Breast Cancer Flashcards
What percentage of men have breast cancer?
Rare in men with only 1% of breast cancer occurring in men
What are the risk factors for breast cancer?
Mutated BRCA1 or 2 genes which are normally tumour suppressors
Family History
Age
Uninterrupted oestrogen exposure: nulliparity, 1st pregnancy > 30yrs, early menarche, late menopause, HRT, obesity, COCP
No breastfeeding
Previous cancer
What is the clinical presentation of breast cancer?
Lumps
Lump or thickening in the breast usually painless (cyclical or not)
Change in size or contours of the beast especially skin tugging
Change in colour or appearance of the areola
Redness and peau d’orange
Nipple inversion
Cancer symptoms such as breathlessness, weight loss, back pain, abdominal mass etc.
Ask about previous lumps, cancers and mammograms. Must not forget family history.
What questions should be explored in the history of a woman suspected of having breast cancer?
Ask about periods and pregnancies and breast feeding
Pain
History of trauma?
Bilateral/unilateral
Related to menstrual cycle
Discharge
Discharge or bleeding
Amount, colour and consistency
What criteria should women be referred to the 2 week wait cancer clinic for?
Unexplained breast lump in >30yra
Symptomatic or nipple change in >50yrs
Consider if skin changes or axillary lump in >30yrs
How are women with suspected breast cancer investigated?
Clinical – inspection and examination
Radiological – Mammograms (40 and above), USS and MRIs
Pathological – Fine needle aspiration cytology, core biopsy, excisional biopsy and Vacuum assisted core biopsy
How are breast lumps managed according to the FNA result?
If lump is cystic then aspiration should be done. If the fluid is clear and no lump is left then give reassurance, if there is a lump left then core biopsy and if the fluid is bloody then send for cytology.
If FNA shows a solid lump then a core biopsy is taken, if this reveals clear fluid then reassurance can be given otherwise await histology reports.
What’s the difference between FNA and core biopsy?
FNA – quick less uncomfortable, lower morbidity but requires core biopsy if malignant
Core Biopsy – removes small amount of tissue, high morbidity and pain, takes longer but allows receptor status and grade of tumour
What marker can be used to monitor breast cancer progress?
CA15-3 – can be used to monitor breast cancer (also found raised in hepatocellular and pancreatic cancer as well as cirrhosis, benign breast disease and normal health).
What investigations should be done if breast cancer presents late?
CXR, bone scan, liver USS, CT/MRI, PET CT, LFTs and Calcium levels.
What are the two types of non invasive breast cancers?
Non-invasive Ductal and Lobular Carcinoma in Situ. Most often presents as mammographic calcifications (clusters or linear and branching) but can present as a mass. Can spread through ducts and lobules and be very extensive. Histologically often shows central (comedo) necrosis with calcification. Non-obligate precursor of invasive carcinoma.
Describe invasive ductal carcinoma?
Invasive ductal carcinoma, no special type – 70-80%. Well-differentiated type has tubules lined by atypical cells. Poorly differentiated type has sheets of pleomorphic cells – 35-50% 10-year survival.
Describe invasive lobular carcinoma?
Invasive lobular carcinoma – 5-15% – Infiltrating cells in a single file, cells lack cohesion – Similar prognosis to IDC.
What is Paget’s disease of the breast?
(Related to DCIS)
Malignant cells can extend to nipple skin via the epidermis and so without crossing BM. Paget’s disease – Unilateral red and crusting nipple, eczematous or inflammatory conditions of the nipple should be regarded as suspicious and biopsy performed to exclude. If you have Paget’s you definitely have DCIS.
What is inflammatory breast cancer?
Rare rapidly progressive form caused by obstruction of the lymph drainage causing erythema and oedema. Usually a primary cancer treated with neo-adjuvant chemotherapy followed by total mastectomy +/- radiotherapy
Where does breast cancer metastasise to?
Breast cancer commonly metastasises to brain, liver, lung, bone, adrenal and ovary.
What are the 3 receptors that can be involved in breast cancer?
Oestrogen receptor (if positive then better prognosis) Progesterone receptor (if positive then better prognosis) Herceptin over expression (aggressive disease and poorer prognosis)
What are the 4 stages of breast cancer?
Stage 1 – confined to breast and mobile
Stage 2 – growth confined to breast, mobile with affected lymph nodes in ipsilateral axilla
Stage 3 – tumour fixed to muscle and skin involvement larger than tumour
Stage 4 – complete fixation of tumour to breast and distant metastasis
Describe the TNM staging criteria for breast cancer?
T1 < 2cm, T2 2-5cm, T3 >5cm, T4 fixed to chest wall or peau d’orange
N1 mobile ipsilateral nodes, N2 fixed nodes
What surgery is used to manage breast cancer?
Wide local excision
Mastectomy +/- breast reconstruction
Axillary node biopsy or sentinel node biopsy
What criteria would indicate mastectomy vs wide local excision?
Mastectomy Multifocal tumour Central tumour Large lesion in small breast DCIS >4cm Patient Choice
Wide Local Excision Solitary lesion Peripheral tumour Small lesion in large breast DCIS <4cm Patient choice
What adjuvant therapy can be given alongside surgery for managing breast cancer?
Radiotherapy – recommended for all patient who have WLE as it reduces recurrence and increases survival (axillary node radiotherapy if found to be involved in sampling but no surgical clearance). For mastectomy it is offered to T3-T4 and then with positive nodes.
Chemotherapy – considered in all patient as also reduces recurrence and increases survival
What hormonal therapy is available for breast cancer?
Hormonal therapy
- Oestrogen Antagonists – tamoxifen used in pre (and peri) menopausal women – increased risk of DVT, endometrial cancer and osteoporosis
- Aromatase Inhibitors – Arimidex, letrozole and exemestane used in postmenopausal women – prevents oestrogen production in post-menopausal women. Increased risk of Osteoporosis (DEXA scan indicated before starting) and menopausal symptoms.
Biological
1. Herceptin (Trastuzumab) – contraindicated in heart disorders
How should late stage breast cancer be managed?
Late stage disease – radiotherapy to painful bony lesions, (bisphosphonates can be useful). If relapse after initial success, then consider chemotherapy. Hormonal and biological treatments as usual.
Describe the breast cancer screening programme
2-view mammography every 3 years for women aged 47-73 in the UK
If someone has only 1 first degree relative or second degree relative diagnosis with breast cancer what criteria would require them to be referred to genetics?
If the person concerned only has one first-degree or second-degree relative diagnosed with breast cancer they do NOT need to be referred unless any of the following are present in the family history:
• age of diagnosis < 40 years
• bilateral breast cancer
• male breast cancer
• ovarian cancer
• Jewish ancestry
• sarcoma in a relative younger than age 45 years
• glioma or childhood adrenal cortical carcinomas
• complicated patterns of multiple cancers at a young age
• paternal history of breast cancer (two or more relatives on the father’s side of the family)
