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Gwen - Reproductive Medicine (Obs, Gyn, Breast) > Breast Cancer and Screening > Flashcards

Breast Cancer and Screening Flashcards

1
Q

What are risk factors related to the development of breast cancer?

A

OESTROGEN INCREASE

  • Gender
  • Age (rare <25 years)
  • Menstrual history (increased oestrogen exposure)
  • Age at first pregnancy
    • ​Early age reduces risk
    • Pregnancy >30 years is increased risk
    • Nulliparity is increased risk
  • Not breastfeeding
  • PMH
    • Past breast cancer,
    • Previous surgery for benign breast disease
    • Radiation
    • Drugs - HRT, small increase on COCP
  • Family history
  • Alcohol
  • Obesity
  • Genetics
    • BRCA1/2 gene
    • TP53
    • PTEN
    • HER2

‘3 Ages’ - Early menarche, Late menopause, 1st pregnancy after 30 yrs

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2
Q

What are examples of non-invasive breast carcinoma?

A
  • Ductal carcinoma in situ
  • Lobular carcinoma in situ
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3
Q

What are examples of invasive breast cancer?

A
  • Infiltrating ductal carcinoma
  • Infiltrating lobular carcinoma
  • Mucinous carcinoma
  • Medullary carcinoma
  • Papillary carcinoma
  • Tubular carcinoma (low grade, good prognosis)
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4
Q

Where is the BRCA 1 gene located?

A

Chromosome 17q

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5
Q

Where is the BRCA 2 gene located?

A

Chromosome 13q

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6
Q

What is the risk associated with BRCA 1 gene mutation?

A

65%

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7
Q

What is the risk associated with BRCA 2 gene?

A

45%

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8
Q

What is the risk of ovarian cancer associated with the BRCA 1 gene?

A

39%

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9
Q

What is the risk of ovarian cancer with the BRCA 2 gene?

A

11%

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10
Q

How is oestrogen thought to play a part in the development of breast cancer?

A

Overexposure increases the risk of breast cancer:

  • Early menarche - more period cycles
  • Late manopause - more period cycles
  • HRT - oestrogen exposure
  • OCP - oestrogen exposure
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11
Q

What is ductal carcinoma in situ?

A

A pre-cancerous or non-invasive cancerous lesion of the breast found in cells lining the milk ducts of the breast. In situ refers tot he fact that cells have not moved out of the mammary duct and into any of the surrounding tissue.

Doesn’t form palpable tumour.

Segmentla areas affected.

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12
Q

What is lobular carcinoma in situ?

A

An incidental microscopic finding with characteristic cellular morphology and multifocal tissue patterns. The condition is a laboratory diagnosis and refers to unusual cells in the lobules of the breast.

Tends to be multifocal and bilateral.

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13
Q

What age group does DCIS commonly occur in?

A

40-60 years

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14
Q

What is the risk of preogression from non-invasive to invasive

A

Low grade DCIS = 30% in 15 years

High grade DCIS = 50% in 8 years

LCIS = 19% in 25 years and bilaterally

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15
Q

Who does LCIS occur more commonly in; premenopausal or postmenopausal women?

A

Premenopausal women

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16
Q

What is the most common type of invasive carcinoma?

A

Ductal carcinoma (85%)

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17
Q

How is DCIS seen on mammography?

A

Microcalcification - unifocal or widespread

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18
Q

What age group do medullary cancers tend to affect?

A

Younger women

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19
Q

What breast cancer tend to more commonly affect older age groups?

A

Colloid/mucoid

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20
Q

What percentage of breast cancers are oestrogen receptor positive?

A

60-70%

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21
Q

What proportion of those with breast cancer express HER2 gene?

A

Approximately 30%

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22
Q

What is paget’s disease of the nipple associated with?

A
  • DCIS
  • Invasive carcinoma
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23
Q

What is Paget’s disease of the nipple?

A

90% of patients have an invasive carcinoma (typically intraductal)

Roughening, reddening and slight ulceration of the nipple, similar to the skin changes of eczema. It is a result of intraepithelial spread of intraductal carcinoma.

It is often Limited to the nipple and can extend to the areola. Pain or itching, scaling and redness, Ulceration, crusting, serous or bloody discharge are all features

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24
Q

How does breast cancer spread?

A
  • Local - skin, pectoralis muscles, opposite breast
  • Lymphatic - axillary and internal mammary nodes
  • Blood - bone, lungs, liver, brain
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25
Q

What are symptoms of breast cancer?

A
  • Lump
  • Bleeding/discharge from the nipple
  • Change in shape/contours
  • Change in appearence
  • Redness
  • Painless or pain
    • ​More commonly painless
    • If pain can be cyclical (worse in latter 1/2 of cycle and releived by period or non cyclical)
  • Symptoms of metastatic disease - weight loss, breathlessness, back pain, abdominal mass
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26
Q

What are signs of breast cancer?

A
  • Lump - fixed, non-fluctuant, hard
  • Asymmetrical breast shape
  • Dimpling
  • Recent non-reversible nipple inversion
  • Discharge
  • Skin cahnges
    • Peau d’orange
    • Erythema
    • Ulceration (late sign)
  • Paget’s disease of the nipple
  • Axillary/supraclavicular lymphadenopathy
  • Signs of mets - hepatomegaly, lung signs
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27
Q

What is the following?

A

Ulcerating breast cancer

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28
Q

What is the following?

A

Dimpling - caused by by retraction of ligaments of cooper

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29
Q

What is the following?

A

Peau d’orange - combination of oedema of breast and tethering by ligaments of cooper

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30
Q

What is the following?

A

Paget’s disease of the nipple

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31
Q

What is the following?

A

Nipple inversion/retraction

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32
Q

What are causes of nipple discharge?

A
  • Duct ectasia
  • Intraductal papilloma/adenoma/carcinoma
  • Lactation
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33
Q

What are causes of nipple inversion?

A
  • Duct ectasia
  • Carcinoma
  • Benign inversion
  • Post-surgical
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34
Q

If you suspected breast cancer, what investigations would you consider doing?

A

Triple assessment:

  1. Clinical examination
  2. Mammography/Ultrasound
    • <35 - ultrasound
    • >35 - ultrasound + mammography
  3. Histology/cytology
    • FNA (for palpable lesions)
    • Core biopsy (US guided) (for non palpable)
35
Q

What investigatiions would you consider doing to stage a breast cancer?

A
  • Bloods - FBC, U+E, LFT
  • Imaging - CXR, Isotope bone scan
  • CT if mets suspected
    • Abnormal CXR
    • Neurological symtpoms
    • Hepatosplenomegaly
    • Lymphadenopathy
    • LFTs abnormal
  • Bone scintigraphy if
    • Distant mets
    • Bone pain
    • Lymphd node mets
    • Advanced local disease
36
Q

What is stage 1 breast cancer defined as?

A

Confined to the breast, mobile

37
Q

What is stage 2 breast cancer defined as?

A

Growth confined to breast, mobile, lymph nodes in ipsilateral axilla

38
Q

What is stage 3 breast cancer defined as?

A
  • Tumour fixed to muscle
  • Skin involvement
  • Ipsilateral lymph nodes
39
Q

What is stage 4 breast cancer defined as?

A
  • Complete fixation to chest wall
  • Distant mets
40
Q

What does T1 staging mean in breast cancer?

A

<2cm

41
Q

What does T2 staging mean in breast cancer?

A

2-5cm

42
Q

What does T3 staging mean in breast cancer?

A

>5cm

43
Q

What does T4 staging mean in breast cancer?

A
  • Fixity to chest wall
  • Peau d’orange
44
Q

What does N1 mean in terms of breast cancer staging?

A

Mobile ipsilateral nodes

45
Q

What does N2 mean in terms of breast cancer?

A

Fixed nodes

46
Q

What surgical options are available for treating breast cancer?

A
  • Wide local excision
  • Mastectomy +/- reconstruction +/- axillary node sampling/SNB/sugical clearance
47
Q

Indications for mastectomy

A

If tumour >4cm

If <4cm then wide local excision

48
Q

How is radiotherapy used in breast cancer?

A
  • Always given after conservative therapy
  • Sometimes after mastectomy with high risk of recurrence (if >4cm with +ve axillary nodes)
  • Axillary radiotherapy as equal alternative to clearence
  • Treatment of bony mets
  • Neoadjuvant - shrink to remove
49
Q

What are complications of radiotherapy treatment of breast cancer?

A
  • Pneumonitis
  • Pericarditis
  • Brachial plexopathy
  • Local lymphoedema
50
Q

How is chemotherapy used in breast cancer?

A
  • Adjuvant therapy in cases with poor prognostic features
    • ​Endocrine unresponsive tumours/HER2
  • Can be used in selected cases as neoadjuvant to shrink tumour
  • Treatment of metastatic disease
51
Q

What are poor prognostic markers for breast cancer?

A
  • Young age/pre-menopausal
  • Lymph node inolvement
  • Tumour grade
  • Tumour size
  • Absence of oestrogen receptors
  • Presence of HER2 receptors - more aggressive
  • Lymphovascular invasion
52
Q

What age group does chemotherapy have better effects on breast cancer in?

A

<50 yrs

53
Q

What are the main types of chemotherpeutic drugs used in breast cancer?

A
  • Anthracyclines
  • Taxanes
54
Q

What is the most important aspect of post-surgical management of breast cancer?

A

Eradication of micromets:

  • Hormonal therapies
  • Chemotherapy
  • Targeted therapies
55
Q

What endocrine therapies are available for post-surgical treatment of cancer?

A
  • Tamoxifen - specific oestrogen receptor blocker
  • Aromatase inhibitors eg anastrazole POST MENOPAUSAL WOMEN ONLY - blocks conversion of androfens to oestrogen in peripheral tissues
  • Herceptin (monoclonal antibody eg hereptin)
56
Q

What endocrine treatment would you use to prevent recurrence and increase survival in somoene who was premenopausal and had a oestrogen receptor positive tumour?

A

Tamoxifen​ - 5 years

57
Q

When are endocrine treatments used in breast cancer?

A

Aim to reduce oestrogen activity - oestrogen or progesterone receptor positive disease

58
Q

How does tamoxifen work

A

Blocks oestropgen production (so increases risk of endometrial cancer, CVD, VTE)

59
Q

What endocrine treatment would you use to prevent recurrence and increase survival in somoene who was postmenopausal and had a oestrogen receptor positive tumour?

A
  • Tamoxifen - 5 years if excellent prognosis
  • Aromatase inhibitors - 5 years if poorer prognosis
60
Q

Where are androgens synthesised in post-menopausal women?

A

Synthesized by the adrenal glands and converted in subcutaneous fat to estrone by the enzyme aromatase (hence aromatase inhibitors)

61
Q

What drug can potentially be used in HER2 +ve disease breast cancer?

A

Hercepten - HER2 receptor blocker

62
Q

Where are the most common places for breast cancer to spread to?

A
  1. Lymph nodes
  2. Bone
  3. Liver
  4. Lungs
  5. Brain
63
Q

What can be a serious side efffect of tamoxifen which needs to be monitored for?

A

Uterine cancer - ask about unusual PV bleeding

64
Q

What complications can occur follwoing treatment to axillary disease in breast cancer?

A
  • Lymphoedema
  • Sensory disturbance (intercostobrachial n.)
  • Decrease ROM of the shoulder joint
  • Nerve damage (long thoracic, thoracodorsal, brachial plexus)
  • Vascular damage
  • Radiation-induced sarcoma
65
Q

What is a sentinal node biospy?

A

Procedure investigating nodes which cancer drains to. It involves:

  • Patent blue dye and/or radiocolloid injected into periareolar area or tumour
  • Gamma probe/visual inspection used to identify sentinal node
  • Sentinal node is biopsied and sent for histology +/- immunochemistry

If node clear then no further treatment

If contains tumour then clearance/radiotherapy to the nodes

66
Q

How would you follow-up a patient following remission of breast cancer?

A
  • Clinical examination 6 monthly for 5 years
  • Yearly after that - ?discharge after 5 or 10 years
  • Mammogram of breast(s) at yearly intervals for 10 years
67
Q

What endocrine treatment would you consider using in post-menopausal women?

A

Aromatase inhibitors

68
Q

What is axillary clearance?

A

Removal of all axillary lymph nodes

69
Q

What is the difference between grading and staging in breast cancer?

A

GRading is based on cellular changes (e.g. how aggressive the cellular changes are) and staging is how advanced the tumour is (how far it has spread)

70
Q

What patients are normally suitable for breast conservation surgery?

A
  • Tumour size <4cm
  • Breast/tumour size ratio
  • Suitable for radiotherapy
  • Single tumour
  • Minimal in situ component
  • Patient’s wish
71
Q

If somebody had a 2cm breast cancer, what would the risk be of other invasive or in-situ cancer being present be?

A

Dependent on distance from primary tumour:

  • 1cm - 60%
  • 2cm - 40%
  • 3cm - 20%
  • 4cm - 10%
72
Q

If sentinal lymph node biopsy was found to be positive, what management options are available?

A
  • Axillary clearence
  • Radiotherapy to all axillary nodes
73
Q

When is axillary node clearance normally indicated?

A

If FNAC shows malignant cells, or SLNB is +ve

74
Q

What is the drug name for herceptin?

A

Trastuzumab

75
Q

What is involved in breast screening?

A
  • NHS Breast Screening Programme offers routine breast screening mammorgraphy every 3 years for all women between 50 years and 70 years of age.
  • Offered annually in certain circumstances - High risk
76
Q

What are the wilson criteria for developing a screening programme?

A
  • Important – the condition should be an important one
  • Acceptable treatment for the disease
  • Treatment and diagnostic facilities should be available
  • Recognisable at an early stage of symptoms
  • Opinions/policy on who to treat as patients must be agreed
  • Guaranteed safety e.g. low radiation exposure
  • Examination must be acceptable by the patient
  • Natural history of the disease must be known
  • Inexpensive test
  • Continuous screening i.e. not a one-off
77
Q

What is a potential cardiovascular side effect of HER-2?

A

Cardiomyopathy - which can lead to cardiac failure

78
Q

What test do you need to do before starting someone on trastuzumab?

A

MUGA (Multiple-gated acquisition) scan - nuclear imaging used to assess ejection fraction and ventricular function

79
Q

What test would you consider doing after operating on a lobular breast tumour in the right breast?

A

MRI breasts - chance that lobular cancers are more diffuse and can be bilateral

80
Q

What is important to remember about lobular carcinomas when assessing someone clinically?

A
  • They can be difficult to palpate
  • They are frequently bilateral
81
Q

What tumour markers are linked to breast cancer?

A

CA15-3, CEA

82
Q

Sensitivity of triple assessment

A

Clinical exam - 88%

Mammography - 93%

US - 88%

Biopsy - 94%

83
Q

Who would you refer if a lady presented with breast lump?

A

If >30 and have an unexpected breast lump

or >50 and discharge, retraction, other changes in one nipple only.

Gwen - Reproductive Medicine (Obs, Gyn, Breast) (49 decks)

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