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Breast > Malignant Breast Disease > Flashcards

Malignant Breast Disease Flashcards

1
Q

What are the different types of breast carcinoma?

A

DCIS (non-invasive ductal carcinoma in-situ)

Lobular carcinoma in situ (LCIS)

Invasive ductal carcinoma (IDC) -NST (no special type)

Invasive Lobular carcinomas (ILC)

Inflammatory breast cancer (similar presentation to breast abscess or mastitis)

Paget’s disease of the nipple

Rare breast cancers (special IDC)

  • medullary breast cancer
  • mucinous breast cancer
  • tubular breast cancer
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2
Q

What are the 2 sub-categories of IDC?

A

No special type (NST= 85%

Special types:

  • lobular
  • tubular
  • medullary
  • mucinous
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3
Q

What is the difference between DCIS and IDC?

A

DCIS:

  • classified as pre-malignant tumour
  • has not punctured the basement membrane (definition of being non-invasive)
  • micro-calcifications on mammogram but can be undetectable
  • usually asymptomatic-> diagnosed incidentally

IDC:

  • originates in cells of breast ducts
  • invaded through the basement membrane
  • accounts for 80% of invasive breast cancers
  • seen on mammograms= irregular brighter areas (calcifications)
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4
Q

How would you differentiate between a cancerous lump and a benign lump?

A

Malignant features:

  • hard
  • irregular
  • painless
  • fixed or tethered
  • nipple retraction
  • skin dimpling
  • peau d’orange->infiltration into lymphatics underneath skin
  • blood stained discharge-> due to infiltration into vessels
  • Paget’s disease of the nipple
  • change in breast shape/contour
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5
Q

How might inflammatory breast cancer present and what other breast condition might it be mistaken for?

A

Swollen, warm and tender breast with peau d’orange

Presents similarly to mastitis or breast abscess but does not respond to antibiotics

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6
Q

What is Paget’s disease of the nipple?

A

Erythematous scaly rash which looks like eczema of the nipple

Can indicate breast cancer involving the nipple or DCIS or invasive breast cancer

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7
Q

What are the different routes of spread for breast cancer? What are the most common sites for metastasis?

A

Direct extension

  • skin
  • muscle
  • chest wall

Lymphatic
-axillary and internal thoracic nodes

Haematological

  • lungs
  • liver
  • bone
  • brain
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8
Q

What are the risk factors associated with breast cancer?

A 
Female 
Age 
FH
Genetics= BRCA (80-90% life time risk)
Oestrogen exposure 
-early menarche
-late menopause 
-parity (nulliparous > multiparous)
-later preg age 
-OCP/HRT
Chest radiation-> especially in early adulthood/adolescents (think about radiotherapy for lymphoma)
Alcohol
Overweight
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9
Q

What are protective factors for breast cancer?

A

Breast feeding

Physical activity

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10
Q

What is the process of investigating and diagnosing a suspected malignant breast lump?

A

Triple assessment

  • clinical examination
  • Imaging (US <35 or >35 mammography)
  • biopsy

FBC + LFT= look for signs of mets
CXR/CT scan/ bone scans/ liver USS= looking for signs of spear

Assess receptor status (ER, HER20= done via core biopsy sample

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11
Q

What is the normal action of the BRCA genes and which chromosome are they on?
What other cancers might people with these mutations be at risk of?

A

Tumour suppressor genes

BRCA1

  • chromosome 17
  • 80-90% life time risk of breast cancer
  • 50% develop ovarian cancer

BRCA2

  • chromosome 13
  • 60% develop breast cancer by 80
  • 20% develop ovarian cancer
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12
Q

What is the breast cancer screening programme?

What are the possible negatives?

A

Mammogram offered every 3 years to women aged 50-70 years with the aim of detecting breast cancer earlier

Cons:

  • anxiety + stress
  • exposure to radiation
  • FN= missing cancer + false reassurance
  • FP= unnecessary further testing
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13
Q

What criteria would make a patient high risk, leading to them being referred from primary care for screening?

A

1st degree relative with breast cancer under 40

1st degree male relative with breast cancer

1st degree relative with bilateral cancer, diagnosed <50

2 1st degree relatives with breast cancer

I.e. significant family history

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14
Q

What are the different options offering to women at higher risk?

A

Annual mammogram

Chemoprevention

  • tamoxifen (pre-menopausal)
  • anastrozole (post-menopausal)

Risk reducing bilateral mastectomy or oophorectomy

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15
Q

What is the criteria for referring a women for 2 week wait referral?

A

Unexplained breast lump in patients age 30 + above

Unilateral nipple changes in patients age 50+

Unexplained lump in axilla in patients aged 30+

Skin changes suggestive of breast cancer

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16
Q

Why is calcification seen on mammogram in breast cancer?

A

Calcium is deposited in instances of high cell turnover

17
Q

How can breast cancer be staged?

What investigations might be required to stage a breast cancer?

A

Staged I-IV

TNM

  • tumour
  • nodes
  • mets

NPI

  • <3/4= good prognosis + doesn’t require adjuvant chemo
  • higher= indicates increased risk of systemic mets

Investigations:

  • triple assessment
  • lymph node assessment and biopsy
  • MRI of breast and axilla
  • Liver USS
  • CT TAP
  • isotope bone scan
18
Q

What is the difference between staging and grading?

What does the grading of breast cancer depend on?

A

Staging is used to asses the size and spread of a primary tumour and if any mets is present (histopathology)

Grading is used to assess the biological behaviour to indicate how aggressive a cancer is (cytology)

Breast cancer grading depends on degree of:

  • tubule formation
  • nuclear pleomorphism
  • mitoses
19
Q

What are the different receptors that are tested for in breast tissue sample? Why is this done?
What is triple negative breast cancer?

A

Oestrogen receptors
Progesterone receptors
Human epidermal growth factor (HER2)
Knowing the receptor status of a breast cancer can help to guide treatment

Triple negative= breast cancer cells don’t express any of the receptors (associated with worse prognosis due to limitations for treatment options)

20
Q

How can lymph nodes be assessed in patient diagnosed with breast cancer?

A

Ultrasound of axilla

Ultrasound-guided biopsy

Sentinel LN biopsy (during surgery)
-isotope contrast and blue dye injected into tumour area and see where it travels to first= sentinel lymph node

21
Q

What are the different treatment options for breast cancer? What must be done before treatment is started?

A 
Surgery 
Chemo
Radiotherapy 
Hormonal therapy 
Biological therapy

MUST discuss patient case at MDT and consider patient factors to determine which treatment or combination of treatments will be best for patient

22
Q

What are the 2 different types of surgery available to treat breast cancer and what do they involve?

A

Wide local excision

  • breast conserving surgery where lump and healthy margin of tissue removed
  • requires post-op radiotherapy to remove any remaining cancer cells

Mastectomy

  • removal of entire breast
  • can have reconstructive surgery i.e. implants or tissue flaps (latissium dorsi or TRAM)
23
Q

What are the 3 different types of surgery which can be performed on the axilla to assess axillary node status?

A

Sentinel lymph node biopsy
-identification and excision of sentinel LN

Axillary node sampling
-min of 4 LN removed to histological examination

Axillary node clearance= when positive node identified
-all LN removed
BUT= risk of lymphoedema

24
Q

When is radiotherapy used in breast cancer?

A

After WLE to reduce the risk of recurrence

25
Q

When is chemotherapy used in breast cancer?

What type of chemo should be used?

A

Neo-adjuvant= before surgery to try and shrink size of tumour

Adjuvant= post-surgery to decrease risk of recurrence

Anthracylcine= epirubicin/doxorubicin

26
Q

How can chemotherapy be used specifically in premenopausal women?
What are the consequences of this form of chemo?

A

Can undergo ovarian ablation
-decreased the oestrogen production to decrease cancer cell stimulation i.e. decreases cancer growth or reduces risk of recurrence

S.E= infertility

27
Q

How can receive hormone therapy?
What is the aim of hormone therapy in breast cancer?
What are the different forms and what are the SE?

A

Oestrogen positive breast cancer
Decrease oestrogen levels or decrease the effects of oestrogen on tumour

Premenopausal:

  • Tamoxifen (SERM)
    • SE= increased risk of endometrial cancer + DVT
  • Ovarian ablation
    • radiotherapy/surgery/Goserelin

Post menopausal

  • Aromatase inhibitor eg anastrozole/letrozole/exemestane
  • SE= increases risk of oestoporosis
28
Q

What is the MOA of Tamoxifen?
Which demographic of breast cancer patients is this recommended for?
What are the pros and cons of this drugs?

A

Selective oestrogen receptor modulator working to block or stimulate ER (depending on site)

  • blocks breast tissue ER
  • stimulates bone and uterus ER

Premenopausal

Pros:
-protective against osteoporosis

Cons:
-risk for endometrial cancer

29
Q

What is the MOA of Letrozole/anastrozole/exemestane?
Which demographic of breast cancer patients is this indicated for?
What are the possible cons of taking this drug?

A

Aromatase inhibitor= inhibits the enzyme in adipose tissue which converts androgens to oestrogen i.e. adipose tissue is main source of oestrogen in post menopausal women

Post menopausal

Can increase risk of osteoporosis

30
Q

When is biological therapy used to treat breast cancer?

What therapies are available and what is their MOA?

A

HER2 positive cancers

Trastuzumab (herceptin)
-MAb which binds to HER2 receptor to downregulate the signals from HER2 receptors to counteract their over expression

Neratinib
-tyrosine kinase inhibitor used to slow the growth of breast cancer

31
Q

Why can chronic lymphoedema occur on breast cancer?
How can this be managed conservatively?
What should be avoided if patient suffers from lymphoedema?

A

Removal of axillary LN in axillary node clearance leads to impaired drainage of excess fluid from tissue leading to accumulation in the associated drainage area i.e. arm swollen

Management:

  • massage techniques to manually drain lymph
  • compression bandages
  • weight loss if overweight
  • good skin care= due to being prone to infection due to loss of immune role of lymphatic system

Avoid taking blood or cannulating side with lymphoedema

32
Q

What are the 2 cell types in breast tissue and what is their primary function?

A

Luminal epithelium= production of milk

Myoepithelium= contraction to expel milk from ducts

33
Q

What would be some of the features of a malignant breast cancer in a histopathology sample?

A

Pleomorphic nuclei
Discohesive struction
Invasion through basement membrane
i.e. complete loss of normal lobule and duct structure with poorly differentiate cells

34
Q

What 5 investigations would you do if lung carcinoma or lung mets were suspected?

A

Chest radiography

Pulse oximetry -> quick way to establish if patient is hypoxc

Serum calcium and albumin -> looking for bone and liver mets

Liver function tests-> looking for liver mets

35
Q

What investigations are indicated in someone with possible metastatic breast carcinoma?

A

CT chest and abdomen
-important for staging i.e. looking for mets

Needle biopsy of breast lesion

Ultrasound breast

Bone scan

36
Q

What is the most common site of breat metastase?
What other type of metastasis is breast carcinoma associated with?
What can occur as a complication of these mets?

A

Lung mets

Endobronchial metastasis

Lung mets can lead to pneumothorax (very rarely)

Breast (3 decks)

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