Breast medicine Flashcards
(43 cards)
What are the types of breast cancer?
- Invasive ductal carcinoma
- Invasive lobular carcinoma
- Ductal carcinoma-in-situ (DCIS)
- Lobular carcinoma-in-situ (LCIS)
- Inflammatory breast cancer
- Paget’s disease of the nipple
Rare types - Medullary, mucinous, tubular, others
What are the causes/risk factors for developing breast cancer?
Multifactorial:
- Genetic: BRCA1/2, TP53, PTEN
- First degree relative affected
- Hormonal: Prolonged oestrogen exposure (early menarche, late menopause)
- COCP and HRT
- Radiation exposure to the chest
- Lifestyle: Alcohol, smoking, obesity
What chromosome is affected in BRCA1/2?
BRCA1 - chromosome 17
Around 70% will develop breast cancer by aged 80
Around 50% will develop ovarian cancer
Also increased risk of bowel and prostate cancer
BRCA2 - chromosome 13
Around 60% will develop breast cancer by aged 80
Around 20% will develop ovarian cancer
What is Ductal carcinoma in situ and what are the features?
Pre-cancerous or cancerous epithelial cells of the breast ducts
Localised to a single area
Often picked up by mammogram screening
Potential to spread locally over years
Potential to become an invasive breast cancer (around 30%)
Good prognosis if full excised and adjuvant treatment is used
What is Lobular Carcinoma In Situ and what are the features?
A pre-cancerous condition occurring typically in pre-menopausal women
Usually asymptomatic and undetectable on a mammogram
Usually diagnosed incidentally on a breast biopsy
Represents an increased risk of invasive breast cancer in the future (around 30%)
Often managed with close monitoring (e.g., 6 monthly examination and yearly mammograms)
What is invasive ductal carcinoma?
Also known as invasive breast carcinoma of no special/specific type (NST)
Originate in cells from the breast ducts
80% of invasive breast cancers fall into this category
Can be seen on mammograms
What is invasive lobular carcinoma?
Around 10% of invasive breast cancers
Originate in cells from the breast lobules
Not always visible on mammograms
What is inflammatory breast cancer?
1-3% of breast cancers
Presents similarly to a breast abscess or mastitis
Swollen, warm, tender breast with pitting skin (peau d’orange)
Does not respond to antibiotics
Worse prognosis than other breast cancers
What is Paget’s disease of the nipple?
Looks like eczema of the nipple/areolar
Erythematous, scaly rash
Indicates breast cancer involving the nipple
May represent DCIS or invasive breast cancer
Requires biopsy, staging and treatment, as with any other invasive breast cancer
How does breast cancer usually present?
Often involves a woman aged over 50 years presenting with a unilateral, hard, painless lump in the upper outer quadrant of her breast.
- Painless lump (hard, irregular, non-mobile)
- Skin changes (erythema, peau d’orange, dimpling)
- Nipple changes (inversion, deviation, pagets, discharge)
- Axillary lymphadenopathy (most commonly)
- Systemic (anorexia, weight loss, fatigue)
Mets - (bone, lung, liver, brain) - usually picked up through screening before mets
What does the breast cancer screening programme involve?
Mammogram every 3 years to women aged 50 – 70 years (being expanded to 47-73).
Who may be offered breast cancer screening earlier?
A first-degree relative with breast cancer under 40 years
A first-degree male relative with breast cancer
A first-degree relative with bilateral breast cancer, first diagnosed under 50 years
Two first-degree relatives with breast cancer
Offered annual mammogram and earlier screening
What is the potential management strategies for women with a high risk of developing breast cancer?
Chemoprevention may be offered for women at high risk, with:
- Tamoxifen if premenopausal
- Anastrozole if postmenopausal (except with severe osteoporosis)
Risk-reducing bilateral mastectomy or bilateral oophorectomy (removing the ovaries) is an option for women at high risk. (rare)
What is the referral criteria for suspected breast cancer?
2 week wait referral for suspected breast cancer for:
- Unexplained breast lump in patients aged 30+
- Unilateral nipple changes in patients aged 50+ (discharge, retraction or other changes)
Consider 2 week referral:
- An unexplained lump in the axilla in patients aged 30 or above
- Skin changes suggestive of breast cancer
Non-urgent referral for under 30 with an unexplained breast lump with or without pain
What investigations are done in suspected breast cancer?
Clinical (Hx and exam)
Imaging (mammography/USS/MRI)
Biopsy (FNA or core biopsy)
Lymph Node assessment - if diagnosed with breast cancer:
- USS axilla
- Sentinel node biopsy during breast surgery
Staged using the TNM system
What are the common areas of metastasis for breast cancer?
LLBB:
Liver
Lungs
Bone
Brain
What is the general treatment options for breast cancer?
Surgery
Radiotherapy
Hormone therapy
Biological therapy
Chemotherapy
What breast cancer receptors can be targeted with treatment?
Oestrogen receptors (ER)
Progesterone receptors (PR)
Human epidermal growth factor (HER2)
Triple negative breast cancer is when none of these are present (worse prognosis)
What are the surgical options for treating breast cancer?
- Breast conserving (wide local excision)
- Mastectomy
Indications -
Mastectomy (multifocal tumour, central, large, DCIS > 4cm)
Wide local excision (solitary lesion, peripheral, small, DCIS <4cm)
Breast reconstruction surgery for both
Axillary clearance (increases risk of chronic lymphoedema)
What are some complications of surgical management of breast cancer?
- Lymphoedema (swelling of arm due to impaired lymphatic drainage)
- Seroma (fluid accumulation at surgical site)
- Mastectomy flap necrosis (inadequate blood supply to the skin)
When is radiotherapy used in breast cancer and what are the side effects?
Important in patients who have breast conserving surgery. Also used in post mastectomy.
SEs:
- General fatigue from the radiation
- Local skin and tissue irritation and swelling
- Fibrosis of breast tissue
- Shrinking of breast tissue
- Long term skin colour changes (usually darker)
- Radiation pneumonitis
How is chemotherapy delivered in breast cancer?
Neoadjuvant to shrink tumour size pre-op and adjuvant in high risk cases
What are the main biological therapies in breast cancer?
Trastuzumab (Herceptin) targets the HER2 receptor. It may be used in patients with HER2 positive breast cancer.
Notably, it can affect heart function; therefore, initial and close monitoring of heart function is required.
Pertuzumab - monoclonal antibody that targets the HER2 receptor used in combination with herceptin.
Neratinib (Nerlynx) - tyrosine kinase inhibitor, reducing the growth of breast cancers. Used in HER2 +ve.
What hormonal therapies are used in hormone positive breast cancers?
Tamoxifen - selective oestrogen receptor modulator (SERM). Blocks oestrogen receptors in breast tissue, and stimulates oestrogen receptors in the uterus and bones. This means it helps prevent osteoporosis, but it does increase the risk of endometrial cancer.
Aromatase - found in fat (adipose) tissue that converts androgens to oestrogen. Primary source of oestrogen in postmenopausal. Blocking the creation of oestrogen in fat tissue.
Both are taken for 5-10 years in oestrogen positive breast cancer
