Breast Carcinoma Flashcards
What is the most comomn presentation of breast cancer?
The most common presentation of breast cancer is a palpable lump i.e. investigate all
(the most common presentation of breast cancer is a lump but not all lumps are breast cancer)
What are the 3 stages of triple assessment of breast cancer and why do we do this?
triple assessment allows pre-operative diagnostic accuracy of ~99%
- Clinical assessment = Hx and exam
- radiological assessment = US +/- mammogram
- Pathological assessment = FNA (Cytology) and or/core biopsy
The first stage of triple assessment is the clinical assessment Hx and exam.
What signs of breast cancer O/E maybe found?
- Skin tethering,
- nipple changes,
- asymmetry,
- hard, irregular lump
The first stage of triple assessment is the clinical assessment Hx and exam.
What are the tumour markers for breast cancer?
Commonly used tumour marker:
CA15-3 (produced by cancer cells)
or CA27-29
The 2nd part of the triple assessment for breast cancer is radiological assessment = US +/- mammogram.
When is a mammogram used & what can be seen?
if > 35 y/o = mammography
=> identifies microcalcifications and densities
- DCIS (pre-cancer): white micro-calcifications
- Benign: circumscribed, regular contours
- Malignant: speculated masses (needle shaped)
A patient > 35 y/o has a mammogram as part of her triple assessment for her breast lump.
What does it mean if on the mammogram there is white micro-calcifications?
DCIS aka Pre-cancer!
A patient > 35 y/o has a mammogram as part of her triple assessment for her breast lump.
What does it mean if on the mammogram there is lesion with circumscribed, regular contours?
= benign
A patient > 35 y/o has a mammogram as part of her triple assessment for her breast lump.
What does it mean if on the mammogram there is speculated masses (needle shaped)?
A malignant breast lump
What would a mammogram of DCIS aka Pre-cancer show?
white micro-calcifications
What would a mammogram of a woman with a benign breast lump show?
a lesion with circumscribed, regular contours
What would a mammogram of a woman with a malignant breast lump show?
speculated masse(s) (needle shaped)
The 2nd part of a triple assessment is radiological assessment - US +/- mammogram
When is an USS used / what is seen?
USS is used in ALL AGES
as esp. if younger, the breast tissue maybe too dense for mammography (when older the breast tissue becomes more fatty than glandular)
USS is good for distinguishing solid & cystic lesions
USS can be used to guide needle biopsy
The 3rd stage of the triple assessment is pathological assessment w/ FNA (cytology) and/or core biopsy
What are the differences?
FNA
- uses a smaller needle
- may need to repeat (as can miss the floating cells)
- no LA needed
Core biopsy
- LA needed
- nick made in skin
- larger needle
A patient undergoes pathological assessment for a breast lump as part of the triple assessment, her lump is diagnosed as C3. What does this mean and what does the “C” mean?
C3 is c for Cytology 3 and it is the same grading as B3 = core biopsy 3 but just shows that the cells were looked at in a different way.
the scale of pathological assessment goes from C1/B1 - C5/B5
C3/B3 equates to the lump being equivocal as to if it is cancerous/not but actually that it favours benign.
(C4/B4 also = equivocal but favours malignant)
A patient undergoes pathological assessment for a breast lump as part of the triple assessment, her lump is diagnosed as B1.
What does this mean and what does the “B” mean?
B1 = core biopsy 1 and is the same grading as C1 but just shows that the cells were looked at in a different way. as 3 is c for Cytology 1
the scale of pathological assessment goes from C1/B1 - C5/B5
C1/B1 equates to the lump sample being inadequate or NOT diagnostic
- C1/B1
- Inadequate or not diagnostic
- C2/B2
- Benign e.g. fibroadenoma, fibrocystic change
- C3/B3
- Equivocal, favours benign
- C4/B4
- Equivocal, favours malignant
- C5/B5
- Malignant (DCIS is included in this)
A patient undergoes pathological assessment for a breast lump as part of the triple assessment, her lump is diagnosed as B2.
What does this mean and what does the “B” mean?
B2 = core biopsy 2 and is the same grading as C2 but just shows that the cells were looked at in a different way as the C is for Cytology 2
the scale of pathological assessment goes from C1/B1 - C5/B5
C2/B2 = equates to the lump sample being benign e.g. fibroadenoma, fibrocystic change
- C1/B1
- Inadequate or not diagnostic
- C2/B2
- Benign e.g. fibroadenoma, fibrocystic change
- C3/B3
- Equivocal, favours benign
- C4/B4
- Equivocal, favours malignant
- C5/B5
- Malignant (DCIS is included in this)
Age impacts DDx (order) for breast lumps.
What is the order for ddx of breast lumps in young patients?
1 fibro adenoma,
(in older: 1) carcinoma, 2) fibrocystic change , 3) fibro adenoma e.g. order reverses)
Age impacts DDx (order) for breast lumps.
What is the order for ddx of breast lumps in older patients?
OLDER:
- # 1 carcinoma,
- # 2 fibrocystic change,
- # 3 fibro adenoma
[YOUNG: #1 fibro adenoma,#2 fibrocystic change, #3 carcinoma much less common]
What is the most common age group for breast cancer to affect?
- 40-70 yrs
- may occur at any age but rare
- rare <25y/o
breast cancer = 2nd commonest form of cancer to affect women in the developed world; lifetime risk 1 in 9 ; 1 in 8 women in UK;
–> Mortality decreasing; incidence increasing (more detected by screening, RFs)
What is the national breast screening programme protocol?
2-view mammography
every 3yrs
for women 47-73
in UK has ↓breast cancer deaths by 30% in women >50yrs
what is the aim of the 2-view mammography every 3yrs for women 47-73 in UK (national breast screening programme)?
- Aims to identify DCIS (pre-cancer, microcalcifications) & small invasive carcinomas at an early stage before symptoms & signs
- –> Reduce morbidity & mortality of cancer
- Women 47-73yrs invited for screening mammogram every 3yrs (range currently being extended to from 50-70yrs)
- IF Suspicious features → further assessment (imaging e.g. US, exam, FNA/core biopsy)
nulliparity decreases the risk of breast cancer true or false
False it increases the breast cancer risk
due to (unnoposed?) oestrogen exposure so other factors include:
- Oestrogen exposure
- Obesity (peripheral aromatisation androgens to oestrogen)
- Late menopause, early menarche
- Nulliparity, no breast feeding
- Exogenous oestrogen -
- COCP/coil,
- HRT >10yrs
Besides oestrogen exposure what ae the other RF’s for breast cancer?
- Age: >50yrs high risk
- Gender: females 100x more likely than men, but male not impossible
- Genetics: 5-10% breast cancers familial
- BRCA1/2 - tumour suppressor gene, AD, 80-90% chance developing breast cancer, also ovarian cancer risk . B1 with uterine, B2 w/ prostate (e.g. male at risk!) and pancreatic
- P53 - Li-Fraumeni syndrome, germinline mutation, less common
- PMH breast cancer/ previous breast conditions (AHD, LCIS)
- Age at first pregnancy: >30yrs high risk
- Irradiation
- Alcohol consumption
What are protective factors against breast cancer?
- being physically active
- breastfeeding
- diet
- aspirin
- NSAIDs
Where is the most common place on the breast to have a breast cancer?
50% are in the upper outer quadrant
What signs and symptoms of breast cancer would a lump show?
- usually painless (pain is a benign sign)
- hard
- gritty
- immobile
- tethered
- ill-defined edges
- irregular
*
What signs and symptoms of breast cancer would a nipple show?
- discharge
- blood stained
- inverted
- eczema in pagets disease
- retraction
What signs and symptoms of breast cancer would skin changes show?
- dimpling
- puckering
- colour changes
- peau d’orange (cutaneous oedema 2o to dermal lymphatic obstruction)
- ulceration
besides, limp, nipple and skin changes what other features may indicate breast cancer?
lymphadenopathy - enlarged nodes (axilla etc)
systemic features:
- weight loss,
- anorexia,
- bone pain,
- jaundice,
- anaemia,
- malignant pleural and pericardial effusions
How do you investigate breast mets and where would they go to?
Ix: CT CAP, bone scan, PET CT
- lymph nodes
- bone
- brain
- lung
- liver
What investigations are done for imaging of breast cancer?
- US +/- mammogram (aged >35yrs)
- MRI useful in lobular cancer (multifocal, bilateral), mammographically occult cancers, young patients (+mri for spine/bone mets)
What Ix are used for pathology use/samples in breast cancer?
FNA +/- core biopsy
What Ix are used for staging of breast cancer?
- CXR (lung mets)
- bone scan (bone mets)
- liver US (liver mets)
- CT/MRI or PET-CT (chest, abdo & pelvis)
- LFTs & Ca2+ (liver and bone mets)
- [breast cancer also mets to lymph nodes & brain as well as lung and liver]
What is the sentinel lymph node and its importance?
- 1st node draining a cancer, if clear very high likelihood cancer hasn’t spread elsewhere
-
Prognostic information, avoid unnecessary risks of lymph node clearance (S/E of which = lymphedema, shoulder stiffness)
- Dye and/or isotope (Tc-99m) injected into to tissue around tumour
- inspect nodes for staining & use Gamma probe to assess which nodes have taken up radionuclide
- hot (radionuclide) and blue (stain)
- inspect nodes for staining & use Gamma probe to assess which nodes have taken up radionuclide
Why is a pre-operative US of axilla always done?
to idenfiy if the axilla has abnormal looking lymph nodes or not
if they are abnormal looking –> FNA or core biopsy to see if shows cancer = remove and if normal do a sentinel node biopsy…
if they looked normal on USS then do a sentinal node biopsy too
if SNB biopsy is fine then its all good, but if cancer then need a LYMPH node CLEARANCE (s/e = lymphoedema, shoulder stiffness)
What is DCIS (white microcalcifications on mammography e.g. >35y/o)?
pre-cancer
where the epithelial cells show cytological signs of malignancy but basement membrane is still intact
- doesnt usually form a mass
- often but not always assoc w/microcalcifications on mammography
- usually a unifocal lesion concentrated in one area of the breast
- DCIS is SURGICALLY EXCISED
What is invasive ductal carcinoma?
- the most common breast cancer - invasive ductal carcinoma ~70%
- it is an invasive adenocarcinoma (glandular epithelium)
- IDC = tumour cells invaded through basement membrane into the adjacent tissue, this invasion means the tumour has potential to metastasise
- has invasive growth, metastatic potential
- usually presents as a palpable breast mass
If invasive adenocarcinoma (glandular epithelium) is the pathology of most breast cancers with 75% being ductual, 15% being other (tubular, cribriform, mucinous, inflammatory)
What is the other 10% category of breast carcinoma?
Lobular carcinoma
- can get lobular carcinoma in situ
- its rarer than DCIS and tends to be multifocal
- (why MRI is better for lobular cancer due to the multifocal, bilateral presentation)
-
invasive Lobular carcinoma (10-15%):
- tumour cells infiltrate breast tissue as LINEAR cords of cells (single file) pattern or as single cells which appear to be separate from one another
- dis-cohesive growth pattern is a reflection of loss of function of the E-cadherin-cetenin cell adhesion system (part of signlanning and cancer)
A woman has DCIS cells in the epidermis of the skin of her nipple and areola.
What is the name for this?
Pagets disease of the nipple
the DCIS cells in the epidermis may extend along the major ducts and reach the nipple & enter the deeper layers of the epidermis and spread within it through the nipple and areola
How do you diagnose/recognise pagets disease of the nipple?
-
biopsy provides definitive diagnosis
- is a skin “reaction” to DCIS –> characteristic eczematous clinical appearance
- pagets disease is a manifestation of DCIS but most women with DCIS dont have pagets
- in some cases there is also an underlying invasive carcinoma associated with DCIS
- (is not the same as pagets of the bone)
What is the staging system used for breast cancer?
TMN
and the staging is the most important prognostic factor - especially lymph node status
in breast cancer there is stage 1-4
A womans breast cancer involves a tumour fixed to the muscle, the ipsilateral lymph nodes and skin involvement larger than the tumour. What stage breast cancer is this?
Stage 3!
stage 1= confined to the breast and mobile
stage 2 = confined and mobile + LN in ipislateral axilla
S3 = fixed, skin involvement + LN
S4 = complete fixation of tumour to chest wall, distant mets
A womans breast cancer is 3cm wide and mobile ipsilateral nodes and no mets.
What is the TNM staging?
T2N1M1
- T1<2cm, T2 2–5cm, T3 >5cm, T4 Fixity to chest wall or peau d’orange;
- N1 Mobile ipsilateral nodes; N2 Fixed nodes;
- M1 Distant metastases.
What do oestrogen receptor and Her2 status apply to in breast cancer?
the absence of these receptors is a poor prognostic factors
e.g. being these receptors negative is a poor prognostic factor
- as if they have these receptors they can respond to
- hormonal therapy if ER +ve or
- herceptin if HER2 oncogene
What is the difference between a breast cancer positive for HER2 or negative for HER2?
- HER2 oncogene POSITIVE has a poorer prognosis without treatment, there is a good response to herceptin (monoclonal antibody against HER2 receptor)
- HER2 oncogene negative = less aggressive (but i guess just be aware herceptin wont work)
What is the difference between ER postive breast cancer and ER negative breast cancer in terms of grade and aggresiveness?
ER +ve = lower grade, less aggressive & likely to respond to hormonal therapy
ER-ve = higher grade, more aggressive & unlikely to respond to hormonal therapy
How many grades (showing differentiation) are there for breast cancer?
1-3
Why is histological subtype useful to know in breast cancer?
Some subtypes e.g. tubular carcinoma are associated with better prognosis
What are excision margins used for?
Complete excision of the primary tumour is important for reducing risk of local recurrence
What are luminal-type A or Type B, Her-2-enriched, Basal-like classifications of breast cancer?
they are genomic classifications
luminal type A & b are typically ER+ve = lower grade e.g. 1 or 2
Her-2-enriched = overexpresses HER2 (oncogene) and is potentially amenable to HER2 targeted treatments
Basal-like = may have common molecular origin with serous carcinoma of the ovary; they are -ve for both ER and HER2 - they are grade 3 (the highest grade)… [so cannot use hormonal/HER2]
What is the medical management of breast cancer?
medical management is adjuvant to reduce risk of systemic relapse after primary surgery
although med Rx is occasionally used as Rx of choice in elderly or those unfit for surgery
in metastatic disease, medical therapy is palliative to increase survival e.g. hormonal and endocrine, chemotherapy, radiotherapy for pain of bony mets or syx from cerebral or liver disease
- Hormonal
- targeted/biological
- radiotherapy
- chemotherapy
- bisphosphonates
When is hormonal therapy used for breast cancer?
- ER+ patients
-
Tamoxifen - anti-oestrogen (YOUNG LADIES) - risk endometrial cancer, as different action on different receptors in uterus vs breast (gives unopposed oestrogen in uterus
- SERM (selective oestrogen receptor modulator) - antagonist in breast, agonist in endometrium [protective against osteoporosis]
- Letrozole - aromatase inhibitors - block oestrogen synthesis (>55YEARS, POST-MENOPAUSAL) - can cause osteoporosis!
- Ovarian ablation - LHRH agonists & oophorectomy (e.g. decrease oestrogen)
When is targeted/biological therapy used in breast cancer?
- HER2R +ve patients
- Trastuzumab (Herceptin) - monoclonal antibody against HER2 (EGFR) receptor
What is radiotherapy given with for breast cancer?
+Given with wide local excision
(Radiotherapy is also used palliatively for metastatic breast cancer for pain of bony mets or symptoms from cerebral or liver disease)
When is chemotherapy offered in breast cancer?
can be used for PRE-SURGERY (neo-adjuvant) to down size tumours before surgery to allow for breast conserving > mastectomy
but USUALLY given adjuvant (after primary Rx) e.g. usually given post-op, pre-radiotherapy
- so chemo therapy is offered to patients with high risk features: +ve nodes, poor grade, young patients
- e.g. anthracyclines, cyclophosphamide, 5FU, methotrexate
- doxorubicin –> cardiomyopathy
What should be given for someone who is on letrozole e.g. blocks oestogen synthesis and so is used if >55y/o, post menopausal and can cause osteoporosis?
bisphoshonates are given as part of the medical therapy
Breast surgeons have said for a womans breast cancer they are doing breast conserving surgery, what does this mean?
- <20% resection volume of the cancer
- = Wide local excision with radiotherapy
- **do a WIRE GUIDED excision if non-palpable
Can be done if:
- Patient choice
- Low tumour : breast ratio
- Unicentric disease
- No previous radiotherapy to breast
- Location appropriate (not central/retro-areolar)
Breast surgeons have said that a patient has a breast cancer >20% resection volume. This means breast conserving surgery is not appropriate. What does this make the next most appropriate option?
>20% resection volume = MASTECTOMY
non-radical mastectomy preserves pec muscles (+ you dont normally need adjuvant/afterwards radiotherapy) while radical removes the pec muscles
Mastectomy can be given in:
- patient choice
- multi-centric or multi-focal disease
- High tumour : breast ratio
- Extensive DCIS
- Recurrence
- Inflammatory cancer
- Risk reduction e.g. genetic risk in BRCA carrier
- Patients unable to commit to radiotherapy
What are the different types of breast reconstruction that can happen?
- immediate or delayed
- Latissimus dorsi flap
- TRAM flap (transverse rectus abdominis)
- Prosthesis
What surgery is used for metastatic disease?
- surgery limited to procedures for symptomatic control of local disesee
- e.g. mastectomy to remove fungating tumour
How does sentinal node biopsy help with lymph node management in breast cancer?
Sentinel node biopsy
- (normal on US, detect with radioactive dye & Geiger counter)
- 1-2 nodes primarily draining tumour - avoid major axillary surgery where not necessary
If +ve, requires full axillary node clearance
How does axillary node sampling help with lymph node management in breast cancer?
- ≥4nodes samples
- avoids complete disruption of axillary lymph drainage
-
If notes +ve, requires adjuvant radiotherapy (radiotherapy after the surgery e.g. the 1o rx) to axilla or axillary node clearance –>.
- Axillary node clearance (malignant)
- optimises diagnosis & treatment of axilla
- :( - Increases risk of lymphoedema greatly (and another S/E is shoulder stiffness)
- optimises diagnosis & treatment of axilla
- Axillary node clearance (malignant)
A pre-menopausal woman with breast cancer (stage 1-3A) is hormone receptor (ER+ve) what is the treatment pathway if they have a mastectomy vs breast conserving therapy (e.g. >20% or <20% resection)?
If mastectomy of hormone +ve –> mastectomy –> chemo up to 6mo.–> tamoxifen (5yrs)
IF breast conserving surgery –> chemo (before or after surgery) –> radiation –> tamoxifen (5 yrs)
A pre-menopausal woman with breast cancer (stage 1-3A) is hormone receptor (ER-ve) negative, what is the treatment pathway if they have a mastectomy vs breast conserving therapy (e.g. >20% or <20% resection)?
Mastectomy –> chemo
breast conseving sugery –> chemo –> radio
(so if Horm +ve then give tamoxifen for 5 yrs at end)
its mostly surgery first then chemo then radio if breast conserving otherwise thats it…
