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MS3 - Breast > Breast cancer > Flashcards

Breast cancer Flashcards

1
Q

Main cause of breast cancer

A

Oestrogen exposure

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2
Q

protective factors against breast cancer

A

breastfeeding

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3
Q

features of family history risk for breast cancer

A
  1. 10% Ca breast is familial
    - One 1st degree relative = 2x risk
  2. 5% assoc. with BRCA mutations
    - BRCA1 (17q) → 80% breast Ca, 40% + ov Ca
    - BRCA2 (13q) → 80% breast Ca
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4
Q

Conditions with increased oestrogen exposure

A
  • Early menarche, late menopause
  • HRT, OCP (Million Women Study)
  • First child >35yrs
  • Obesity
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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
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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
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7
Q

invasive ductal carcinoma o/e?

A
  • Commonest: ~70% of cancers

- Feels hard (scirrhous)

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8
Q

features of phyllodes tumour

A
  • stromal tumour

- large, non-tender mobile lump

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9
Q

methods of spread for breast cancer

A
  1. Direct extension → muscle and/or skin
  2. Lymph → p’eau d’orange + arm oedema
  3. Blood →
    - Bones: bone pain, #, ↑Ca
    - Lungs: dyspnoea, pleural effusion
    - Liver: abdo pain, hepatic impairment
    - Brain: headache, seizures
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10
Q

breast cancer screening

A
  • Every 3yrs from 47-73

- 10% false negative rate.

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11
Q

general presentation of breast cancer

A
  • lump (most common)
  • skin changes
  • nipple changes
  • symptoms of mets
  • screening
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12
Q

presentation of pt with breast lump

A
  • Usually painless
  • 50% in upper outer quadrant
  • ± axillary nodes
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13
Q

presentation of pt with breast skin changes

A
  • Paget’s: persistent eczema

- Peau d’orange

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14
Q

presentation of pt with nipple changes

A
  • discharge

- inversion

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15
Q

presentation of pt with mets symptoms

A
  • Pathological #
  • SOB
  • Abdominal pain
  • Seizures
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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
  1. Bloods
    - FBC, LFTs, ESR, bone profile
  2. Imaging: help staging
    - CXR
    - Liver US
    - CT scan
    - Breast MRI: multifocal disease or with implants
    - Bone scan and PET-CT
  3. 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
  1. Wide Local Excision + radiotherapy (80% treated like this)
  2. 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
Q

evidence for sentinel node biopsy

A
  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
Q

other axillary surgical options

A
  • 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
Q

breast surgical complications

A
  • Haematoma, seroma
  • Frozen shoulder
  • Long-thoracic nerve palsy
  • Lymphoedema
28
Q

Nottingham prognostic index for breast cancer

A
  • 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
Q

general systemic treatment or breast cancer

A
  • radiotherapy
  • chemotherapy
  • endocrine therapy
30
Q

radiotherapy for breast cancer

A
  • 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
Q

chemotherapy for breast cancer

A
  • 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
Q

endocrine therapy for breast cancer

A
  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
Q

treating advanced breast cancer (stage 3-4)

A
  • 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
Q

Reconstruction following breast surgery

A

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
Q

latissmus dorsi myocutaneous flap features

A
  • Pedicled flap: skin, fat, muscle and blood supply
  • Supplied by thoracodorsal A. via subscapular A.
  • Usually used with an implant
36
Q

Transverse rectus abdominis myocutaneous flap features

A
  • 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

MS3 - Breast (1 decks)

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