Breast conditions and cancer Flashcards
describe the incidence and mortality of breast cancer over time
incidence is increasing as mortality is decreasing
what % of breast cancer patients are asymptomatic
50
common symptoms of breast cancer
lump in breast bleeding or non physiological discharge from nipple pain in breast altered shape/contour or skin change lumpy breast
what happens at a triple assessment clinic?
clinical exam by hx and exam
radiology by USS or mammogram
core biopsy - cytology is rarely used so core or vacuum core biopsy for histopathology
grading of needle core biopsy?
B1 - unsatisfactory/normal B2 - benign B3 - atypical but probably benign B4 - suspicious of malignancy B5a - CIS B5b - invasive carcinoma
what is the intermediate paradigm of breast cancer
breast cancer is a potentially systemic disease and so early detection through screening and local control prevents metastatic spread
treatment for early breast cancer - local
radiotherapy
surgery
treatment for early breast cancer - systemic
chemotherapy
hormonal - tamoxifen, aromatase inhibitors, GnRH, oophorecotmy
where may later of advanced breast cancer present and management?
bone or soft tissue
systemic therapy to improve QOL or symptom control
what is an ANDI
alternations in normal development and involution
anything thats not cancer
fibrocystic change, cyst, papilloma
example of a hormonal change leading to breast condition
gynaecomastia
example of inflammatory benign breast conditions
mastitis
abscess
describe the physiology of lactation
babies cries heard in higher centres and removes prolactin inhibition and stimulates oxytocin release
prolactin stimulates milk secretion and oxytocin stimulates smooth muscle contraction and ejection of milk
ejection partly triggered by mechanoreceptors in nipple from suckling
NPI <3?
excellent prognosis
NPI<3.4?
good prognosis
NPI 3.41-5.4?
moderate prognosis
NPI >5.41
poor prognosis
methods of breast conservation surgery?
wide local excision
image guided local excision
oncoplastic surgery
what is the alternative to breast conserving surgery
mastectomy
chemotherapy given as neoadjuvant?
FEC and taxane ±herceptin
true/false - mastectomy is more effective than breast conserving surgery + radiotherapy
false, they are just as effective
what is WLE used for, what is the margin and where is cut
palpable symptomatic cancers
just below skin to pectoral fascia
aim for >1cm
when is image guided local excision used, margin and method?
asymptomatic cancers detected on screen
1mm margin
clips, RF wave, magnetic seed
what is oncoplastic breast conservation
oncological surgery with additional aim to avoid tissue deformity
types of oncoplastic breast conservation surgery
therapeutic mastopexy
therapeutic reduction mammoplasty
volume replacement
what is a mastectomy and types
removal of all breast tissue
standard or skin sparing
options for reconstruction following mastectomy
immediate/delayed external implant LD pedicle flap deep inferior epigastric artery free flap inferior/superior gluteal artery free flap transverse upper gracilis free flap profunda artery free flap
risks associated with breast reconstruction implant
infection rippling migration capsular constriction revision surgery ALC lymphoma
options for lymph node breast cancer treatment
USS axilla and biopsy
sentinel node biopsy
axillary clearance
axillary radiotherapy
risk of axillary clearance
lymphoedema
how is lymphoedema avoided in axillary clearance surgery
tracer injection to only remove nodes that are stained due to uptake of lymph from breast
what intrinsic subtype of breast cancer has the best prognosis
luminal like A
what intrinsic subtype of breast cancer has the worst prognosis
triple negative
systemic tx for luminal like A cancer
ET alone
ChT if high risk, large tumour or multiple nodes
systemic tx for luminal like ABcancer
ChT and ET
systemic tx for luminal like B and HER2+ve cancer
ChT and anti-HER2 and ET
if chemo contraindicated then just anti-HER2 and ET
systemic tx for HER2+ve non luminal
ChT and anti-HER2
systemic tx for triple negative cancer
ChT
indications for neoadjuvant therapy
downsize tumour
enrol pt into trial
locally advanced disease needing rendered operable
large primaries or large to breast
for what type of cancers is genomic testing carried out
ER+ve sensitive cancers
what kind of genomic test is carried out on breast cancers and what does it indicate
oncotype dx
risk of recurrence
likelihood of ChT benefit after surgery
acute side effects of chemotherapy
fatigue myelosuppression leading to infection, anaemia, thrombocytopaenia N&V alopecia mucositis diarrhoea constipation renal neurotoxicity infertility
late side effects of chemotherapy
cardiotoxicity infertility neruopathy renal impairment osteoporosis carcinogenesis
neoadjuvant tx in HER2+ve cancers
preop ChT and trastuzumab and pertuzumab
what to do drugs if there is clinical response to neoadjuvant tx in HER2+ve cancer
if ER-ve then 1 yr dual blockade trastuzumab and pertuzumab or just trastuzumab
other cases 1yr trastuzumab
side effects of HER2 targeted drugs
congestive HF severe diarrhoea hand-foot syndrome ILD/pneumonitis transaminitis
neoadjuvant endocrine therapy?
ER+ve
pre/perimenopausal - letrozole + gosrelin or tamoxifen ±gosrelin
postmenopausal - letrozole
side effects of AI
joint pain osteoporosis hot flushes fatigue sweating weight gain sexual dysfunction loss libido mood swings
treatment recommendations for ER+ve breast cancer postmenopause
low risk - tamoxifen or AI 5yr
high risk - extended adjuvant AI
treatment recommendations for ER+ve breast cancer premenopause
low risk - tamoxifen 5yr
high risk - ovarian suppression +tam or OS +exmestane
who can be given adjuvant bisphosphonates
postmenopause and considered risk for tx with adjuvant AI or HER2+ve or ER low/neg
premenopausal with ovarian suppression
what is the usual drug for adjuvant bisphosphonate
3yr 6monthly zoledronate
staging workup for met disease
hx and exam
biochem and haematoilogy
chest, abdo, bone imaging
not head unless symptomatic
describe action of CDK4/6 inhibitors
block CDK4/6 so prevent phosphorylation of Rb so halt cell cycle
when are CDK4/6 inhibitors best when given with
ET
toxicities of CDK4/6 inhibitors
neutropaenia
diarrhoea
increased AST/ALT
QTc prolongation
early toxicities radiotherapy
fatigue
skin reaction
hair loss in radiation field
late toxicities radiotherapy
breast change discomfort telangectasia lymphoedema heart vessel damage asymptomatic/symptomatic lung fibrosis
