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General Surgery > Malignant Breast Disease > Flashcards

Malignant Breast Disease Flashcards

1
Q

What are the top causes of cancer in women?

A

1 - Developed: Lung
- Developing: Cervical
2 - Breast

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2
Q

What is the approximate lifetime risk of developing breast cancer?

A

1 in 10

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3
Q

When do most deaths occur following breast cancer?

A

Within first 5 years after the diagnosis is made

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4
Q

What are the major risk factors for breast cancer?

A
  • Female sex

- Advancing age (only 2% of

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5
Q

What are the minor risk factors for breast cancer?

A
  • Wide oestrogen window (early menarche, late menopause)
  • Low parity
  • Late birth of first child
  • Hormone replacement therapy
  • Oral contraceptive pill use
  • Smoking
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6
Q

What are controversial/uncertain risk factors for breast cancer?

A
  • No lactation
  • Alcohol
  • Diet
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7
Q

What percentage of breast cancers are estimated to be caused by genetic variants?

A

5-10% of all women, but ~25% of women

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8
Q

What cancers do BRCA gene mutations predispose to?

A

Breast

Ovarian

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9
Q

What are common symptoms of breast cancer?

A
  • Painless breast lump (80%)
  • Change in breast appearance (13%)
  • Nipple discharge (2%)
  • Eczematous change of the nipple (Paget’s)
  • Asymptomatic (5%) –> picked up on screening mammogram
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10
Q

What are common signs of breast cancer?

A
  • Thickened area/ ill-defined shelving mass
  • Skin dimpling
  • Nipple retraction
  • Visible mass
  • Skin oedema
  • Palpable axillary lymph nodes
  • Fixity to the skin or underlying muscle
  • Ulceration
  • Supraclavicular nodes
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11
Q

What is the Ddx in the early stages of the formation of a differential?

A
  • Fibroadenoma
  • Cyst
  • Fat necrosis
  • Breast abscess
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12
Q

How is the diagnosis of breast cancer made?

A

Triple assessment:

  • History/examination
  • Radiological assessment (mammogram, ultrasound)
  • Tissue confirmation (FNAB, core biopsy)
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13
Q

What are the uses of mammography?

A
  • Suggest, but NOT make a diagnosis
  • Screening
  • Exclusion of bilateral disease
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14
Q

In which group of women is mammography not useful and why?

A
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15
Q

Features of malignancy on mammogram?

A
  • Microcalcification (DCIS)
  • Density with surrounding spiculation
  • Distortion of normal breast architecture
  • Tethering
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16
Q

Indications for mammography?

A 
- Proven cancer:
  ~ Exclude bilateral disease
  ~ Exclude DCIS
  ~ Follow-up
- Clinical problems:
  ~ Discrete mass or vague thickening in women >30 y/o
  ~ Single nipple discharge
  ~ Focal mastalgia
  ~ Unexplained nipple retraction
- Screening:
  ~ Positive family history (screen 10 yr before 1st degree relative acquired disease)
  ~ >55 y/o every 2 years (UK guideline)
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17
Q

What are the uses of ultrasonography in assessing breast lumps?

A
  • Detects whether lesion is solid or cystic
  • Useful for biopsy guidance in impalpable lesions
  • Particularly useful in young women: dense tissue
  • Not sensitive in differentiating between benign and malignant solid lesions
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18
Q

Benefits and drawbacks of FNAB?

A
  • Quick, same-day results
  • Allows for some interpretation of cell morphology
  • Is insufficient tool to make diagnosis of breast Ca
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19
Q

Gold standard for tissue diagnosis?

A

Trucut/core biopsy

Can yield useful info on tumour type, biology and hormone receptor status

20
Q

How is primary breast cancer divided up pathologically?

A
  • Non-invasive epithelial cancers (carcinoma-in-situ)
  • Invasive epithelial cancers
  • Mixed connective and epithelial cancers (rare)
21
Q

List the types of non-invasive epithelial cancers

A
  • Lobular carcinoma in situ

- Ductal carcinoma in situ

22
Q

List the types of invasive epithelial cancers

A
  • Invasive lobular (10-15%)

- Invasive ductal carcinoma: most commonly infiltrating ductal carcinoma (50-70%)

23
Q

List the types of connective and epithelial mixed cancers

A
  • Phylloides tumours (benign and malignant)
  • Carcinosarcoma
  • Angiosarcoma
24
Q

List the tumour size classifications of breast cancer

A 
Tis - tumour in situ
Tx - tumour can't be assessed
T0 - no tumour
T1 - tumour 5cm
T4 - extension of tumour to skin or chest wall
25
Q

List the lymph node spread classifications of breast cancer

A

N0 - no axillary nodes
N1 - mobile axillary nodes
N2 - fixed axillary nodes
N3 - ipsilateral internal mammary nodes are involved

26
Q

List the metastatic classifications of breast cancer

A

Mx - metastases suspected but not confirmed
M0 - no distant metastases
M1 - metastases present

27
Q

List the stages of breast cancer

A

Stage 0 - cancer in situ
Stage 1 - T1 without nodes
Stage 2 - T1/2 with nodes; or T3 +- nodes
Stage 3 - Locally advanced in breast (T4) or nodes (N2/3)
Stage 4 - Distant metastases

28
Q

Outline the metastatic screening process

A

All patients: CXR, LFTs
If LFTs abnormal, or T3: liver U/S
If >T3: Bone scan (beware false + in arthritis)
Selected cases: bone X-ray/CT/MRI

29
Q

What does Her-2-neu receptor positivity imply?

A
  • Very aggressive tumour

- May be treated with Herceptin (Trastuzumab)

30
Q

What is the benefit in knowing the patient’s cancer’s hormone receptor status?

A

ER+/PgR+ patients may respond to endocrine maneuvres such as Tamoxifen (ER receptor site competitor)

31
Q

What are the surgical options for removal of breast cancer?

A
  • Wide local excision (breast-conserving)

- Total mastectomy

32
Q

What are the pros/cons of WLE vs total mastectomy?

A
  • WLE has same survival rate as total mastectomy
  • WLE has a slightly higher local recurrence rate
  • Better preservation of breast/body image etc
33
Q

When is a patient suitable for a wide local excision?

A
  • Single lesion
34
Q

What are the surgical options for removal of lymph nodes in breast cancer?

A
  • Sentinel lymph node biopsy (SLNB)

- Axillary nodal clearance

35
Q

Which patients are suitable for SLNB?

A
  • T1/2 lesion
  • No palpable lymph nodes
  • No prior axillary surgery, irradiation or neo-adjuvant chemotherapy
36
Q

What is the purpose of adjuvant therapy?

A

Used in addition to curative surgery, to eradicate subclinical metastases. 1-4% of women relapse within 5 years without this therapy. Always indicated, except perhaps in very small lesions

37
Q

Types of adjuvant therapy

A
  • Radiotherapy
  • Chemotherapy
  • Endocrine manipulation
    ~ Premenopausal: Tamoxifen; LHRH antagonists (medical, reversible menopause); progesterones; oopherectomy (effective, but rarely done)
    ~ Postmenopausal: Aromatase inhibitors (stop peripheral conversion of precursors to oestrogen); Tamoxifen; progesterones
  • Biological modifiers e.g. Herceptin for Her-2-neu+ (not done in government hospitals)
38
Q

Treatment for Stage 0 breast Ca

A
  • WLE if focal or well-localised

- Total mastectomy without axillary node clearance

39
Q

Treatment for Stage 1 &2 breast Ca

A
  • Total mastectomy and SLNB or WLE and SLNB if N0 disease
  • If N1 or SLNB was +ve, then axillary node clearance
  • Adjuvant therapy:
    ~ Low risk (node -ve,
40
Q

Treatment for Stage 3 Breast Ca

A

Triple modality approach: chemotherapy, surgery (mastectomy and ANC) and radiotherapy
Hormone therapy may be added if receptor positive
Neoadjuvant therapy is often used to downsize the tumour

41
Q

Treatment for Stage 4 breast Ca

A

Incurable metastatic disease –> palliative care
Chemotherapy in younger women with rapidly-growing visceral metastases
Endocrine manipulation useful for older women with hormone responsive disease and bone metastases
Most women fall somewhere in between these groups - refer to oncologist

42
Q

Paget’s disease of the nipple

A
  • Intradcutal carcinoma which invades the breast
  • Presents as nipple erythema, itching, crusting and rawness
  • Often mimics eczema, but is differentiated by the fact that it always involves the nipple and moves out to the areola
  • Tissue diagnosis by punch biopsy
  • Mammogram shows underlying invasive carcinoma
  • Treated with total mastectomy, with good survival rates if no invasive component
43
Q

Inflammatory breast cancer

A
  • Locally advanced carcinoma which mimics a cellulitis/abscess
  • Present clinically with ed, hot, oedematous breast of rapid course
  • May be no palpable mass or mammographic findings of malignancy
  • Tissue biopsy NB
  • Dermal lymphatic invasion is shown histologically - characteristic
  • Aggressive treatment needed: neoadjuvant chemotherapy followed by mastectomy if resectable
44
Q

Male breast cancer

A
  • ~1% of all breast cancers
  • Late presentation of disease and advanced stag
  • Rx: mastectomy +- ANC, with Tamoxifen; radiotherapy often required for chest wall
45
Q

Breast cancer in pregnancy and lactation

A
46
Q

Survival rates in breast cancer

A
  • Most powerful factor affecting survival is the stage of the disease
  • 5 year survival of Stage 0 and 1 ~100%, declining to ~20% in Stage 4 disease

General Surgery (15 decks)

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