breast cancer Flashcards
what are the risk factors for breast cancer ?
previous breast cancer
family history / BRCA positive or TP53 mutation
age
oestrogen exposure:
- nulliparous / >30 first pregnancy
- early menarche/ late menopause
- HRT/ COCP
previous radiation to chest
lack of breast feeding
high fat diet, obesity, lack of exercise, high alcoholhow can breast cancers be classified ?
most cancer arise from epithelial lining of ducts
cancers can be invasive or not (in situ):
- non invasive:
1. ductal carcinoma in situ (DCIS) - unifocal or widespread but do not invade basement membrane so limited to ductal system
2. lobular carcinoma in situ (LCIS) - multifocal - invasive:
1. invasive ductal carcinoma (85%) - breaks through BM and invades
2. invasive lobular carcinoma
3. others - tubular, mucinous, papillary and medullayr
how do breast cancers present? (breast, systemic, metastatic)
breast symptoms:
- lump, asymmetry, retraction/dimpling
- skin changes: peau d’orange, redness, itching
- nipple: discharge, retraction, displacement , inversion
- mastalgia, temperature change
Systemic upset/ paraneoplastic:
- weight loss, anaemia (pallor, pale conjunctiva)
- signs of dehydration
- maybe fever/ night sweats (more lymphoma/leuk)
- thrombophlebitis/ thrombocytosis - DVT symptoms
- dermatomyositis
symptoms of metastasis
- bone pain, fractures, hypercalcaemia, vertebral collapse
- hepatomegaly and jaundice, ascites
- brain: focal neurology, memory/personality change, seizures, N&V, cranial nerve palsies and sensory deficit
- spinal cord compression
- pericardium, pericardial effusion and AF
- lung: consolidation, pleural effusion
- fundoscopy - choroidal mets
- lymphadenopathy - axillary, supraclavicular, cervical, lymphoedema
what is the referral criteria by NICE for breast cancer
2ww for those
- > 30yrs with unexplained lump without pain
- > 50yrs with unilateral nipple changes (discharge, retraction)
those <30 with lump have less urgent referral
where do breast cancers spread?
lymphatics
vasculature
locally - pericardium, pleura etc
metastasis - brain, bone, lung, liver, adrenals, ovaries
what is the arterial supply to the breast?
external mammary (lateral thoracic) internal mammary (thoracic) intercostal arteries
what is Pagets disease of the nipple?
defined as chronic eczematous change of nipple.
associated with high grade invasive cancer where malignant cells infiltrate into epidermis via mammary duct epithelium.
cells proliferate - thick skin, scaling , erythematous, discharge, itching
all eczema of breast should be investigated for breast cancer.
how do the majority of intraductal carcinomas present?
painless lump with bloody nipple discharge
how does inflammatory breast carcinoma present?
large rapidly growing mass that is painful.
red and warm overlying skin
how are breast lumps assessed/ diagnosis of breast cancer?
Triple therapy
- clinical examination
- imaging
- cytology/ histology
how are breast cancers clinically assessed in the triple assessment?
examination by inspection and palpation of the breast
palpation of axillary nodes
how are breast cancers imaged in triple assessment?
bilateral mammogram for those >35yrs
USS / MRI for those <35 yrs (because young women have dense breast)
MRI indicated for dense breasts, lobular carcinoma, <40yrs, good for BRCA associated cancers.
how is cytological / histological information obtained in triple assessment?
fine needle aspiration for cystic lumps
- quick and less uncomfortable - negative results does not exclude (false negatives are common ) but false positives are rare.
sterotactic core biopsy (sterotactic = image guided) - for solid lumps
- more pain and takes longer but can determine expression of receptors and grade of tumour
wide local excisional biopsy - complete removal of tumour (part of treatment)
incisional biopsy - part of lesion is removed if >/= 4cm
what are the features of malignancy on mammogram?
irregular
speculated
radio-opaque mass
microcalcifications - can be benign or malignant need to be confirmed by histology
what does cancer staging depend on?
type, size, margins, nodes, distant metastasis, grade, vascular/ lymphatic infiltration, receptor expression
what staging investigations are required for lung cancer?
node biopsy:
- for all patients with early invasive breast cancer but no evidence of axillary node involvement do a sentinel node biopsy.
- for those with palpable lymph node - FNA of node and cytological examination.
- if either of the above are positive, axillary clearance is indicated (removal of 11-20 nodes)
cytogenetics: receptor expression (ER, Progesterone, HER2)
bloods - LFTs, FBC, Ca, bone profile
imaging:
- CXR, USS liver
- CT CAP if abnormal LFT, CXR, hepatomegaly, neurological signs or lymphadenopathy.
- bone scan/ scintigraphy - if bone pain, local advanced disease or lymph node involvement
- PET scan
what is a sentinel node biopsy?
inject blue dye into the tumour and the first node draining the tumour will be the first to appear blue thus the sentinel node can be identified and excised for histology.
sentinel node = first node in drainage of tumour.
what tumour markers are found in breast cancer?
CEA and CA125
describe stages 0 to 4 in breast cancer.
0= cancer only found in epithelial membrane of duct/ lobule 1 = confined to breast, mobile, <2cm 2 = confined to breast, ipsilateral axillary nodes, 2-5cm, mobile 3 = fixed to muscle, ipsilateral axillary nodes, matted, may have spread to overlying skin >5cm 4 = complete fixation to chest wall, distant metastasis.
describe the TNM staging for breast cancer.
T1 = <2cm T2 = 2-5cm T3 = >5cm T4 = fixed to chest wall/ peau d'organge
N1 = mobile ipsilateral nodes N2 = fixed nodes N3 = ipsilateral mammary nodes
M1 = distant metastasis
describe the stepwise management of treat stage 1 - 2 breast cancer
- surgery: wide local excision or massectomy to remove mass
- axillary node surgery: sentinel node biopsy +/- axillary clearance
- adjuvant radiotherapy after wide local excision to stop local recurrence. may also need radiotherapy to chest wall in high risk massectomy patients. May also use radiotherapy on axilla if lymph node positive but no axillary clearance was performed
- adjuvant chemotherapy - for advanced receptor negative disease
OR adjuvant hormonal therapy if receptor positive. e.g. tamoxifen
when may neoadjuvant chemotherapy be used in breast cancer?
neoadjuvant chemo may be used in large inflammatory carcinomas to reduce tumour size before surgery and reduce the need for massectomy. MRI can be used to monitor response to neoadjuvant chemo before surgery.
however usually treatment starts with surgical removal.
