Breast Week Flashcards
What is the sentinal node?
sentinel lymph node (SLN) is the first axillary lymph node that will collect cancerous cells from the breast if the cells have entered the lymphatic system (nb there can be more than 1)
What adjuvant treatment should be given to ER postiitve tumor patients?
Tamoxifen or Aromatase Inhibitors (e.g. anastrozole)
What adjuvant treatment should be given toHER2 postiitve tumor patients?
trastuzumab (Herceptin)
If a woman has already has radiotherapy in prev cancer is she able to have it again
Normally no
In terms of HER2/ER/PR, when is chemo indicated?
Chemotherapy with anti-HER2 therapy is indicated for HER2 positive cancers even for small tumours.
Similarly, chemotherapy is also indicated in ‘triple negative’ cancers (ER negative, PR negative, HER2 negative) even in small tumours.
What are these? Are they normal?
These are Montgomery’s tubercles which are sebaceous glands in the areola around the nipple. They are a normal finding, but may become more pronounced during pregnancy.
Why might having “dense” breasts cause problems?
- 5 x more likely to develop breast cancer
- Harder to distinguish lumps on mammogram
What does each stage mean in “P” assessment of lump?
P1 = normal
P2 = benign
P3 = uncertain
P4 = suspicious
P5 = malignant
What is screening?
Asking healthy, symptom free people of a certain group (e.g. age) to come in and have some tests that pick up common asymptomatic disease in that group, so that we can treat them early and give a better outcome.
What are some disadvantages of breast screening?
- Mammography is uncomfortable and involves a small amount of radiation
- False-positive results may cause unnecessary anxiety
- Breast screening occasionally misses a cancer
- Breast cancer may occur in the interval between screening appointments
- Screening may diagnose a cancer which never needed treating
How often is breast screening done?
Every 3 years
What should you tell someone going for screening to prepare them?
- Mrs Gupta will need to undress to the waist so she might prefer to wear a top and skirt or trousers rather than a dress.
- Women are normally advised not to wear talcum powder or deodorant as these can cause artefacts on the mammogram.
- She will be asked some questions about her previous breast history, HRT use and family history.
- She might like to know that all mammographers in the NHS breast screening programme are female.
Of 100 women having breast screening, how many will be recalled from screening and how many will have breast cancer?
4 women will be recalled, 1 of these will be diagnosed with breast cancer.
What are some causes of microcalcifications?
Malignant:
- DCIS
Benign:
- fibroadenomas
- cysts
- trauma or
- surgery to the breast
What kind of biopsy is needed in microcalcifications?
Stereotactic (mammogram guided) biopsy
- USS does not show microcalcifications well
Why is a specimen x-ray performed after a stereotactic core biopsy?
To check the tissue is from the right area - i/e showing microcalcifications
What pattern does microcalcification in DCIS form?
Why?
Branching pattern following the milk ducts.
Because the cancer forms in the milk ducts and doesn’t spread accross the basement membrane
How is DCIS followed up?
Annual mammogram and clinical examination for five years
What are the risk factors for breast cancer?
Genetic:
- BRACA1/2 40% lifetime risk of breast/ovarian cancer
- 1st degree relative premenopausal relative with breast cancer (e.g. mother)
- Previous Breast Cancer
- p53 gene mutations
- Dense breasts
Obs/gynae - Oestrogen exposure:
- nulliparity
- 1st pregnancy > 30 yrs (=twice risk of women having 1st child < 25 yrs)
- Not breastfeeding (not HER2)
- early menarche
- late menopause
Lifestyle:
- Obesity
- Smoking
- Alcohol
Treatments:
- Radiation of chest
- HRT
- COCP
Which quadrant do breast cancers most commonly occur?
Upper outer
What is the most common type of breast cancer
Invasive ductal carcinomas are the most common type. Some may arise as a result of ductal carcinoma in situ (DCIS).
There are associated carcinomas of special type e.g. Tubular that may carry better prognosis.
Name some examples of benign breast lesions
- Fibroadenoma
- Breast Cyst
- Sclerosing adenosis
- Epithelial hyperplasia
- Fat necrosis
Explain a mammogram to a patient:
- How much radiation will I get?
- Will it hurt?
- Will the mammographer be male?
- Will it cause my cancer to spread?
- 2 months worth
- Rarely painful but often uncomfortable
- No - excempt from sexual discrimination act
- no
What is as effective (when appropriate) as a mastectomy?
Wide local exision + radiotherapy
When is chemotherapy most effective?
When pt is at risk of micrometastases
Name 3 indications for mastectomy:
- Multifocality (2+ lumps in one breast, esp. if far apart)
- Local recurrence
- DCIS or invasion >4cm (esp. in small breast)
What tool is used to estimate breast cancer survival and benefits of hormone therapy?
PREDICT
What is the only test where 1 does not mean normal?
C; cytology; 1 is inadequate sample
When should you check your breasts?
Once a month, between days 10 and 14 (↓cyclical lumps). Check using a mirror. Don’t over-check.
“sisters not twins”
Name some red flags on examination
- Nipple inversion
- Nipple eczema (Paget’s)
- Inflammatory breast signs (very aggressive)
What do the letters stand for:
- P
- U
- M
- C
- B
- P - palpation
- U - USS
- M - mammogram
- C - cytology (FNA)
- B - biopsy
What does cytology tell you?
Benign or malignant. Does not tell you type of cell (e.g. DCIS or invasive), or structure or hormone receptors etc.
What are the 3 signs of liver mets?
- Jaundice
- Pain
- Weight loss
What are the treatments for cyclical mastalgia?
- Well-fitted bra
- Topical NSAIDs
- Evening primrose oil / flax seed oil
- Hormonal agent e.g. danazol
Breast pain is classified into 2 types
- Cyclical
- Non-cyclical
Mastitis is classified into 2 types
- Lactational
- Milk stasis
- Infection (staph. aureus)
- Non-lactational
- Smoking damages ducts
- Infection (staph. aureus, enterococci, anaerobics)
Can someone with lactational mastitis continue to breast feed?
Yes but use a pump if it is too painful
What are the 2 most common causes of breastfeeding problems?
Mastitis
Engorgement
Do fibroadenomas need treatment?
No. If the diagnosis of a fibroadenoma has been made through triple assessment then she does not need any treatment.
In certain circumstances, excision of a fibroadenoma may be considered if the lesion is very large (>4cm), if it is growing, or if the patient requests it.
Generally, fibroadenomas stay the same size. However, some do get smaller with time, and some do increase in size, especially in teenage girls and in pregnant women.
What does this show?
Popcorn calcification of fibroadenomas
Cysts:
The patient asks you:
- Does it need treatment?
- Could it turn into cancer?
- Do I need to come back if I find another lump?
-
Does it need treatment?
Cysts are benign and therefore don’t really need treatment. However, if the cyst is causing the patients symptoms such as a lump or pain, then the fluid is usually aspirated. -
Could it turn into cancer?
Cysts do not turn into cancer. -
Do I need to come back if I find another lump?
Yes. Even if patients are known to have cysts, they should be advised to see their doctor if they find a new lump, rather than assume it is another cyst.
When would you send cyst fluid for cytology?
If it is blood-stained
What proportion of breast cancers are due to an inherited fault in one of the breast cancer genes?
1 in 20 (5%) are due to BRACA 1 /2
Who are your first, second and third degree relatives?
First-degree relatives are parents, siblings and children.
Second-degree relatives include grandparents and aunts/uncles.
Third-degree relatives include cousins and great aunts/uncles.
What is the inheritance pattern of BRACA 1 or 2?
Autosomal dominant
For patients with a strong FH of breast cancer, what are their options?
Early detection: she will be advised to be breast aware and to report any changes in her breasts to her doctor as soon as possible. She will also be offered screening, which for Dawn will involve annual MRI screening, plus annual mammograms when she reaches the age of 40.
Manage risk factors: options she may consider are risk-reducing surgery (risk-reducing mastectomy and risk-reducing oophorectomy) and risk-reducing drugs such as tamoxifen.
What does “enhanced screening” involve?
- Enhanced screening starts at a younger age (40 not 50)
- Enhanced screening involves both MRI and mammography
- Breast screening is no longer needed after bilateral risk-reducing mastectomy.
- Enhanced screening is performed every year instead of every three years
Which chromosomes are BRACA 1 and 2 found on?
BRACA 1 - Chr 17 (long q arm)
BRACA 2 - Chr 13 (long q arm)
