Breast Surgery Flashcards
Common sites of breast cancer metastases
Bone
Liver
Lung
Brain
Common age of breast cancer diagnosis
50-70
affects 1/10 women in Ireland
Breast cancer subtypes
The 3 main receptors looked at are oestrogen R, Progesterone R ( both called HR) and HER2 • HR+/HER2- Ø 75% of all cancers • HR-/HER2- Ø i.e. triple negative • HR+/HER2+ HR-/HER2+
What does triple assessment refer to?
Triple assessment
1. Clinical hx and examination
2. Radiological investigations
3. Histology
What are the differentials for a lump in the breast?
- Tumor
- Sebaceous cyst
- Abscess
- Fibroadenoma
- Lipoma
- Lymphoma
- Papilloma
- Fat necrosis
- Enlarged lymph node
What are the histological types of breast cancer?
5 types Ductal Lobular Tubular Papillary Mucinous
Symptoms that patients with breast disease might present with
Could be asymptomatic
- Lump - Nipple discharge / bleeding - Nipple changes - Skin changes - colour or texture Skin dimpling
What is the most common type of breast cancer?
Invasive ductal carcinoma
followed by invasive lobular
Risk factors for breast cancer
Female gender Age Obesity Radiation exposure Hormone related - early menarche - late menopause - nulliparity - HRT Genetic factors - single gene - BRCA1 &2 - multigenic ( 1 in 4 risk group )
What lifestyle factors increase the risk of breast cancer?
Smoking
Obesity
Alcohol
What are the indications for a mastectomy?
Tumor size relative to size of breast Inflammatory breast cancer Not eligible for radiotherapy Patient choice BRCA1 or 2
Management of inflammatory breast cancer
Neoadjuvant chemo
Mastectomy
Axillary clearance
Radiotherapy
In what situation could you not do radiotherapy?
Scleroderma
Unsuitable skin e.g. from previous skin grafts
What impact does the removal of axillary LNs have on prognosis?
does not improve prognosis
Cancer in the lymph is a marker of spread but not the only route i.e. could have haemorrhage spread
What mastectomy patients should also have radiotherapy?
T4 disease
T4 and LNs involved
Tumor 4-5cm in size
How is the axilla assessed?
Clinical exam for palpable nodes
US to see cortex and medulla clearly
US guided FNA
How does tamoxifen work?
Block oestrogen from stimulating cancer cells.
Acts as normal oestrogen at other cells so there is no loss of 2º sex characteristics
Why would you not use tamoxifen as prophylaxis to breast cancer?
There is a risk of causing endometrial cancer
What group of patients could take tamoxifen?
pre and post menopausal
women and men
Side effect of tamoxifen?
Night sweats and hot flushes
What patients should have a SLNB?
Patients with node-negative disease on imaging
Should a patient with a high oncotype Dx score be given adjuvant chemo?
Yes should be considered with scores above 26
What is the role of hormone therapy in breast cancer?
Given to patient with hormone receptor ( ER or PR) positive breast cancer to reduce the risk of local and distant recurrenc
What are aromatase inhibitors?
Aromatase inhibitors inhibit the synthesis of oestrogen from androgens.
Used in post-menopausal women
Possible side effects of tamoxifen?
Endometrial cancer
Hot flushes
Thromboembolic events
Role of radiotherapy in systemic breast cancer?
No
it is used to reduce local recurrence of breast cancer
When is oncotype Dx used?
Used in patients with early luminal breast cancer to determine if chemo will give an added survival benefit.
Why not use MRI for all breast cancer diagnosis?
Higher sensitivity so used in patients with lobular breast cancer and for high risk screening. But higher false positive rates so not suitable for general population
ER+ premenopausal woman medication
Tamoxifen
ER+ postmenopausal woman medication
Anastrozole
Role of trastuzumab in breast cancer tx?
aka herceptin.
Used for HER+ breast cancer
Surgery for DCIS >4cm
Mastectomy
Surgery for multifocal tumor
Mastectomy
Breast staging T1,T2,T3,t4
T1 = < 2cm T2 = 2 - 5cm T3 = > 5cm T4a = Invades skin T4c = Invades chest wall and skin T4d = Inflammatory breast cancer [no matter the size]
Antibiotic for acute mastitis
Flucloxacillin
Lumpy breasts, may be painful, Symptoms worse before period
Fibroadenosis
Benign
Most malignant form of brain tumor
Gliobastoma
What is the prognosis of triple neg breast cancer?
Worst prognosis
agressive
Which breast cancer subtype has the best prognosis?
HR+ ( ER or PR) and HER -ve
surgical mgmt of DCIS (ductal carcinoma in situ)
Wide local excision [ v low risk pts] or lumpectomy and XRT or mastectomy w or w/o SLNB
Surgical options for Invasive ca
Lumpectomy and XRT with SLNB or mastectomy w SLNB
Size for removal of a fibroadenoma
more than 3cm if causing discomfort
1st line tx of mastitis
continue breast feeding
tender lump around areola ± green nipple discharge in a 50yo woman
mammary duct ectasia
halo sign
most likely breast cyst
symmetrical slit like retraction with cheese like discharge
duct ectasia
Aromatase inhibitor anastrozole side effects
Osteoporosis
suitable for post menopausal women only
old women get osteoporosis
osteoporosis is a side effect of what type of medication used in breast cancer?
Aromatase inhibitors
used in ER+ cancer in post menopausal women
endometrial cancer is a possible side effect of which type of breast cancer medication ?
tamoxifen - used for ER+ cancer
can be used in both pre and peri menopausal women
