Invasive Breast Cancer Flashcards by Kirsty Sutherland

Invasive carcinoma of the breast can be classified into…

Invasive ductal carcinoma 75-85%
Invasive lobular carcinoma 10%
Other subtypes 5% such as medullary carcinoma or colloid carcinoma

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It is now known that almost all breast carcinomas arise in…

The terminal duct lobular unit (the classification remains in use due to the different behaviour of the two main subtypes )

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What other invasive carcinomas are there (other than ductal and lobular)?

Tubular
Mucinous
Papillary
Medullary

All shown distinct patterns of growth

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Who are ILCs most common in?

Older women

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What makes ILCs difficult to detect?

Characterised by a diffuse (stromal) pattern of spread

By time of diagnosis, tumour large

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What risk factors are there for breast cancer?

Female
Age - risk doubles every 10 years until menopause
Mutations to certain genes - the tumour suppressor genes BRCA1 and BRCA2
FH in a first degree relative
Previous benign disease
Obesity
Alcohol
More common in developed countries
Degree of exposure to unopposed oestrogen - early menarche, late menopause, nulliparous women, first pregnancy after 30, oral contraceptives or HRT
Breastfeeding decreases risk
Previous breast cancer (10x)
Radiation exposure, especially in childhood or adolescence

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How much is the risk increased if a FH of breast cancer in a first degree relative?

1.5-2 x increased if one relative

4-6 x if two affected relatives

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What clinical features are associated with breast cancer?

Breast lump 
Asymmetry
Swelling - all or part of breast
Abnormal nipple discharge 
Nipple retraction 
Skin changes - dimpling, peau d’orange or Paget’s- like changes
Mastalgia (constant)
Palpable lump in axilla

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What potential differentials are there?

Benign tumours
Cysts
Infective causes - abscess

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What is the gold standard for diagnosis of breast lumps?

The triple assessment

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Apart from symptomatic presentation, breast cancers are detected by screening. What is the criteria for screening?

Women
Aged 47-73
Registered with GP
Mammogram (X-ray test) every 3 years

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What is the single most important prognostic factor in breast cancer?

Nodal status

However, size, grade, receptor status also influences prognosis

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What staging system is used?

The Nottingham Prognostic Index NPI

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How is the Nottingham Prognostic Index calculated?

(Size x 0.2) + nodal status + grade

Size is diameter of lesion in cm
Nodal status is number of axillary lymph nodes involved: 0=1, 1-4=2, >4=3

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What is the cancer’s grade based on?

The Bloom-Richardson classification

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What is the NPI score predicting?

5 year survival percentage

A variety of factors outside the NPI are now used in prognostics such as…

Vascular invasion

Receptor status

What receptor statuses are there?

Oestrogen receptor ER
Progesterone receptor PR
Human epidermal growth factor receptor HER2

Describe the lumps in breast cancer

Craggy surface
Firm consistency
Fixed to different layers of tissue
Single mass

(Not as mobile or smooth as benign counterparts)

Where is the most common location for the lump?

Upper outer quadrant - 50% occur hear

What type of nipple discharge may indicate cancer?

Bloody or serous (not milky)

Spontaneous and unilateral

Is breast cancer common?

Most common non skin malignancy in women

Accounts for 20% of all malignancies in women

1 in…. will develop breast cancer at some time in their life

What is the average age at diagnosis?

Male breast cancer accounts for what percentage of all cases of breast cancer?

Men have an increased risk if...

Klinefelter’s syndrome Male to female transsexuals Men treated with oestrogen for prostate cancer

Hereditary breast cancer accounts for what percentage of breast cancer?

10%

What is BRCA1 and BRCA2?

Breast cancer associated gene | Both are tumour suppressor genes - their proteins repair damaged DNA

What is the lifetime breast cancer risk if patient carries BRCA1?

60-85% risk | Median age at diagnosis is approximately 20 years earlier than sporadic cases

By the time the cancer is palpable, how many will have axillary lymph node metastases?

More than half

What does peau d’orange mean?

When cancer cells block the lymphatic drainage, fluid can accumulate in the breast = oedema. The fluid can pull down on the hair follicles, leading to appearance like an orange skin

How does breast cancer spread?

Lymph nodes via lymphatic - usually ipsilateral axilla | Distant metastases via blood vessels - bones, lungs, liver, brain

Describe medullary ductal carcinoma

Rare - 3 to 5% of breast cancers Often triple neg Less likely to involve lymph nodes, more responsive to treatment May have better prognosis than more common types of invasive ductal carcinomas

Describe stage 1 breast cancer

The cancer is small and only in breast tissue or it might be found in lymph nodes close to breast 1A tumour 2cm or smaller and not spread outside breast 1B small breast cancer cells found in nodes close to breast - no tumour found in breast or 2cm or smaller

Describe stage 2 breast cancer

2A tumour larger than 2cm but not larger than 5cm and no cancer in nodes or there is no tumour or tumour less than 2cm and cancer cells in 1 to 3 nodes in armpit of near breast bone (ipsilateral) 2B between 2-5cm tumour spread to 1-3 nodes in armpit or breast bone (ipsilateral) or larger than 5 cm and no spread to nodes

Describe stage 3

Means the cancer has spread from breast to lymph nodes close to breast or to the skin of the breast or to the chest wall Also called locally advanced breast cancer

Describe stage 4

Means cancer has spread to other parts of body Also called advanced cancer, secondary breast cancer or metastatic breast cancer In stage 4: tumour can be any size, lymph nodes may or may not contain cancer cells, the cancer has spread to other parts of body e.g bones, brain, lungs, liver Any T, any N and M1

When should patients be referred using cancer pathway referral (for appointment within 2 w)?

Aged 30 and over and have an unexplained breast lump with or without pain Or aged 50 and over with any of following symptoms in one nipple: discharge, retraction, other changes of concern Consider referral if skin changes that suggest breast cancer or aged 30 and over with unexplained lump in axilla Consider non urgent referral in people under 30 with unexplained breast lump with or without pain