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Obs and Gynae > Breast Cancer > Flashcards

Breast Cancer Flashcards

1
Q

What are the risk factors for breast cancer?

A 
Female (99% of breast cancers)
Oestrogen Exposure (years of menstruation, few/no children/no breastfeeding)
Alcohol
Obesity
Family history (first-degree relatives)
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2
Q

Genetics linked with breast cancer

A

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

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3
Q

What does breast cancer metastasize to?

A

2L’s - lungs and liver

2B’s - bones and brain

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4
Q

Ductal Carcinoma In Situ

DCIS

A

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

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5
Q

Lobular Carcinoma In Situ (LCIS)

A 
"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)

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6
Q

Invasive breast cancer (ILC)

A

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

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7
Q

inflammatory breast cancer

A

presents similar to breast abscess or mastitis
swollen, red, tender breast with pitting skin (peau d’orange)
does not respond to antibiotics
worse prognosis

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8
Q

Paget’s disease of the nipple

A

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

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9
Q

rarer types of breast cancer

A

Medullary Breast Cancer
Mucinous Breast Cancer
Tubular Breast Cancer
Multiple others

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10
Q

What is the triple diagnostic assessment?

A

once a patient has been referred for specialist service under a 2 week wait referal for suspected cancer

  1. clinical assessment
  2. breast imaging (ultrasound, mammography)
  3. biopsy (FNA, core biopsy)
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11
Q

ultrasound vs mammogram

A

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

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12
Q

lymph node assessment

A

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

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13
Q

sentinel lymph node biopsy

A

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

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14
Q

what is an oestrogen receptor status (ER)

A

Performed on the tumour cells
Determines whether oestrogen promotes growth of breast cancer cells
Helps to guide chemotherapy choice and prognosis

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15
Q

what is human epidermal growth receptor 2 status

HER2

A

Performed on tumour cells
Determines the presence of HER2
Helps guide chemotherapy choice and prognosis

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16
Q

staging of breast cancer:

A

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

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17
Q

surgery options for breast cancer

1. cancer removal

A

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)
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18
Q

surgery options for breast cancer

2. axillary clearance

A

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

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19
Q

surgery options for breast cancer

3. chronic lymphodema

A

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

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20
Q

what chemotherapy is used in women with ER+ve

A

oestrogen receptor-positive women (ER +ve)

pre menopausal= tamoxifen
post menopausal= aromatase inhbitors (anastrozole, exemestane, letrozole)

21
Q

HER 2 +ve

A

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

22
Q

chemotherapy types

  • neoadjuvant
  • adjuvant
A

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

23
Q

examination of the breast

1. inspection

A

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
24
Q

examination of the breast

2. palpation

A

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).

25
Q

examining the breast lump

A 
Location
Size
Shape (round / oval / irregular)
Consistency (soft / firm / hard)
Margins (irregular / smooth)
Mobile / fixed to skin or chest wall
Tenderness
Discharge
26
Q

what is the NHS breast cancer screening?

A

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

27
Q

breast cancer screening for high risk patients

A

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

28
Q

radiotherapy in breast cancer

A

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)

29
Q

reconstructive surgery

A

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

30
Q

implants (reconstructive surgery)

A

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

31
Q

latissimus dorsi flap (reconstructive surgery)

A

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

32
Q

TRAM flap

Transverse rectus abdominis flap

A

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

33
Q

Deep Inferior Epigastric Perforator Flap (DIEP flap)

A

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

34
Q

who should get a triple assessment referral?

A

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.

  1. breast exam
  2. mammogram / ultrasound
  3. core biopsy (more of a sample) and FNA
35
Q

breast cancer in men

A

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

36
Q

types of biopsy

A

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

37
Q

types of breast cancer

A

37
Breast cancer types

Breast cancer that arises from the duct tissue (ductal DCIS) or lobular tissue (lobular LCIS)

  1. Carcinoma in situ (has not spread beyond the local tissue)
  2. 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
38
Q

more types of biopsy

A

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.

39
Q

types of carcinoma

  • anaplastic
  • mucinous
  • inflammatory
A

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

40
Q

best initial imaging modality for breast malignancy

A

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.

41
Q

IDC invasive ductal carcinoma

A

most common type of breast cancer (80%)

malignancy starts in milk ducts and invades fibrous or fatty tissue outside of the duct.

triple assessment

42
Q

anatomy

  • coopers ligaments
  • serratous anterior
A

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.

43
Q

epithelial hyperplasia

A 
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

44
Q

comedocarcinoma

A

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
45
Q

Anastrozole

A

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.

46
Q

Tamoxifen

A

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

47
Q

biopsy

  • calcification
  • sterotactic
A

calcification: chalk spots on mammograms
ageing
biopsy to ensure they are harmless

steroetactic?
found with mammogram
chalk spots
white specs

guide wire localisation

48
Q

malignant breast disease

A

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)
49
Q

fungating breast tumour

A

painless
clean up, antibiotic gel
carbon dressing to absorb the smell

advanced cancer left lump to develop

Obs and Gynae (27 decks)

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