Breast Cancer Flashcards
What are risk factors of breast cancer?
Family history - Genetic - BRCA1 and BRCA2 Uninterrupted oestrogen exposure: - Nulliparity - 1st pregnancy > 30 years old Early menarche Late menopause Combined hormone replacement Therapy COCP Not breastfeeding Past breast cancer
What are the types of breast cancer?
Ductal - arise from duct tissue
Lobular - arise from lobular tissue
Invasive - spreads beyond local tissue
In-situ - does not spread beyond local tissue
Invasive ductal carcinoma
Invasive lobular carcinoma
Ductal carcinoma in-situ
Lobular carcinoma in-situ
What is the most common type of breast cancer?
Invasive ductal carcinoma
(No special Type NST)
70%
10-15% are invasive lobular carcinoma
Others: Medullary Mucinour Tubular Denoid cystic
Paget’s disease of the nipple
Inflammatory breast cancer
What must you consider for prognosis of breast cancer
Oestrogen receptor +ve indicates a better prognosis HER2 +ve (growth factor receptor gene) is associated with aggressive disease and poorer prognosis
What is Paget’s disease of the nipple? How can you tell it is Paget’s and not other DDx?
Eczematoid change of the nipple associated with underlying breast malignancy
In half of these patients it is associated with underlying mass lesion such as invasive carcinoma
Differs from eczema of the nipple in that it involves the nipple primarily and only later spreads to the areolar.
(The opposite occurs in eczema)
How do you investigate for breast cancer?
Triple assessment:
- Clinical examination
- Radiology: ultrasound for <35years and US for >35yyears
- Histology/cytology (FNA or US guided core biopsy - best for new lumps)
What should you consider if there is clear fluid on biopsy/aspirate
Reassurance if there is not FHx and biopsy shows a non-proliferative lesion
When should you refer 2WW for breast caner?
30+ with an unexplained breast lump with or without pain
50+ with any of following in one nipple only:
Discharge
Retraction
Other changes of concern
If <30 - consider non-urgent referral with unexplained breast lump with or without pain
How is breast cancer staged?
Stage 1: Confined to breast, mobile
Stage 2: Growth confined to breast, mobile, lymph nodes in ipsilateral axilla
Stage 3: Fixed to muscle, ipsilateral lymph nodes fixed, skin involvement larger than tumour
Stage 4: Complete fixation of tumour to chest wall, distant mets
OR TNM
T1 <2cm T@ 2-5cm T3 >5cm T4 - fixed to chest wall or peau d’orange
N1 - mobile ipsilateral nodes N2 fixed nodes
M1 distant mets
What are options for management of breast cancer?
Surgery Radiotherapy Chemotherapy Hormonla Endocrine Agents Reconstruction
What are surgical options?
Mastectomy
Wide Local Excision
With axillary node sampline/surgical clarance or sentinel node biopsy
± Breast reconstruction
What are indications for mastectomy vs Wide Local Excision
Mastectomy: Multifocal tumour Central tumour Large lesion in small breast DCIS > 4cm Patient choice
Wide Local Excision: Solitary lesion Peripheral tumour Small lesion in large breast DCIS < 4cm Patient choice
What is a sentinel node biopsy?
Biopsy of first draining lymph node of breasts
Decreases axillary clearances in lymph node negative patients
Patent blue/radiocolloid dye injected into periareolar area or tumour
Gamma probe/visual inspection used to identify sentinel node
Biopsied and sent for histology and immunohistochemistry and further clearance only if positive
What radiotherapy for breast cancer?
After wide local excision to reduce risk fo recurrence
What chemotherapy?
Adjuvant chemotherapy reduces recurrence
E,g, Cyclophosphamide + Methotrexate + 5-FU
What hormonal therapy?
Aim to reduce oestrogen activity in oestrogen receptor positive or progesterone receptor positive disease
Tamoxifen is a ER blocker
- Can cause endometrial cancer - report PV bleeding
Aromatase inhibitors (Anastrozole) reduces peripheral oestrogen synthesis - used in post-menopausal women
Ovarian ablation GnRH analogues (Goserelin)
What conservative management for breast cancer
Breast care nurses
Emotional/psychological support
What biological therapy for breast cancer?
Trastuzumab (Herceptin)
Useful for HER2 positive tumours in combination with chemotherapy
Who is screened for breast cancer?
2 view mammography
Every 3 years
47-73 years old
When can women at increased risk due to FHx be offered screening?
One first degree female relative diagnosed with breast cancer at younger than 40
One first degree male relative with breast cancer at any age
One first degree relative with bilateral breast cancer where the first was diagnosed < 50
Two first degree relatives/one first and one second-degree relative with breast cancer at any age
What are prognostic factors in breast cancer?
Tumour size Grade Lymph node status ER/PR status Presence of vascular invation
Nottingham Prognostic Index is widely used
0.2x tumour size x histological grade + nodal status
