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Cancer care > Breast cancer > Flashcards

Breast cancer Flashcards

1
Q

Anatomy of the breast

A
  • Overlies pec major + serratus anterior, from 2nd to 6th rib
  • Tissue is glandular, fibrous tissue + fat
  • The glandular tissue s divided into lobes radiating around nipple, ducts from lobes open to nipple surface
  • mammary glands: modified sweat glands as series of ducts + secretory lobules, each lobule drained by a lactiferous duct, ducts converge at the nipple
  • connective tissue stroma which condenses to suspensory ligaments of cooper, which attach the breast to the dermis + percotrla fascia
  • pectoral fascia: base of breast lies on this
  • retromammary space: layer of loose CT between breast + PF, potential space, used in reconstructive surgery
  • vascular: internal thoracic artery (medial, from subclavian), lateral side branches from axillary + intercostal arteries
  • lymph: 75% to axillary nodes, 20% to parasternal nodes, 5% to posterior intercostal nodes
  • neuro: cutaneous branches of 4th-6th intercostal nerves, lactation controlled y prolactin
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2
Q

What are the common types of breast lumps in different age groups?

A
  • 20s - fibroadenoma
  • 30-50 - fibrocystic changes
  • 50s - cysts
  • > 50 - cancer
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3
Q

What should you note when describing a breast lump?

A
  • number
  • size in cm
  • shape, well circumscribed or not
  • location by quadrant or clock face
  • mobile/fixed
  • skin changes
  • fluctuant?

remember chaperone!

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4
Q

Where do the majority of breast cancers arise?

A

Upper outer quadrant

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5
Q

What are the main features of breast examination?

A
  • inspection on edge of bed, look for scars dimpling redness symmetry, nipple direction, tethering
  • manouevres: look if equal. slowly raise arms to ceiling, hands on hips and push down/Buddha
  • palpate cervical, supraclavicular + axillary LN (sub scapular, lateral, central + pectoral; hold their arm with same hand and examine w opposite hand)
  • palpate breast tissue with hand resting above side examined, note clock face position, size in mm, shape, surface, consistency (soft-ear lobe, firm-nose, hard-chin), margins, mobility, fixation, nipple
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6
Q

What is the P score in a breast clinic?

A

P1=completely normal
P2=benign change
P3-4=intermediate
P5=definitely cancer

Features of cancer based on shape (irregular), surface (craggy), consistency (hard), margin (ill-defined), mobility (fixed), skin changes like oedema/dimpling/red, inverted nipple, large matted LN

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7
Q

Causes of breast pain

A
  • Cyclical: physiological, fibroadenosis

* Non-cyclical: fibroadenosis, infection, carcinoma (uncommon)

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8
Q

Causes of lumps

A
  • Soft: lipoma, cyst
  • Hard: cancer, fibroadenoma, cyst, fat necrosis, inflammation
  • Visible: cyst, carcinoma, Phylloides
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9
Q

Causes of skin changes

A
  • Dimpling/tethering: cancer
  • Peau d’orange: cancer (dermal oedema) or infective
  • Redness: infection (hot), mammary duct ectasia, inflammatory cancer
  • Ulceration: neglected slow-growing carcinoma
  • Eczematous rash of nipple/areola: Paget’s disease (esp u/l + persistent)
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10
Q

Causes of nipple changes

A
  • Recent inversion or shape change: cancer or mammary duct ectasia (both fibrosis underneath lesion)
  • Discharge: pregnancy/hyperprolactinaemia (milky), physiological (clear), peri-menopause/duct ectasia/cyst (green), cancer/ductal papilloma (bloody)
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11
Q

Mastalgia

A
  • Cyclical - usually b/l in PMS or from HRT
  • Non-Cyclical - meds like contraception/AD/antipsychotics, or extra-mammary

M: reassure, pain control, better bra/soft support at night, if v bad Danazol (anti-gonadotrophin)

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12
Q

Fibroadenoma

A

Occur @ repro age as a highly mobile lump

Leave alone unless v big

May calcify in old age

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13
Q

Ductal adenoma

A

Benign tumour usually in older females, nodular so can mimic cancer

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14
Q

Intraductal papilloma

A

Females in 40-50 typical

Mostly near lactiferous duct near nipple - may cause bloody/clear discharge from a single duct

Often excised to check not cancer (but not pre-malignant)

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15
Q

Lipoma

A

Soft mobile adipose tumour, low MP, only remove if sx

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16
Q

Phylloides tumour

A

Fibroepithelial tumour, often older women
1/3 have malignant potential so WLE these
‘leaf like’

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17
Q

Breast abscess

A

Tender fluctuant mass usually due to S aureus

M: ABx, aspirate, may debride

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18
Q

Gynaecomastia

A

Male breast tissue due to imbalanced ratio of O:T

99% benign

Causes: physiological (newborn, adolescent delayed T surge/older people have less T), low testosterone (Klinefelter, renal disease), high oestrogen (liver disease, obesity, Leydig cell tumours), medication causing either increased oestrogen or reduced testosterone (digoxin, metronidazole, spironolactone, antipsychotics, anabolic steroids, cannabis)

CF: rubbery/firm mass from nipple growing out, sometimes tender
-Differential is pseudogynaecomastia which is just fat

M: tamoxifen can help if tender

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19
Q

Mastitis

A

Acute/chronic inflammation usually a/w S aureus infection but can also be in neonates

Causes: lactational (esp in first 3m of bf/weaning, causes cracked nipples + milk stasis) or non-lactational (central inflammation, RF is smoking as duct walls damaged)

RF: obesity, large breasts, eczema, poor hygiene, smoking

CF: red tender swollen breasts, nipple retraction, discharge, may lead to cellulitis/abscess

M: washing + drying, continue milk drainage as otherwise will get blocked, antifungal/steroid cream or broad spec Abx as appropriate

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20
Q

Fibroadenosis/fibrocystic disease

A

Occurs in reproductive age group usually 30-50ish, as breasts continually changing due to hormones

Can cause focal/general modularity and often painful, cysts in distended lobules, may be tender or fluctuant, may have fibrosis

Aspirate as 2-3x increased breast cancer risk

21
Q

Mammary duct ectasia

A

Chronic inflammation due to dilated shortened lactiferous ducts, common in post-menopausal

CF: green/yellow/cream discharge from single/multiple ducts, mass, symmetrical slit-like nipple retraction

Is a normal variant of breast involution, if DC is a problem can excise the duct

22
Q

Periductal mastitis

A

Younger age group than duct ectasia, more common in smokers

CF: inflammation, abscess, mammary duct fistula

23
Q

Fat necrosis

A

Acute inflammation due to ischaemic necrosis of fat lobules

P/w a lump, sometimes other breast changes. Self limiting but exclude cancer

24
Q

Mondor’s disease

A

Local thrombophlebitis of a breast vein

25
Q

RF for breast cancer

A
  • Men - usually a/w BRCA mutations
  • Familial in 10%: BRCA1/BRCA2/TP53 mutations
  • Prolonged oestrogen window so early menarche, late menopause, nulliparity, COCP + HRT all increase risk, as well as obesity
  • Not breastfeeding
  • Previous BC
  • Atypical duct or lobule hyperplasia
  • Post-menopausal obesity as androgens converted to oestrogens in adipose
  • High alcohol consumption
26
Q

What is the main histological type of breast cancer?

A

Adenocarcinoma

27
Q

Non-invasive breast cancer

A

I.e. confined to the basement membrane

  • Ductal carcinoma in situ: commonest, 20-30% become invasive if don’t treat - usually WLE/mastectomy
  • Lobular carcinoma in situ: rarer but much higher risk of invasion, more in pre-menopausal asymptomatic women
28
Q

Invasive breast cancer

A
  • Invasive ductal carcinoma (80%): often no special type
  • Invasive lobular carcinoma (10%)l more older women, diffuse stromal pattern so harder to pick up
  • Well-differentiated types (often better prognosis): medullary (young, a/w BRCA1), mucinous, tubular, papillary (central so often DC), metaplasic (the exception as large + often triple neg)
  • Inflammatory BC: v aggressive, cf diffuse erythema, peau d’orange (dermal lymphatic invasion), suspect in older women not responding to Abx, may be masked in pregnancy by chronic mastitis
  • Paget’s disease of nipple: underlying carcinoma, in the nipple-areola complex, usually u/l insidious lesion causing an eczematous change/itch/red on nipple + areola, flattened nipple, discharge
  • Phylloides tumour: may be borderline or malignant, dep on histology
29
Q

Male breast cancer

A

Linked to BRCA2, Klinefelter

M: mastectomy + Tamoxifen (most ER+)

30
Q

Where do breast cancers typically metastasise to?

A

Bone, lung, liver, brain, adrenals, ovary

Lobular carcinoma a/w unusual mets like skin + GIT

31
Q

Breast cancer screening

A

47-73 / 50-70 (self refer if over), invited if reg with GP every 3y
or
if have a high risk condition invited more often

is for mammogram

32
Q

Radiological features

A

Mammograms if >40 with any breast symptoms, of USS if <40 with abnormality on examination (no point in pain as US can only show discrete areas); MRI 2nd line

Mammogram signs: irregularity, spiculated, radio-opaque masses, micro-calcification

33
Q

Pathological investigations

A
  • FNA: for cytology. Quick but only see cells so if malignant cells present need biopsy
  • Core biopsy: removes small amount of tissue for histology, can determine receptor status + tumour grade – check ER + HER2 receptors, as PR usually correlates with ER
  • Punch biopsy for nipple lesions
34
Q

What is the triple assessment?

A

Process at breast clinic for any symptomatic breast

  1. Clinical: brief history (about the lump, FH of any cancer, menopausal, meds/hormones (esp HRT, anticoagulants), relevant PMH like radiotherapy for lymphoma) and examination P1-5 score
  2. Imaging: M or U score, in specific cases like BRCA carriers may do MRI
  3. Biopsy for B score or C score for FNC

Then go to a breast results clinic where surgeon gives results + management options, and breast care nurse to answer further qs + adv about access to BCNs + arrange any further ix

35
Q

Staging

A

TNM
T based on side; inflammatory breast cancer automatically is T4d
N
M

36
Q

Outline the management options for breast cancer

A
  • Surgery: in all unless very unwell or frail. WLE for breast conservation, or mastectomy, always offered reconstruction. Based on CF + patient choice. Also do sentinel LN sampling, unless clinical/radiological evidence of enlarged in which case do dissection
  • Adjuvant radiotherapy: after WLE or to chest wall after mastectomy if RF for recurrence like a large high grade tumour
  • In pre-menopausal may reduce oestrogen via oophorectomy or GnRH analogue to down regulate pituitary
  • Endocrine treatments
  • Adjuvant chemotherapy if high risk, less effective if hormone receptor positive
  • Targeted therapy with trastuzumab, +/- pertuzumab (MAB) or lapatinib (TKi)
  • Neoadjuvant if need to make it smaller for surgery
  • Palliative treatment can also add many years like surgical resection of unifocal mets, endocrine treatments, chemo, anti-osteolytic with bisphosphonates/denosumab (anti-RANKL MAB)
37
Q

Who is eligible for endocrine treatment?

A

Tumours that are ER positive

  • Pre-menopausal: usually tamoxifen
  • Post-menopausal: usually a mixture of tamoxifen and an aromatase inhibitor
38
Q

How do endocrine therapies work?

A

Given after surgery/radio

  • Tamoxifen: SERM so a mixed agonist/antagonist of oestrogen receptor. Is also bone-protective
  • Fulvestrant: a more selective SERM
  • Synthetic progestogens e.g. medroxyprogesterone acetate. Acts on PR receptor + affects pituitary/adrenals, can be used in metastatic instead of tamoxifen
  • Aromatase inhibitors like anastrozole, letrozole. They reduce oestrogen by blocking aromatase thus reducing oestrogen production in post-menopausal women only
39
Q

Side effects of endocrine therapies

A

They’re because of oestrogen deprivation and usually last the course of the treatment (5y standard)

  • Tamoxifen: hot flush, weight gain, mood change, PV discharge, thromboembolism, endometrial hyperplasia/neoplasia
  • AIs: hot flush, vaginal dryness, arthralgia, skin rash, osteoporosis, adverse lipid profile
40
Q

Targeted therapies

A

Given if cancer over-expresses the HER2 receptor (in about 20%) – trastuzumab (Herceptin)

  • Monoclonal antibody given IV or SC
  • ADR - myocardial toxicity - do not give with anthracyclines + monitor LVEF before + during
  • MAB pertuzumab or TKi lapatinib useful when used alongside
41
Q

What factors indicate a poorer prognosis?

A
  • Young age, pre-menopausal
  • Large high grade tumour
  • Triple negative (ER, PR + Her2 receptor negative)
  • Positive nodes
42
Q

What is the Nottingham Prognostic Index?

A

A calculation to estimate the prognosis based on tumour size, grade and node
% correlates to a % 10y survival

43
Q

What increases the likelihood of having a BRCA mutation?

A

mother/sister BC <40; 2 close relatives from same side of family with BC (one must be mother/sister/daughter); 3 close relatives BC any age; dad/bro BC; mum/sister with cancer in both breasts with first cancer <50; one close with OC and one with BC (at least one mum/sister/daughter); close relative of Ashkenazi Jewish origin with BC/OC; close relative with pancreatic cancer and breast/ovarian

44
Q

Paget’s disease vs eczema?

A

Eczema usually involves areola and spares nipple

Paget’s usually starts at nipple and spreads to areola

45
Q

Epidemiology

A

Commonest breast cancer in women who don’t smoke

46
Q

What is triple negative breast cancer?

A

When ER, PR + HER2-receptor negative
in 15%
a/w BRCA + younger patients
if they respond to chemo they have a good prognosis (about half)

47
Q

Why are AI preferable in post-menopausal women?

A

Although they have a similar efficacy to tamoxifen, there is a lower risk of VTE + uterus hyperplasia (which older people are more susceptible to anyway)

48
Q

Benign breast tumours

A
  • Fibroadenoma – most common, in women of reproductive age, highly mobile on palpation, made up of stromal + epithelial tissue, v low malignant potential, most leave unless really big. Localised form of the changes in breast tissue rather than an actual tumour. Can calcify in old age.
  • Adenoma – ductal adenoma, benign glandular tumour, usually older females, nodular lesions so can easily mimic malignancy so most go the clinic
  • Papilloma – intraductal papilloma, in females 40-50s, most in subareolar region near nipple (near lactiferous duct) so can cause bloody/clear discharge (as fibrovascular core) from a single duct, can appear similar to ductal carcinoma on imaging so usually biopsied, sometimes excised to ensure no other atypical cells, but they aren’t pre-malignant + don’t increase risk of cancer
  • Lipoma – soft, mobile, adipose tumour, low malignant potential, normally only removed if compressing/symptoms
  • Phyllodes tumour – rare fibroepithelial tumours, often larger and in older people, epithelial + stromal tissue, 1/3 have malignant potential so most are widely excised. ‘Leaf like’ on microscopy
  • Breast abscess – infection usually with S aureus, causes a tender fluctuant mass, treat with Abx and aspiration. If there is overlying skin necrosis need surgical debridement
  • TB – rare in the west, usually secondary, half have a chronic breast/axillary sinus
49
Q

What infections can you get in the breast and who is most at risk?

A

Cause pain, swelling, erythema

Commonest in pre-menopausal women , often cackled nipples/poor breastfeeding technique

Can get cellulitis, breast abscess or sub-areolar abscess

Cancer care (13 decks)

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