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3A Womens health > Breast cancer, papilloma, pagets disease of the nipple > Flashcards

Breast cancer, papilloma, pagets disease of the nipple Flashcards

1
Q

What is the background for breast cancer?

A

● Breast cancer is the commonest cancer in the UK (15% of new cancer cases annually).
● There are approximately 56,000 new cases of breast cancer every year.

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2
Q

What are the pre-invasive types of
breast cancer?

A
  1. Ductal carcinoma in situ (DCIS).
    ● Neoplastic proliferation of epithelial cells - confined to duct without
    invasion through basement membrane.
    ● Precursor to invasive breast cancer.
    ● Comedo and non-comedo subtypes.
  2. Lobular carcinoma in situ (LCIS).
    ● Neoplastic proliferation of epithelial cells, confined to TDLU.
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3
Q

What are the invasive (penetration through basement membrane) types of breast cancer?

A
  1. Invasive ductal carcinoma (commonest - 75%).
    ● Neoplastic proliferation of epithelial cells that invades through the ductal
    basement membrane.
  2. Invasive lobular carcinoma
  3. Medullary carcinoma
    ● More prevalent in the younger population.
    ● Higher grade than IDC.
  4. Many others - including mucinous, tubular, papillary, inflammatory etc.
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4
Q

What is the Nottingham criteria which we use to grade how bad a breast cancer is?
What is it scored on?

A

○ Gland formation
○ Nuclear atypia / pleomorphism
○ Mitosis counts (indicates rate of cellular reproduction)
● A higher grade carcinoma is one that is markedly different from normal breast tissue
and is considered poorly differentiated.

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5
Q

What is the aetiology and pathophysiology of breast cancer?

A

● Complex series of genetic mutations and deranged cellular signalling leads to generation
of malignant cells.
● Breast cancer can be linked to inherited genetic mutations such as BRCA1.

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6
Q

What is the 5 step process for malignant cells to metastasise?

A
  1. Invasion through basement membrane
  2. Intravasation (entry into circulation)
  3. Circulation
  4. Extravasation
  5. Colonisation
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7
Q

What are the commonest sites of breast cancer metastasis?

A

bones, liver, lungs and brain.

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8
Q

What are the RFs for breast cancer?

A
  1. Increasing age
  2. Female sex (100:1 F:M incidence)
  3. Family history
  4. Inherited genetic mutations e.g. BRCA1
  5. Endogenous oestrogen exposure:
    a. Early menarche
    b. Nulliparity / absence of breastfeeding
    c. Late menopause
  6. Exogenous oestrogen and progestin exposure:
    a. Systemic hormonal HRT
    b. Systemic hormonal contraception
    Female (99% of breast cancers)
    Increased oestrogen exposure (earlier onset of periods and later menopause)
    More dense breast tissue (more glandular tissue)
    Obesity
    Smoking
    Family history (first-degree relatives)
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9
Q

What are the signs and symptoms of breast cancer?

A

● Symptoms include: breast lump
● Signs include: nipple discharge, nipple retraction, skin changes e.g. peau d’orange,
axillary lymphadenopathy.

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10
Q

What are the metastatic features of breast cancer?

A

weight loss, bony pain, shortness of breath.

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11
Q

What are the different types of staging we use for breast cancer?

A

● TNM staging (tumour, node, metastasis) - see Cancer Research UK for full details.
● Alternative staging:
○ Stage 1A: <2cm, isolated to breast
○ Stage 1B: <2cm, minor axillary LN spread
○ Stage 2A: <2cm, spread to 1-3 ipsilateral LNs.
○ Stage 2B: 2 - 5cm, minor axillary nodal spread or 2 - 5cm with 1-3 ipsilateral
nodes or >5cm, no nodal spread
○ Stage 3A: 4-9 ipsilateral nodes or >5cm with 1-3 ipsilateral nodes
○ Stage 3B: spread to skin / chest wall
○ Stage 3C: >10 axillary nodes or supraclavicular spread or parasternal + axillary
spread
○ Stage 4: distant metastatic spread to organs.

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12
Q

What is the screening programme for breast cancer?

A

● NHS screening programme: 3-yearly mammogram for women aged 50-71.

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13
Q

What is the 2 week wait criteria for breast cancer?

A

○ Unexplained breast lump in a woman aged >30.
○ Unexplained axillary lump in a woman aged >30.
○ Unilateral nipple changes in a woman aged >50.
○ Skin changes suggestive of breast cancer, any age.

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14
Q

What is first line for breast cancer investigations for breast cancer?

A

breast imaging
○ >30 or highly suspicious for cancer: mammogram
○ <30: breast ultrasound
○ Plus: ultrasound of the axilla +/- needle biopsy

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15
Q

What is second line investigations for breast cancer?

A

biopsy
○ Fine needle aspiration and cytology
○ Plus: oestrogen / progesterone receptor testing, HER2 receptor testing.

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16
Q

If the patient has symptoms/ signs suggestive of metastasis what should we do?

A

○ CT scan (CT thorax-abdomen-pelvis, CT head).

17
Q

What are the features of a mammogram?

A

● Pre-invasive: unifocal / widespread microcalcifications
● Invasive carcinoma:
1. Irregular spiculated mass
2. Clustered microcalcifications
3. Linear branching calcifications.

18
Q

What is first line management for breast cancer?

A

● Dependent on histology, staging, receptor positivity, physiological reserve; but broadly:
● First Line: surgery
○ Tumour excision or mastectomy +/- breast reconstruction
○ Plus sentinel lymph node biopsy (no evidence of nodal spread) or axillary node
clearance.
● Plus: radiotherapy
○ Whole breast / partial-breast
○ If tumour is invasive (i.e. not DCIS, LCIS), systemic third line therapy is indicated:

19
Q

What is adjuvant therapy for breast cancer?

A

systemic therapy (guided by the PREDICT tool)
○ Oestrogen-receptor positive:
■ Pre-menopausal / male - tamoxifen (anti-oestrogen)
■ Post-menopausal - anastrozole / letrozole (aromatase inhibitor, prevents
peripheral oestrogen synthesis).
The Peer Teaching Society is not liable for any false or misleading information. 76
■ Note - tamoxifen therapy can be continued long-term (5 years) before
switching to an aromatase inhibitor.
○ HER2 (human epidermal growth factor receptor 2) positive:
■ Trastuzumab (Herceptin)
○ Chemotherapy:
■ Including a taxane and an anthracycline
■ E.g. ACT: doxorubicin, cyclophosphamide and paclitaxel

20
Q

What is systemic therapy for breast cancer

A

systemic therapies can be neoadjuvant i.e. used to reduce tumour size before
attempting surgery.

21
Q

What is Paget’s disease of the nipple/ breast

A

Rare cutaneous breast cancer manifestation

22
Q

What does pagets disease of the bone cause?

A

Eczema like skin changes in nipple, areola

23
Q

What is the pathogenesis for Paget’s?

A
  • Epidermotropic theory: underlying mammary carcinoma present > malignant cells migrate through ductal system > nipple epidermis
  • In situ transformation theory: nipple keratinocyte transformation > malignant cells
24
Q

What are the S + S of pagets?

A
  • Unilateral
  • Nipple + adjacent areolar skin
  • scaly
  • itching
  • burning
  • erythematous
  • Bloody nipple discharge
  • nipple inversion
  • pain
  • palpable masses - worst prognosis
25
Q

What investigations are done for paget’s?

A

Mammogram- identify assosciated mass, microcalcifications, tissue distortion
US guided mass core bopsy, histopathological analysis
Nipple scrape cytology/full-thickness wedge/ punch biopsy
Malignant, intraepithelial adenocarcinoma cells (paget cells) present

26
Q

What is the treatment for Paget’s?

A

Mastectomy, breast-conserving surgery
Whole breast radiotherapy

27
Q

What is an intraductal papilloma?

A

warty lesion that grows within one of the ducts in the breast. It is the result of the proliferation of epithelial cells

28
Q

What is the typical presentation of an intraductal papilloma?

A

The typical presentation is with clear or blood-stained nipple discharge.

29
Q

What type of tumours are intraductal papilloma’s?

A

Intraductal papillomas are benign tumours; however, they can be associated with atypical hyperplasia or breast cancer.

30
Q

What are the S + S of intraductal papilloma?

A

Intraductal papillomas can occur at any age, but most often occur between 35-55 years.

Intraductal papillomas are often asymptomatic. They may be picked up incidentally on mammograms or ultrasound.

They may present with:

Nipple discharge (clear or blood-stained)
Tenderness or pain
A palpable lump

31
Q

How is one diagnosed with papilloma?

A

3A Womens health (33 decks)

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