ERS Case 3: Breast Cancer Flashcards
Anatomy, Lymphatic drainage of breast and its relationship with adjacent structures
See lecture
Areola: - contain sebaceous glands —> enlarge during pregnancy —> secrete oily substance —> protective lubricant for areola and nipple
Physiological changes of breast in relation to menstrual cycle
Estrogen —> growth of milk ducts
Progesterone —> formation of milk glands
Cyclical change felt —> swelling, pain
Breast texture may change during menstruation —> lumpy
Signs and symptoms of breast lump, formulate DDx, explain underlying pathology-physiological processes
See lecture
Signs and symptoms
- Skin changes
- Inflammation
- Change in size / shape
- Nipple retraction
- Bloody discharge
DDx
Inflammatory
1. Acute mastitis and Breast abscess —> Tender, Fluid collection
2. Fat necrosis —> Firm + Fixed
Benign
- Fibroadenoma —> Firm + Mobile
- Fibrocystic change —> Compressible, come and go
- Galactocele —> Milk retention cyst
Carcinoma-in-situ
- Ductal
- Lobular
Malignant
- Invasive carcinoma of no special type / Ductal carcinoma
- Invasive lobular / Tubular / Mucinous
Integrate findings of clinical, radiological, pathological assessment with view to diagnosis and management
Imaging:
- Mammography
- Ultrasound
- MRI (little role) —> only when carcinoma undetectable by mammography
Definitive diagnosis
- Core-cut biopsy
- FNAC
Treatment modalities available for breast cancer and possible SE
Factors to consider:
- Size
- Histologic type and grade
- Lympho-vascular permeation (Skin infiltration —> Surgery CI; Metastatic disease —> Chemotherapy)
- LN metastasis
- Proliferation rate
- Clearance from resection margins
- Steroid hormone receptor status
- HER2 oncogene expression
- Patient factors
Treatment:
- Local excision
- Partial / Total mastectomy
- Radiotherapy + Chemotherapy
- Estrogen full antagonists: Fulvestrant
- SERM
- CDK4/6 inhibitor
- Aromatase inhibitor
- Trastuzumab
Ask a good family history to assess possibility of hereditary breast cancer
See lecture
BRCA1 and BRCA2
Families with >=3 individuals with breast / ovarian cancer
—> highest risk of carrying mutations in either genes
Testing done on affected individuals first
—> identify a particular mutation
—> Test whether unaffected family members have inherited this mutation
Recognise risks associated with hereditary breast cancer and explain available management options of patients at risk
- Screening
- Mammography - Chemoprevention / Endocrine prevention
- Tamoxifen (for ER +ve), Raloxifene
- Aromatase inhibitor (Anastrozole) - Prophylactic mastectomy
Epidemiology and Risk factors for breast cancer
Epidemiology
- Commonest cancer among female in HK
- 3rd leading cancer deaths among female (after Lung, Colorectal)
- median age: 57
Risk factors
- Genetic disposition (BRCA1, BRCA2)
- Hormonal imbalance (long reproductive life, nulliparity, late child, functioning ovarian tumours)
- Environmental influence (obesity)
Role and limitations of mammographic screening and genetic testing
Mammographic screening:
- Screening / Diagnostic
- size + extent
- for non-palpable lesions
- characterise palpable lesions
- check for bilaterality
- multi-focal
- presence of DCIS
- micro-calcifications
- limitations: False-positive, Overdiagnosis (DCIS may never turn malignant), Some carcinoma can still be undetected
Genetic testing limitations:
1. BRCA gene very large, absence of mutational hot-spots
—> difficulties in genetic testing
2. Negative result cannot exclude possibility of other genes involved
3. Ethical issues
- health insurance
- disclosure of information
- potential benefit of knowing not inherited must weigh against possible harm of finding oneself at risk
Medical and Psychosocial needs of cancer patient
Treatment:
- significant short / long term SE
—> Physical / Cognitive / Emotional / Social / Vocational loss / Psychosocial stress
Physical, mental, social problems (financial burden, disability)
