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Breast Cancer Flashcards

1
Q

What is the epidemiology of breast Ca

A

Most common cancer in females
Lifetime risk of 6.45^
Leading cause of death

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2
Q

What is the breast cancer stage distribution in Singapore

A

1- 33%
2- 40%
3- 15%
4 - 11%

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3
Q

What is the breast cancer screening in Singapore

A

BSE - No change in mortality
Mammography - 20% mortality reduction from 40-74
Screening - 50-69 most effective

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4
Q

What is the recommended screening for normal patients/HRT

A

Below 40:
BSE 7-10 days after menstruation, no imaging needed

40-49 Annual mammogram, for screening

50-69 Bi-annual mammogram

70+ optional bi-annual mammogram

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5
Q

What are the recommendations for those with increased risk due to family history

A

5-10 years before onset of breast disease in family member

If BRCA: Start at 25-30

Perform: Monthly BSE
6 monthly clinical breast exam with optional ultrasound/MRI

Annual mammogram

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6
Q

What is the types pathology of breast Ca

A

Noninvasive, invasive and inflammatory

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7
Q

Elaborate on noninvasive

A

DCIS and Lobular intraepithelial neoplasia

DCIS: Proliferation of malignant ductal cells from terminal ductal-lobular unit, confined by basement membrane

  • Myopethelial cell layer is intact
  • Unicentric, pre invasive lesion
  • Positive for e-cadherin

LIN: Covers LCSI and ALH, from the terminal ductal lobular unit

LCIS is if >50% of loosely cohesive cells, if not considered ALH

  • Multicentric, NOT pre-malignant, negative for e cadherin
  • Associated with incvreased risk of DCIS
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8
Q

What is the presentation of DCIS and LIN

A

DCIS: Asymptomatic with mammographic abnormlaities on screening

  • Microcalcification
  • Occasionally has palpable lesion and nipple discharge

LIN: Incidental finding

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9
Q

Classification of DCIS

A

Presence absence of comedo necrosis

Comedo: DCIS with central necrosis, increased risk of malignancy

Non-comedo - not as concerning

Also classified into low, intermediate and high nuclear grade

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10
Q

Classification of LIN

A

Pleomorphic - more aggresive

Classical- less concerning

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11
Q

What is the prognonosis of DCIS and LIN

A

DCIS - 1/3 progress to IDC
10% have concurrent invasive carcinoma
Low risk of mets or recurrence

LIN
Pleomorphic: similiar to DCIS
40% of carcinomas that arise from LIN develop from in situ lesions
5% have synchronus breast cancer

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12
Q

What are the types of invasive breast carcinoma?

A

No special type vs special type

Special type: 50-75% of all lesions

71% have ER, 47% have PR, 18% have HER2

Classical special type - most commonly an invasive lobular carcinoma

  1. 8% have HER+
    - Higher risk of positive margins because disease is not easily imaged
    - Distinct pattern of mets to GI tract, gynacological organs, peritoneum or retroperitoneum
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13
Q

What is the presentation of inflammatory breast carcinoma

A

Rapid swelling with skin changes and nipple depression

Underlying cancer is poorly differentiated and invades breast parenchyma

Often mistaken for mastitis, treat with multimodal therapy

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14
Q

What arethe important biomarkers of breast cancer

A

Her2+ - Previously poor survival but now can treat with herceptin to improve survival

Triple negative - poor prognosis

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15
Q

What is the clinical presentation of breast Ca

A

Asymptomatic

Symptomatic:

  • Lump in breast/axilla
  • Nipple changes/discharge
  • Mets to bone, liver, lungs, brain, abdomen
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16
Q

What are the features suggestive of breast Ca

A

Irregular/nodular surface
Poorly defined areas
Firm/hard consistency

No tenderness or fluctuance
Lymphadenompathy
Possible tethering/nipple involvement

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17
Q

What is the mode of spread of breast Ca

A

Local, lymphatic, hematogenous

Local - skin, subcutaneous tissue, muscle

Lymphatic - axillary, internal mammary, infraclavicular and supraclavicular lymph nodes

Blood - lungs brain bone liver adrenal ovaries

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18
Q

What investigations to carry out for breast Ca

A

Triple therapy, followed by

Biochemical investigations

  1. FBC
  2. Renal panel
  3. Liver function test
  4. Calcium panel

Imaging:

  1. CT TAP
  2. Bone scan
  3. MRI spine/MRI brain
  4. PET scan
19
Q

TNM staging of breast cancer

A 
T: 
1 - <2m
2- 2-5cm
3 more than 5 cm
4 - Extension

N: 0
1

M: X
0
1

20
Q

What is the management of breast cancer

A

Local-regional control (radiotherapy, surgery) and

systemic therapy (chemotherapy, hormonal therapy, targeted therapy)

21
Q

What is the surgical measurement of breast Ca

A
  1. Prep for op
  2. Breast conserving surgery - remove tumour with clear margins (t1-t2 cancers)
    Only 1 tumour to remove
    MUST follow up with post op radiotherapy
  3. Mastectomy

Modified radical mastectomy - Total mastectomy and axillary clearance level 1 and 2

Simple mastectomy - just removal of breast, KIV axillary clearance (recommended)

4. Breast reconstruction 
Can be 
-Implant
-Lat dorsi flaps
-Rectus abdominis flaps
22
Q

What is the axillary management

A

Sentinel lymph node biopsy - inject blue dye intro intradermal plane in vicinity of tumour before surgery

  • Blue dye may be on breast for up to 4 weeks, green urine 1 week post op
  • Multiple blue lymphatic ducts converging into the sentinel node is the medial axilalry nodal basin
  • Use geiger counter to detect radioactivity
  • Biopsy sentinel lymph node and send for frozen section (cytology)

For isolated tumour - no further treatment
For spread - axillary clearance

23
Q

What is axillary clearance

A

Remove >10 nodes from the axillary level 1 and 2, level 3 removed if grossly enlarged

24
Q

What is the adjuvant radiotherapy of breast cancer

A

5 weeks, 1 cycle from Monday to Friday

External beam whole breast radiotherapy or axillary radiotherapy

WBRT:
Indications - T3/T4 disease, >4 axillary lymph nodes involved

Axilalry radiotherapy - for those with >4 involved nodes

25
What are the side effects of radiotherapy?
Short term - skin irritation, tiredness, swelling Long term - pigmentation, pneumonitis, fractures, cardiac toxicity, RT induced cancer Axillary radiation - lymphedema, axillary fibrosis
26
What is neoadjuvant chemotherapy?
Place clip into tumour prior to neoadjuvant therapy, operate according to pre-op staging - Follow up with MRI to monitor disease, increases chances of BCS - Reviews prognostic information of breast Ca
27
What is adjuvant chemotherapy?
Stage 3 or locally advanced breast cancer, Her 2 positive, triple negative breast cancer
28
What are the side effects of chemotherapy?
Tiredness, n/v, lethargy, myelosuppresion, cardiomyopathy, infections, diarrhea
29
What are the uses of hormonal therapy?
Hormone/biologic therapy are usually adjuvant, but can be neoadjuvant when locally advanced, palliative treatment and preventive treatment in high risk patients ER/PR+ have 90% response
30
What are SERMs?
Selective estrogen receptor modulators - Tamoxifen Used for adjuvant setting, decreases incidence of breast Ca only evident in ER+ Ca Act as estrogen receptor antagonists Decreases recurrence when taken for 5 years. If high risk, premenopaulsal women can undergo further ovarian suppression
31
What are aromatase inhibitors?
Letrozole - inhibit peripheral conversion of testosterone and androstenedione to estradiol Indicated for post menopausal patients, where the main source of estrogen is conversion of androstenedione to estradiol in peripheral tissues Improvement in disease free survival
32
What is trastuzumab?
Herceptin - binds to her2 gene to block epidermal growth factorreceptor IV administration for 1 year with chemotherapy Disease free survival and benefit increased
33
What are the side effects of SERM, AI and trastuzumab?
SERM - Increased risk of endometrial cancer - Menopausal symptoms from tamoxifen flare - Thromboembolic fractures - Cataract AI - Osteoperosis - Hyperlipidemia - Musculoskeletal pain Herceptin -Cardiotoxic
34
What are the complications of breast surgery?
``` Hemorrhage/hematoma Infection Seroma Intercostal intercostobrachial nerve injury Restricted surgical mobility Skin flap necrosis Recurrence ```
35
What are the complications of axillary clearnace?
``` Bleeding Seroma formation Nerve injury Axillary vein thrombosis Lymphatic fibrosis Lymphedema Frozen shoulder ```
36
What is the prognosis of breast cancer?
Nottingham prognostic index Size of tumour Number of lymph nodes involved Grade of tumour Nodal involvement most important factor
37
What is breast cancer follow up
3-6 months for 3 years, then 6-12 months for 2 years, then annually therafter Post treatment MMG should be 1 year after initial MMG, 6 months after raditation therapy is complete -Annual MMG for contralateral breast Genetic counselling for BRCA ``` Survival data for patients Stage 1 - 100% Stage 2 -90% Stage 3 - 70% Stage 4 -30% ```
38
Approach for atypical ductal hyperplasia
1. Core biopsy confirmed -> excision biopsy or surgical excision 2. No need for axillary staging 3. Margins irrelevant Consider: Chemoprophylaxis of mastectomy
39
Approach for LIN
Same as ADH, but if diagnosed coincidentally following excision of coexisting breast lesion, no need for removal because LIN is diffuse
40
Approach for DCIS
20% of screening detected cancers Breast conserving surgery with wire-needle localization to identify area to be excised, with intra op x ray to ensure all suspicious microcalcifications are removed OR Simple mastectomy if BCS is unsuccessful/contraindicated If patient is high risk (comedo DCIS/high nuclear grade/size/lesion) perform mastectomy with SNLB 1-2mm margins required +/-adjuvant radiation and hormone therapy
41
How to treat stage 1/2 breast cancer
BCT + SNLB + radiation therapy If node positive, adjuvant radiation, chemotherapy, hormonal therapy indicated Prognosis for local recurrence: Increased in 1. Young patients 2. HER2 positive, triple negative patients 3. Presence of lymphovascular invasion 4. Tumour grade and margin status
42
What is the approach to locally advanced breast cancer
Neoadjuvant therapy, surgical excision (simple mastectomy) , axillary lymph node dissection If inflammatory - skin punch biopsy to confirm diagnosis Aggressive multimodal therapy, neoadjuvant chemotherapy and surgery
43
What is the approach for metastatic breast cancer
Systemic treatment, palliative surgery to remove bleeding/fungating tumours and palliative radiation therapy for painful bone metastasis

Breast (5 decks)

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