Breasts Flashcards
How common is breast cancer?
Commonest cancer in UK
11,500 deaths per year
1 woman in 8 will develop disease
90% women survive 5 years/more
5 year survival 82%
What can increase your risk of breast cancer?
Main risk factors - female, getting older, significant family history (BRCA1 or 2 or other genes)
Also…
Radiotherapy treatment < 35 years (Hodgkin’s)
Li Fraumeni syndrome
Late first childbirth (> 35)
Alcohol consumption
HRT for > 5 years
Oral contraceptive use
Obesity (post menopausal)
Not breast fed
Nulliparous
Lack of exercise
Extrogenous oestrogens
Late onset menarche
What genes are associated with increased breast cancer risk?
BRCA1 - female breast, ovarian - 40-80% lifetime risk
BRCA2 - female and male breast, ovarian, prostate, pancreatic - 20-80% lifetime risk
Li Faumeni - Tp53 - breast, sarcoma, leukaemia, brain, adrenocortical, lung - 56-90% lifetime risk
Cowdens - PTEN - breast, thyroid, endometrial - 25-50% lifetime risk
Peutz-Jeghers - STK11 - breast, ovarian, cervical, uterine, testicular, colon, small bowel - 32-54% lifetime risk
Hereditary diffuse gastric cancer - CDH1 - early onset diffuse gastric cancer, lobular breast cancer - 60%
What some modifiable lifestyle risk factors are there for breast cancer?
Weight
Exercise
Alcohol
Extrogenous oestrogens
What some non-modifiable lifestyle risk factors are there for breast cancer?
Age of menarche and menopause
Early parity and breast feeding
Breast density
Heredity
Who is the NHS breast screening programme offered to?
Women aged 47-73
What is the 5 year survival rate improvement from the breast cancer screening programme?
Rises from 80-95%
What is the triple assessment/fast track for breast cancer diagnosis?
Clinical score P1-5 (1 normal, 5 clearly malignant) (from physical examination)
Imaging score U1-5 or M1-5 (USS/mammogram)
Biopsy score B1-5
Need concordance on MDT review
What is MRI scanning useful for?
Useful for assessment of implants
Contrast enhanced high sensitivity for invasive breast carcinoma
High risk screening - inherited/iatrogenic
Evaluating response of chemotherapy
What are the presenting S&S for breast cancer?
Painless lump
- Irregular
- Hard
- Fixed
Nipple discharge (can be bloody)
Nipple in-drawing
Skin tethering
Bone pain/pathological fractures, jaundice, SOB - metastases
Pain not common
What surgery for operable breast cancers are available?
Breast conservation + radiotherapy
Mastectomy
Surgery to axilla
When would you do breast conservation + radiotherapy?
Small tumour relative to breast size < 25% volume or 25-50%
No previous radiotherapy to breast
Pre-operative chemotherapy may allow breast conservation
Patient choice
Older patient who can have GA
What can affect the outcome of the breast conservation surgery?
Tumour size relative to breast
Position of tumour in breast
Re-excision or not
Radiotherapy fibrosis
When would you do a mastectomy?
Large tumour relative to breast size
More than one cancer in same breast if in different quadrants
May have immediate or delayed reconstruction
Patient choice
BRCA genes
Inflammatory cancer
What options are there for breast cancer treatment?
Surgery
Chemotherapy - for high risk disease
Endocrine therapy
Adjuvant therapy
What are the risk factors for high risk breast cancer?
Young age
ER -ve
HER-2+ve
High grade
Node positive
Ki67 positive
Tumour size
High oncotype DX recurrence score
Complex algorithms
What endocrine therapy is there for breast cancer?
Tamoxifen
Aromatase inhibitors
How does tamoxifen work?
Inhibits oestrogen receptor on breast cancer cells
Increases survival 15-25% in women with ER+ cancer
What are the complications of tamoxifen treatment?
Hot flushes, nausea, vaginal bleeding, rarely thromboses and endometrial cancer
How do aromatase inhibitors work?
Inhibit aromatase enzyme responsible for conversion of androgens to oestrogens in post-menopausal females
Slightly better anticancer efficacy than tamoxifen
What are the S/E of aromatase inhibitors?
Hot flushes, reduced bone density and joint pains, no DVT/endometrial cancer risk
What is the adjuvant therapy available for breast cancer treatment?
Transtuzumab - 1 year, 3 weekly alongside chemotherapy
Radiotherapy
When should adjuvant radiotherapy be used?
Always after wide local excision, local recurrence rate 35% without, 10-12% with
Increased use of mastectomy wound radiotherapy for high risk cancers
May be used for axilla in low risk cases with positive SLNB where low axilla treated as part of breast irradiation or full formal axillary RT as good alternative to axillary clearance with lower rate of lymphoedema
Palliative/neoadjuvant uses
What is the TNM staging for breast cancer?
T0 no evidence primary
T1 < 2cm
T2 2-5cm
T3 > 5cm
T4 extends to chest wall or skin or inflammatory
N0 no nodes
N1 mobile nodes
N2 fixed/matted nodes
N3 internal mammary nodes
M0 no metastases
M1 metastases
What do HER-2, Neu, and EGFR-2 mean for breast cancer prognosis?
Marker of poor prognosis
HER-2 +ve has worst prognosis
15% of all breast cancers
Penchant for the brain, 50% have metastatic
What are the advantages of primary reconstruction of the breast?
Increased options for skin preservation and therefore better objective cosmesis
Reduced psychological trauma from disfigurement
What are the disadvantages of primary reconstruction of the breast?
May delay chemotherapy or radiotherapy if complications
Radiotherapy may spoil result
What are the advantages of delated breast reconstruction?
Minimal risk of delays in other adjuvant therapies from complications
Irradiated tissue may be excised when reconstructing and healthy tissue used to recreate breast
What are the disadvantages of delated breast reconstruction?
Loss of intra-mammary fold
Limited skin preservation options
Period without a breast - may never have reconstruction or face long delays as no longer urgent
When is radiotherapy needed for breast cancer treatment?
Difficult to predict before surgery
T3 and T4 cancers usually attract a recommendation for post-operative chest wall radiotherapy
High grade PLUS nodal disease may be offered radiotherapy
Close margin posteriorly, careful review of imaging
What are the problems with radiotherapy?
High rate of capsule formation with implants
Skin viability risk
Wound healing
Loss of elasticity
Fat necrosis
Fibrosis
Implant extrusion
How can you recreate a breast?
Implant based
Autologous (use of patient’s own tissues)
Latissimus dorsi flap
How can you treat locally advanced breast cancer?
Attempt to shrink with either radiotherapy, chemotherapy or hormone therapy
Stage for metastases - USS liver, CXR, bone scan, bloods
Very high risk recurrence/metastases
Salvage surgery may be possible
Where does breast cancer metastasise to?
Bone 70%
Soft tissue 25%
Pleura 48%
Lung 67%
Liver 50%
Brain 20%
How can you treat metastatic breast cancer?
Hormonal treatments - slow acting, only suitable for hormone sensitive cancers, longer lasting control
Bisphosphonates and denosumab
Radiotherapy - bone, brain, soft tissues, axillary nodes, palliative surgery
Chemotherapy - CMF, doxorubicin, taxanes, herceptin, rapid action, high toxicity
Newer agents - multiple trials
Symptoms control and social/financial support
What is the population risk of breast cancer?
12% lifetime risk
What is a moderate lifetime risk of breast cancer?
17-30%
What is a high lifetime risk of breast cancer?
> 30%
- Definite gene carriers lifetime risk up to 80%
What strategies are there to manage moderate risk of breast cancer?
Screening - annual mammograms 40-50
Consider prophylactic SERM
Lifestyle advice
What strategies are there to manage high risk of breast cancer?
Enhanced screening
Risk reducing mastectomy
Risk reducing salpingo-oophorectomy
Lifestyle advice
Prophylactic SERM
What strategies are there to manage women with BRCA1 and 2 genes?
30-40 annual MRI
40-50 annual mammograms, annual MRI
50-60 annual mammograms, annual MRI if dense breasts
60-70 triennial mammograms, MRI if dense breasts
Risk reducing surgery - 90% breast cancer risk reduction, 99% ovarian cancer risk reduction BUT complex decision
How common are benign breast lumps?
10 to 1 benign to malignant ratio seen in breast clinic
Name 4 differentials of breast lump
Benign breast change
Fibroadenoma
Cyst
Sebaceous cyst
Papilloma
Fat necrosis/haematoma
Mastitis/abscess
Cancer
Sarcoma, lymphoma, metastases
Implant related (capsule, rupture, edge, crease)
What are the characteristics of a malignant lump?
Hard - lobular cancer/DICS may be diffuse thickening
Irregular margin - high grade cancer may have pushing edge and feel and look on imaging like a fibroadenoma
Skin tethering/fixation
Nodal swelling
Older age
How does age determine the management of a potentially malignant breast lump?
> 40 - mammography, USS and biopsy
25-40 - USS and biopsy
< 25 - free hand biopsy
In whom are fibroadenomas most common?
Predominantly puberty to 25-30
How do fibroadenomas present?
Smooth, mobile (breast mouse), non-tender
1-3cm
Giant variants and multiple juvenile FA
How do you treat fibroadenomas?
Leave unless increasing in size, atypical history, tender
In whom are breast cysts most common?
35-55
How do breast cysts present?
Size varies from 1mm to 20cm but on average symptomatic ones 1-2cm and often multiple
May feel cystic but if tense may be hard/irregular and difficult to tell from cancer
How do you treat breast cysts?
Aspirate symptomatic cysts, ceases at menopause unless on HRT
What is a benign breast change?
Fibrocystic change
In whom are benign breast changes most common?
Puberty to menopause but usually younger end of range
How do benign breast changes present?
Often tender/painful
Cyclical variation
Feels like rubbery nodularity
How do you treat benign breast changes?
Reassure
What implant problems can you get?
Capsule formation affects 5%
Rupture incidence relates to duration of implantation
Migration
Changes in body habitus and ptosis
What is breast sepsis?
Mastitis
What are the symptoms of breast sepsis?
May have associated pyrexia and flu-like symptoms
May be lactational or non-lactational
May progress to abscess formation
What can cause acute peripheral/lactation sepsis?
Age < 40
Staph aureus
Cause - pregnancy and lactational blocked duct, diabetes
How do you treat acute peripheral/lactation sepsis?
Serial aspiration, avoid drainage surgically as may cause lactational fistula
Flucloxacillin
Continue to feed
What can cause acute peri-areolar sepsis?
Duct ectasia and periductal mastitis, smoking
Age < 50
Staph aureus, step, bacteroides, enterococci
How can you treat acute peri-areolar sepsis?
Serial aspiration, surgical drainage, total duct excision, fistulectomy
Co-amoxiclav
What are the indications for surgery of an abscess?
Failure of repeated aspiration and antibiotics
Large multi-located collection
Overlying skin necrosis
Patient intolerance of aspiration
Unable to aspirate
How is chronic periductal mastitis treated?
Total duct excision
Use either radial or peri-areolar incision to resect all sub-areolar ducts
What are the risks of total duct excision?
Nipple numbness, nipple necrosis, recurrent sepsis
How does breast fistulation occur?
Recurrent bouts of sepsis/abscess formation
Progressive scarring
Fistulectomy and total duct excision
What is an important differential of mastitis?
Inflammatory breast cancer
How does inflammatory breast cancer present?
Breast red, oedematous, swollen, axillary lymphadenopathy, mass or thickening
If fails to settle with 1-2 weeks of antibiotics always refer for imaging and biopsy
What does physiological nipple discharge look like?
Non-spontaneous
Bilateral
Yellow/creamy
Reassure
What does hormonal nipple discharge look like?
Milky, multiduct
Large volume
Rarely bloody in epithelial hyperplasia of pregnancy
What investigations should you do for hormonal nipple discharge?
Pregnancy test
Serum hormone profile
If bloody, monitor
What does duct ectasia nipple discharge look like?
Green-ish brown
Multiduct
How do you treat duct ectasia?
Reassure or total duct excision if volume excessive
What does papilloma nipple discharge look like?
Clear or bloody
Uniduct
What investigations should you do with papilloma nipple discharge?
Imaging and proceed to microdochectomy
Small mass within dilated ductal system
Mass usually biopsied under USS
What treatment is there for papillomas?
Usually benign but generally removed
Multiple associated with increased breast cancer risk
What does DCIS nipple discharge look like?
Clear or bloody
Uniduct
What investigations should you do in DCIS?
Imaging and proceed to microdochectomy
What should you suspect with blood stained nipple discharge and what should you do?
Majority due to duct ectasia then papillomas then DCIS
Rarely bilateral in pregnancy due to epithelial hyperplasia
All require imaging
Cytology of nipple aspirates unhelpful
If imaging unhelpful, microdochectomy required
What is the cause of pre-menopausal cyclical breast pain?
Hormonal
What is the causes of pre-menopausal non-cyclical breast pain?
MSK, trauma, tender lump
What is the cause of post-menopausal cyclical breast pain?
On HRT - hormonal
What is the cause of post-menopausal non-cyclical breast pain?
MSK, trauma, tender lump
What is cyclical breast pain?
Breast swelling/tenderness
Usually in week prior to menstruation
Usually mild, self-limiting and last for a few cycles only
Settles after menses commences
What is the aetiology of cyclical breast pain?
poorly understood, no consistent histological correlates, no endocrine correlates
How can you manage cyclical breast pain?
Breast pain diary
Reassurance - NSAIDs, low fat diet and avoid methylxanthines
Ensure has correctly fitting bra
Usually settles within a few months
No benefit to evening primrose oil derivates, vitamins, diuretics
How common is breast cancer?
Most common cancer in the UK
Second biggest cause of cancer deaths in women after lung
Survival higher than that for cervical cancer and much higher than that of other major cancers in women - cervical, colorectal, ovarian, lung
96% survive breast cancer for at least one year after diagnosis
85% survive for 5 years or more
Earlier detection and improved treatment means survival rates have risen
Survival doubled in last 40 years
Risk increases with age
What improved chances of survival from breast cancer?
Changes in surgical management
New chemotherapeutic agents
Tamoxifen
NHS breast screening programme
What can increase you risk of getting breast cancer?
Radiotherapy treatment before 35
BRCA 1 and 2 gene carriers
HRT
Li Fraumeni syndrome
Moderate-high alcohol consumption
Not breast feeding
Nuliparous
What are the 4 stages of breast screening?
Invitation
Screening mammography
Assessment - average about 5% recalled, USS, biopsy
Results, surgery, further treatment
Why might women be recalled for breast cancer screening?
Mass - may be well defined, poorly defined, spiculate
Microcalcification
Parenchymal deformity/distortion
Asymmetric density
Enlarged axillary lymph nodes
Clinical recall
Technical recall
How does imaging for breast lumps change based on age?
> 35 - mammogram and targeted USS
< 35 - targeted USS then mammogram if suspicious - difficult to see cancers in under 40s a breasts denser due to more ducts
What anatomical structures within the breast need to be differentiated between on mammogram and how is this done?
Glandular tissue (more dense)
Fatty breast tissue (less dense)
Where do breast cancers tend to form in the breast?
Around lobules
What is lymphatic drainage from the breast like?
Mostly to axillary lymph nodes
25% internal mammary lymph nodes
Infraclavicular lymph nodes
Supraclavicular lymph nodes
What positions are required for a mammogram?
Cranio-caudal (front) - entire body of gland and retromammary fat, nipple centre
Medio-lateral oblique (side) - chest wall, axillary tail
What is a tomogram?
Mammogram but like CT - can scroll through images
What are the level 1 lymph nodes in breast?
Pectoral axillary lymph nodes (anterior)
Subscapular axillary lymph nodes (posterior)
Humeral axillary lymph nodes (lateral)
What are the level 2 lymph nodes in breast?
Central axillary
Apical axillary
Interpectoral
What are the level 3 lymph nodes in breast?
Apical axillary
What are the two different types of axilla surgery? What is the purpose of them?
Full axillary clearance
- If glands clinically involved
- High complication rate
Limited axillary clearance
- If clinically normal
- No effect on mortality
- Removes targeted hot nodes or samples nodes
What are the different types of breast cancer and how can you tell the difference?
Ductal
- Hard knot in breast
- Easier to see and diagnose
- More common
Lobular
- More diffuse and spreading
- More likely to be missed
- Subtle thickening
