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Phase 3a Gynaecology > Breast management > Flashcards

Breast management Flashcards

1
Q

What proportion of breast cancer will be cured long-term?

A

80%

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2
Q

Why are breast cancer cases increasing?

A

Lifestyle eg obesity
Increased screening and detection
Ageing population

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3
Q

What proportion of women in the uk will develop breast cancer?

A

1 in 8

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4
Q

How does breast cancer present?

A 
Skin tethering 
Breast lump - usually painless
Pau de orange 
Bloody nipple discharge
Nipple inversion or in-drawing 
Locally advanced disease - cancer has invaded most of the breast 
Metastases eg bone

Signs: painless lump which is irregular, hard and fixed

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5
Q

How do we diagnose breast cancer?

A

Use a tripple assessment:

  1. clinical score 1-5: normal-clearly malignant
  2. imaging score 1-5
  3. biopsy score 1-5
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6
Q

Is pain a common feature of breast cancer? If not, what is it likely due to?

A

No it is unlikely for BC to be painful (though it can rarely present as a painful lump)
Cysts and hormonal changes

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7
Q

What is microcalcification due to?

A

DCIS

or can be an invasive cancer

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8
Q

What are the main investigations for breast cancer?

A

Mammogram

ultrasound and core biopsy

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9
Q

When are MRIs used to diagnose breast cancer?

A

Carriers of BRCA 1 and 2
Young women with more dense breasts
Women with breast implants

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10
Q

What are the surgical options for pts with breast cancer?

A
  1. Breast conservation - lumpectomy or wide excision: always give radiotherapy afterwards
  2. Mastectomy

Both procedures will involve some surgery to the axilla

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11
Q

What factors would mean that breast conservation surgery can be done instead of mastectomy?

A
  • Small tumour relative to breast size usually <25%
  • Neoadjuvant chemotherapy - where the pt is given chemo before surgery. this can shrink the tumour making it suitable for lumpectomy
  • No previous radiotherapy to the breast
  • Pt choice
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12
Q

What factors would mean that a mastectomy would be the preferred option over breast conservation?

A
  • large tumour relative to breast size
  • more than one tumour in the same breast esp if in different quadrants
  • patient choice
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13
Q

What factors affect the outcome from conservation surgery?

A

tumour size relative to breast size
position of tumour in the breast
radiotherapy fibrosis

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14
Q

What type of axillary surgery will a pt with a large palpable node undergo?

A

Full axillary clearance - remove all of the nodes from the underarm

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15
Q

What type of axillary surgery will a pt with clinically normal nodes undergo?

A

Limited axillary surgery
Sentinel node biopsy
Remove between 1-4 glands under the arm
Identify which nodes are most likely to have cancer in by using a radioactive dye or blue dye

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16
Q

What are the advantages of full axillary clearance?

A

Accurate staging
Good local control - 1% reccurance rate in axilla
No need for further surgery or radiotherapy

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17
Q

What are the disadvantages of full axillary clearance?

A 
10-12% lymphoedema 
Seroma - fluid build up at site of excision
Arm stiffness 
axillary numbness 
Longer admission and surgical time
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18
Q

What are the advantages of limited axillary surgery?

A

No significant complications
No drains
Day surgery

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19
Q

What are the disadvantages of limited axillary surgery?

A

May need clearance or radiotherapy

20
Q

What do you do if you do a sentinel node biopsy after surgery and you find no axillary disease?

A

No further axillary surgery

21
Q

What do you do if you find large volume axillary disease after surgery?

A

Second axillary clearance

22
Q

What do you do if you find small volume axillary disease after surgery with a low risk cancer?

A

No further treatment

or radiotherapy to axilla

23
Q

What are the two most common types of breast cancer?

A

Ductal

Lobular

24
Q

How does ductal carcinoma feel?

A

Lump

25
Q

How does lobular carcinoma feel?

A

Diffuse and difficult to feel

26
Q

How are breast cancers graded?

A

1-3
Grade 1 - slow growing, well differentiated and good prognosis
Grade 3 - looks nothing like breast tissue

27
Q

How are breast cancers staged?

A 
TNM staging 
Tumour: 
T0 - no evidence of a primary 
T1 - <2cm 
T2- 2-5 cm 
T3 - >5cm 
T4 - extends to chest wall or skin or inflammatory

N0 - no nodes
N1 - mobile nodes
N2 - fixed nodes
N3 - internal mammary nodes

M0 - no mets
M1 - mets

Stage 1 - disease confined to the breast
Stage 2 - breast and axilla
Stage 3 - Locally advanced
Stage 4 - mets

28
Q

What is the Nottingham prognostic index?

A

Looks at patients who have stage 1 and stage 3 cancer and takes into account heir grade, nodes and size to identify those with poor prognosis if only offered surgery

Can offer these women adjuvant chemo and hormone therapy

29
Q

What are the 4 types of receptors that can be present in breast cancer?

A

ER - oestrogen receptor
Her-2 - herceptin receptor
PgR - progesterone receptor
Ki67- marker of proliferation

30
Q

What is the importance of identifying the type of receptor on breast cancer cells?

A

Prognosis

Guides treatment options

31
Q

What is Predict?

A

An online calculator tool that takes into account age, tumour size, grade, stage and receptor type and assesses response and prognosis following different treatment options

32
Q

What is oncotype dx?

A

A multi-gene array - looks for 21 different genes which have prognostic significance and derives a score to see whether she would benefit from chemo or not

33
Q

What are the adjuvant treatments for breast cancer?

A 
Tamoxifen 
Aromatase inhibitors 
Radiotherapy 
Chemotherapy 
Traztuzumab 
Bisphosphonates
34
Q

What is tamoxifen and who is it given to?

A

Tamoxifen is an inhibitor of the oestrogen receptor on breast cells
All pts with ER+ disease who are pre-menopausal

35
Q

What are aromatase inhibitors and who are they given to?

A

Inhibit the aromatase enzyme responsible for converting androgens to oestrogens in post-menopausal females

Only effective in post-menopausal women as it doesn’t affect the ovaries production of oestrogen and is better than Tamoxifen after the menopause

All pts with ER+ disease who are post-menopausal

36
Q

Who is radiotherapy given to?

A

All women who have a lumpectomy
Women with aggressive disease after mastectomy
Used in axilla of pts with positive sentinel node biopsy after surgery

37
Q

Who is chemotherapy given to?

A

Aggressive disease phenotype: Her 2+ or ER-, grade 3 or node positive, large tumour size, young age
So only for women with high risk disease

38
Q

What is Traztuzumab and who is it given to?

A

A Her-2 targeted therapy used in conjuction with another Her-2 targete therapy called Pertuzamab
All Her2+ disease

39
Q

Who gets bisphosphonates and why are they used?

A

High risk cancer in post-menopausal women with Her2+ disease

Improves survival from cancer as reduces the rate of bone mets

40
Q

Are Her 2+ cancers aggressive or not?

A

They are very aggressive and are well-known markers of poor prognosis and commonly metastesizes to the brain

41
Q

How long is tamoxifen given for?

A

5 or 10 years

42
Q

What are the side effects of tamoxifen?

A 
Hot flushes 
Nausea 
Vaginal bleeding 
Thromboses 
Endometrial cancer
43
Q

What are the side effects of aromatase inhibitors?

A

Hot flushes

Reduced bone density

44
Q

What are the side effects of trastuzamab?

A

can cause heart failure

45
Q

When is wire localisation used?

A

For impalpable cancers that will be operated on

Phase 3a Gynaecology (13 decks)

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