Breast cancer Flashcards
Incidence
Classification: Preinvasive vs invasive
1 in 8 women
Pre-invasive
- no invasion below basement membrane, clinically undetectable, no mets
Invasive:
- beyond basement membrane, may have mets
Types of preinvasive [2]
Types of invasive [5]
Preinvasive
- DCIS
- Lobular CIS
Invasive:
o Invasive ductal carcinoma non-special type (NSV): 85%
o Invasive lobular carcinoma: 10%
o Special type: 5% (tubular, medullary, mucinous etc)
o Inflammatory: cancerous cells block lymph drainage causing inflamed breast appearance
o Paget’s disease of the nipple
Where does breast ca mets to? Describe by the 3 mechanisms of metastases: local, lymphatic and blood
o Local: skin, pectoral
o Lymphatic: axillary and internal mammary lymph nodes
o Blood: lungs, liver, bones, brain
RF [9]
- previous breast, ovarian or endometrial cancer
- FHx, known BRCA1/2
- early menarche and/or late menopause
- delay in 1st age of pregnancy
- OCP or HRT
- ionising radiation
- P53 mutation
- obesity
- previous surgery for benign disease
Protective factors of breast ca
• Protective factors: several pregnancies, breastfeeding
Presentation [5]
- hard and fixed lump or thickening
- discharge or bleeding, change in breast size or contour
- skin or muscle tethering
- peau d’Orange skin dimpling
- enlarged axillary or supraclavicular lymph nodes
Presentation of metastatic breast ca [6]
- bone pain
- pleural effusion
- anorexia and weight loss
- neuropathic pain, weakness
- headache, seizures
- spinal cord compression
NHS screening program for breast ca
When to do urgent referrals (within 2 weeks) [4]
NHS screening programme every 3 years for women aged 47-73y/o
Refer people using suspected cancer pathway (apt within 2w) if
- > 30y/o and unexplained breast lump
- > 50y/o and any one of
- discharge
- nipple retraction
- or any other changes of concern
- also consider if skin changes suspicious of breast cancer or >30 and unexplained axilla lump)
When are non urgent referrals indicated?
What is triple assessment of breast lumps
<30y/o unexplained breast lump with or without pain
• Triple assessment of breast lumps: clinical examination, imaging, cytology
Mammogram
Sensitivity
Indications [3]
Findings [4]
93% sensitivity
• Ind: >35y/o or <35y/o and strong suspicion or FHx risk >40%
• Findings:
- dominant mass, asymmetry
- architectural distortion, parenchymal contour
- calcified fibroadenomas (most benign but small % cancerous or pre-cancerous)
- irregular or ill-defined, spiculated
USS
Specificity
Indications [2]
Findings [4]
88% specificity
• Ind: <35y/o or to differentiate between solid and cystic masses
• Findings: irregular outline, interrupted architecture, acoustic shadowing, anterior halo
MRI with gadolinium contrast
Indication [6]
- problem solving
- implants
- indeterminate lesion after triple assessment
- dense breast,
- screening of high risk women
- lobular disease for multifocality
Fine needle aspiration and cytology Sensitivity How to do Findings Cons Complications [4]
a 23G needle is used to aspirate cells under XR or US guidance; 94% sensitivity
Unspecified adenocarcinoma vs benign lesion, grading of cancer
High rate of false -ves so best to do core needle biopsy as well
Cx: pain, haematoma, fainting, infection, PTX
Findings of FNAC that differentiate unspecified adenocarcinoma from benign
- UNSPECIFIED ADENOCARCINOMA: high cellularity, loss of cohesion, cell crowding, nuclear polymorphism, hyperchromasia, absence of bipolar nuclei
- Benign: low or moderate cellularity with flat sheets of cells of uniform size and bipolar nuclei in the background
Needle core biopsy definition
Indications [3]
Findings [4]
14G needle used to obtain intact tissue strand which is fixed in formalin using XR or USS guidance
Ind:
- all cases of suspected radiological or cytological suspicion
- architectural distortion and micro calcification OR breast screening
Findings:
- invasive or non-invasive
- histological subtype and grade
- immunohistochemistry
- commedo necrosis (high grade DCIS)
TMN staging of breast ca
Describe T1-T4
Describe T4a to T4d
• T1: <2cm • T2: 2-5cm • T3: >5cm • T4: fixed to skin or muscle o T4a: chest wall o T4b: skin (incl. ulceration and oedema) o T4c: chest wall and skin o T4d: inflammatory breast cancer
Staging of breast ca [5]
- Bloods
- Baseline CXR (will have multiple lesions throughout lung fields if mets)
o CT chest abdo: baseline and at regular intervals for lung and liver mets
o Isotope bone scan: baseline and when complain or bone pain or abnormal bloods; shows increased areas of uptake if bony mets
o PET: to identify distant disease if CT inconclusive
What bloods to do in staging of breast ca [5]
FBC, U&E and creatinine, LFTs, serum calcium (bone scan if elevated), CA15-3 (inflammatory breast Ca)
Management surgical [3]
- Breast conservation: wide local excision, quadrantectomy or segmentectomy (equal to mastectomy for survival in tumours <4cm) FOLLOWED BY RT
- Mastectomy
- Regional control (lymph clearance)
- Sentinel lymph node (SLN) biopsy
- Surgical or RT axillary clearance
Indication for breast conservation [5]
- DCIS or tumour <4cm (clinically)
- low tumour to breast size ratio
- suitable for RT
- solitary tumour
- minimal in situ cancer component present
- patient preference (most important)
Indications for mastectomy [5]
- unsuitable for conservation or patient preference
- multifocal tumour
- central
- high tumour to breast size ratio
- tumour or DCIS >4cm
Regional control - lymph clearance
Two methods [2]
Sentinel lymph node biopsy
Surgical or RT axillary clearance
SLN biopsy [3]
Complication
SLN = 1st node to receive lymphatic drainage to which tumour spreads (NO skip lesions)
- peritumoural injection of 99m Tc sulphur colloid +ve isosulphan blue dye
- sentinel node found using Geiger counter
- if biopsy negative no further mx rqd
• Cx: 1 in 100 have anaphylaxis
How to manage micromets [4]
- Hormone therapy on estrogen receptor
- Chemotherapy
- RT
- Anti-HER2 immunotherapy trastuzumab herceptin
Mx of inflammatory breast cancer
• Inflammatory breast cancer: neo-adjuvant chemo then total mastectomy +/- RT
Nottingham prognostic index
The Nottingham Prognostic Index can be used to give an indication of survival. In this system the tumour size is weighted less heavily than other major prognostic parameters.
Tumour Size x 0.2 + Lymph node score(From table below)+Grade score
Molecular characteristics of breast cancers Luminal A Luminal B Triple negative basal type HER2 type
- Luminal A (most common): ER and/or PR +ve
- Luminal B: ER or PR +ve and HER2 +ve
- Triple negative (basal type): ER, PR and HER -ve
- HER2 type: HER2 +ve only
Paget’s disease of the nipple [3]
Presentation
- intra-epithelial spread of intraductal carcinoma causing large pale staining cells of the nipple epidermis
- can be limited to nipple or extends to areola
- although no palpable mass can get a lesion in some pts and underlying lymphadenopathy
Presentation
nipple itching, swelling, redness, ulceration, crusting, serous or bloody discharge
o involves nipple centrally and spreads out laterally (opposite of dermatitis)
