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BREAST > BREAST CARCINOMA > Flashcards

BREAST CARCINOMA Flashcards

1
Q

Describe/ summarise basics:

A
  • Can be ductal (arising from milk ducts) or lobular (originating from lobules).
  • They can be in situ or invasive.
  • Paget’s disease is an infiltrating carcinoma of the nipple epithelium (represents 1% of all breast cancers).
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2
Q

What are the 3 main types?

A

DCIS: Ductal carcinoma in situ
LCIS: Lobular carcinoma in situ (isn’t malignant, but are cancerous changes)
Paget’s disease

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3
Q

Lifetime risk of UK females developing breast cancer

A

1 in 8/9

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4
Q

Most common cause of lump in what age group

A

> 60 (postmenopausal),

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5
Q

How old are most people with breast cancer?

A

can affect women of any age (most commonly >50)

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6
Q

What % of cases are male?

A

Only 1% of cases are male.

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7
Q

How common is the cancer in women?

A

Most common cancer in women in the world

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8
Q

How common is death from this cancer?

A

2nd most common cause of death from cancer in UK

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9
Q

What is the aetiology?

A

Over-proliferation of cells in either the lobules or ducts of the breast

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10
Q

What are the genetic risk factors?

A

BRCA1/2 genes

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11
Q

What % of women with BRCA1 develop breast cancer by 70?

A

55-65% of women with the BRCA1 mutation will develop breast cancer by the age of 70,

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12
Q

What % of women with BRCA2 develop breast cancer by 70?

A

45% of women with inherited BRCA2 will develop breast carcinoma by the same age.

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13
Q

What are the risk factors?

A 
•	Female sex
•	Old age
•	Smoking
•	Previous history
•	Family history
•	Genetics – BRCA1, BRCA2 and TP53 mutations carry very high risk
•	No children
•	Uninterupted oestrogren receptors:
o	Nulliparity
o	Early menarche
o	Late menopause
o	1st pregnancy >30yrs
o	HRT
o	Obesity (fat produces small amounts of oestrogen)
o	Not breastfeeding
•	Radiation to chest (even small doses)
•	High alcohol intake
•	Men with Klinefelter’s syndrome
•	Gynaecomastia
•	Adult height
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14
Q

What is most common presentation?

A

Painless lump in breast

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15
Q

4 most common symptoms

A
  • Lump (80%)
  • Nipple change (10%)
  • Skin contour changes (5%)
  • Nipple discharge (3%)
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16
Q

How is a lump likely to present?

A

painful in 20% - hard, irregular, fixed, painless, skin dimpling

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17
Q

How is skin likely to present?

A

dimpling or thickening of the breast skin, inverted nipple, bloody discharge, eczematous patch of skin on the nipple and surrounding areola

18
Q

What % of all lumps aren’t malignant?

A

90%

19
Q

Other symptoms

A
  • Breast pain/mastalgia alone uncommon
  • Bloody nipple discharge – intraduct carcinoma
  • Swelling or lumps in the armpit may also be noticed (axillary sentinel node involvement).
  • Change in shape or size of breast
  • Rarely (most common in advanced inflammatory carcinoma) breast mastalgia (pain) may develop.
20
Q

Signs

A
  • Peau d’orange
  • Skin ulceration
  • Nipple inversion
  • Gross deviation
  • Discharge (clear – concerning because cysts don’t usually discharge/bloody), tethered lump (to skin above or chest wall), hard and non-tender lump, nodes feel matted and fixed together/to other structures in axillary involvement.
  • Fixity to pectoral muscles (engage muscles when examining on that side).
21
Q

Where might it metastasise?

A

bone, liver, brain, lungs – examine for hepatomegaly/abdominal pain. .

22
Q

Other non-breast symptoms?

A

Tender spine (bone), breathlessness (respiratory symptoms), headaches and cognitive symptoms

23
Q

Investigations - triple assessment

A
  1. clinical examination
  2. radiology (ultrasound <35 years, mammogram >35years),
  3. histology/cytology (core biopsy – can be ultrasound guided).
Mammography
Fine needle aspiration
Core biopsy
Staged using TNM
Can also do USS of breast and surrounding lymph nodes
24
Q

Cystic lumps are aspirated, any residual mass is biopsied and the aspirate is studied - what do the results mean?

A

Clear aspirate is discarded and the patient can be reassured (more emphatically with no family history and biopsy shows non-proliferative lesion) and discharged from hospital. Bloody aspirate is sent to cytology for assessment.
Solid lumps undergo a core biopsy – any clear fluid is a reassuring sign of a simple cyst, but otherwise malignancy is expected.

25
Q

What does T0 - T4 mean?

A

TO - no primary tumour, or tumour in situ
T1 - 0-2cm
T2 - 2-5cm
T3 - >5cm
T4 - tumour of any size with extension to chest wall

26
Q

What does N0 - N3 mean?

A

N0 - no lymph node metasteses
N1 - cancer cells present in 1-3 axillary lymph nodes
- lymph node tumour >2mm
N2 - cancer cells present in 4-9 axillary lymph nodes
N3 - cancer cells in infra-supra-clavicular lymph nodes

27
Q

What does M0-M1 mean?

A

M0 - No evidence of cancer metastasis

M1 - Cancer found in other areas of the body

28
Q

What surgical treatment is offered?

A

Wide local excision or mastectomy with radiotherapy followed by breast reconstruction.

29
Q

What are the indications for total mastectomy?

A

tumour >4cm in diameter, central site of any considerable size, multi-focal cancer (ILC most commonly), widespread DCIS in one breast, recurrence, BRCA 1/2 genes indicated, patient requests!

30
Q

What are the indications for wide local excision or lumpectomy?

A

<4cm in diameter, not involved with central structures, one tumour discovered.

31
Q

When do we use Tamoxifen?

A

Adjuvant hormonal therapy if the tumour is positive for hormonal receptors → Tamoxifen.

32
Q

When do we use Herceptin?

A

Herceptin can be used in those expressing HER2 gene.

33
Q

When do we use adjacent chemotherapy?

A

Adjuvant chemotherapy required for patients with endocrine unresponsive tumours.

34
Q

What are the risks of surgery?

A

wound infection, haematoma, excessive bleeding, GA problems.

35
Q

What do they do with HER2 results?

A

Younger patients get immunochemistry test for HER2 receptors (scored 0-infinity)
1 or less = no HER2 receptors present
2-3 = unsure → do FISH genetic test for HER2 (more expensive!)
3+ = HER2 positive, treat with supplementary Herceptin

36
Q

Risks of short term chemotherapy?

A

hair loss, appetite loss, nausea and vomiting, diarrhoea, mouth sores, decrease in all blood cells→ fatigue, infection susceptibility, increased bruising and bleeding. Heart and nerve damage are transient but can be permanent!

37
Q

Risk of long-term chemotherapy?

A

infertility (ovarian damage), bring on menopausal symptoms, decreased menstruation, osteoporosis, leukaemia, chemo-brain (mind fog – poor short term memory and poor concentration) can last a few years.

38
Q

Risks of radiotherapy?

A

pericarditis, pneumonitis and fractured ribs, redness of skin, discomfort and swelling, tiredness, may affect potential for reconstruction (skin taught), skin pigmentation.

39
Q

Endocrine agents as a treatment

A

all aim to decrease oestrogen activity in oestrogen receptor positive tumours. Tamoxifen is an oestrogen receptor blocker (5 year course) – can cause uterine cancer, look for vaginal bleeding. Aromatase inhibitors – Anastrasol is aimed as oestrogen in the periphery in post-menopausal women. Pre-menopausal oestrogen positive women can have an ovarian ablation.

40
Q

Differentials

A

Fibrocystic breast disease
Lump – fibroadenoma, cysts, fat necrosis, abscess
Lump, discharge and nipple retraction – Duct ectasia (Slit inversion – periductal mastitis)

41
Q

Complications

A

Chemo: infection, fatigue, bruising, bleeding, sleep disturbances
Psychological: depression, fear, sadness, feelings of isolation, sleep disturbances.
Radiation: inflamed lung tissue, heart damage, secondary cancers
Hormone therapy: effects of low oestrogen I.e. Osteoporosis
Mastectomy: temporary swelling of breast, breast tenderness, hardness due to scar tissue, wound infection or bleeding, lymphedema, phantom breast pain

42
Q

Prognosis

A

Depends on biological characteristics of the cancer and the patient and on appropriate therapy.

BREAST (4 decks)

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