Breast Cancer Flashcards
Epidemiology
Most common cancer in UK
Affects 1/8 women by 80
- Incidence= 20K/ year
5th most commonest cause of cancer deaths
Genetic associations with breast Cancer
5% associated with BRCA mutations
- BRCA1= Breast ca, Ovarian Ca
- BRCA2= Breast Ca
Hormonal association with breast cancer
Increased oestrogen exposure
- Early menarche (<12), late menopause (>55)
- HRT, OCP (<45)
Obesity
First child >30
Risk factors for breast cancer (6)
Female (1:200)
Older
Proliferative breast disease
Genetic associations
- BRCA1, 2
Family history- 1st degree relative= 2x risk
Oestrogen exposure
Having children >35/ no children
Caucasian <40
Black > 40
- Asians are at low risk
(Breast feeding is protective)
Subtypes of Breast Ca
Ductal carcinoma
- Arising from lining of the lactiferous ducts.
- Includes Ductal carcinoma in situ (DCIS)= non invasive
- Invasive ductal carcinoma
Lobular carcinoma
- Developing from lobules supplying the ducts
Phyllodes tumour
Medullary
- Affects younger Pts
Colloid/ mucinous
- Elderly
Pathology of breast Ca
Cancer typically arises from lining of lactiferous ducts/ lobules supplying the ducts.
DCIS/ LCIS
Ductual carcinoma in situ
- Non-invasive, pre-malignant cancer arising from duct
- Has potential to become invasive
- Presents as microcalcification on
mammogram.
Lobular carcinoma in situ
- Neoplastic proliferation of cells in lobules
- Increased risk of invasive lobular/ ductal carcinoma developing in either breast
Common sites of spread for breast Ca
Local= muscle and skin
Lymph nodes
Bones, Lungs, Liver, Brain
Breast Ca presentation
Breast lump
- Usually painless
- Commonly in upper, outer quadrant
Axillary lymphadenopathy
Skin changes
- Persistent eczema= Paget’s
- Peau d’orange (orange peel appearance)
Nipple
- Discharge
- Inversion
Signs of mets
- Bone pain
- SOB
- Abdominal pain
- Seziures
First line investigation for Breast ca
Mammography
- For screening and diagnosis
Findings
- Clustered calcification (focal/ diffuse)
Investigations for breast Ca
Fine needle/ Core biopsy
Sterotactic biopsy (microcalcifications)
MRI/ USS
- Better tissue enhancement
- Evaluates axillary node envolvement
Hormone receptor testing
- Oestrogen and progesterone
HER2 receptor testing/ Gene expression assays
Primary invasive breast cancer
Cancer that originates in the duct/ lobule of the breast, and has penetrated past the basement membrane.
- Has not spread to other organs but to surrounding tissues.
Treatment of early stage invasive breast Ca
- Stage 2-2B (T2 N1 M0)
- Lumpectomy/ total mastectomy
- Can include breast reconstruction.
- Neoadjuvant/ adjuvant chemo
+ Lymph node resection
HER2 positive
- Trastuzumab +/- pertuzumab (neoadjuvant or adjuvant)
- A
Treatment of early stage invasive breast Ca
- Stage 2-2B (T2 N1 M0)
- HER2 positive disease
Lumpectomy/ total mastectomy
- Trastuzumab +/- pertuzumab (neoadjuvant or adjuvant)
- Trastuzumab ematansine
Neratinib (high risk patient)
- Trialed after trastuzumab based therapy
Treatment of early stage invasive breast Ca
- Hormone receptor-positive disease
- Pre and post menopausal
Lumpectomy/ total masectomy
Pre-menopausal:
1. Tamoxifen
2. Ovarian function suppression
- Goserelin
Post menopausal:
1. Neoadjuvant/ adjuvant
aromatase inhibitor
- Anastrozole, letrozole, exemestane
+ radiotherapy if mastectomy
Treatment of locally advanced stage invasive breast Ca
- Neoadjuvant chemo
+ Surgery/ Lymph node resection
Risk categories
- Low (2)
- Moderate (6)
- High (5)
Low= 12.5% lifetime risk
- No FHx
- 1st/ 2nd degree relative has BC >45
Moderate risk= 25%
- One 1st degree relative <40
- Two 1st/2nd degree relatives with BrCa <60
- Two 1st/2nd degree relavtives with OvCa
- Bilateral BrCa <60
- Three 1st/2nd degree with BC/ OvCa
- First degree male relative with BC
High risk= 50%
- 4 1st/2nd degree relatives with BC/ OvCa
- One family member with BC +Ca
- 3 relatives with BC <40
- Askanazi jew relative
- Cancer syndrome in family
Hodgkins disease and breast cancer
Treated with HD in children = increased risk 25 years post treatment
- Risk = 15-33%
When treated in young adulthood (20-29)
- increased risk (15-25), not as high as childhood treatment.
Screening for BC
Every 3 years from 47-70
Specificity
- False negative rate= 10%
Types of benign tumours
Fibroadenoma
- Most common benign growth
Adenoma
- Benign glandular tumour
Papilloma
- Intraductal, Subareolar region
Lipoma
Phyllodes
- Fibroepithelial= stromal and epithelial tissue
Fibroadenoma
- Features
- Presentation
- Management
Features
- Stromal and epithelial benign growth of lobules
- Common in women of reproductive age
Presentation
- Very mobile
- Well defined and rubbery
- Mainly <5cm
- Multiple/ bilateral
Management
- Low malignant potential
- Left in situ with follow up
- Indication for incision= >3cm
Adenoma
- Features
- Presentation
Benign glandular tumour
- Occurs in elderly
Presents
- Nodular, similar to carcinoma
- Diagnose via triple assessment: examine, image, biopsy.
Papilloma
- Features
- Presentation
- Management
Benign intraductal breast lesion, subareolar
Presentation
- Bloody/ clear discharge
Management
- Biopsy
- Microdochectomy
Lipoma
- Features
- Presentation
- Management
Benign adipose tumour
Presents
- Soft and mobile mass
- Low malignant potential
Management
- Removed if enlarging significantly/ causing compressive symptoms
Phyllodes tumour
- Features
- Presentation
- Management
Fibroepithelial
- Epithelial and stromal (leaf like appearance)
Presentation
- Older age group
- Grow rapidly
Management
- 1/3 have malignant potential
- Wide excision/ mastectomy
Treatment of:
- DCIS
- LCIS
DCIS
- Wide complete excision
- If widespread multifocal= complete mastectomy.
LCIS
- Low grade= monitoring
- Invasive, BRCA1/2 = Bilateral prophylactic mastectomy
Invasive ductal carcinoma
- Features/ types
Most common type of breast carcinoma
Types
- Tubular
- Cribriform
- Papillary
- Colloid
Nottingham prognostic index
Staging system for primary breast cancer prognosis
- Lower score= higher survival rate
Feattures
- Size
- Grade (bloom-richardson classification)
- Nodal status (number of lymph nodes involved)
Receptor status
Cancers checked for responses to certain hormones/ growth factors before targeted therapy.
receptors checked
- Oestrogen
- Progesterone
- Human growth factor (HER)
Breast screening
50-70 age group
- Invited for mammogram every 3 year.
Paget’s disease of the nipple
- Description
- Presentation
- management
Roughing/ redding/ slight ulceration of nipple
- Indicates underlying neoplasms
- Malignant ductal cells in epidermis
Presentation
- Itching/ redness in nipple/ areola
- Flaking thickened skin
- area affected is painful/ sensitive
- Flattened nipple +/- discharge
- ALWAYS involves nipple, whereas eczema always involves areola and spares nipple.
Management
- surgery
- underlying malignancy= radiotherapy
Trastuzumab (known as _____) is a ______ that acts by______
Herceptin
- Monoclonal antibody
- Blocks HER2 receptors
Pertuzumab (known as _____) is a ______ that acts by______
Perjeta
- Monoclonal antibody
- Blocks HER2 receptors
What targetted breast cancer therapy has a risk of cardiotoxicity?
Herceptin (Trastuzumab)
What targetted breast cancer therapy has a risk of alopecia, neutropenia and anaemia?
Pertuzumab (Perjeta)
Neratinib (known as _____) is a ______ that acts by______
Nerlynx
- tyrosine kinase inhibitor
- Blocks HER2 receptor
What targetted breast cancer therapy has a risk of diarrhoea, stomatitis and muscle spasms?
Neratinib
Adverse effects of tamoxifen
Serious effects
- Stroke, VTE
- Endometrial cancer
- Visual disturbance
Common
- Hot flushes
- Vaginal bleeding/ irregular periods
Adverse effects of aromatase inhibitors
Osteoporosis, joint disorders
Alopecia
