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Integration for clinical application > Lecture 13- Breast cancer > Flashcards

Lecture 13- Breast cancer Flashcards

1
Q

What does normal breast tissue look like histologically?

A
  • Composed of ducts and acinar arranged into lobules
  • Ductal cells are cuboidal surrounded by myoepithelial cells allowing contraction of the duct
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2
Q

Prepubertal breast

A

– few lobules (before puberty male and female breasts are identical)

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3
Q

Menarche ​

A

– increase in number of lobules, increased volume of interlobular stroma

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4
Q

Menstrual cycle

A

– follicular phase lobules quiescent, after ovulation cell proliferation and stromal oedema, with menstruation see decrease in size of lobules

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5
Q

Pregnancy

A

– increase in size and number of lobules, decrease in stroma, secretory changes

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6
Q

breast during pregnancy:

A
  • Less fibromuscular stroma
  • Luminal cells become bigger and paler due to containment of colostrum (large lipid filled cells)
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7
Q

Cessation of lactation-

A

atrophy of lobules but not to former level

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8
Q
  • Increasing age
A
  • terminal duct lobular units (TDLUs) decrease in number and size, interlobular stroma replaced by adipose tissue (mammograms easier to interpret)
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9
Q

How can breast conditions present?

A
  • Pain
  • Palpable mass
  • Nipple discharge
  • Skin changes
  • Lumpiness
  • Mammographic abnormalities
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10
Q

Which breast conditions cause pain

A
  • Physiological
    • Cyclical and diffuse pain
  • Ruptured cysts, injury and inflammation
    • Non-cyclical and focal
  • Occasionally presenting complaint is breast cancer
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11
Q

Which breast conditions cause palpable mass

A
  • Causes include
    • Normal nodularity
    • Invasive carcinoma
    • Fibroadenoma
    • Cysts
  • Most worrying if hard, craggy and fixed
  • No women should be allowed to have a lump in the breast without a firm diagnosis
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12
Q

Which breast conditions cause mammographic abnormalities

  • Worrying findings include
A
  • densities and calcifications
    • Densities – invasive carcinomas, fibroadenomas, cysts
    • Calcifications – ductal carcinoma in situ (DCIS), benign changes
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13
Q

who are invited for mammographic screening

A
  • Women between 47-73 years invited every 3
  • years
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14
Q

Easier to detect lesions in breasts of

A

older women because they have more adipose tissue and breast is less dense (also more likely statistically to have invasive carcinoma)

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15
Q

Are breast conditions common?

A
  • Breast symptoms and signs are common
  • Most breast symptoms and signs will be benign
  • Fibroadenoma most common benign tumour
  • Breast cancer most common non-skin malignancy in women
  • Mammographic screening increases detection of small invasive tumours and in situ carcinomas
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16
Q

(1) Fibroadenomas

A

Can occur at any age during reproductive period
– Often <30 years

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17
Q

(2) Phyllodes tumours (very similar to fibroadenomas

A
  • Most present in 6th decade
  • Have potential to be malignant but present much later
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18
Q

(3) Breast cancer

A
  • Rare before 25 years (except for some familial cases)
  • Incidence rises with age
    • 77% occurs in women >50 years
    • Average age at diagnosis is 64 years
  • In UK:
    • 45,500 new female cases and 300 new male cases a year
    • 12,500 deaths per year
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19
Q

How do we classify pathological conditions of the breast?

A
  • Disorders of development
    • E.g.Extra nipples
  • Inflammatory conditions
  • Benign epithelial lesions
  • Stromal tumours
  • Gynaecomastia
  • Breast carcinoma
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20
Q

inflammatory conditions

A

acute mastitis

fat necrosis

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21
Q

(1) Acute mastitis

A
  • Almost always occurs during lactation
  • Usually Staphylococcus aureus infection from nipple cracks and fissures
  • Erythematous painful breast, often pyrexia
  • May produce breast abscesses
  • Usually treated by expressing milk and antibiotics (stopping breast feeding)
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22
Q

2) Fat necrosis

A
  • Presents as a mass, skin changes or mammographic abnormality
  • Often history of trauma or surgery
  • Can mimic carcinoma clinically and mammographically
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23
Q

Benign epithelial lesions

A

Fibrocystic change

  • Commonest breast lesion
  • May present as a mass or mammographic abnormality
  • Mass often disappears after fine needle aspiration (FNA)
  • Histology – cyst formation, fibrosis and apocrine metaplasia
  • Can mimic carcinoma clinically and mammographically
  • Dilated ducts
  • Metaplasia- apocrine cell
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24
Q

stromal tumours e.g.

A

e.g., fibroadenoma, phyllodes tumours, lipoma, leiomyoma, hamartoma

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25
Q

Fibroadenomas

A
  • Present with a mass, usually mobile, or mammographic abnormality
  • ‘Breast mouse’ – mobile and elusive
  • Can be multiple and bilateral
  • Can grow very large and replace most of the breast
  • Macroscopically - well circumscribed, rubbery, greyish/white
  • Histology - composed of a mixture of stromal and epithelial elements
  • Can mimic carcinoma clinically and mammographically
  • Localised hyperplasia rather than true neoplasm
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26
Q

what do fibroadenomas look like

A
  • Glandular and stromal elements
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27
Q

Gyaecomastia

A
  • Enlargement of male breast
  • Unilateral or bilateral
  • Often seen at puberty and in the elderly
  • Can mimic male breast cancer especially if unilateral
  • No increased risk of cancer
28
Q

gynaecomastia caused by

A

Caused by relative decrease in androgen (testosterone) effect or increase in oestrogen effect

29
Q

What causes gynaecomastia

A
  • Occurs in most neonates secondary to circulating maternal and placental oestrogens and progesterone
  • Transient gynaecomastia affects more than half of boys in puberty as oestrogen production peaks earlier than that of testosterone
  • Klinefelter’s syndrome
  • Oestrogen excess - cirrhosis of the liver (when oestrogen not metabolised effectively)
  • Gonadotrophin excess - functioning testicular tumour, e.g., Leydig and Sertoli cell tumours, testicular germ cell tumours
  • Drug-related – spironolactone, chlorpromazine, digitalis, cimetidine, alcohol, marijuana, heroin , anabolic steroids
30
Q

most type of breast cancers are

A

adenocarcinomas

  • Most common in the upper outer quadrant (50%)
  • Other malignant tumours are very rare e.g. primary sarcomas such as angiosarcoma
31
Q

Risk factors of breast cancer

A

Major risk factors are related to hormone exposure

  • Gender
  • Uninterrupted menses
  • Early menarche (< 11 years)
  • Late menopause
  • Reproductive history - parity and age at first full term pregnancy
  • Breast-feeding
  • Obesity and high fat diet
  • Exogenous oestrogens – HRT slightly increases risk (1.2-1.7 times), long term users of COCP possibly have an increased risk
  • Breast density
  • Geographic influence
    • Higher incidence in US and Europe
    • Possible explanations include diet, physical activity, breast-feeding, environmental factors, alcohol consumption
  • Atypical changes on previous biopsy (4-5 times)
  • Previous breast cancer (10 times)
  • Radiation
    • Increased risk with previous exposure to therapeutic radiation (especially in childhood or adolescence), e.g. mantle radiation for Hodgkin’s lymphoma
  • Genetics
32
Q

NAME THE GENES ASSOCIATED WITH BREAST CANCER

A
  • BRCA1 (BReast CAncer associated gene 1) or BRCA2
    • Both tumour suppressor genes – their proteins repair damaged DNA
    • 0.1% of population has BRCA1 germline mutations
    • Lifetime breast cancer risk for female carriers is 60- 85%
    • Median age at diagnosis is approximately 20 years earlier than sporadic cases
    • Carriers may undergo prophylactic mastectomies
  • Another gene involved in hereditary breast cancer is P53 (Li-Fraumeni syndrome)
33
Q

Li-Fraumeni syndrome

A

Another gene involved in hereditary breast cancer is p53

34
Q

What is pagets disease?

A
  • Cells can extend to nipple skin without crossing BM = Paget’s disease
    • Unilateral red and crusting nipple
    • Eczematous or inflammatory conditions of the nipple should be regarded as suspicious and biopsy performed to exclude Paget’s disease
    • Requires further investigation
35
Q

how do we classify breast carcinoma

A
  1. in situ
  2. invasive
  3. ductal
  4. lobular
36
Q

In situ carcinoma

A
  • Neoplastic population of cells limited to ducts and lobules by basement membrane (BM), myoepithelial cells are preserved
  • Does not invade into vessels and therefore cannot metastasise or kill the patient
37
Q

Whys is Ductal carcinoma in situ (DCIS) a problem?

A
  • Non-obligate precursor of invasive carcinoma
  • Presentation
    • Mammographic calcifications (clusters or linear and rbanching and can be seen as a mass)
  • Can spread through ducts and lobules and be very extensive
  • Histologically often shows central necrosis with calcification
38
Q

Invasive carcinoma

A
  • Neoplastic cells have invaded beyond BM into stroma
  • Can invade into vessels and can therefore metastasize to lymph nodes and other sites
  • Usually presents as a mass or as mammographic abnormality
  • By the time a cancer is palpable more than half of the patients will have axillary lymph node metastases
  • Peau d’orange – involvment of lymphatic drainage of skin
39
Q

why do we always refer if nipples inverted

A

tumour may be tethered to nipple

40
Q

Carcinomas can be ductal or lobular:

  • Invasive ductal carcinoma, no special type (Invasive ductal Carcinoma No special type (IDC NST))
A
  • 70-80%
  • Well-differentiated type – tubules lined by atypical cells
  • Poorly differentiated type – sheets of pleomorphic cells
  • 35-50% 10 year survival
41
Q

Invasive lobular carcinoma ​

A
  • 5-15%
  • Infiltrating cells in a single file, cells lack cohesion
  • Similar prognosis to IDC NST
42
Q

other types of breast carcinoma

A

Other types, e.g. tubular (1-2%, excellent prognosis), mucinous (1-6%, excellent prognosis, often older women)

43
Q

what does invasive breast carcinoma look like?

A
  • Irregular
  • Condensed part which tugs other tissue in e.g. inverted nipple or breast dimple
44
Q

invasive ductal carcinoma NST histology

A
45
Q

invasive lobular carcinoma histology

A
  • Very small and can resemble lymphocytes
  • Infiltrate very subtilty in the stroma
  • Don’t always form a palpable mass
46
Q

mucinous carcinoma histology

A
47
Q

How does breast cancer spread?

A
  • Lymph nodes via lymphatics– usually in the ipsilateral axilla
  • Distant metastases via blood vessels – bones (most frequent site), lungs, liver, brain
48
Q

Invasive lobular carcinoma can spread to

A
49
Q

What factors determine prognosis in breast cancer?

A
  • In situ disease (cant really be fatal) or invasive carcinoma
  • Tumour stage:
    • Tumour size and locally advanced disease – invading into skin or skeletal muscle
    • Lymph Node metastases
    • Distant Metastases
  • Tumour grade
  • Histologic subtype – IDC NST has poorer prognosis
  • Molecular classification and gene expression profile
50
Q

which breast cancer has a poorer prognosis

A

IDC NST

51
Q

Tumour grade

A
  • Grade 3- doesn’t resemble tissue of origin- poorly differentiated

the higher the grade the less differentiated

52
Q

molecular classififaction of breast carcinomas

A

oestrogen receptor postive and negative

53
Q

both oestrogen receptor positive and negative carcinoma can be either

A

Her2 positive or negative

54
Q
  • Oestrogen receptor positive=
A

better prognosis

55
Q

Her2 positive and oestrogen positive=

A

better prognosis (can have Herceptin)

56
Q

Oestrogen receptor negative and HER2 negative =

A

poor prognosis and usually BRCA1

57
Q

How do we investigate and diagnose breast cancer?

A
  • Triple approach
    • Clinical – history, family history, examination
    • Radiographic imaging – mammogram (in older) and ultrasound scan (in younger)
    • Pathology – core biopsy and fine needle aspiration cytology (FNAC)
58
Q

What is mammographic screening?

A
  • Started in the UK in the late 1980s
  • Women 47–73 years
  • 2 view mammograms every 3 years
  • Aim is to detect small impalpable cancers and pre-invasive cancer (incidence of DCIS has increased from 5% of breast cancers to 25% in screened populations)
  • Look for asymmetric densities, parenchymal deformities, calcifications
  • Assess abnormalities using further imaging, core biopsy and FNAC
59
Q

What are the therapeutic approaches in breast cancer?

A

Local and regional control

  • breast surgery
  • axillary treatment
  • poster-operative radiotherapy to chest and axilla

Systemic control

  • chemotherapy
  • hormonal treatment
  • herceptin
60
Q

Breast surgery

A

mastectomy or breast conserving surgery – decision depends on patient choice, size and site of tumour, number of tumours, size of breast

61
Q

Axillary surgery

A

– extent depending on whether there are involved nodes (sentinel node sampling or axillary dissection)

62
Q

What is sentinel lymph node biopsy?

A
  • Reduces the risk of postoperative morbidity
  • Intraoperative lymphatic mapping with dye and/or radioactivity of the draining or ‘sentinel’ lymph node(s) – the one most likely to contain breast cancer metastases
  • If the sentinel node(s) is negative axillary dissection can be avoided – e.g. avoid lymphodema
63
Q

Chemotherapy

A

if benefits thought to outweigh the risks; if given before surgery = neoadjuvant

64
Q

Hormonal treatment

A

e.g. tamoxifen – depending on oestrogen receptor status (approximately 80% of cancers are ER positive)

65
Q

Herceptin treatment

A

depending on Her2 receptor status (approximately 20% of cancers are Her2 positive)

  • Her2 is a member of the human epidermal growth factor receptor family
  • Encodes a transmembrane tyrosine kinase receptor
  • Herceptin = trastuzumab = humanised monoclonal antibodies against the Her2 protein
66
Q

How do we improve survival from breast cancer?

A
  • Early detection – awareness of disease, importance of family history, self-examination, mammographic screening
  • Neoadjuvant chemotherapy – early treatment of metastatic disease
  • Use of newer therapies – e.g. Herceptin
  • Gene expression profiles
  • Prevention in familial cases
    • genetic screening, prophylactic mastectomies

Integration for clinical application (13 decks)

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