Breast Lecture 4 - Treatment of Breast Disease Flashcards
what is the incidence of breast cancer?
- Affects 1 in 8 women
- Accounts for one quarter of malignancies in women
- 55,000 new cases per year in the UK;
- >490 new cases annually in Grampian
- >9,000 diagnosed each year are <50 years old
- >11 400 deaths annually
- Around 300 new cases per year in men
what are the risk facotrs for breast cancer?
- Age: Increased incidence (biggest risk factor, 25% of breast cancers are diagnosed in patients over 75)
- Previous breast cancer
- Genetic: BRCA1 and BRCA2 (5%)
- Early menarche and late menopause (exposure to oestrogen)
- Late or no pregnancy
- HRT
- Alcohol (>14 units per week)
- Weight
- Post Radiotherapy treatment for Hodgkin’s disease
what is the presentation of breast cancer?
- Asymptomatic: Breast Screening (50-70 yrs)
- Symptomatic: Outpatient Clinic
- Lump (most common presentation)
- Mastalgia (persistent unilateral pain)
- Nipple discharge (blood-stained)
- Nipple changes (Paget’s disease, retraction)
- Change in the size or shape of the breast
- Lymphoedema (Swelling of the arm)
- Dimpling of the breast skin
new patient clinic - one stop shop
what is it?
- CLINICAL: History and Examination
- RADIOLOGICAL: Bilateral mammograms / USS
- CYTO-PATHOLOGICAL: FNA- cells only (cytology), Core Biopsy- tissue (histo-pathology)
what information is gathered in a history?
Present Complaint (Where is the lump, how long, size, shape)
Previous Breast Problems
Family History (Previous FH of breast or ovarian cancer to know if they are high risk)
Hormonal Status
Drug History
what is checked on examination
BOTH Breasts, Axillae, SCF (supraclavicular fossa)
Signs and Symptoms - what are they?
Most common thing is a lump or thickening in the breast
Mostly painless so patients need to be breast aware
Inversion or retraction of the nipple
how is breast imaging done?
- The breast can be imaged with mammography, ultrasound or MRI
- Mammography is the most sensitive in older women
- Sensitivity is reduced in young women due to the presence of increased glandular tissue (<35yrs)
MRI is only for ladies with certain types of breast cancer and other restrictions
Cytology/Histology - how is it done?
FNA (Fine Needle Aspiration) -> Cytology
Core Biopsy -> Histo-Pathology:
- Invasive versus in-situ
- ER, PR, HER2 receptor status
How Good Are the Tests? - what is the sensitivity of each test?
Pathological types of breast cancer - what are the two classes?
invasive and non-invasive
Pathological types of breast cancer - what are some invasive types?
80% Ductal Carcinoma
10% Lobular Carcinoma
10% Others (Mucinous, Tubular, Papillary, Medullary, Sarcoma, Lymphoma)
Pathological types of breast cancer - what are some non-invasive types?
DCIS
LCIS
(Ductal Carcinoma In Situ
17% screening detected)
(Lobular Carcinoma In Situ)
Management of Cancer - whata re the key steps?
- Diagnose the disease
- Staging of the disease (Need to know how far the cancer has spread so stage the disease)
- Definitive treatment
Treatment of breast cancer - multidisciplinary approach
who is involved?
- Breast Surgeon
- Radiologist
- Cytologist
- Pathologist
- Clinical Oncologist (can give systemic therapy and radiotherapy)
- Medical Oncologist (only gives systemic therapy)
- Nurse counselor
- Psychologist
- Reconstructive surgeon
- Patient and partner
- Palliative care
Assessing the severity (“Staging”) - how is it done?
Want to know what’s going on and how far the cancer has spread
- FBC, U&Es, LFTs, Ca2+/PO2-
- Chest x ray
- Others as clinically indicated
- No reliable tumour markers
TNM classification
what is the T? - Primary Tumour
Tx Primary tumour cannot be assessed
T0 Primary tumour not palpable
T1 Clinically palpable tumour -size < 2 cm
T2 Tumour size 2-5 cm
T3 Tumour size > 5 cm
T4a Tumour invading skin
T4b Tumour invading chest wall
T4c Tumour invading both
T4d Inflammatory breast cancer
TNM classification
what is N? - Regional Lymph Nodes
N0: No Regional lymph nodes palpable
N1: Regional lymph node palpable - mobile
N2: Regional lymph node palpable - fixed
TNM classification
what is M? - Distant Metastasis
Mx: Distant metastasis cannot be assessed
M0: No distant metastasis
M1: Distant metastasis
What Management/Treatment can be done?
Surgery
+/- Radiotherapy
+/- Chemotherapy
+/- Hormonal Therapy
Neo-Adjuvant (treatment before surgery) versus Adjuvant (treatment after surgery) - All can be given in neo-adjuvant or adjuvant setting
what are the two main types of surgical procedures to the breast?
- Breast conservation surgery
- Mastectomy (breast removal)
Randomized controlled trials:
breast conservation + radiotherapy = mastectomy
for overall survival in tumours less than 4cm
But if you only do breast conserving surgery with no radiotherapy then you have an increased risk of local recurrence and does impact on survival
What patients are suitable for breast conservation surgery?
- Tumour size clinically<4cm – IN THE OLD DAYS
- Breast/Tumour size ratio
- Suitable for radiotherapy
- Single tumours – IN THE OLD DAYS
Patient’s wish – most important!!
Surgery to the AXILLA - what is its function and what does it achieve?
- Prognostic information/Staging
- Regional control of disease/eradication in the axilla
what is a Sentinel lymph node biopsy and what is tis function?
- first node to receive lymphatic drainage
- first node the tumour spreads to
- if negative, rest of nodes in lymphatic basin are negative
- Only performed when preoperative axillary USS normal/benign
What is the Treatment of the axilla if SLN is negative or psitive?
- If SLN is negative (= clear of tumour) - no further treatment required
- If SLN contains tumour - either remove them all surgically (clearance= ANC) or give radiotherapy to all the axillary nodes
(Use 2 dyes)
what are some complications of axillary treatment?
- Lymphoedema (10-17%)
- sensory disturbance (intercostobrachial n.)
- decrease ROM of the shoulder joint
- nerve damage (long thoracic, thoracodorsal, brachial plexus)
- vascular damage
- radiation-induced sarcoma
What are factors associated with increased risk of disease recurrence?
come back to this in regards to NPI
- Lymph node involvement (NPI)
- Tumour grade (NPI)
- Tumour size (NPI)
- Steroid receptor status (negativity- ER/PR neg)
- HER2 status (positivity- HER2 pos)
- LVI- lymphovascular invasion
(NPI - The Nottingham prognostic index (NPI) is used to determine prognosis following surgery for breast cancer)
prevention/adjuvent treatment - what can be done locally?
• Radiotherapy
prevention/adjuvent treatment - what can be done systemically?
- Hormone therapy
- Chemotherapy
- Targeted therapies
How is radiotherapy given?
- All patients after WLE (wide local excision) as adjuvant treatment
- over 3 weeks
- Boosts reduce local recurrence
- After Mx if there is local involv./signif LN involv.
what are some complications of radiotherapy?
• Complications: immediate - longterm
Skin reaction - Skin telangiectasis
Radiation pneumonitis (radiation goes to other strucutres)
Cutaneous Radionecrosis/Osteonecrosis
Angiosarcoma
hormone therapy - who gets it and what does it do?
osteogren receptor positive (ER+)
blocks stimulation of cell growth by oestrogen
what are examples of hormone therapy and how are they used?
left blocks receptor
Right blocks the synthesis
diagram showing where the different hormonal treatments act
chemotherapy clinical trial shave shown it benefits who the greatest?
- in younger women (<50 years)
- In patients with increasing adverse prognostic factor (grade 3, LN pos, ER neg, HER2 pos)
What is HER2 positivity and Anti-HER2 therapy?
Trastuzumab (Herceptin®)/Pertuzamab
- Monoclonal antibody against HER-2 receptor
- Given to patients with over-expression of HER2 and chemotherapy (Don’t work just by itself)
- 50% decrease risk of recurrence
- 33% increase in survival at 3 years!
(If we can block this then cell division wont happen)
what follow up is done?
- Many different protocols – poor evidence base
- Clinical examination for 1-5 years
- Mammogram of breast(s) at yearly intervals for 3-10 years
- Best person to keep an eye on it - PATIENT itself
- Open Access to service
metastatic spread- what local sites may it spread to?
Chestwall
Skin
Nipple
metastatic spread- what distant sites may it spread to?
Contralateral Breast
Bone
Lung
Liver
Brain (Her 2 positive cancers can go to brain)
Bone Marrow
(Bone then lung then liver is most common)
