Malignant Breast Disease Flashcards
What is a carcinoma in situ?
What are the two main types for breasts?
Malignancies contained within basement membrane
Pre-malignant
Typically found imaging
- ductal carcinoma in situ (DCIS)
- lobular carcinoma IS (LCIS)
What is DCIS? How to treat
Ductal carcinoma in situ
Most common non-invasive breast malignancy
20% breast cancers
20-30% without treatment -> invasive
Subtypes:
Comedo, cribriform, micropapillary, solid
Often detected screening - microcalcifications
✅complete wide excision
✅ mastectomy
What is LCIS? How to treat
Much rarer DCIS
Greater risk -> invasive
Incidental finding biopsy
✅ low grade - monitor
✅bilateral prophylactic mastectomy if BRCA1/2
How common is carcinoma of the breast? What can invasive carcinoma of the breast be classified into? Where does each arise from?
Most common cancer western world
1/10 women
- invasive ductal carcinoma 75-85%
Further classified (tubular, cribriform, papillary, mucinous, medullary) - invasive lobular carcinoma 10%
Older, diffuse pattern spread - Other subtypes (medullary, colloid) 5%
~ almost all breast carcinomas arise terminal duct lobular unit
Risk factors for breast cancer
Female Older (doubles every 10yrs -> menopause) Mutated BRCA1/2 TSG FH 1st degree Benign disease Alcohol Developed countries Unopposed oestrogen exposure (early menarche, late menopause, nulliparous, 1st baby after 30yrs, oral contraceptives, HRT)
Clinical features breast cancer
Can be asymptomatic
Picked up screening - 50-79yrs mammogram every 3yrs
Lump Asymmetry Swelling Nipple discharge Nipple retraction Skin changes (dimpling, peau d’orange, Paget’s) Mastalgia Axiallary lump
Prognosis of breast cancer
Nodal status most important factor
Also size, grade, receptor status*
Nottingham prognostic index:
(Size X 0.2) + nodal status + grade
Diameter cm LNs 1-4=2, >4=3 Bloom-Richardson
Score 2-2.4 93% 85% >3.4 70% >5.4 50%
*oestrogen R, progesterone R, human epidermal growth factor R
Lady presents with roughening, reddening and slight ulceration of the nipple. She also states it’s itchy and the skin feels flaky & thickened. What are you concerned about? What other signs May someone have? What must you be careful not to confuse it with? Investigations? Management?
Paget’s disease of the nipple - rare
97% also have underlying neoplasm
Hypothesised early malignant cells migrate from ducts to nipple surface
Other features:
Painful
Flattened nipple
Yellow/ bloody discharge
Often mistaken dermatitis/ eczema (nearly always involves areola & spares nipple)
Biopsy - sometimes whole nipple
Breast & axilla exam
Mammogram/ USS/ MRI
✅surgical +/- radioT
A 58yr old woman with confirmed invasive ductal carcinoma states she doesn’t want radiotherapy what is the most appropriate treatment option?
Mastectomy affected breast
What is breast conserving treatment of breast cancer and when is it used?
Wide local excision - most common, 1cm margin
Localised operable disease
No evidence metastatic
How is sentinel node biopsy done? What May you do if it comes back positive?
Removing first LNS which drain area
Inject blue dye with radioisotope into peri-areolar skin
Radioactivity detection/ visual identify
Removed -> histology
Positive:
Axillary node clearance - remove all LNs axialla
Complications: paraesthesia, stromal formation, lymphoedema, seroma, wound infection
Name the borders of the axilla
Anterior - pec major/ minor
Lateral - inter tubular sulcus numerous head
Medial - serratus anterior & thoracic wall
Posterior - teres major, lat dorsi, scapularis
Apex/ axillary inlet - 1st rib/ scapular/ clavicle
Base
Contents of axilla
Axillary artery & branches
Axillary vein & branches (cephalic & basilic)
Brachial plexus & branches
Biceps brachi
Coracobrachialis
LNs - lateral, apical, pectoral, central, posterior
When are hormone treatments used, give some examples?
Malignant non-met adjuvant
Usually after primary surgery but treatment of choice unfit
Biggest contributor improved survival
- tamoxifen pre-menopause, blockage oestrogen Rs, increased thromboembolism/ uterine ca
- aromatase inhibitors e.g. Anastrozole, letrozole, exemestane bind oestrogen Rs inhibit growth, post-menopause
- immunotherapy with specific growth factor Rs e.g. HER-2 - Herceptin MCAb ❌cardiotoxicity
Mammoplasty vs wide local excision
A therapeutic mammoplasty is similar to a wide local excision in that the problem area plus a margin is removed. However, this operation is used to maintain the shape and contour of the breast especially if a relatively large area has to be removed.
