Breast Oncology Flashcards
Aetiology & Risk Factors?
increasing age
Family history
Endogenous hormone factors
Reproductive – lower age at menarche, older age at menopause, nulliparous, older at time of first birth. (Breast feeding protective)
Obesity in post-menopausal women
Exogenous hormone factors
Hormone replacement therapy (combined oestrogen/progesterone)
Higher socio-economic status
Moderate alcohol intake
Genetic (BRCA 1 & 2, p53, ATM)
Proliferative fibrocystic changes in breast, especially with atypia
Personal history of DCIS or invasive breast ca or endometrial ca
Previous exposure to ionising radiation – eg Hodgkin’s
Lymphatic drainage of the breast?
Laterally –> axillary lymph nodes – levels I-III
From here –>supraclavicular nodes
Medially –> internal mammary nodes (deep to 1st 3 intercostal spaces within 4cm of midline)
Pathology of breast cancer? (epithelial)
Carcinoma in situ
Ductal carcinoma in situ – proliferation of malignant cells in the ducts that does not breach the basement membrane.
Pathology of breast cancer? (Lobular)
Lobular carcinoma in situ – proliferation of malignant cells in the lobules that does not breach the basement membrane
Often more poorly defined
Greater risk of multifocality and bilaterality cf IDC
Others – including medullary, colloid (mucinous), tubular, Paget’s disease, adenoid cystic
Pathology of breast cancer? (Ductal)
Ductal (intraductal) carcinoma (infiltrating carcinoma of no special type)
Proliferation of malignant cells that breach the basement membrane
Grade 1 – 3 depending on malignant cells look and how arranged
Routes of spread?
Invasion of lymphatics risk of spread to lymph nodes (axilla, supraclavicular fossa, internal mammary nodes) & subsequent vascular spread & distant mets
Symptoms & signs of breast cancer?
• Lump – most commonly related to benign disease
• Change in size or shape
• Nipple discharge, itching, bleeding or retractions
• Skin changes
–>Fungation or ulceration from direct invasion
–>Dimpling from underlying tumour fixation
–>Lymphoedema due to invasion of dermal lymphatics (peau d’ orange)
–>Erythema and warm from inflammatory breast cancer
How does the Her 2 gene cause breast cancer?
- Cell which leads to cell proliferation
- Gene amplification → overexpression → uncontrolled activation → proliferation and metastasis
- Overexpression in 25% of breast cancers
Clinical presentation of breast cancer includes?
• Pain (uncommon)
• Nodal disease – palpable nodes, arm oedema, nerve
• Distant metastases
• Usually asymptomatic mammographic abnormality
o Soft tissue mass
o Miro calcifications
What is the aim of early screening methods?
o Aim – get tumour while still small and confined in breast
o Breast self-examination, clinical breast examination, screening mammography
What does mammography screening involve?
o Every 2 years for women 50-69 age group reduces mortality 20-35%
o False -ve and +ves can occur → higher in young women due to dense breasts
o No need in older women as co-morbid conditions compete for high risk of mortality
• After screening biopsy → definitive surgery → high risk metastatic disease CT head, chest, abdo and pelvis scans and bone scans
TNM stage 1 for breast cancer?
Stage O non invasive (DCIS or LCIS)
TNM stage2 for breast cancer?
Stage 2 = primary >2 but <5cm, 1-3 nodes or >5cm no nodes
TNM stage 3 for breast cancer?
Stage 3 = primary >5cm with nodes or involves skin or chest wall or >4 axillary nodes
TNM stage 4 for breast cancer?
Stage 4 = tumour spread distantly usually to lung, liver and bone
Early breast cancer management?
Surgery, radiotherapy, chemotherapy, endocrine therapy → better outcome using full range of treatment options
Possible treatment sequences after surgery?
Chemo → RT
RT → chemo
Chemo → RT → Chemo
Concurrent
What does sentinel node biopsy involve?
Ist draining node within a LN basin to receive lymphatic drainage from a tumour site
<10% false -ve rate
What is the aim of breast cancer surgery?
Aim is to excise all tumour
What is a modified radical mastectomy?
Removal of whole breast and underlying fascia over pectoralis major muscle with axillary dissection
What does breast conversing surgery involve?
Wide local excision +/- axillary dissection and RT to whole breast
Why might breast conserving surgery not be suitable for all patients?
Multicentric disease, diffuse microcalcifications, inflammatory, previous RT, pregnancy, persistently +ve margins after re-excision
Why might we use adjuvant radiotherapy?
o Either as part of breast conserving therapy or following mastectomy
o Reduces risk of local recurrence by 70% and all recurrence by 50%
o Even small no nodal cancers show benefit from radiation therapy
o Tamoxifen alone following lumpectomy is a realistic choice only for women >70 with small completely resected ER +ve tumour
o RT to supraclavicular, axilla and internal mammary nodes if regional nodal involvement and risk of relapse
What are the field inclusion margins for the breast? (supine)
WHOLE BREAST: Medial, 1cm lat, 1cm inf, sup to include all breast tissue (lower edge of clavicular head to base of axilla)
CHEST WALL: entire mastectomy scar with bolus (may by alternate days on and off or full and scar)
NODAL: if high suspicion of occult nodal disease
SUPRA CLAV: >4 axillary nodes involved (inf to 2nd costal cartilage, medial, lat at coracoid process, sup at cricoid cartilage)
AXILLARY: increase risk of lymphoedema and not usually done if dissection has been performed, treated if residual disease
INTERNAL MAMMARY: involvement increase with medial tumours however very hard area to irradiate and can use either extended tangents, matched electron field, IMRT/VMAT
