Breast cancer Flashcards
How can breast cancer present?
Lump Nipple discharge or inversion Cutaneous changes Skin dimpling/deformity/puckering Axillary mass Lymphoedema US/Mammography detected
What cutaneous changes can breast cancer present with?
Erythema
Peau d’orange
Nipple ulcer/eczema
What makes up the triple assessment?
Clinical evaluation
Imaging (US/Mammography)
Tissue diagnosis with needle biopsy (FNAC, core biopsy +/- imprint cytology)
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
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
Management of fibroadenoma:
Surgical excision if >3cm Phyllodes tumours (rapidly growing sarcoma, 10% malignant) should be widely excised (mastectomy if the tumour is large)
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
Management of breast cysts:
Aspiration
If blood stained/persistently refill then should be biopsied/excised
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
Management of sclerosis adenosis:
Biopsy
Excision not mandatory
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
Management of epithelial hyperplasia:
No atypical features = conservative
Atypical features = close monitoring/excision
Features of fat necrosis:
40% of cases have traumatic aetiology
Physical features may mimic carcinoma
Mass may initially increase in size
Management of fat necrosis:
Imaging and core biopsy
Features of duct papilloma:
Usually present with nipple discharge
If large, may present with a mass
No increased risk of malignancy
Management of duct papilloma:
Microdochectomy
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
Early screening if (age)…
One first degree relative who developed cancer under 40
Early screening if (male)…
One first degree male relative at any age
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
