Breast cancer Flashcards
1
Q
Triple assessment (3)
A
- Clinical assessment (history + examination)
- Imaging assessment (mammography/ ultrasound)
- Needle biopsy (+/- FNA)
2
Q
Scoring system for triple assessment: (5)
A
- Normal
- Benign
- Intermediate/probably benign
- Suspicious
- Malignant
3
Q
Triple assessment: Scoring Prefixes (BUMP)
A
B - Biospy
U - Ultrasound
M - Mammography
P - Palpation
4
Q
Risk of breast cancer:
- Higher risk (2)
- Lower risk (3)
A
Higher risk:
- HRT use
- Earlier menarche
Lower risk:
- Longer duration of breastfeeding
- Earlier age at first birth
- Increasing parity
5
Q
Breast cancer: Family hx
- Useful questions to ask (3) - DAN
A
- Degree - Whether affected family members are 1st, 2nd or 3rd degree relatives
- Age (that affected family members developed breast cancer)
- Number - How many family members are affected?
6
Q
Accessory (Supernumerary) Nipples: Definition
A
- Relatively common
- Occur along mammary ridge (within vertical line of nipple)
- May just be nipple, or have associated breast tissue.
- May be mistaken for mole.
7
Q
Breast imaging: BROAD categories (2)
A
- SYMPTOMATIC breast imaging: performed on women who present with breast symptoms, usually in a breast clinic.
- SCREENING: refers to mammography performed on asymptomatic women as part of a breast
8
Q
Mammography: Views
A
A standard mammogram consists of two view of each breast:
- MLO: Mediolateral oblique
- CC: Craniocaudal view
9
Q
Why is the breast compressed during mammography?
A
- Spreads out glandular tissue.
- Reduces overlying structures.
- Holds breast still.
- Reduces risk of blurring.
- Compressed breast = uniformly thin.
- This helps avoid problems with under or overexposure of parts of the image.
- Making breast thinner also reduces radiation exposure for woman.
10
Q
Ultrasound: Characteristic of masses:
- Benign (2)
- Malignant (2)
A
Benign:
- Round/ovoid
- Well defined
Malignant:
- Irregular
- Ill-defined
11
Q
Fine Needle Aspiration (FNA): Definition
A
A needle attached to a syringe is introduced into the lesion and multiple passes are made through the lesion whilst suction is applied.
Suction is then released, and the material spread onto microscopic slides and sprayed with fixative.
12
Q
Core Biopsy: Definition
A
Local anaesthetic is injected into the skin + breast tissue.
A small incision is made and multiple cores of tissue are taken from the breast lesion using a hollow cutting needle fired by an automatic gun.
13
Q
FNA vs. Core Biopsy
A
FNA: ADVANTAGES: - Quick + easy to perform. - Processing times are rapid (can be as little as 30 mins - compared to core biopsy which is several days) - Low cost procedure. - Very few complications.
DISADVANTAGES:
- FNA requires highly trained + experienced pathologist.
- It is difficult to classify a malignant lesion as invasive or non-invasive.
- Does not provide the same amount of tissue as core biopsy.
- Cannot ascertain receptor status of cancer.
14
Q
Breast anatomy: Structure of the breast (8)
A
- Chest wall
- Pectoralis muscles
- Breast lobules
- Nipple
- Areola
- Milk ducts
- Fatty tissue
- Skin
15
Q
Breast anatomy: Breast boundaries
A
- Upper: 2nd rib
- Lower: 6th rib
- Lateral: mid-axillary line
- Medial: lateral edge of sternum
16
Q
Breast anatomy:
- Number of lobes
- Number of lobules
A
Number of lobes: 15-20
Number of lobules (per lobe): 20-40
17
Q
Breast anatomy: Cooper’s Ligament - Definition
A
Definition: Thin sheets of fascia that extend like a mesh through the breast parenchyma, attaching to the dermis and the superficial and deep fascial layers. They provide support to the breast.
18
Q
Breast anatomy: Lymphatic drainage
A
Two main groups of lymph nodes which drain the breast:
- Axillary nodes
- Internal mammary nodes
75% of lymphatic drainage of the breast goes to the axillary nodes.
19
Q
Axillary nodes: Levels (3)
A
There are 20-30 axillary nodes. The are divided into 3 ‘levels’:
Level 1: nodes inferior to pectoralis minor
Level 2: nodes behind pectoralis minor
Level 3: nodes above pectoralis minor
20
Q
Histology of the breast
A
- Terminal portion of the duct of the duct system is known as the terminal duct lobular unit (TDLU).
- The TDLU consists of a lobule and its associated terminal duct.
- Breast cancer is thought to originate in the TDLU.
21
Q
Physiology of the breast
A
- Before puberty: male + female breasts = identical.
- After puberty: oestrogen + progesterone cause proliferation (of breast).
- Fully functional development of pregnancy occurs with hormonal changes of pregnancy + lactation.
- Fatty tissue > in proportion.
- Pigmentation of nipple + areolar also occurs.
- Follow birth: lactation is established.
- 2 hormones are involved in lactation.
- Prolactin: which is iatrogenic.
- Oxytocin: which is released in response to suckling.
- Oxytocin: causes contraction of myoepithelial cells - increasing supply of milk. It also mediates secretion of prolactin.
- After menopause: atrophy of glandular elements + decrease in fibrous tissue occurs.
22
Q
Skin tethering: Definition
A
Means that the lump is attached to the skin, but can be moved in an arc without moving the skin. If the lump is pulled outside the arc, the skin indents.
23
Q
Skin fixation: Definition
A
Is where the lump cannot be moved with moving the skin.
24
Q
Most common site for breast cancer
A
Approximately 50% of breast cancers occurs in the upper outer quadrant of the breast.
25
Mammogram: Info for patients
- 2 months worth of background radiation.
- Some women experience a bit of discomfort/pain
- All mammographers are female.
- (one of the only jobs exempt from the Sex Discrimination Act)
- 2 x-rays are taken of each breast.
26
Breast cancer: Cancer receptors (3)
- Oestrogen receptor (ER)
- Progesterone receptor (PR)
- Human epidermal growth factor receptor (HER2)
27
Chemotherapy: DEFINITIONS
- Neoadjuvant: Before breast surgery
- Adjuvant
- Neoadjuvant: Before breast surgery
| - Adjuvant: After breast surgery
28
Goal of Chemotherapy
The goal of adjuvant chemotherapy is to eradicate micrometastatic disease and hence increase the chance of a cure.
29
NICE guidelines: The MDT
NICE recommends that all patients with cancer should be managed by a multidisciplinary team.
A MDT is composed of different members from different healthcare professions with different specialised skills and expertise.
They all collaborate together to make recommendations that facilitate quality patient care.
30
Benefits of the effective MDT
- Receive accurate diagnosis and staging.
- Offered choice of treatments.
(decided by group of experts, rather than one doctor)
- Receive better coordination + continuity of care.
- Treated in line with locally agreed policies and national guidelines.
- Be offered appropriate + consistent information.
- Psychological and social needs are considered.
31
PREDICT: Decision making aids
PREDICT is an online tool used to estimate breast cancer survival and the benefits of hormone therapy, chemotherapy and trastuzumab.
32
PREDICT: Factors (9)
- Age at diagnosis
- Mode of detection
- Tumour size in mm
- Tumour grade
- Number of positive nodes
- ER status
- HER2 status
- KI67 status
- Gen chemo regimen
33
How does cancer affect a person's life?
- Work
- Financial strain
- How they are treated by other people?
- Priorities in life change
- Side effects from treatment
- Impact on relationships
- Worry of cancer returning
- Changed body image
- Any positive changes?
34
Breast cancer: Epidemiology
- Commonest malignancy in women.
- Disease is the commonest cause of death among women aged 40-50.
- Screening is offered every 3 years from ages 50-70.
- >12000 deaths occurs each year.
- Survival rates vary by age at diagnosis.
35
Breast cancer: Risk factors
- Age (>55)
- Genetic
- Previous benign disease
- Geographical location
- Exposure to radiation
- Family hx
- Combined HRT (current use)
- Age at menopause (>54)
- Weight (BMI >30)
- Alcohol consumption
- Age at first full pregnancy
- Oral contraceptive (current use)
36
Genes predisposing to breast cancer (9)
- BRCA1
- BRCA2
- TP53
- CHEK2
- ATM
- FGFR2
- TOX3
- MAMKI
- IS F1
37
Breast cancer: Important features of family hx
1. Age at onset of breast cancer in affected relatives.
2. Presence of bilateral breast cancer in affected relatives.
3. Multiple cases of breast cancer in the family (particuarly on one side)
4. Other related early-onset tumours such as sarcoma, glioma or childhood adrenal cancer.
5. Number of affected individuals (large families are more informative)
38
Risk factors for local recurrence of cancer after breast conservation surgery
- Involved margins
- Patients age <35 (or >50)
- Lymphatic/vascular invasion
- Histological grade II or III
39
Breast-conservation surgery: DEFINITION
Breast-conservation surgery for invasive cancer consists of excision of the tumour with a 1cm macroscopic margin of normal tissue (wide local excision) combined with removal of the sentinel or all of the axillary nodes.
There are lower levels of psychological morbidity following breast conservation compared with mastectomy; it also improves body image, freedom of dress, sexuality and self esteem.
In most breast units conservation surgery tends to be limited to lesions < 4cm.
There is no age limit for breast conservation.
40
Therapeutic Mammoplasty: Definition
Definition: operation to remove a breast cancer (therapeutic) and reshape/remodel (mammoplasty)
41
Breast conservation surgery: Failure rate
Incomplete excision at breast-conserving surgery is seen in 20-25% of patients.
Patients who carry BRCA1 and BRCA2 mutations have a high incidence of new ipsilateral and contralateral breast cancers after breast-conserving surgery.
42
Mastectomy
1/3 of symptomatic localised breast cancers are unsuitable for treatment by breast conservation but can be treated by mastectomy.
Mastectomy removes breast tissue with some overlying skin, usually including the nipple. Increasingly nipple-sparing mastectomy is being performed.
The breast is removed from the chest wall muscles (pectoralis major, rectus abdominus and serratus anterior),, which are left intact.
Mastectomy should be combined with some form of axillary surgery. The pectoral fascia does not require to be removed unless involved.
Most patients treated by mastectomy are suitable for some form of breast reconstruction, which may be performed at the same time as the initial mastectomy.
43
Breast conserving surgery: Complications (4)
- Failure to excise all of disease
- Bleeding
- Infection
- Seroma
44
Breast conserving surgery: Radiotherapy
All patients should receive radiotherapy to the breast after breast conserving surgery.
Radiotherapy reduces significantly the number of local recurrences and also improves overall survival.
45
Radiotherapy: Complications
- Immediate skin reactions
- Skin telangiectasia
- Cardiac deaths
- Radiation pneumonitis
- Cutaneous radionecrosis
- Osteoradionecrosis
46
Breast cancer + lymph nodes
Pre-operative clinical or radiological assessment of lymph node involvement is not completely accurate. Only 70% of involved nodes are clinically detectable.
Only histopathological assessment of nodes visualised on ultrasonography, or excised at surgery, provides accurate prognostic information.
Lymph nodes are ineffective barriers to the spread of cancer, and metastasis indicates biologically aggressive disease that requires systemic adjuvant treatment.
47
Factors associated with lymph node involvement
- Large tumour
- Poorly differentiated tumour (grade III)
- Symptomatic (compared with screen-detected) tumour
- Lymphatic or vascular invasion in/around tumour
- HER-2 positive breast cancer
- ER negative
48
Breast cancer: Staging the axilla
| - Important factors (2)
Presence/absence of involved axillary lymph nodes is the single best predictor of surviving breast cancer + important treatment decisions are based on it.
Important factors:
- Number of involved nodes
- Level of node involvement
49
Sentinel node biopsy: DEFINITION
Identification of the sentinel node by peritumoural, intredermal or subareolar injection of both blue dye (isosulfan blue or patent blue V) and radioisotope colloid followed by histological assessment of blue and/or radioactive nodes.
It assesses lymph node involvement.
Sentinel node biopsy produces less morbidity (↓ sensory loss, ↓ arm swelling) than a full axillary dissection).
50
Axillary lymph node clearance: DEFINITION
In patients who have large suspicious axillary lymph nodes seen on ultrasound and confirmed by FNA or core biopsy, axillary node clearance remains standard treatment.
It is also known as 'lymph node dissection' or 'lymphadenectomy' - removal of all the lymph nodes + possible tumour.
51
Axillary surgery: Morbidity (2)
- Arm swelling
| - Lymphoedema
52
Lymphoedema: DEFINITION
Is defined as arm swelling greater than 10% increase in volume from baseline or a 200ml or greater increase in arm volume as measured by perometry or water displacement.
It is a chronic symptom that is essentially incurable. Although the physical symptoms can be controlled with treatment.
53
Lymphoedema: TREATMENT (4)
- Skin care: maintains good skin condition + reduces risk of infection
- Exercise: promote lymph flow + maintains good limb function
- Manual lymph drainage: gentle skin massage encourages lymph flow, carried out by trained therapist
- Support/compression: Multilayer lymphoedema bandaging, compression garments, maintain adequate weight
54
Breast cancer: Risk factors for metastatic disease
- Axillary node involvement
- Poor histological grade
- Large tumour size
- Histological evidence of lymphovascular invasion in and around tumour site
55
Breast screening: Overview
- For women aged 47-51
- Every 3 years
- For every 100 screened: 4 are recalled
- 1 of which will have breast cancer
56
Breast cancer: Looking for METASTASIS (4)
- CT (soft tissue + brain)
- MRI
- PET scan
- Bone scintigraphy
57
Breast density (+ breast cancer risk)
↑ density = ↑ risk
58
Breast cancer: TREATMENT overview
- Locoregional (2)
- Systemic (2)
The main treatment for breast cancer are:
Locoregional:
- Surgery
- Radiotherapy
Systemic:
- Hormonal therapy
- Chemotherapy
- Targeted cancer drugs
Patients might have a combination of these treatments.
59
Breast cancer: Treatment - SURGERY
- Types (2)
- Axillary management (2)
TYPES:
- Lumpectomy (Breast conservation = wide local excision + radiotherapy)
- Mastectomy
AXILLARY MANAGMENT:
All patients with invasive breast cancer should have surgical management of the axilla:
- Sentinel lymph node biopsy
- Axillary node clearance
60
Mastectomy: INDICATIONS
- Tumour size >4 cm in diameter
| - Multi-focal tumour
61
Breast cancer: Treatment - HORMONAL therapy
- Tamoxifen
- Anastrozole (non-steroidal Aromatase Inhibitors)
- Letrozole (non-steroidal Aromatase Inhibitors)
- Exemestane (steroidal Aromatase Inhibitors)
- Goserelin (Zoladex) - (GnRH agonist)
62
Breast cancer: Treatment - CHEMOTHERAPY
- Indication (4)
- Examples
Chemotherapy uses anti cancer (cytotoxic) drugs to destroy cancer cells. The drugs circulate throughout the body in the bloodstream.
Indication:
- Advanced steroid hormone-receptor-negative tumour
- Aggressive disease
- Metastasis (to visceral sites)
- Short disease free interval following treatment
Examples:
- Anthracycline (such as doxorubicin or epirubicin) combined with fluorouracil and cyclophosphamide, and sometimes methotrexate
N.B. Chemotherapy is not of benefit for:
- Postmenopausal women with ER-positive, HER2 receptor-negative breast cancer
63
Breast cancer: Treatment - TARGETED cancer drugs
| - Anti-HER2 therapies
- 15% of breast cancers have amplification of the HER2 gene.
- These cancers have intrinsically worse prognosis than other cancers.
TRASTUZUMAB (Herceptin):
- Monoclonal antibody
- Against the domain of the HER2 receptor.
- Improves overall survival.
Other anti-HER2 therapies:
- Lapatinib
- Pertuzumab
64
HORMONAL therapy: TAMOXIFEN
- For treating ER positive cancer (in premenopausal women).
- 80% of breast cancers = ER positive.
- Oestrogen binds to these receptors.
- Then stimulate cell proliferation.
- Tamoxifen = partial oestrogen receptor modulator.
- It prevents oestrogen binding to its receptor (on cancer)
- It is effective in all age groups.
65
HORMONAL therapy: AROMATASE INHIBITORS (AIs)
- For treating ER positive cancer (in postmenopausal women).
- For postmenopausal women, AIs = superior to tamoxifen.
- They should not be used in pre-menopausal women.
- They act by blocking the conversion of androgens to oestrogens in peripheral tissues.
- This ↓ oestrogen available to bind to cancer + stimulate cell proliferation.
Non-steroidal Aromatase Inhibitors (AIs)
- Anastrozole
- Letrozole
Steroidal Aromatase Inhibitors (AIs)
- Exemestane
66
HORMONAL therapy: GnRH agonist
- Example: Zoladex (Goserelin)
- Supresses production of sex hormones
- (testosterone + oestrogen)
- GnRH agonists have been shown to be as effective therapeutically as surgical ovarian ablation in pre- and perimenopausal women with advanced breast cancer.
- The combination of a GnRH agonist such as goserelin with the peripheral oestrogen antagonist, tamoxifen, may be used to produce 'combined oestrogen blockade'.
67
CHEMOTHERAPY: Side effects
- Fatigue + lethargy
- Alopecia (temporary?)
- Nausea + vomiting
- Induction of menopause
- Risk of infection
- Oral mucositis
- Diarrhoea
- Weight gain
- Specific side effects of certain drugs
68
TAMOXIFEN: Side effects
- VTE
- Hot flushes
- Altered libido
- GI upset
- Vaginal discharge/dryness
- Menstrual disturbance
- Weight gain
- Endometrial cancer
69
AROMATASE INHIBITORS: Side effects
- Hot flushes
- Joint and muscle pain
- Osteoporosis
- Fatigue
- Vaginal dryness
70
TRASTUZUMAB: Side effects
- Flu-like symptoms
- Allergic reaction
- Cardiac dysfunction
71
Breast cancer + BISPHOSPHONATES
Bisphosphonates prevent treatment-related bone loss associated with oestrogen suppression in early breast cancer.
72
Psychological adjustment: DEFINITION
'Psychological adjustment' is defined as the 'cognitive and behavioural responses the patient makes to the diagnosis of cancer'
73
Psychological adjustment to cancer involves accommodating the following: (5)
- Searching for meaning
- Dealing with loss of control
- Managing uncertainty about the future
- Need for openness
- Need for emotional and medical support
74
Disclosure by patients is INHIBITED by: (5)
- Closed questions
- Leading questions
- Multiple questions
- Questions with a physical focus
- Offering advice/reassurance (especially if premature)
75
Disclosure by patients is PROMOTED by: (7)
- Open directive questions
- Questions with a psychological focus
- Clarification of psychological aspects
- Summarising
- Screening questions
- Empathy
- Educated guesses
76
Criteria for ANXIETY state
- Persistent anxiety, tension or inability to relax.
- Present for >1/2 of the time for 4 weeks.
- Cannot pull self out of it or be distracted by others.
- Substantial departure from normal mood.
Plus at least four of the following:
- Initial insomnia
- Irritability
- Impaired concentration
- Intolerance of noise
- Panic attacks
- Somatic manifestations
77
Criteria for DEPRESSIVE illness
- Persistent low mood
- Present for >1/2 of the time for 4 weeks
- Cannot be distracted out of it by self or others
- Qualitatively/quantitatively significantly different from normal mood
- Inability to enjoy oneself
Plus at least four of the following:
- Diurnal variation of mood
- Repeated or early waking
- Impaired concentration/indecisiveness
- Feeling hopeless or suicidal
- Feelings of guilt, self-blame, being a burden or worthlessness
- Irritability and anger for no reason
- Loss of interest
- Retardation or agitation
78
Reading Mammograms
MLO: tells you if it is upper or lower
CC: tells you if its is lateral or medial
