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Breast Surgery > Breast Cancer > Flashcards

Breast Cancer Flashcards

1
Q

Describe breast cancer findings on examination

A
  • May be hard, irregular, painless, fixed lesions
  • May be tethered to the skin or the chest wall
  • May cause nipple retraction
  • May cause skin dimpling or oedema (peau d’orange)
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2
Q

Two week urgent referral criteria

A
  • A discrete lump with fixation, that enlarges and/or with any concerns (e.g. family history)
  • Women over 30 with a persistent breast or auxiliary lump or focal lumpiness after their menstrual period
  • Previous breast cancer with new suspicious symptoms
  • Skin or nipple changes suggestive of breast cancer
  • Unilateral bloody nipple discharge
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3
Q

Breast Cancer RF

A
  • Female (99% of breast cancers)
  • Oestrogen Exposure (years of menstruation, few/no children/no breast feeding)
  • Obesity
  • Smoking
  • Family history (first degree relatives)
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4
Q

Genetic predisposition

A

•BRCA genes are tumour suppressor genes
•Faulty BRCA1 gene
◦Chromosome 17
◦Around 60% (to 80%) will develop breast cancer
◦Around 40% will develop ovarian cancer
◦Also increased risk of bowel and prostate cancer

•Faulty BRCA2 gene
◦Chromosome 13
◦Around 40% will develop breast cancer
◦Around 15% will develop ovarian cancer

•Many other rarer genetic abnormalities are associated with breast cancer (e.g. TP53 and PTEN genes)

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5
Q

Where are breast cancer metastasis?

A
  • Lungs
  • Liver
  • Bones
  • Brain
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6
Q

Ductal Carcinoma in Situ

A
  • Pre-cancerous or cancerous epithelial cells of the breast ducts
  • Localised to a single area
  • Often picked up by mammogram screening
  • Potential to spread locally over years
  • Potential to become an invasive breast cancer (around 30%)
  • Good prognosis if full excised with adjuvant treatment
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7
Q

Lobular Carcinoma in Situ

A
  • Also referred to as “lobular neoplasia”
  • A pre-cancerous condition occurring typically in pre-menopausal women
  • Asymptomatic and undetectable on mammogram
  • Usually diagnosed incidentally on breast biopsy
  • Represents an increased risk of invasive breast cancer in the future (around 30%)
  • Usually managed with close monitoring (e.g. 6 monthly examination and yearly mammograms)
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8
Q

Invasive Breast Cancer (NST)

A
  • NST = No Specific Type
  • Also known as Invasive Ductal Carcinomas
  • Originate in cells from the breast ducts
  • 80% of invasive breast cancers fall into this category
  • Show up on mammograms
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9
Q

Invasive Lobular Breast Cancer

A
  • Around 10% of invasive breast cancers
  • Originate in cells from the breast lobules
  • Not always visible on mammograms
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10
Q

Inflammatory Breast Cancer

A
  • 1-3% of breast cancers
  • Presents similarly to a breast abscess or mastitis
  • Swollen, warm, tender breast with pitting skin (peau d’orange)
  • Does not respond to antibiotics
  • Worse prognosis than other breast cancers
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11
Q

Paget’s Disease of The Nipple

A
  • Looks like eczema of the nipple/areolar
  • Erythematous, scaly rash
  • Indicates breast cancer involving the nipple
  • May represent DCIS or invasive breast cancer
  • Requires biopsy, staging and treatment as with any other invasive breast cancer
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12
Q

NHS BC screening

A
  • Offered to women aged 50 to 70 (extended in some areas)
  • Individual offered screening every 3 years
  • Involves a simple mammogram
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13
Q

Limitations of Screening

A
  • False positives and negatives

* Exposure to radiation (causes around 5 cancers per 10,000 women who undergo full screening)

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14
Q

High Risk Screening

A

•Patients should be offered genetic counselling and pre-test counselling prior to testing
•Tests available for BRCA1, BRCA2, TP53 and PTEN genes
•Screening for breast cancer in high risk patients consists of annual mammograms ◦Aged 40-49 if moderate risk
◦Aged 40-59 if high risk
◦Aged 40-69 if known BRCA positive
◦Consider offering aged 30-59 if high risk

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15
Q

Triple diagnostic assessment

A

Once a patient has been referred for specialist services under a two week wait referral for suspected cancer they should initially receive triple diagnostic assessment comprising of:
•Clinical Assessment
•Breast Imaging (ultrasound or mammography)
•Biopsy (fine needle aspiration or core biopsy)

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16
Q

Ultrasound vs Mammogram

A
  • Younger women have denser breasts with more glandular breasts
  • Ultrasound:

◦Typically used to assess lumps in younger women (e.g. <30)
◦Useful in distinguishing solid lumps (e.g. fibroadenoma / cancer) from cystic lumps

•Mammogram:

◦More effective in older women
◦Pick up calcifications missed by ultrasound

17
Q

Assessing Lymph Nodes

A
  • Before surgery: everybody offered axillary ultrasound and ultrasound guided biopsy of any abnormal nodes
  • During surgery: where no abnormal lymph nodes are found using Sentinal Lymph Node Biopsy
18
Q

Sentinal Node Biopsy

A
  • Performed during breast surgery for cancer
  • Where no abnormal lymph nodes identified prior to surgery
  • Isotope contrast and a blue dye are injected into the tumour area
  • This is carried through the lymphatics to the first lymph node (the sentinel node)
  • This node shows up blue and on the isotope scanner
  • This node is then sampled to stage the cancer
19
Q

Types of Surgery

A

•Breast Conserving Surgery ◦Lumpectomy
◦Wide Local Excision
◦Quadrantectomy (removal of a quarter of the whole breast)

•Mastectomy (removal of the whole breast)

20
Q

Axillary Clearance (when offered and complication)

A
  • Offered to patients where early invasive breast cancer has been demonstrated in axillary nodes
  • Involves removing the majority or all lymph nodes from the axilla
  • Increases risk of chronic lymphedema in that arm
21
Q

Chronic Lymphodema following axillary node clearance

A
  • Can occur in the ipsilateral arm to the breast undergoing surgery
  • This can have a large impact on the patient’s quality of life
  • Patients should be informed of the risk of lymphoedema prior to surgery
  • Resting the arm post operatively, certain exercises and avoiding injury or infection reduces the risk of developing lymphoedema
  • Specialist lymphoedema services available

N.B. Do not take bloods from this arm

22
Q

When is radiotherapy offered?

A

Offered following Breast Conserving Surgery with Clear Margins

23
Q

Describe why radiotherapy and why its offered

A
  • Radiotherapy allows for breast conserving surgery with equal outcomes to full mastectomy in patients with early breast cancer
  • Radiotherapy post-surgery reduces local recurrence
  • Involves radiotherapy delivered from multiple angles to concentrate radiation on targeted area
  • Usually involves daily treatments for 3-5 weeks
24
Q

Side effects of radiotherapy in breast cancer

A
  • General fatigue from the radiation
  • Local skin and tissue irritation and swelling
  • Fibrosis of breast tissue
  • Shrinking of breast tissue
  • Long term skin colour changes (usually darker)
25
Q

What should oestrogen receptor positive women be offered?

A
  • Premenopausal women should be offered Tamoxifen

* Post-menopausal women should be offered an aromatase inhibitors (anastrozole, exemestane or letrozole)

26
Q

What should HER2 positive women be offered

A
  • Should be offered trastuzumab (Herceptin), a monoclonal antibody (biological therapy) that disrupts the HER2 receptor
  • Given every 3 weeks for 1 year following initial treatment
  • Impacts heart function, therefore initial and close monitoring of heart function essential
  • Contraindicated in women with congestive heart failure and certain heart conditions
  • Common side effects: Diarrhoea, tumour pain, headaches.
27
Q

Chemotherapy

A

•Used in one of three scenarios: ◦Neoadjuvant therapy – intended to shrink the tumour prior to surgery
◦Adjuvant chemotherapy – after the surgery to reduce recurrence
◦For treatment or control of metastatic or recurrent breast cancer

28
Q

When is reconstructive therapy offered

A
  • Offered to all patient having a mastectomy
  • Immediate reconstruction done at the same time as the mastectomy
  • Reconstruction can be delayed for years after initial mastectomy
  • May not be possible due to required chemo or radiotherapy or comorbidity
29
Q

Implants

A
  • Simple procedure with minimal scarring
  • Reasonable appearance but less natural feel (cold, less mobile and static size and shape)
  • Long term problems include hardening, leakage, and shape change
30
Q

Latissimus Dorsi flap

A
  • Portion of the latissimus dorsi plus skin and fat tissue
  • Tunnelled under skin to the breast area
  • “Pedicled” refers to keeping the original blood supply and moving the tissue under the skin to a new location
  • “Free flap” refers to cutting the tissue away completely and transplanting it to a new location
31
Q

Transverse rectus abdominus flap

A
  • Portion of rectus abdominis along with blood supply and skin
  • Either as pedicled flap (tunneled under skin) or free flap (transplanted)
  • Risk of abdominal hernia due to weakened abdominal wall
32
Q

Deep Inferior Epigastric Perforator Flap

A
  • Skin and subcutaneous fat from abdomen (no muscle)
  • Transplanted from abdomen to breast
  • Transplant the Deep Inferior Epigastric Artery with fat and skin
  • Tissue transplanted to reconstruct breast
  • Vessels attached to branches of the internal mammary artery and vein
  • Very complex procedure with microsurgery
  • Less risk of abdominal wall hernia as muscle are intact
33
Q

Surveillance Mammography

A
  • No screening for women with total mastectomies
  • Yearly mammograms for 5 years in patients with early breast cancer
  • After 5 years, screening frequency is based on the risk category for the individual

Breast Surgery (2 decks)

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