Malignant conditions of the breast Flashcards
Breast cancer risk
women in 20s: rare
women in 30s: uncommon
women 30-60: rises steadily
women 60+: risk [[decreases/stays same/increases]]
Breast cancer risk
women in 20s: rare
women in 30s: uncommon
women 30-60: rises steadily
women 60+: risk stays same
Risk factors for breast cancer:
Think of 5.
Risk factors for breast cancer:
- earlier menarche (first menstruation)
- late menopause
- older at first preg
- oral contraceptive use / the pill
- HRT (hormone replacement therapy)
- obesity
- tallness
- denser breasts
- alcohol
- family history
- BRCA1/BRCA2
- Li-Fraumeni syndrome (TP53 tumour suppressor gene mutated, so p53 protein affected)
Symptoms of possible breast cancer
Think of 5.
Symptoms of possible breast cancer
- new lump in breast or axilla
- altered shape/size/feel of breast
- dimpling of skin, and ‘peau d’orange’ = skin oedema looking like orange peel
- rash, redness
- nipple changes: inversion, discharge, rash
- not often pain
Investiagtion of breast abnormalities
- clinical examination: inspection and palpation at different positions
- imaging: ultrasound, X-ray mammography, MRI
- fine needle aspiration: for cytology, so microscopy of cells
- core biopsy: (guided by imaging) with microscopy of tissue sections
- excisional biopsy: diagnostic or therapeutic or both
Breast screening
UK women, between 47 and 73, invited every 3 years, for mammogram, may self-refer after 73.
Breast cancer treatment
- surgery aims to remove all cancer tissue with margins of free
- lumpectomy (aka Wide Local Excision) (removing suspected malignancy with a margin of normal breast tissue) has a very high risk of recurrence risk
- but WLE plus radiotherapy works better, simple results to full mastectomy
- neoadjuvant (treatment before main treatment, e.g. chemotherapy) may have enough tumour regression for ‘breast-conserving’ surgery, regardless some women still choose mastectomy.
Pic in folder of surgical margin.
The axilla in breast cancer
like other carcinomas, breast cancer can spread to local lymph nodes.
Staging of axilla is important for prognosis.
Axilla lymph node clearance (removal) not necessary if sentinel node biopsy is negative.
Axillary clearance has impact on morbidity –> limitation of arm movement and lymphoedema.
Pics.
Steroid hormone receptors overexpressed in 80% breast cancers
Tamoxifen
- Oestrogen receptors and progesterone receptors over-expressed
- ER/PR positive carcinomas respond to endocrine treatment –> Tamoxifen is an oestrogen antagonist
- Tamoxifen affects bone and endometrium agonistically though, and there’s an increased risk of endometrial cancer in women with it
Steroid hormone receptors overexpressed in 80% breast cancers
Aromatase inhibitors
e.g. Letrazole, Anostrazole
- aromatase inhibitors prevent conversion of androgens to oestrogens
- this process normally occurs in adipose tissue so may partly explain obesity-breast cancer link
- the reduction of oestrogen prevents oestrogen stimulated growth of tumour
Her2 positive carriers
- Her2 (gene) over-expressers have worse breast cancer prognosis
- Trastuzumab (Herceptin) is a monoclonal antibody
- it targets her2
Chemo for breast cancer?
- surgery + radiotherapy combo usually sort local breast cancer (but not distant sites)
- Endocrine treatments (Tamoxifen and aromatase inhibitors) can help prevent metastatic relapse to distant sites for ER+/PR+ breast cancer
- ER- / PR- / Her2- (‘triple negative’ cancers) are a therapeutic challenge
Breast cancer grading
Based on 3 histological properties:
- nuclear pleomorphism
- number of mitoses per mm^2
- degree of gland formation by cancer cells
Grades:
Grade 1: well differentiated and slow growing
Grade 2: in between 1 and 3
Grade 3: cancers poorly differentiated and fast growing
Nottingham Prognostic Index
Score based on:
- _____
- ____ _____
- ____
_____: grade 1 would be 1 point, grade would be 2 points etc.
_____ ____: 0 nodes involved is 1 point, 1-3 nodes is 2 points and 4+ is 3 points.
___:
length in cm x 0.2 = points, e.g. a 1cm tumour would be 0.2 points.
Nottingham Prognostic Index
Score based on:
- grade
- nodal status
- size
Grade: grade 1 would be 1 point, grade would be 2 points etc.
Nodal status: 0 nodes involved is 1 point, 1-3 nodes is 2 points and 4+ is 3 points.
Size:
length in cm x 0.2 = points, e.g. a 1cm tumour would be 0.2 points.
________ Prognostic index:
- good prognostic group: < __ points
- intermediate p.g: __-__
- Poor p.g: >__
Nottingham Prognostic index:
- good prognostic group: < 3.4 points
- intermediate p.g: 3.4-5.4
- Poor p.g: >5.4
Two main divisions of breast cancer:
- ______ _____ ______ (IDC)
- ______ _____ ______ (ILC)
‘carcinoma in situ’ is still used in breast pathology when a non-invasive lesion is not established cancer. For other organs, the neoplastic epithelial precursor lesion is called ‘high grade dysplasia’.
Therefore ‘carcinoma in situ’ = ‘high grade dysplasia’
Two main divisions of breast cancer:
- invasive ductal carcinoma (IDC)
- invasive lobular carcinoma (ILC)
‘carcinoma in situ’ is still used in breast pathology when a non-invasive lesion is not established cancer. For other organs, the neoplastic epithelial precursor lesion is called ‘high grade dysplasia’.
Therefore ‘carcinoma in situ’ = ‘high grade dysplasia’
‘_____ _______ _ ___’ (DCIS) and ‘_____ ______ _ __’ (LCIS) are terms also used.
‘_______ ______ _________’ (ADH) and ‘______ _______ __________’ (ALH) are equivalent to low grade dysplasia.
So ‘carcinoma in situ’ = high grade dysplasia and ‘atypical hyperplasia’ = low grade dysplasia
‘ductal carcinoma in situ’ (DCIS) and ‘lobular carcinoma in situ’ (LCIS) are terms also used.
‘atypical ductal hyperplasia’ and ‘atypical lobular hyperplasia’ are equivalent to low grade dysplasia.
So ‘carcinoma in situ’ = high grade dysplasia and ‘atypical hyperplasia’ = low grade dysplasia
Carcinoma in situ (high grade dysplasia) is ‘malignant looking proliferation of epithelial cells, within the ________ _________’
No extension into breast stroma, no communication with blood or lymphatic vessels.
Carcinoma in situ (high grade dysplasia) is ‘malignant looking proliferation of epithelial cells, within the basement membrane’
No extension into breast stroma, no communication with blood or lymphatic vessels.
ADH, DCIS, ALH and LCIS seems to imply that these lesions originate in ducts and lobules respectively.
This is not the case, it is assumed all of the lesions originate at the _______ ____ ______ ____
Terminal duct lobular unit
TDLU
Invasive ductal carcinoma (IDC) vs invasive lobular carcinoma (ILC)
The difference between them is morphological.
In ___ there are specific features due to the loss of cell to cell adhesion molecule E-cadherin. ‘______’ typically means ‘has lost E-cadherin’.
Features of ILC include widespread malignant cells, often in single file or whirls around pre-existing parenchyma (‘functional part’.)
Invasive ductal carcinoma (IDC) vs invasive lobular carcinoma (ILC)
The difference between them is morphological.
In ILC there are specific features due to the loss of cell to cell adhesion molecule E-cadherin. ‘lobular’ typically means ‘has lost E-cadherin’.
Features of ILC include widespread malignant cells, often in single file or whirls around pre-existing parenchyma (‘functional part’.)
- Luminal B has a better prognosis than Luminal A.
True or false.
- Luminal A and Luminal B are the two ER+ subtypes. Name the three ER- subtypes.
- False, Luminal B is worse than A.
- ‘Normal-like’, ‘Her2 enriched’ and ‘triple negative / basal like’
There is a great pic of the 5 subtypes in the folder. Read it.
