Breast Cancer Flashcards
1
Q
What in situ
A
Malignant cells
Contained in BM
No metastatic spread
2
Q
What are two types
A
Ductal - DCIS
Lobular - LCIS
3
Q
DCIS
A
Invasive in same breast and place
+Ve EVAD
Most common
Seen as microcalcification on mammogram
4
Q
LCIS
A
Invasive in different breast or area
Bilateral
Multicentricity
-ve ECAD
5
Q
What are invasive cancer types
A
Ductal = 70%
Lobular
6
Q
What type of cancer
A
Adenocarcinoma
7
Q
What are special types
A
Tubular
Cribriform
Medullary
8
Q
What else can you get in breast
A
Other types of cancer
e.g. sarcoma / neuroendocrine
9
Q
Why are they. special type
A
Good prognosis
Oestrogen +VE
10
Q
Why does breast cancer kill
A
Mets
11
Q
Where does it metastasis too
A
Skin / pec Axillary + internal mammary nodes Lung Liver Bone Brain Lymphaics
12
Q
What does it cause in lymphatics
A
Lymphagitis carcinomatosis
Needs biopsy
13
Q
What are genes associated with breast
A
BRCA 1+2 - AD - 50-85% increased risk - Increased risk of ovarian as well TP53 PTEN
14
Q
What does triple assessment do
A
Scores lump on likelihood of malignancy
B - biopsy score
U or M - imaging score
E - examination
15
Q
What is the scoring
A
1 = unsatisfactory or normal 2 = benign 3 = atypia likely benign but Ix 4 = suspicious 5A = in situ 5b = invasive
16
Q
How is cancer grade
A
1,2,3
Rate of mitosis
17
Q
Stages of breast cancer
A
1 = confined breast 2 = breast + LN of same breast 3 = fixed to muscle 4 = chest wall or skin
18
Q
Symptoms of breast cancer
What is lump like
A
Asymptomatic Painless lump = most common - Commonly hard, irregular and painless - Tethered to skin or chest wall Discharge Bleeding Abnormal contour Skin dimpling Change in colour / appearance of aerola Nipple inversion Nipple deviation Nipple retraction Peu d'orange
19
Q
If bleeding
A
Malignant until proven otherwise
20
Q
What is peu d’orange
A
Redness / Pitting of skin
Inflammatory carcinoma
Often misDx as abscess or infection
21
Q
RF for breast cancer
A
Genetics FH Age Female Exposure oestrogen - Early menarche - Late menopause - Nulliparity - No breastfeeding Radiation / RT Previous cancer Prolonged HRT COCP Obesity Alcohol Smoking
22
Q
What do people who have had Rx for Hodgkin’s / BRCA1 +2 +Ve get = high risk
A
Prophylactic mastectomy
1/3 get breast cancer
Can do annual mammography + MRI
23
Q
What increases FH risk
A
Early onset
Multiple
Ovarian
Male
24
Q
When do you do a genetic referral
A
1st degree <40 Male breast Bilateral <50 Breast + ovarian 3x 1st or 2nd degree Multiple at young age Known gene
Can test for BRCA1,2, TPEN, PT53
25
What is important to ask in FH
```
Age of onset
- Any other early
Any bilateral
Multiple
Any ovarian
Any male
```
26
How do you investigate
Triple assessment
H+E
Imaging - mammogram or USS
FNAC / biopsy
27
Sensitivity of H+E
88%
28
Sensitivity of imaging
```
M = 93%
U = 88%
```
29
Sensitivity of biopsy
94%
30
What do you do if solid lump
Biopsy
| USS guided best if new
31
What do you do if cystic
FNA
If bloody = cytology
If clear = reassure
32
What do you do to stage
```
Bloods
CXR
Isotope bone scan
Liver USS
CTCAP
PET-CT
```
33
What bloods
FBC
U+E
LFT
Bone - Ca + phosphate
34
When do you do bone scan
Spread to LN
35
What is imaging of choice for staging
CTCAP
36
When do you do CTCAP
If 4+ nodes
37
What molecular markers is there
ER - best prognosis
PR
HER-2 - aggressive
38
Who is high risk
Gene carrier
| RT in the past
39
What do high risk patient get
Annual mammography +MRI
| Prophylactic mastectomy / tamoxifen
40
When do you investigate axilla and how
USS
| Every invasive cancer undergoing Rx
41
What do you do if axilla normal
SNB if no abnormal nodes found prior to surgery
42
If SNB +ve
Axillary node clearance OR
| New trial
43
What do you do if USS abnormal
USS guided core biopsy
44
If biopsy +ve or symptomatic
Axillary node clearance
| No need to do SNB before op
45
If biopsy -ve / suspicious
SNB
46
What do you do if mastectomy for DCIS
Do SNB anyway as may actually be invasive
47
Can you do WLE for DCIS
Yes
48
What is local Rx for breast cancer
Wide Local Excision
| Mastectomy
49
What do you always give after WLE
```
RT
Unless CI
Risk of focal disease not detected
1cm = 60%
2cm = 40%
3cm = 20%
```
50
WLE
Can do wire guided if can't feel or DCIS so know where
X-ray after to make sure removed
Remove with 1mm margin
51
When would you do mastectomy over WLE
```
INFLAMMATORY
RT not an option
Size ratio of tumour / breast
Tumour >4cm
DCIS >4cm
Not enough clearance
Extensive disease
Multifocal
High risk of another cancer
FH
Site of tumour - central
Cosmesis
Patient choice
```
52
What can you do in axilla
Clearance if evidence of disease in nodes
RT if don't want clearance
Neoadjuvant chemo
SNB if not been proven disease
53
How do you treat DCIS
Mastectomy
| WLE
54
When do you treat axilla in DCIS
If big enough to need mastectomy as risk of invasive
55
Reconstruction option
Can be immediate or delayed after mastectomy
Not always possible if co-morbid, RT, chemo
Implants
Lat dorsi flap
TRAM flap
56
What has poor prognosis
```
LN status = best
Tumour size
Tumour grade
Tumour type
Age
Absence of ER / PR
Presence of HER-2
NPI
```
57
What improved HER-2 +Ve prognosis
Chemo
| Tratuzumab
58
What is NPI
Nottingham Prognostic Indicator
Size
Grade
Node
59
How do you follow up
No clear evidence
6 monthly H+E
Yearly mammogram
60
Complications of surgery
Serum fluid (inflammatory)
Wound infection
Bleeding
Psychological
61
Complications of axilla surgery
Common
Lymphoedema
Firmness of breast / swelling
```
Uncommon
Brachial plexus injury
Muscle hameatoma
Sensory loss / nerve damage
Vascular
```
62
Complications of RT
```
General fatigue
Local skin irritation
Fibrosis of breast tissue
Lymphoedema
Sensory disturbance - inner arm
Decreased ROM
Nerve and vascular damage
Rib fractures
Pneumonitis
Radiation induced sarcoma
```
63
What nerves damage
Long thoracic - serratus
Thoracodorsal - lat dorsi
Brachial plexus - pec
64
How do you Rx lymph oedema
```
Skin care
Exercise
Manual drainage
Support
Compression
```
65
What is Paget's Nipple Disease
Intraepithelial spread of DCIS or invasive ductal
66
How does Paget's present
```
Erosion of nipple
Looks like eczema
Unilateral often
Pain
Itching
Scaling
Redness
Ulceration / crust
Serous or bloody discharge
Peu d'orange
```
67
How do you investigate Paget's / eczema on breast
3x assessment
68
What do you do with skin lesion
Punch biopsy
69
What do you do for any red scaly lesion of nipple
Punch Biopsy
70
How do you differentiate from eczema / psoriasis
Erosion starts on nipple usually
| Eczema = more on areola
71
How do you Rx
WLE + SNB + RT
72
When do you always give RT adjuvant
After WLE
73
When do you give chest wall RT after mastectomy
DCIS
4+ node
5cm invasive T3
Inflammatory
74
What are other uses of RT
Painful bony lesion
| Brain mets
75
What are CI ro RT
```
Previous cancer in chest with RT Rx
Pacemaker
Pregnancy
Skin condition
Patient choice - travel / dependence
Shoulder injury as can't raise hands above head
Excellent prognosis
Elderly
```
76
Why is already had RT to chest
Higher risk of 2 cancer
| Lung or heart damage
77
What do all male breast cancer need
BRCA 2 test
