Breast cancer Flashcards by Chris Mason

How can breast cancer present?

Lump
Nipple discharge or inversion
Cutaneous changes
Skin dimpling/deformity/puckering
Axillary mass
Lymphoedema
US/Mammography detected

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What cutaneous changes can breast cancer present with?

Erythema
Peau d’orange
Nipple ulcer/eczema

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What makes up the triple assessment?

Clinical evaluation
Imaging (US/Mammography)
Tissue diagnosis with needle biopsy (FNAC, core biopsy +/- imprint cytology)

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How do you interpret the diagnostic score from the triple assessment ?
P/E, M, U, C, B

Normal = 1
Benign = 2
Intermediate = 3
Suspicious of malignancy = 4
Malignant = 5

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Features of a fibroadenoma:

Mobile, firm breast lumps
12% of breast masses
Over 2 years, 30% will decrease in size
Confer no increased risk of malignancy

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Management of fibroadenoma:

Surgical excision if >3cm
Phyllodes tumours (rapidly growing sarcoma, 10% malignant) should be widely excised (mastectomy if the tumour is large)

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Features of breast cysts:

Present as smooth, discrete lumps (may be fluctant i.e. moveable and compressible)
Small increased risk of breast cancer esp if younger
7% of all Western women will present at one point

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Management of breast cysts:

Aspiration

If blood stained/persistently refill then should be biopsied/excised

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Features of sclerosing adenosis (radial scars and complex sclerosing lesions):

Presents as breast lump or breast pain
Mammographic changes mimicking carcinoma
Distortion of distal lobar unit +/- hyperplasia
Disorder of involution, no increased risk of breast cancer

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Management of sclerosis adenosis:

Biopsy

Excision not mandatory

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Features of epithelial hyperplasia:

Variable presentation of different types of lump
Increased cells in terminal lobular unit (may be atypical)
Atypical features and FH of breast cancer confers greatly increased risk

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Management of epithelial hyperplasia:

No atypical features = conservative

Atypical features = close monitoring/excision

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Features of fat necrosis:

40% of cases have traumatic aetiology
Physical features may mimic carcinoma
Mass may initially increase in size

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Management of fat necrosis:

Imaging and core biopsy

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Features of duct papilloma:

Usually present with nipple discharge
If large, may present with a mass
No increased risk of malignancy

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Management of duct papilloma:

Microdochectomy

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Referral to clinic if a first/second degree relative developed breast cancer only in the context of one of the following…

Age of diagnosis < 40
Bilateral breast cancer
Male breast cancer
Ovarian cancer
Jewish ancestry
Sarcoma < 45 years old
Glioma/childhood adrenal cortical carcinomas
Multiple cancers at a young age
Two or more relatives on the father's side

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Early screening if (age)…

One first degree relative who developed cancer under 40

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Early screening if (male)…

One first degree male relative at any age

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Early screening if (bilateral)…

One first degree relative with bilateral if the first primary was diagnosed under the age of 50

Early screening if (any age)…

2 first-degree/1 first-degree and 1 second-degree at any age

1 first/second degree relative diagnosed with breast cancer at any age as well as 1 first/second degree relative diagnosed with ovarian cancer at any age

3 first/second degree relatives diagnosed with breast cancer at any age

Genetic risk factors for breast cancer:

BRCA1/2 confer a 40% lifetime risk

p53 mutations

Menstrual/pregnancy risk factors for breast cancer:

Nulliparity
1st pregnancy >30 years old (twice risk of 1st at 25)
Not breastfeeding
Early menarche
Late menopause
Combined HRT, combined oral contraception

Other risk factors for breast cancer:

Obesity
Previous surgery for benign disease (scar hides lump)
Ionising radiation

What is immunohistochemistry used for in breast cancer?

Oestrogen receptor and herceptin status

What may be seen on mammography of cancer?

Dystrophic calcification

Most common type of breast cancer?

Invasive ductal carcinoma | some may arise from DCIS

Why is a sentinel lymph node biopsy used?

To minimise the morbidity of an axillary dissection

When would a mastectomy be performed?

``` Multifocal tumour Central tumour Large lesion in small breast DCIS >4cm Patient choice ```

When would a wide excision be performed?

``` Solitary tumour Peripheral tumour Small lesion in large breast DCIS <4cm Patient choice ```

DCIS =

Ductal carcinoma in situ

LCIS =

Lobar carcinoma in situ

Treatment options for DCIS?

Wide excision or mastectomy as well as any combination of RT and tamoxifen or reconstruction

What are contraindications to breast-conserving surgery?

Diffuse disease Multi-focal disease Central disease Large operable cancer

What additional therapy to excision/mastectomy might invasive disease require?

RT Onoplastic procedure Reconstruction Axillary surgery

Management of large operable cancer?

Neo/adjuvant chemo-endocrine therapy Mastectomy +/- reconstruction Axillary surgery

Management of locally advanced breast cancer (LABC) and inflammatory breast cancer (IBC)?

Multi-modality systemic treatment Then surgery (BCS can be used, pending response but not for IBC; reconstruction contraindicated in IBC) - mastectomy Followed by RT (+sCF)

Management of stage 4 metastatic disease?

Generally palliative, however oligometastatic disease is managed with curative intent

What is ALNC?

Axillary lymph node clearance Levels I, II and III Sentinel lymph node biopsy carried out

Problems with ALNC?

More than 50% of patients have -ve nodes Risk of lymphoedema in 25% Damage to sensory nerves (interccostobrachial) May lead to limitation of shoulder movement

What is the management when there is axillary LN involvement?

Standard of care is ALNC Alternatively you can have systemic treatment and sentinel lymph node biopsy based on the response If SLNB +ve then ALNC/systemic treatment/local irradiation

What do ER, PR and HER-2 denote about the cancer?

ER +ve = Estrogen receptors - give ET PR +ve = Progesterone receptors Her-2 +ve = Human epidermal growth factor receptor positive (1 in 5 breast cancers, herceptin recommended for almost all Her-2 +ve breast cancers)

Indications for post-mastectomy RT?

Tumour larger than/equal to 5cm +/- 4 or more involved axillary lymph nodes LABC

What is Oncotype Dx?

Recurrence score between 0 and 100 Used to predict recurrence of ER +ve BC and DCIS Based on age Helps decide whether to use chemo on early stage hormone R+ve cancers or RT in DCIS

BRCA1 risks:

Breast cancer = 40-50% Second primary breast cancer = up to 60% Ovarian cancer = up to 50% Prostate cancer = minimal increase

BRCA2 risks:

``` Breast cancer = 60-85% Second primary breast cancer = up to 60% Ovarian cancer = up to 30% Pancreatic cancer = 3% Male breast cancer = 6% Prostate cancer = 14% by age 80 Minimally increased risk of gastric, thyroid, gall bladder cancers and lymphoma ```

TP53 risks:

Breast cancer = 80-90% High risk of sarcoma and childhood leukaemia Adrenal cancer Li-Fraumeni syndrome

Prophylactic mastectomy =

>90% risk reduction

Metastases of breast cancer?

``` Lymph nodes Liver Lung Bones Brain ```