Breast Disease Flashcards
What is the epidemiology of breast cancer, including risk factors?
Affects 1/9 women
Rare in men
Risk factors:
FH/genetics - BRCA genes
- 5-10% are due to BRCA1/A2 mutations
- BRCA1 = 65% lifetime risk breast cancer, 40% ovarian cancer; 40-60% chance of developing a second breast cancer
- BRCA2 = 45% lifetime risk breast cancer, 11% ovarian cancer
Both are tumour suppressor genes
Uninterrupted oestrogen exposure: Nulliparous or 1st pregnancy >30yrs; early menarche; late menopause; HRT Current COCP usage Increases with age Obesity Increased alcohol intake Lack of exercise Not breastfeeding Past breast cancer
What is the pathophysiology of breast cancer?
Types:
Adenocarcinoma = Invasive ductal carcinoma = most common
Invasive lobular carcinoma
Non-invasive ductal carcinoma-in-situ (DCIS)
Non-invasive lobular CIS
Medullary cancer
Colloid/mucoid cancer
60-70% are oestrogen receptor positive - gives better prognosis
30% express HER2 (growth factor receptor gene) - associated with aggressive disease and worse prognosis
How does breast cancer present?
Usually presents early(ish) with a painless, irregular, hard breast lump
A change in the size or shape of the breast
Dimpling of the skin or thickening in the breast tissue
Inverted nipple
A rash (like eczema) on the nipple
Discharge from the nipple
Swelling or a lump in the axilla (40% at time of presentation - but most of these are occult)
How do you investigate breast cancer?
Triple assessment:
1) Clinical examination
2) Radiology – USS for <35yrs; mammography + USS >35yrs (USS better for invasive cancers, mammography better at DCIS)
3) Histology/cytology – US guided biopsy
Results: Cystic lump - Aspirate → If bloody then cytology If clear then reassure Residual mass → core biopsy
Solid lump -
Core biopsy →
Malignant → plan treatment
Non malignant → reassure
Staging using CXR/bone scan/MRI/PET etc
What is a sentinel node biopsy?
Sentinel node = hypothetical first lymph node or group of nodes that drain a cancer → these are the sites most likely to be affected by a metastasising cancer
Procedure involves injecting blue dye or radiocolloid into the tumour for visual/radiological visualisation of the node → identified and biopsied → cytology/histology etc
Aims to reduce unnecessary axillary node clearance in those without affected lymph nodes
How is breast cancer staged?
1 – confined to breast, mobile
2 – confined to breast, mobile, ipsilateral axillary lymph node involvement
3 – fixed to muscle but not chest wall, ipsilateral axilalry lymph node involvement, skin involvement
4 – complete fixation to chest wall, distant metastases (bone, lung, liver, pleura, skin, brain)
OR Tumour, Nodes, Metastasis (TNM) system:
T0 - no pimary T1 - <2cm T2 - 2-5cm T3 - >5cm T4 - chest wall/skin involvement N0 = no nodes N1 = mobile nodes N2 = fixed nodes N3 = internal mammary nodes M0 = no mets M1 = mets
How do you treat stage 1-2 breast cancer?
Surgery:
Lumpectomy with wide local excision (WLE) or mastectomy ± breast reconstruction
± axillary node clearance or sentinel node biopsy
Radiotherapy:
For all patients with invasive cancer after a WLE → reduce recurrence; also for axillary nodes if affected but not cleared
(SE: lymphodema, brachialplexopathy)
Chemotherapy:
Adjuvant – reduces recurrence and improves survival -
Epirubicin + CMF (cyclophosphamide + methotrexate + 5-FU)
How do you treat stage 3-4 breast cancer?
Radiotherapy to bony lesions + bisphosphonates (for all post menopausal w/ER+ to decrease pain and fracture risk)
Tamoxifen in ER+
Trastuzumab in HER+ tumours + chemo
What hormonal treatments can be used in breast cancer?
To reduce oestrogen activity (feeding the cancer)
Used in oestrogen + progesterone receptor positive cases (ER+, PR+)
Tamoxifen - ER blocker - in premenopausal (SE: menopausal symptoms)
Aromatase inhibitors targeting peripheral oestrogen synthesis – anastrozole
(only in post menopausal) (SE: similar to Tamoxifen but no DVT or endometrial Ca risk)
Herceptin/trastuzumab - HER2+ - SE: headache, fever, rash, cough
GnRH analogues – goserelin – reduce recurrence and increase survival
(only in pre menopausal ER+ve)
How does breast cancer screening work?
2-view mammography every 3yrs for women aged 47-73
For BRCA1/2 carriers – annual MRI surveillance is better than mammography; for women from age 30; bilateral prophylactic mastectomy can reduce incidence by 90%
What are the features of cystic breast disease?
Epidemiology:
Common 35-55yrs, esp perimenopausal
Pathophysiology:
Benign cysts
Presentation: Fluid filled, rounded lumps Not fixed to surrounding tissue Can be multiple Occasionally painful
Investigations/treatment:
Aspiration +/- cytology if suspicious = diagnostic and therapeutic (if painful)
Asymptomatic will cease at menopause unless on HRT
What are the features of fibroadenomas of the breast?
Epidemiology:
Usually presents <30yrs but can occur up to menopause
Pathophysiology:
Benign overgrowth of collagenous mesenchyme of one breast lobule
Presentation:
Firm, smooth, mobile, painless lump
May have multiple
1/3 regress, 1/3 stay the same, 1/3 enlarge
Treatment:
Observation + reassurance
If in doubt – refer for USS = usually conclusive
Surgical excision if large
What are the features of intraductal papilloma?
Benign lesions of the milk ducts
Second most common cause of bloody nipple discharge in women aged 20-40 (behind duct ectasia - blockage)
What is infective mastitis?
Infection of mammary duct
Red, tender, swollen, painful area; may be lactational or non-lactational possible associated pyrexia and ‘flu-like’ symptoms
Usually S.aures
Give Abx - flucox OR erythromycin (normally respond within 48hrs); possible serial aspiration
May occasionally progress to abscess formation
Continue to breastfeed (unless Abx contraindicate)
