Breast cancer (SURG) Flashcards
How common is breast cancer?
Second most common malignancy in women
When is the peak incidence for breast cancer? (2)
- postmenopausal
- incidence increases with age - 50% of breast cancers are diagnosed in women >65
What are some risk factors for breast cancer? (7)
- increased exposure to oestrogen:
- not having kids
- early menarche <13y
- late menopause >51y
- obesity
- COCP
- HRT
- smoking
- alcohol consumption
- Fx of breast cancer
- hereditary breast ovarian cancer syndrome (mutations in BRCA1/2)
- increasing age
- radiation exposure
What can cause increased exposure to oestrogen, increasing risk of breast cancer? (6)
- not having kids
- early menarche <13y
- late menopause >51y
- obesity
- COCP
- HRT
Name two genes associated with breast cancer.
- BRCA-1
- BRCA-2
What are the different types of breast cancer?
- invasive ductal carcinoma - most common
- non-invasive breast cancer:
- ductal carcinoma in situ (DCIS)
- lobular carcinoma in situ (LCIS)
What is non-invasive breast cancer?
- does not extend beyond basement membrane and cannot spread through lymphatics or bloodstream
- ductal carcinoma in situ (DCIS) - increased risk of invasive ductal carcinoma at that site
- lobular carcinoma in situ (LCIS) - increased risk of ductal OR lobular carcinoma developing in either breast
- higher grade DCIS/LCIS may progress to high-grade invasive breast cancer
Describe the continuum of progression of breast cancer.
Typical hyperplasia –> atypical hyperplasia –> ductal carcinoma in situ (DCIS) –> invasive ductal carcinoma
What does the NHS breast screening programme include?
Mammogram every 3 years for women 50-70 years old
When should we refer women for suspected breast cancer?
Refer women aged >30 with an unexplained breast lump using a suspected cancer pathway referral
Aged >50 with nipple discharge, retraction or other concerning features
What are the clinical features of breast cancer? (6)
- breast lump - non-tender, poorly-defined margins, painless, hard mass in upper outer quadrant, may be fixed to deep tissue, smooth or nodular, firm and rigid, does not change shape upon compression
- change in breast shape - asymmetry
- nipple discharge - unilateral, may be bloody (intraductal papilloma or neoplastic)/watery/serous/milky
- axillary lymphadenopathy
- skin thickening/discolouration/ulceration
- Paget’s disease of the nipple - usually caused by DCIS infiltrating nipple
Describe the breast lump in breast cancer. (7)
- non-tender
- poorly-defined margins
- painless
- hard mass in upper outer quadrant
- may be fixed to deep tissue
- smooth or nodular
- firm and rigid, does not change shape on compression
Describe the nipple discharge in breast cancer.
- unilateral (more concerning than bilateral)
- may be bloody (intraductal papilloma or neoplastic)
- or watery, serous or milky
What is Paget’s disease of the nipple (breast cancer)?
- eczema-like hardening of skin on nipple
- bleeding and excoriation
- retraction or scaling of the nipple
- usually caused by ductal carcinoma in situ (DCIS) infiltrating nipple
What might you see on examination of breast cancer? (3)
- irregular, firm, fixed mass
- peau d’orange (orange peel apprarance)
- axillary lymphadenopathy
Where does breast cancer commonly metastasise? (4)
- bone
- liver
- lung
- brain
What are the signs of bone metastases in breast cancer? (3)
- bone pain
- pathological fractures
- spinal compression
What are the signs of liver metastases in breast cancer? (3)
- abdominal pain and distension
- nausea
- jaundice
What are the signs of lung metastases in breast cancer? (4)
- cough
- haemoptysis
- SOB
- chest pain
What are the signs of brain metastases in breast cancer? (3)
- headaches
- seizures
- cognitive deficits / focal neurological deficits
How do we investigate a breast lump?
Triple assessment:
- clinical examination
- radiology - US for <35y, mammography AND US for >35y
- histology/cytology (FNA or core biopsy: US-guided core biopsy is best for NEW lumps)
What is the main investigation for breast cancer, depending on age?
- women <35y: breast ultrasound (mammogram difficult due to denser breast tissue)
- women >35y: mammography (and US)
What might mammography show in breast cancer?
Calcifications
What are the two ways of taking a biopsy in breast cancer?
- fine needle aspiration –> cytological information
- core needle biopsy –> histological and cytological information
What investigation do we do for all invasive breast cancers?
Sentinel lymph node biopsy
Which investigations are used to stage breast cancer? (3)
TNM:
- core needle biopsy (T)
- sentinel lymph node biopsy (N)
- PET scan (M)
How else can we check for metastases in breast cancer? (7)
- PET scan
- bone scan
- CXR
- FBC
- LFTs
- calcium
- CT CAP
Name a marker for breast cancer.
CA15-3
Which patients do we refer on urgent 2WW pathway for suspected breast cancer? (2)
- > 30y with unexplained breast mass
- > 50y with nipple discharge, retraction or other concerning features
What are some differential diagnoses for breast cancer? (6)
- locally invasive breast cancer (lump +/- nipple inversion, discharge or tenderness)
- atypical hyperplasia (progresses to invasive breast cancer)
- fibroadenoma (freely mobile, sharp edges for calcifications)
- breast cyst (tenderness, cyclical with menstruation, sharp edges for calcifications)
- mastitis (lactating women, systemic Sx)
- fat necrosis
How do we stage breast cancer?
- IA, IB, IIA, IIB, IIIA, IIIB, IIIC
- stages IA, IB & IIA are early-stage
- stages IIIA, IIIB & IIIC are locally-advanced
What classification can we use for ductal carcinoma in situ (breast cancer)?
Van Nuys score for DCIS: size, margin, age, pathological classification
What is triple-negative breast cancer?
- characterised by 3 negative biomarkers: oestrogen receptors (ER), progesterone receptors (PR), HER2
- highly heterogenous = difficult diagnosis
- limited response to hormonal and immune therapies & very aggressive = difficult treatment
What is the first-line treatment most of the time for breast cancer?
Surgery
What is a mastectomy?
Removal of the entire breast and possibly other structures e.g. lymph nodes and muscles
List indications for a mastectomy. (4)
- ductal carcinoma in situ (high-grade DCIS)
- multifocal tumour
- central tumour
- large lesion in small breast
What is a wide local excision (breast cancer)?
Removal of just the area of cancer, aims to keep most of the breast tissue
Whole breast radiotherapy recommended after - may reduce risk of recurrence by 2/3
In which patients with breast cancer do we do a wide local excision?
For smaller, solitary lesions which are peripherally located
Low-grade DCIS
What is recommended after a woman has had a wide local excision for breast cancer?
Whole breast radiotherapy recommended after - may reduce risk of recurrence by 2/3
What is the treatment for clinical (palpable) axillary lymphadenopathy in breast cancer?
Axillary lymph node clearance - can cause lymphoedema and functional arm impairment
If no surgery wanted: axillary radiotherapy
Who is hormonal therapy offered to in breast cancer?
Adjuvant therapy to women who are oestrogen receptor (ER) positive
Which hormonal therapies are offered for breast cancer?
- pre-menopausal (or >60): Tamoxifen (oestrogen receptor modulator/antagonist)
- side effect: VTE
- post-menopausal: Anastrozole (aromatase inhibitor)
- side effect: osteoporotic fractures due to reduced E2
Who is biological therapy offered to in breast cancer?
If HER2 positive –> Trastuzumab (Herceptin)
Can cause cardiac toxicity - do echo first
What systemic therapy can be done for breast cancer?
Chemotherapy - can be given as neoadjuvant or adjuvant
What do we give for chemotherapy-induced N&V in breast cancer?
5HT-3 antagonist e.g. ondansetron (+ metronidazole)
How do we manage low-grade ductal carcinoma in situ (breast cancer)?
Surgical excision (wide local excision)
How do we manage high-grade ductal carcinoma in situ (breast cancer)? (4)
- mastectomy +/- breast reconstruction
- axillary node sentinel biopsy and staging –> axillary node clearance
- radiotherapy (treat microscopic disease and reduce risk of ipsilateral recurrence)
- hormonal therapy (tamoxifen or anastrozole depending on menopause)
How do we manage lobular carcinoma (breast cancer)?
- low risk: observation + hormonal Rx
- high risk: double mastectomy
How do we manage early-stage breast cancer (stage I to IIB) and locally advanced breast cancer (stage IIB to III)? (3+2)
- mastectomy +/- breast reconstruction
- SNLB + axillary lymph node dissection (ALND)
- neoadjuvant or adjuvant chemotherapy (ACT - doxorubicin + cyclophosphamide + paclitaxel)
- (HER2: +trastuzumab)
- (hormonal Rx depending on pre/post menopause: tamoxifen/anastrozole)
How do we manage metastatic breast cancer? (4)
- hormone receptor positive: tamoxifen (pre-menopause) or anastrozole (post-menopause, aromatase inhibitor)
- HER2 +ve: trastuzumab
- PD-L1: atezolizumab
- triple negative: chemotherapy
When is mastectomy vs wide local excision done in breast cancer? (4)
- multifocal vs solitary lesion
- central vs peripheral tumour
- large lesion in small breast vs small lesion in large breast
- DCIS>4cm vs DCIS<4cm
What are some complications of breast cancer? (6)
- pleural effusion
- paraneoplastic syndromes
- high recurrence rate
- lymphoedema of arm
- progression into invasive carcinoma
- chemotherapy-related neutropenia or N&V
What is the most important factor for breast cancer prognosis?
Stage at time of diagnosis - earlier stages have significantly better prognosis due to less spread
