderly)
- inflammatory (pain, erythema, swelling, peau d’orange)
- papillary
- phyllodes tumour
6
Q
Ductal carcinoma in situ/lobular carcinoma in situ mammogram feature?
A
- Non-invasive pre-malignant condition
- Microcalcification on mammography
- 10x ↑ risk of invasive Ca
7
Q
invasive ductal carcinoma o/e?
A
- Commonest: ~70% of cancers
- Feels hard (scirrhous)
8
Q
features of phyllodes tumour
A
- stromal tumour
- large, non-tender mobile lump
9
Q
methods of spread for breast cancer
A
- Direct extension → muscle and/or skin
- Lymph → p’eau d’orange + arm oedema
- Blood →
- Bones: bone pain, #, ↑Ca
- Lungs: dyspnoea, pleural effusion
- Liver: abdo pain, hepatic impairment
- Brain: headache, seizures
10
Q
breast cancer screening
A
- Every 3yrs from 47-73
- 10% false negative rate.
11
Q
general presentation of breast cancer
A
- lump (most common)
- skin changes
- nipple changes
- symptoms of mets
- screening
12
Q
presentation of pt with breast lump
A
- Usually painless
- 50% in upper outer quadrant
- ± axillary nodes
13
Q
presentation of pt with breast skin changes
A
- Paget’s: persistent eczema
- Peau d’orange
14
Q
presentation of pt with nipple changes
A
- discharge
- inversion
15
Q
presentation of pt with mets symptoms
A
- Pathological #
- SOB
- Abdominal pain
- Seizures
16
Q
differential diagnosis of breast pathology
A
- Cysts
- Fibroadenomas
- DCIS
- Duct ectasia
17
Q
Initial radiological investigation for a lump? Pathological Ix?
A
Radiology - <35yrs: US - >35ys: US + mammography 3. Pathology - Solid lump: tru-cut core biopsy - Cystic lump: FNAC (green / 18G needle) > Reassure if clear fluid > Send cytology if bloody fluid > Core biopsy residual mass > Core biopsy if +ve cytology
18
Q
other investigations for suspected breast cancer
A
- Bloods
- FBC, LFTs, ESR, bone profile - Imaging: help staging
- CXR
- Liver US
- CT scan
- Breast MRI: multifocal disease or with implants
- Bone scan and PET-CT - May need wire-guided excision biopsy
19
Q
clinical staging of breast cancer
A
- Stage 1: confined to breast, mobile, no LNs -
Stage 2: Stage 1 + nodes in ipsilateral axilla - Stage 3: Stage 2 + fixation to muscle (not chest wall)
LNs matted and fixed, large skin involvement - Stage 4: Complete fixation to chest wall + mets
20
Q
TNM staging of breast cancer
A
- Tis (no palpable tumour): CIS
- T1: <2cm, no skin fixation
- T2: 2-5cm, skin fixation
- T3: 5-10cm, ulceration + pectoral fixation
- T4: >10cm, chest wall extension, skin involved
- N1: mobile nodes
- N2: fixed nodes
21
Q
breast cancer surgery options
A
- Aim = gain local control
- Wide Local Excision + radiotherapy (80% treated like this)
- Mastectomy
- Typically large tumours >4cm
- Multifocal or central tumours
- Nipple involvement
- Pt. choice
- Not radical: no longer used
N.B. Same survival, but WLE has ↑ recurrence rates
22
Q
Gold standard biopsy for breast lump
A
sentinel node biopsy
23
Q
rational for sentinel node biopsy
A
- sentinel node = first node that a section of breast drains to.
- If clinically –ve axillary LNs, no need for further dissection
if SN is clear.
24
Q
sentinel node biopsy procedure
A
- Blue dye / radiocolloid injected into tumour
- Visual inspection / gamma probe @ surgery to ID Sentinel node
- sentinel node removed and sent for frozen section
- If node +ve → axillary clearance or radiotherapy
25
evidence for sentinel node biopsy
1. 2 RCTs compared Sentinel Node Biopsy vs. Sentinel Node Biopsy + axillary clearance
2. No differences in overall or disease-free survival
3. ↓ morbidity with Sentinel Node Biopsy alone
- Lymphoedema
- Pain
- Numbness
26
other axillary surgical options
- For clinically -ve axilla options included
1. Axillary sampling
- Removal of lower nodes
- Clearance or DXT if +ve
2. Axillary clearance
- Can be done to various levels
27
breast surgical complications
- Haematoma, seroma
- Frozen shoulder
- Long-thoracic nerve palsy
- Lymphoedema
28
Nottingham prognostic index for breast cancer
- Predicts survival and risk of relapse
- Guides appropriate adjuvant systemic therapy
- (0.2 x tumour size) + histo grade + nodal status
> Histo grade: Bloom-Richardson system (1-3)
29
general systemic treatment or breast cancer
- radiotherapy
- chemotherapy
- endocrine therapy
30
radiotherapy for breast cancer
- Post-Wide Local Excision: ↓ local recurrence
- Post-mastectomy: only if high risk of local recurrence
> Large, poorly differentiated, node +ve
- Axillary: node +ve disease
- Palliation: bone pain
31
chemotherapy for breast cancer
- Pre-menopausal, node +ve, high grade or recurrent
tumours.
- Neo-adjuvant chemo improves survival in large tumours
- 6 x FEC: 5-FU, Epirubicin, Cyclophosphamide
- Trastuzumab (anti-Her2) is used if Her2+ve
- Side Effects: cardiac toxicity
32
endocrine therapy for breast cancer
1. Tamoxifen
> Selective Oestrogen Receptor Modulator: antagonist @ breast, agonist @ uterus
> SE: menopausal symptoms, endometrial Ca
2. Anastrazole
> Aromatase inhibitor → ↓ oestrogen
> Better than tamoxifen if post-men (ATAC trial)
> SE: menopausal symptoms
- If pre-menopausal and ER+ve may consider ovarian ablation or GnRH analogues (e.g. goserelin)
33
treating advanced breast cancer (stage 3-4)
- Tamoxifen if ER+ve
- Chemo for relapse
- Her2+ve tumours may respond to trastuzumab
Supportive
- Bone pain: DXT, bisphosphonates, analgesia
- Brain: occasional surgery, DXT, steroids, AEDs
- Lymphoedema: decongestion, compression
34
Reconstruction following breast surgery
Offered either at 1O surgery or as delayed procedure.
Implants: silastic or saline inflatable
- latissimus dorsi myocutaneous flap
- tranverse rectus abdominis myocutaneous flap
- nipple tattoo
35
latissmus dorsi myocutaneous flap features
- Pedicled flap: skin, fat, muscle and blood supply
- Supplied by thoracodorsal A. via subscapular A.
- Usually used with an implant
36
Transverse rectus abdominis myocutaneous flap features
- Gold-standard
- Pedicled (inf. epigastric A.)
- Or free: attached to internal thoracic A
- No implant necessary and combined tummy tuck
- CI if poor circulation: smokers, obese, PVD, DM
- Risk of abdominal hernia
