Breast Cancer Flashcards
What are the risk factors for breast cancer?
Female (99% of breast cancers) Oestrogen Exposure (years of menstruation, few/no children/no breastfeeding) Alcohol Obesity Family history (first-degree relatives)
Genetics linked with breast cancer
BRCA gene (tumor supressor genes)
Faulty BRCA1 gene
- chromosome 17
around 60% will develop breast cancer
- 40% will develop ovarian cancer
Faulty BRCA2 gene
chromosome 13
40% develop breast cancer
15% develop ovarian cancer
What does breast cancer metastasize to?
2L’s - lungs and liver
2B’s - bones and brain
Ductal Carcinoma In Situ
DCIS
pre-cancerous or cancerous epithelial cells of the breast duct
localised to a single area picked up on a mammogram potential to spread locally potential to become invasive (30%) good prognosis if full excision
non invasive: within the ducts
tends to be asymptomatic
picked up on screening
+/- breast lump
nipple discharge
breast tenderness
cracking of skin
Lobular Carcinoma In Situ (LCIS)
"lobular neoplasia" pre-cancerous condition typically occurs in pre-menopausal women asymptomatic and undetectable on mammogram diagnosed incidentally on bresat biopsy
increased risk of invasive breast cancer
managed with close monitoring (6 monthly examination and yearly mammogram)
Invasive breast cancer (ILC)
gradual breast enlargement
fhx of breast cancer
originates in cells from breast lobules
gone past the duct
hard, fixed mass. nipple inversion, dipple discharge, skin retraction, peau d’organe, lymphadenopathy (palpabel) (axilla/parasternal)
mx: triple assessment
inflammatory breast cancer
presents similar to breast abscess or mastitis
swollen, red, tender breast with pitting skin (peau d’orange)
does not respond to antibiotics
worse prognosis
Paget’s disease of the nipple
looks like eczema of the nipple/areolar
erythematous, scaly rash
indicates breast cancer that involves the NIPPLE
may represent DCIS or invasive breast cancer
biopsy, staging and treatment as with any other invasive breast cancer
Intraductal carcinoma associated with reddening and thickening (resembles eczematous changes) of the nipple/areola
Ix: Punch biopsy
Mammography
Ultrasound
Treatment depends on the underlying lesion
rarer types of breast cancer
Medullary Breast Cancer
Mucinous Breast Cancer
Tubular Breast Cancer
Multiple others
What is the triple diagnostic assessment?
once a patient has been referred for specialist service under a 2 week wait referal for suspected cancer
- clinical assessment
- breast imaging (ultrasound, mammography)
- biopsy (FNA, core biopsy)
ultrasound vs mammogram
younger women have denser breast, more glandular breast
ultrasound:
lumps in younger women <30
can be useful to distinguish solid lumps (fibroadenoma/cancer) from cystic lumps
mammogram
more effective in older women
pick up calcifications missed by USS
lymph node assessment
Before surgery: everybody offered axillary ultrasound and ultrasound guided biopsy of any abnormal nodes
During surgery: where no abnormal lymph nodes are found using Sentinal Lymph Node Biopsy
sentinel lymph node biopsy
sentinel= where the first node is drained to
Performed during breast surgery for cancer
Where no abnormal lymph nodes identified prior to surgery
Isotope contrast and a blue dye are injected into the tumour area
This is carried through the lymphatics to the first lymph node (the sentinel node)
This node shows up blue and on the isotope scanner
This node is then sampled to stage the cancer
what is an oestrogen receptor status (ER)
Performed on the tumour cells
Determines whether oestrogen promotes growth of breast cancer cells
Helps to guide chemotherapy choice and prognosis
what is human epidermal growth receptor 2 status
HER2
Performed on tumour cells
Determines the presence of HER2
Helps guide chemotherapy choice and prognosis
staging of breast cancer:
TNM system used
T (tumour)
TX – unable to assess size Tis – DCIS T1 – < 2cm T2 – 2-5 cm T3 – >5cm T4 – spread to skin or chest wall N (nodes)
NX – unable to assess nodes
N0 – no nodal spread
N1 – spread to axillary nodes but nodes are mobile
N2 – spread to axillary nodes (and fixed) or to internal mammary nodes
N3 – spread to axilla and internal mammary nodes or to infraclavicular or supraclavicular nodes
M (metastasis)
M0 – no petastasis
M1 – metastasis
surgery options for breast cancer
1. cancer removal
remove cancer tissue along with a 2mm ‘clear margin’ of normal breast tissue
Breast-Conserving Surgery Lumpectomy Wide Local Excision Quadrantectomy (removal of a quarter of the whole breast) Mastectomy (removal of the whole breast)
surgery options for breast cancer
2. axillary clearance
Offered to patients where early invasive breast cancer has been demonstrated in axillary nodes
Involves removing the majority or all lymph nodes from the axilla
Increases risk of chronic lymphedema in that arm
surgery options for breast cancer
3. chronic lymphodema
Can occur in the ipsilateral arm to the breast undergoing surgery
This can have a large impact on the patient’s quality of life
Patients should be informed of the risk of lymphoedema prior to surgery
Resting the arm post operatively, certain exercises and avoiding injury or infection reduces the risk of developing lymphoedema
Specialist lymphoedema services available
! do not take blood from this arm
what chemotherapy is used in women with ER+ve
oestrogen receptor-positive women (ER +ve)
pre menopausal= tamoxifen
post menopausal= aromatase inhbitors (anastrozole, exemestane, letrozole)
HER 2 +ve
trastuzumab (Herceptin)
this is a monoclonal antibody biological therapy which disrupts the HER2 receptor
given 3 weeks for 1 year
impacts heart function (monitor)
contraindicated in CHF
side effects: diarrhoea, tumour pain, headaches
chemotherapy types
- neoadjuvant
- adjuvant
Chemotherapy guided by oncologists
Used in one of three scenarios:
Neoadjuvant therapy – intended to shrink the tumour prior to surgery
Adjuvant chemotherapy – after the surgery to reduce recurrence
For treatment or control of metastatic or recurrent breast cancer
Usually around three agents used concurrently
examination of the breast
1. inspection
Examine the patient relaxed, while lifting hands overhead and pressing hands into hips (tensing muscles of the chest wall)
Scars Cosmetic Augmentation Asymmetry (size/shape) Tethering or fixation of overlying skin Nipple eversion/inversion Nipple discharge Erythema Peau D’orange Paget’s disease of the nipple
examination of the breast
2. palpation
Place flat part of fingers over the area and roll tissue underneath
If necessary support tissue with your other hand
Examine away from the abnormal area first to note patients normal breast tissue and so as not to miss other lumps
Choose a strategy so as not to miss any areas (including four quadrants, subareolar and axillary regions).
examining the breast lump
Location Size Shape (round / oval / irregular) Consistency (soft / firm / hard) Margins (irregular / smooth) Mobile / fixed to skin or chest wall Tenderness Discharge
what is the NHS breast cancer screening?
women 50-70 y/o
every 3 years
simple mammogram
1/100 women are diagnosed with breast cancer
limitations to the screening: false +, false -
exposure to radiation
> 50-71 breast cancer screening every 3 years
1 in 8 women get breast cancer
uses mammography radiography to detect small changes in the breast before patient is symptomatic.
> 70 still entitled to screening (ned to arrange self)
screening involves two views of the breast:
cranio caual
lateral oblique by mammography
breast cancer screening for high risk patients
Complex NICE guidelines [CG164] for referral for genetic testing
Review criteria if multiple relatives on the same side with breast / ovarian cancer
Patients should be offered genetic counselling and pre-test counselling prior to testing
Tests available for BRCA1, BRCA2, TP53 and PTEN genes
Screening for breast cancer in high risk patients consists of annual mammograms
Aged 40-49 if moderate risk
Aged 40-59 if high risk
Aged 40-69 if known BRCA positive
Consider offering aged 30-59 if high risk
radiotherapy in breast cancer
Radiotherapy allows for breast conserving surgery with equal outcomes to full mastectomy in patients with early breast cancer
Radiotherapy post-surgery reduces local recurrence
Involves radiotherapy delivered from multiple angles to concentrate radiation on targeted area
Usually involves daily treatments for 3-5 weeks
side effects:
General fatigue from the radiation
Local skin and tissue irritation and swelling
Fibrosis of breast tissue
Shrinking of breast tissue
Long term skin colour changes (usually darker)
reconstructive surgery
Offered to all patient having a mastectomy
Immediate reconstruction done at the same time as the mastectomy
Reconstruction can be delayed for years after initial mastectomy
May not be possible due to required chemo or radiotherapy or comorbidity
implants (reconstructive surgery)
Simple procedure with minimal scarring
Reasonable appearance but less natural feel (cold, less mobile and static size and shape)
Long term problems include hardening, leakage, and shape change
latissimus dorsi flap (reconstructive surgery)
Portion of the latissimus dorsi plus skin and fat tissue
Tunnelled under skin to the breast area
“Pedicled” refers to keeping the original blood supply and moving the tissue under the skin to a new location
“Free flap” refers to cutting the tissue away completely and transplanting it to a new location
TRAM flap
Transverse rectus abdominis flap
Portion of rectus abdominis along with blood supply and skin
Either as pedicled flap (tunneled under skin) or free flap (transplanted)
Risk of abdominal hernia due to weakened abdominal wall
Deep Inferior Epigastric Perforator Flap (DIEP flap)
Skin and subcutaneous fat from abdomen (no muscle)
Transplanted from abdomen to breast
Transplant the Deep Inferior Epigastric Artery with fat and skin
Tissue transplanted to reconstruct breast
Vessels attached to branches of the internal mammary artery and vein
Very complex procedure with microsurgery
Less risk of abdominal wall hernia as muscle are intact
who should get a triple assessment referral?
hospital-based clinic
referral 2ww
2 week wait
aged >30, unexplained breast lump with or without pain
aged >50 with following symptom in one nipple (discharge, retraction, other changes of concern)
skin changes that suggest breast cancer
>30 years old with unexplained lump in axilla
non urgent referral
<30 unexplained breast lump wihtout pain.
- breast exam
- mammogram / ultrasound
- core biopsy (more of a sample) and FNA
breast cancer in men
400 men in the UK every year
increase in age radiotherapy exposure FHX of breast cancer high oestrogen levels (liver cirrhosis/obesity) damage or malfunction of the testes Klinefelter syndrome (47 XXY)
presentation: lump, nipple discharge, bleeding or skin changes.
prognosis is worse
tamoxifen for tx
types of biopsy
FNA - fine needle aspiration: thin needle to collect a small amount of tissue from suspicisou area
Core Needle biopsy- larger needle, removes larger sample
Vaccum AssistedBiopsy- scution device thoruhg a needle to collect multiple/large samples from same biopsy site
Excisional bopsy: removar of entire suspicious area, commonly used for supiciosu skin changes like moles
types of breast cancer
37
Breast cancer types
Breast cancer that arises from the duct tissue (ductal DCIS) or lobular tissue (lobular LCIS)
- Carcinoma in situ (has not spread beyond the local tissue)
- Invasive carcinoma
If cancer has spread.
- invasive ductal carcinoma / no special type (NST) most common
- invasive lobular carcinoma
- ductal carcinoma in situ
- lobular carcinoma insitu
more types of biopsy
Punch biopsy- sharp, circular tool to take sample from below the skin surface
Endoscopic biopsy- sample of tissue during endoscopy using forceps
Laproscopic biopsy- similar but uses a laproscope instead
Bone marrow aspiration and biopsy
remove sample of fluid with a needle. bone marrow biopsy removes a small amount of solid tissue using a needle
liquid biopsy
routine sampel of blood is analysed.
types of carcinoma
- anaplastic
- mucinous
- inflammatory
anaplastic:
a subtype of invasive ductal carcinoma
slightly better prognosis than inflammatory carcinoma
mucinous:
a subtype of invasive ductal carcinoma
slightly better prognosis than inflammatory
inflammatory:
subtype of invasive ductal carcinoma
malignant cells in the lymphatic duct
poor prognosis
best initial imaging modality for breast malignancy
X ray mamography (employed as part of the triple biopsy if >35
US is preferable in woman <35 as the breast tissue is more glandular and dense so mammographic xrays cannot penetrate sufficiently. added benefit of not using ionising (possible teratogenic) radiation.
USS not useful in dense tissue.
IDC invasive ductal carcinoma
most common type of breast cancer (80%)
malignancy starts in milk ducts and invades fibrous or fatty tissue outside of the duct.
triple assessment
anatomy
- coopers ligaments
- serratous anterior
attach to the back and skin
(coopers droopers)
pectoral muscle lobules ducts ribs fatty tissue areolar nipple pectoral muscle (pectoralis major)
wining of the scapula
long thoracic nerve
a complication of radical mastectomy
medical rotation when the arm is abducted at the shoulder joint.
epithelial hyperplasia
Variable clinical presentation Generalised lumpiness / discrete lump Cellularity of the terminal lobular unit Atypical features FHx of breast cancer
increases risk of malingancy
if no atypical features= conservative mx
if atypical features= close monitoring / surgical resection
comedocarcinoma
calcified mass on mammography
breast calcification can be benign but is often suspicious and warrants further testing.
- high grade ductal carcinoma in situ
- not invaded through the breast tissue
- calcification and necrosis often seen
- higher rate of cellular proliferation > death
Anastrozole
aromatase inhibitor used to treat breast cancer, especially in post menopausal women with hormone receptor positive tumour and in patient where the disease has progressed despite treatment with tamoxifen.
Tamoxifen
selective ER modulator
oestrogenic and anti oesotrgenci actions (Depending on the target tissue)
‘selective oestrogen receptor modulator’
in mammary epithelium- strong anti oestrogenic action so helps prevent and tx breast cancer
side effects:
hot flushes, sweats, change in menstrual pattern, loss of sex drive, nausea, visual problems- cataracts, muscle aches, fatigue
biopsy
- calcification
- sterotactic
calcification: chalk spots on mammograms
ageing
biopsy to ensure they are harmless
steroetactic?
found with mammogram
chalk spots
white specs
guide wire localisation
malignant breast disease
phyllodes
excise with margin, no LN, no hormone therapy
cancer- ILC, IDC, DCIS Paget's disease of nipple inflammatory men >50, klinfelters family <40, BRCA1, BRAC2, TP53 p'au de orange (texture of orange peel bobbly)
fungating breast tumour
painless
clean up, antibiotic gel
carbon dressing to absorb the smell
advanced cancer left lump to develop
