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MBBS IV - Junior Clerkship WCS > JC76 (Surgery) - Breast cancer > Flashcards

JC76 (Surgery) - Breast cancer Flashcards

1
Q

Modalities of breast cancer spread

A

Direct spread
•Chest wall
•Skin and subcutaneous tissues

Lymphatic spread
oLateral tumours in outer quadrant and centrally located lesions  Axillary LN
oUpper and lower inner quadrant  Internal mammary LN
oSupraclavicular LN

Hematogenous spread
•Distant metastasis to lungs, liver, bone…etc

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2
Q

Breast cancer risk factors

  • Non-modifiable RF
  • Relevant PMH
A

Non-modifiable:

  • Advanced age
  • Female gender (M : F = 1 : 2000)
  • White ethnicity
  • Inherited BRCA1 and BRCA2 mutation
  • Early menarche <12 and Late menopause >55
Medical history"
High estrogen exposure 
- Nulliparity, no breast feeding 
- Late age of first pregnancy >30 
- Estrogen-secreting ovarian tumor 
- Oral contraceptives and HRT 
- Obesity in post-menopausal

Breast diseases:

  • History of breast cancer
  • History of benign breast disease: ADH, ALH
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3
Q

Breast cancer risk factors

  • Drug hx
  • Family hx
  • Social hx
A

Drug history
• Exposure to therapeutic ionizing radiation

Family history
• History of breast cancer

• Li-Fraumeni syndrome
Germline abnormalities of TP53 gene
Tendency to develop malignancy including breast cancer, sarcoma, brain tumours,adrenocortical cancer and leukemia

• Hereditary diffuse gastric cancer
Germline mutation of CDH1 gene
Associated with development of lobular breast cancer

Social history
• Smoking
• Alcoholism

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4
Q

Ddx breast cancer

A

Benign breast lesions

Paget disease of the nipple

Phyllodes tumours

Breast sarcoma

Lymphoma - mainly non-Hodgkin lymphoma B-cell

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5
Q

Paget disease of nipple

  • Characteristic skin features
  • Disease associated
  • Clinical presentation
  • Workup
A

characterized by eczematoid changes and ulcerated lesions ofnipple-areolar complex

80% associated with HER2 +ve breast cancer

Presents with pain, burning, pruritus, palpable breast mass, bloody nipple discharge or nippleinversion

Workup:
Mammography is mandatory to look for associated mass
USG with biopsy of any mass

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6
Q

Describe structure of breast

A

Breast comprises 3 major structures including skin, subcutaneous tissue and breast tissue

Breast tissue is composed of epithelial and stromal elements
o Epithelial components include ducts that connect structural and functional units of the breast (lobules) to the nipple
o Stromal components include adipose tissues and fibrous connective tissues

Lobules are separated by suspensory ligament of breast (Cooper’s ligament)

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7
Q

Arterial supply of breast

Venous drainage of breast

A

Arterial:
 Internal thoracic (internal mammary) artery (from subclavian artery)
 Lateral thoracic (external mammary) artery (from axillary artery)
 Posterior intercostal artery
 Thoracoacromial artery
 Axillary artery

Venous 
 Internal thoracic vein
 Lateral thoracic vein
 Posterior intercostal vein
 Axillary vein
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8
Q

Lymphatic drainage of breast

A

 Axillary lymph node (75%)

 Internal mammary lymph node (20%)

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9
Q

Define the axillary lymph node levels and location

A

Level I - Inferior and lateral to pectoralis minor muscle - Anterior, posterior and lateral axillary nodes

Level II - Posterior to pectoralis minor muscle and below the axillary vein - Central axillary nodes, Interpectoral nodes

Level III - Medial to pectoralis minor extending up to apex against chest wall (Infraclavicular) - Apical axillary nodes/ Subclavian

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10
Q

List the motor nerves that supply the muscles under the breast

A

Motor nerves
o Thoracodorsal nerve > Supply latissimus dorsi muscle
o Long thoracic nerve > Supply serratus anterior muscle
o Medial and lateral pectoral nerve > Supply pectoralis major and minor muscles

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11
Q

List Non-invasive and Invasive histological types of breast cancer

List histological subtypes with good prognosis, and poor prognosis

A

Non-invasive:

  • Ductal carcinoma-in-situ (DCIS)
  • Lobular carcinoma- in-situ (LCIS)

Invasive

  • Invasive ductal carcinoma (IDC)
  • Invasive lobular carcinoma (ILC)
Good prognosis
• Tubular carcinoma
• Medullary carcinoma
• Mucinous (colloid) carcinoma
• Papillary carcinoma
poor prognosis
• Mixed ductal/lobular carcinoma
• Metaplastic carcinoma
• Micropapillary carcinoma
• Inflammatory breast cancer
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12
Q

DCIS

  • Presentation
  • Tumor characteristics
  • Treatment options
A

Presentation: asymptomatic or painless mass, incidental finding on mammography with microcalcifications

Tumor:

  • From lobules and terminal ducts of breast with ductal predominance, confined to basement membrane
  • E-cadherin + ve ***

Treatment:
Surgical:
- Partial mastectomy for unicentric lesion
- Total mastectomy for multicentric lesion

Axillary LN: DCIS is non-invasive!

  • ALND not indicated for pure DCIS
  • Sentinel LN biopsy for high-grade histology

Adjuvant radiotherapy for partial mastectomy
Adjuvant hormone therapy for ER+ve DCIS

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13
Q

LCIS

  • Presentation
  • Tumor characteristics
  • Treatment options
A

Presentation: Asymptomatic/ incidental finding by mammography

Tumor characteristics:

  • No microcalcifications (easily missed), from lobules and terminal ducts with lobule predominance
  • Non-invasive except for Pleomorphic LCIS
  • E-cadherin -VE

Treatment options: No considered cancer or pre-invasive lesion

  • Lifelong surveillance
  • Chemoprevention with Tamoxifen, Raloxifene, Aromatase inhibitor
  • Bilateral total mastectomy for strong family history
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14
Q

2 most common types of invasive breast cancer

A

Invasive ductal carcinoma (IDC)
 Accounts for 70 – 80% of invasive breast cancers (most common)

Invasive lobular carcinoma (ILC)
 Accounts for 5 - 10% of invasive breast cancers (second most common)

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15
Q

IDC vs ILC

Histological differences
- Metastasis tendencies

A

Histological differences

  • IDC: Cords and nests of cells with varying amount of gland formation
  • ILC: Smalls cells that infiltrate mammary stroma and adipose tissue in a single file pattern

Metastasis tendencies

  • IDC: A/w DCIS, Earlier than invasive lobular carcinoma (ILC)
  • ILC: Later than invasive ductal carcinoma (IDC), Metastasize to unusual location including meninges, gastrointestinal tract and peritoneum
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16
Q

Diagnostic criteria of inflammatory breast cancer

A

o Rapid onset of breast erythema, edema, peau d’ orange or warm breast with or without an underlying palpable breast mass

o Erythema occupying at least 1/3 of the breast

o Duration of history no more than 6 months

o Pathological confirmation of invasive carcinoma

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17
Q

Atypical ductal hyperplasia vs Atypical lobular hyperplasia (ADH/ ALH)

Cell origins
Treatment options

A

Proliferative lesions with cellular atypia that arises from breast ducts (ADH) and lobules (ALH) respectively

Treatment: Both with risk of malignant transformation

  • Core Biopsy for both
  • Excisional biopsy if core biopsy finds atypical hyperplasia
  • Treat like DCIS/ IDC or LCIS/ ILC if malignant
  • Or lifelong surveillance with chemoprevention (Tamoxifen) if not malignant
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18
Q

List 3 major molecular subtypes of breast cancer

Prevalence of each type?

A

Depends on ER, PR, HER2 expressions:

Luminal A and B - 70% of breast cancer

  • Luminal A: ER, PR +ve
  • Luminal B: Triple Positive

HER2 - 15% of breast cancer

Basal-like/ Triple negative: 15% of breast cancer

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19
Q

Luminal A/B, HER2, Basal-like breast cancer

Treatment choice for each

A

Luminal A/B: Hormone treatment

HER2: Anthracycline-based chemotherapy or Herceptin

Basal-like/ Triple negative: Platinum/ PARP inhibitors responsive

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20
Q

Surgical description of breast cancer mass

A
  • Site: 50% of CA breast occurs in upper outer quadrant including the axillary tail
  • Color: Discoloration (smooth and reddening) if tumour is close to overlying skin, Peau d’orange
  • Shape: Spiculated
  • Edge: Irregular or nodular
  • Surface: Dimpling, tethering, erythema
  • Consistency: Solid and stony hard
  • Tenderness: Usually non-tender
  • Mobility: Fixation of lump (Immovable)
  • Lymph nodes: May be palpable and enlarged axillary LN
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21
Q

5D for surgical description of nipple changes

A
  • Deviation/ Displacement
  • Discoloration
  • Dermatitis (Eczema in Paget’s disease of nipple)
  • Depression (Retraction/ Inversion)
  • Discharge
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22
Q

Possible skin changes over breast mass

A
  • Lump/ nodules
  • Ulceration
  • Discoloration: Erythema/ Hematoma/ Ecchymosis (in fat necrosis)
  • Puckering/ Dimpling: Underlying cancer
  • Peau d’ orange
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23
Q

How to elicit skin fixation, skin tethering or muscle fixation of breast mass on P/E

A

o Skin fixation: Try to pick up the skin above the lump

o Skin tethering: Lump behaves as if tied to skin by a piece of string/ Remains separate from skin and can be moved independently within certain limits

o Muscle fixation: Move the lump in 2 perpendicular direction, then contract the pectoralis muscle by asking patient to press against her hip, move the lump again and observe for limited movement

24
Q

Modalities of radiological imaging for breast mass

A

Mammogram (1st-line)

Ultrasound (2nd-line, or for younger patients with dense breasts)

MRI breast (3rd-line)

PET-CT (metastasis)

Ductoscopy

25
Q

Mammogram

  • 2 standard views
  • Descriptors of mammogram (steps to describe)
  • Limitations
A

craniocaudal (CC) and mediolateral oblique (MLO) views

  • CC for inferior, medial and upper portion
  • MLO for axillary tail, axillar lymph nodes and upper outer quadrant

Descriptors:

  1. Symmetry in shape and density
  2. Architecture distortions
  3. Presence of lymph nodes
  4. Presence of breast mass, mass density: Spiculated (stellate) mass or irregular shape for malignancy
  5. Any Calcification

Limitations:

  • NOT preferred in young women (age < 40) due to dense breast (low sensitivity)
  • Cannot make definitive diagnosis
  • Obscuration of borders and extent of primary tumour by dense breast tissues
26
Q

Mammogram

Features of benign vs malignant cancer

A 
Benign: 
 Rim-like calcification
 Large coarse calcifications
 Smooth round or oval calcifications
 Vascular and skin calcification

Malignant:
Pleomorphic, linear or clustered MICROCALCIFICATIONS

27
Q

Ultrasound for breast mass

  • Function
A

Determines whether the mass is solid or cystic

Characterize solid mass as benign or malignant

Identify presence of a prominent vascular supply

Image-guided procedures including FNAC or core biopsy

28
Q

Ultrasound of breast tissue

Features suggesting benign lesion vs malignant lesion

  • Shape
  • Margin
  • Echogenicity
  • Calcification
  • Vascularity
A
29
Q

MRI breast

Indications

Malignant breast cancer features

A

High risk of breast cancer
Breast implants or augmentations
Suspicious lesions on mammogram or ultrasound
Clinically occult tumor with positive LN
Neoadjuvant therapy

MRI abnormalities (malignant features)
• Spiculated or irregular margins
• Rim-like enhancement
• Heterogenous internal enhancement
• Enhancing internal septa
• More rapid uptake of contrast
30
Q

Modalities of imaging for breast cancer metastasis

A 
 CXR for lung metastasis
 USG abdomen for liver metastasis
 Bone scan for bone metastasis
 CT abdomen for liver, adrenal and ovarian metastasis
 CT or MRI brain for brain metastasis
31
Q

Criteria and test for breast cancer HER2 expression

A

o Immunohistochemistry (IHC 3+) defined as uniform intense membrane staining of ≥ 10% of tumour cells by

(OR)

o Presence of HER2 gene amplification by fluorescence-in-situ-hybridization (FISH) defined as:

  • ratio of HER2/CEP17 ratio ≥ 2.0
  • (OR) HER2/ CEP17 ratio < 2.0 with average HER2 copy number ≥ 6 signals/ cell
32
Q

Prognosis of HER2+ breast cancer

A
  • Higher risk of recurrence
  • Higher mortality
  • Relative resistance of hormonal treatment
  • Less benefit from some forms of chemotherapy
33
Q

Sampling methods for palpable and non-palpable breast cancer

A

Methods of biopsy for palpable lumps
• Fine needle aspiration (FNA)
• Core biopsy (Trucut biopsy)/ Vacuum-assisted biopsy
• Excisional and incisional biopsy

Methods of biopsy required for NON-palpable lumps = Image-guided biopsy required with Hook-wire guided excision
o Stereotactic (X-ray guidance)
o Ultrasound (USG)
o MRI-guided
34
Q

Compare FNAC and core biopsy for breast cancer

  • Advantages and disadvantages
A
35
Q

IHC score for protein overexpression in breast cancer

Scoring and histological description

A
36
Q

Outline flowchart for HER2 FISH testing for breast cancer

  • Criteria for ISH positive or negative
A
37
Q

Modalities of treatment for breast cancer

A

Local disease:
o Surgery
o Radiotherapy

Systemic/ metastatic disease:
o Chemotherapy
o Hormonal therapy
o Targeted therapy

38
Q

Treatment options for DCIS and LCIS breast cancer

A 
DCIS: Van Nuys Prognostic Index
• Low score = Wide local excision
• Intermediate score = Wide local excision + Radiotherapy
• High score = Mastectomy
Lymph node management
• Sentinel lymph node biopsy (SLNB)
• Axillary lymph node dissection (ALND)
Systemic: 
Adjuvant radiotherapy or hormonal therapy

LCIS:
Bilateral simple mastectomy with reconstruction
Tamoxifen prophylaxis

39
Q

Treatment for stage 1-3 breast cancer

A

Surgical approach
• BCT (OR)
• Mastectomy with reconstruction

Lymph node management
• Sentinel lymph node biopsy (SLNB) (OR)
• Axillary lymph node dissection (ALND)

± Adjuvant chemotherapy
± Adjuvant radiotherapy
± Adjuvant hormonal therapy
± Adjuvant targeted therapy

40
Q

Treatment for stage 4 breast cancer

A

Palliative chemo, radio, hormonal or targeted therapy

41
Q

Modalities of breast cancer screening

Which modalities are outdated/ poor detection rate

A

Self- breast examination - not recommended

Clinical breast examination - no improvement on survival

Mammogram - 20% reduction in mortality, especially pt. over 50 years old

42
Q

Harms of mammogram screening

A

Over diagnosis (false positive) and over treatemtn
False reassurance (false negative)
Radiation exposure
Pain and discomfort during scan

43
Q

Indication for breast cancer screening in HK

A

Age: 44-69

Risk factors:

  • Family history of breast cancer (1st degree cousin)
  • Previous benign breast disease
  • Nulliparity
  • Late age of one live birth
  • Early menarche and late menopause
  • High BMI and low physical activity

Mammogram screening every 2 years

44
Q

Triple assessment of breast cancer

- Which 3 parts

A

Clinical exam: history and examination

Radiological exam

Pathological exam

45
Q

Surgical mastectomy

  • All types
A

Simple mastectomy (Linear scar)

Radical masectomy

Modified radical masectomy

Skin sparing mastectomy with reconstruction

Nipple sparing mastectomy with reconstruction (low risk or prophylaxis)

46
Q

Surgical lumpectomy

- Margin cut-off

A

2mm for in-situ cancer

No cancer at inked margin for invasive cancer

Histological margin determined intra-operatively, aim for 5-10mm margins

47
Q

Oncoplastic breast surgery

  • Different surgeries are different volume displacement and replacement
A

Level I: <20% breast tissue removed

  • Local tissue rearrangement
  • Crescent or Doughnut mastopexy

Level II: 20-50% breast tissue removed

  • Circumvertical mastopexy
  • Reduction mammaplasty

Volume replacement
> 50% breast tissue removed
- Implant-based reconstruction
- Local/ regional flap reconstruction

48
Q

Axillary dissection for breast cancer

  • Indications
  • Levels of LN removed
  • Preserved structures
  • Complications
A

Indications:
• Clinically +ve nodes
• Sentinel lymph node +ve nodes
• Inflammatory breast cancer (T4d)

Level I and II axillary LN removed (≥ 10 lymph nodes)

Preserved:

  • Long thoracic nerve - serratus anterior - winging scapula
  • Thoracodorsal nerve - latissimus dorsi - shoulder extension
  • Intercostobrachial nerve - axilla parasthesia

Complications:

  • Seroma
  • Lymphedema
  • Nerve injury
  • General surgical complications (infection, pain…etc)
  • Shoulder dysfunction/ Restricted shoulder mobility
49
Q

Sentinel LN biopsy

  • Identification methods
  • Indications
A

Identify by:

  • Blue dye/ Patent blue
  • Radioisotope
  • Supramagnetic iron oxide
  • Indocyanine green

Indications:

  • Early breast cancer with clinical -ve nodes
  • DCIS with planned mastectomy
  • DCIS with suspicious features (> 5 cm or present with a palpable mass)
50
Q

Breast reconstruction choices

  • types of surgery
  • Types of flaps
A

Autologous tissue reconstruction
o TRAM flap: Transverse rectus abdominal muscle (weaken abdominal muscle)
o LD flap: Latissimus dorsi muscle
o DIEP flap: Deep inferior epigastric perforator (preserve abdominal muscle)

Prosthetic devices
o Devices include saline implants, silicone implants or tissue expanders

51
Q

Targeted therapy for breast therapy

- Options

A

Trastuzumab (Herceptin)
• IV infusion monthly for 12 months

Lapatinib

Bisphosphonates/ Denosumab (RANKL monoclonal antibody)
• Osteoclast inhibitors
• Indicated for palliation in patients with bone metastasis

52
Q

Hormonal therapy options for breast cancer

A

Selective estrogen receptor modulators (SERMs) - Indicated in all ER or PR +ve patients
Example: Tamoxifen

Aromatase inhibitors (AI)
Non-steroidal: 
- Letrozole
- Anastrozole
Steroidal:
- Exemestane
53
Q

Selective estrogen receptor modulators (SERMs)

MoA
S/E

A

Mechanism of action
• Antagonist of ER receptor at breast
• Inhibits growth of breast cancer cells by competitive antagonism of ER

S/E: 
Thromboembolic disease*
• Stroke
• Deep vein thrombosis (DVT)
• Pulmonary embolism

Endometrial cancer*
• Partial agonist of ER receptor at uterus

Menopausal symptoms
• Hot flushes
• Tachycardia and sweating

Vaginal discharge, Menstrual irregularities, Sexual dysfunction

54
Q

Aromatase inhibitor

MoA
S/E

A

Mechanism of action
• Inhibits peripheral conversion of testosterone and androstenedione to estradiol

Appropriate for post-menopausal women ONLY

S/E
 Osteoporosis*
 Associated musculoskeletal syndrome
• Bone pain
• Arthralgia
• Joint stiffness
55
Q

Radiotherapy for breast cancer

  • Types
  • Indications
A

Whole breast radiation therapy (WBRT):
Indications
• ALL patients undergoing breast conservation surgery (BCT)
• Post-mastectomy patients with high-risk features

Regional nodal irradiation
Indications
• Node +ve disease with ≥ 4 involved lymph node
• Node -ve T2 tumour with features such as high-grade tumour, high risk receptor biology or lymphovascular invasion
• T3 or T4 primary tumour

56
Q

Complications of breast radiotherapy

A

Whole breast radiation therapy (WBRT)

Short-term complications
o Breast skin fibrosis, radiation dermatitis
o Arm edema
Long-term complications
o Rib fracture
o Cardiotoxicity
o Pulmonary fibrosis or pneumonitis
o Secondary RT-induced malignancy

Regional nodal irradiation
Complications
• Lymphedema
• Axillary fibrosis

MBBS IV - Junior Clerkship WCS (131 decks)

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