Breast cancer Flashcards
(25 cards)
How common is breast cancer?
- Most common cause of cancer in women and the second most common cause of death from cancer in UK
- Incidence rose after introduction of mammography
- 4-6% are metastatic at diagnosis
- Mortality rate has been decreasing
- Male breast cancer contributes to 1% of total cases
Can occur at ANY age so you must always exclude it.
Name 5 risk factors for breast cancer.
- Age - <5% present before 35yrs, <25% before 50yrs
- FH of breast cancer in first degree relative
- Genetic factors -BRCA1,2 and TP53 mutations (but only represent 5%)
- Radiation to chest
- Increased exposure to oestrogens:
- No children/first child after 30yrs
- Early menarche and late menopause (<13 and >51)
- No breast-feeding
- Western diet/alcohol/obesity
- HRT - combined oestrogen and progesterone
- COCP
What is a suspicious FH of breast cancer?
- 3 close blood relatives on same side of the family affected at any age
- 2 close blood relatives developed breast acncer before 60yrs
- 1 close blood relative developed breast cancer before 40yrs
- 1 male close blood relative developed breast cancer
- 1 close blood relative developed bilateral breast cancer
Where do breast cancers arise from?
- Epithelial lining of the ducts - “ductal”
- Epithelium of terminal ducts of the lobules - “lobular”
What are the two types of breast cancer invasiveness?
- Invasive - most taht arise from intermediate ducts are invasive
- In situ
Where does breast carcinoma commonly metastasise to?
- Lungs
- Liver
- Bone
- Brain
Investigations:
- CXR
- Abdo palpation, LFTs, liver US
- Bone palpation for tenderness, serum phosphate and calcium, isotope bone scan (MRI)
- Brain CT
How does breast cancer present? (symptoms)
Breast lump - or under arm, lymph nodes
Painless (but may be tender)
Slowly growing with no cyclical changes
Skin changes - “peau d’orange” represents puckering of the overlying skin in carcinoma
Inverted nipple
Bloody discharge - intraductal carcinoma
Symptoms of metastases - liver, lung, brain - RARE to have FLAWS but may present with back pain (spinal mets)
What are the signs of breast cancer on examination?
Check for:
- Asymmetry
- Contours
- Skin changes
- Nipple changes
Signs of carcinoma:
- Irregular surface
- Indistinct borders
- Hard consistency
- Mobility - no
- Fixity - Maybe
- Lymphadenopathy - maybe
How do you distinguish fibroadenoma from carcinoma?
What is the NICE referral guidance for breast cancer?
Refer with 2WW if:
- aged over 30yrs w/ unexplained breast lump +/- pain
- aged over 50yrs with any of: discharge, retraction, other nipple changes of concern.
Consider 2WW referral if:
- skin changes that suggest breast cancer
- over 30yrs with unexplained lump in axilla
Non-urgent referral if:
- aged <30yrs with unexplained breast lumg +/- pain
Those with genetic predisposition should be referred to local genetics service for formal assessment.
What routine investigations would you do for breast cancer?
- Clinical examination
- Imaging - bilateral mammography + ultrasound of breast and regional lymph nodes - US can be diagnostically more useful in younger patients. Breasts are dense in young women so subtle distinctions will be seen non mammogram.
- FNA or core biopsy - FNA shows type of cells but core biopsy will give additional info on local architecture and invasion
Each step is graded C1-5
This is called triple assessment
What is a concordant vs non-concordant triple assessment?
PRCB
- P - physical exam
- R - radiological exam
- C - cytology
- B - core biopsy
1 - normal
2- benign
3 - unsure
4- probably malignant
5 - malignant
What additional investigations might you do for breast cancer?
- Sentinel lymph node biopsy - stages axilla for patients with early invasive breast cancer
- Monoclonal antibody assay testing for:
- Estrogen and progesterone receptor (ER and PR)
- HER2 (human epidermal growth factor)
- CEA and CA15-3 - prognostic significance controversial
- LFTs
- CXR
- CT if suspected metastases
- Bone scintiggraphy if distant metastases/bone pain
- PET
What are the treatment options for breast carcinoma?
Local treatments - surgery, radiotherapy
Systemic treatments - chemotherapy, hormonal therapy, monoclonal antibodies (e.g. herceptin)
This depends on the size, stage and grade of the tumour.
What does tumour stage indicate?
Spread of cancer and therefore incorporates tumour size, nodal status and presence of metastases
What does tumour grade indicate?
Loss of differentiation of he cancer cells and therefore incorporates histopathological appearance
What causes “peau d’orange” skin?
Carcinoma
There is blockage of the dermal lymphatics by tumour, surgery or radiotherapy resulting in cutaneous oedema. Sweat ducts and hair follicles tether the skin, resulting in dimples with in the oedematous areas.
What is the difference between adjuvant and neo-adjuvant chemotherapy?
Adjuvant - used after surgery to treat any micrometastases which remain following excision.
Neo-adjuvant - delivered before surgery to shrink the primary tumour and minimise metastatic tumour burden. Benefit is that it can assess tumour responsiveness to chemo. Typically givento those at risk of micrometases such as young patients, those with large tumours and those with palpable lymph nodes.
When is mastectomy preferred over breast-conserving surgery?
Wide local excision with radiotherapy is just as effective as mastectomy with low recurrence rate.
But WLE is not possible if tumour is large, has a central position in breast, is multifocal or recurrent.
What methods exist for axillary staging of breast cancer?
Axillary clearance - removal of local lymoh nodes. Levels I-III
Axillary sampling - minimal dissection of axilla undertaen and a selection of at least 4 nodes removed for analysis
Sentinel lymph node biopsy - identifies first node which drains breast and therefore most likely site of metastasis. Dye is injected and sentinel node takes it up. This is usually in low axilla. Avoids high morbidity.
What prognostic index used to be used for predicting breast cancer prognosis?
Which situations would you do a mastectomy over wide local excision?
Size of tumour in relation to size of breast
Patient choice
Recurrence
Risk of recurrence - BRCA gene
Pregnant (you can’t give radiotherapy* after WLE)
Frail/older adults - *Radiotherapy has to be given every day for 3 weeks so this is difficult for them
What is the sentinel node biopsy false negative rate?
3-5%
NB:axillary node clearance has a 30% risk of lymphoedema
What is the screening age for breast cancer in UK?
50-70- anyone registered in GP at these ages will be invited
