Session 7: Breast Cancer Flashcards
Physiological changes seen in breast tissue.
Prepubertal breast with a few lobules.
Menarche hits and there is an increase in lobules, increased volume of interlobular stroma.
During menstrual cycle after ovulation there is proliferation and stromal oedema. With menstruation there is a decrease in size of lobules.
In pregnancy there is an increase in size and number of lobules, there is a decrease in stroma, and there are secretory changes.
Physiological changes in increasing age of breast tissue.
Terminal duct lobular units decrease in number and size.
The interlobular stroma is replaced by adipose tissue.
How may breast conditions present?
Pain
Palpable mass
Nipple discharge
Skin changes
Lumpiness
Give examples of types of pain experience in breast conditions.
Cyclical or diffuse (most commonly physiological)
Non-cyclical and focal (might be a ruptured cyst, injury or inflammation)
Give examples of breast conditions that cause a palpable mass.
Normal nodularity
Invasive carcinomas
Fibroadenomas
Cysts
When are palpable breast mass most worrying?
When they are hard, craggy and fixed
What are the most worrying findings on mammographs?
Densities
Calcifications
What might densities suggest?
Invasive carcinomas
Fibroadenomas
Cysts
What might calcifications suggest?
Ductal carcinoma in situ (DCIS)
Benign changes
Women of which ages are invited to mammographic screening each year?
47-73 years of age
Most common benign breast tumour
Fibroadenoma
What kind of tumour is most common in <30 years?
Fibroadenomas
When are phyllodes tumours most present?
In 60s
They can be malignant
In which ages are breast cancer common?
Rare in young ages and especially younger than 25.
Incidence rises with age and 77% of all breast cancers occur in women >50 years
The average age of diagnosis is 64 years.
Explain acute mastitis.
Almost always occurs during lactation and is usually due to S. aureus infection from nipple crack and fissures.
The presentation is usually erythematous and painful, Patient is also pyrexic.
It may produce breast abscesses.
How is acute mastitis treated?
Expressing milk and antibiotics
What is fat necrosis in breast tissue?
An inflammatory condition which presents as a mass, skin changes or mammographic abnormality.
There is often a history of trauma or surgery.
It can mimic carcinoma both clinically and mammographically.
Explain fibrocystic change.
Benign epithelial lesions which are the most common breast lesions.
They may present as a mass or mammographic abnormality.
The mass often disappears after fine needle aspiration.
Can mimic carcinoma clinically and mammographically.
Histology of fibrocystic change.
Cyst formation
Fibrosis
Apocrine metaplasia
Give examples of stromal tumours.
Fibroadenoma
Phyllodes tumours
Lipoma
Leiomyoma
Hamartoma
Macroscopical features of fibroadenomas.
Present with a mass, usually mobile or mammographic abnormality.
Often called breast mouse as they are mobile and elusive.
Can be multiple and bilateral.
They might grow very large and replace most of the breast tissue.
They are well circumscribed, rubbery and greyish/white.
What is gynaecomastia?
Enlargement of male breast which can be either unilateral or bilateral.
What is gynaecomastia caused by?
Relative decrease in androgen effect or increase in oestrogen effect.
Can often be seen at pubery and in the elderly.
It can mimic breast cancer especially if it is unilateral.
However there is no increased risk of cancer.
Give examples of conditions causing gynaecomastia.
Neonatal secondary to circulating maternal and placental oestrogens and progesterone.
Transient gynaecomastia in puberty as oestrogen production peaks earlier than testosterone.
Klinefelter’s syndrome (XXY)
Oestrogen excesses like due to liver cirrhosis
Gonadotrophin excess (functioning testicular tumour, leydig and sertoli cell tumours, testicular germ cell tumours)
Drug-related
Give examples of drug-related gynaecomastia.
Spironlactone
Chlorpromazine
Digitalis
Cimetidine
Alcohol
Marijuana
Heroin
Anabolic steroids
Most common type of breast cancer.
95% are adenocarcinomas
Where are most breast cancer seen?
In the upper outer quadrant
Give examples of risk factors of breast cancer
Gender
Uninterrupted menses
Early menarche
Late menopause
Reproductive history such as parity and age at first full term pregnancy
Obesity and high fat diet
Exogenous oestrogens
Geographic influence
Previous breast cancer
Radiation
Breast density
How common is hereditary breast cancer
10% of breast cancers
What genes are associated with breast cancer?
BRCA1
BRCA2
p53 (Li-Fraumeni syndrome)
What are BRCA 1 and BRCA 2.
Tumour suppressor genes which increases the risk of breast cancer significantly.
The lifetime risk of female carriers is 60% to 85%
How can breast carcinoma be classified?
Divided into in situ and invasive
Divided into ductal or lobular
What is an in situ breast carcinoma?
Neoplastic population of cells that is limited to duct and lobular by the basement membrane
The myoepithelial cells are preserved
They do not invade into vessels and therefore cannot metastasise or kill the patient.
If a ductal carcinoma in situ cannot metastasise or kill the patient, why is it a problem then?
Because it is a precursor of invasive carcinoma.
It can still spread through ducts and lobular and be extensive.
What is Paget’s disease?
Cells that can extend to nipple skin without crossing the basement membrane.
They are unilateral red and crusting nipple.
How does invasive carcinoma differ from DCIS?
Invasive means it has invaded beyond the basement membrane and into the stroma.
It can invade into vessels and can therefore also metastasise to lymph nodes and other sites.
By the time a cancer is palpable more than half of the patients will have axillary lymphnode metastasis.
What is peau d’orange?
Involvement of lymphatic drainage of skin in breast cancer.
You can see breast cancer sometimes with the naked eye.
How?
In breast cancer there can be nipple retraction.
How is invasive breast carcinoma classified?
Invasive ductal carcinoma, no special type (IDC NST)
Invasive lobular carcinoma
Other types such as tubular and mucinous.
Most common invasive breast carcinoma
Invasive ductal carcinoma (70-80%)
Invasive lobular carcinoma (5-15%)
Mucinous (1-6%)
Tubular (1-2%)
Explain the features of invasive ductal carcinoma
Well differentiated with tubules lined by atypical cells.
There is also a poorly differentiated type with sheets of pleomorphic cells.
Prognosis of IDC NST
35-50% 10 year survival
Explain features of invasive lobular carcinoma
Infiltrating cells in a single file and cells that lack cohesion.
Similar prognosis to IDC NST
How does breast cancer spread?
Lymph nodes via lymphatics and then usually to the ipsilateral axilla.
Distant metastases via blood vessels and then to bones, lungs, liver and/or brain.
There are some odd targets of invasive lobular carcinoma.
Give examples.
Peritoneum
Retroperitoneum
Leptomeninges
GI tract
Ovaries
Uterus
What factors determine prognosis in breast cancer?
Whether it is in situ or invasive
Tumour stage (TNM)
Tumour grade
Histological subtype
Molecular classification and gene expression profile
What is the molecular classification of breast cancer?
Breast carcinoma can either be oestrogen receptor positive or oestrogen receptor negative.
If it is positive then you look at Her2 positive or negative.
If it is negative then you also look at Her2 positive or negative
There is a better prognosis of oestrogen receptor positive breast carcinoma.
How is breast cancer investigated and diagnosed?
Triple approach of:
Clinical - history, FH and examination
Radiographic imaging - mammogram and ultrasound scan
Pathology with a core biopsy and fine needle aspiration cytology
What do you look for on mammographic screening?
Asymmetric densities, parenchymal deformities and calcifications.
What are the therapeutic approaches in breast cancer?
Breast surgery
Axillary surgery
Post-operative radiotherapy to chest and axilla
When is breast surgery done?
Mastectomy or breast conserving surgery where the decision depends on the patient choice
It also depends on the size and site of tumour and number of tumours as well as size of breast.
When is axillary surgery done?
The extent depends on whether there are involved nodes (sentinel node sampling or axillary dissection)
What is sentinel lymph node biopsy?
Reduces the risk of postoperative morbidity and is an intraoperative lymphatic mapping with dye and/or radioactivity of the draining of sentinel lymph node(s).
Sentinel lymph node is the most likely to contain breast cancer metastases.
When is axillary dissection avoided?
If the sentinel lymph nodes are negative.
Give examples of systemic treatment of breast cancer.
Chemotherapy
Hormonal treatment
Herceptin treatment
What is hormonal breast cancer treatment?
E.g. tamoxifen which is given in oestrogen receptor positive breast cancers. (ER+)
Doesn’t work effectively in ER-
Explain herceptin treatment.
Depends on the Her2 receptor status.
If the cancer is Her2 receptor positive then Herceptin treatment can ensue.
Herceptin is trastuzumab which is a humanised monoclonal antibody against the Her2 protein.
How do we improve survival from breast cancer?
Early detection
Neoadjuvant chemo
Use of new therapies such as herceptin
Gene expression profiles
Genetic screening
