Surgery: Breast Cancer Flashcards
Risk factors for breast cancer
- age → >50 female (rare under 35)
- family history → first degree relatives
genetics → BRCA/Li-Fraumeni (5% of breast ca)
- oestrogen exposure: 1st pregnancy >30yrs, OCP/HRT, late menopause, early menarche, obesity
- Alcohol
- Smoking
What’s the risk of developing cancer with BRCA1 and BRCA2 genes?
80-90%
How can breast cancer present?
(symptoms or picked up where)
- Through screening programme i.e. asymptomatic
- Lump –hard, irregular, tethered
- Change in shape
- Ulceration
- Skin changes e.g. Peau d’orange
- Inflammatory breast cancer
- Nipple changes e.g. Paget’s disease, discharge, inversion
- Metastatic cancer – axillary lumps, incidental on scans
- Incidental: Picked up on imaging for something else
Types of malignant breast cancer (names)
Breast cancer staging
(TN)
What histological types of breast cancer have better prognosis?
- Tubular
- mucinous
- medullary
- adenoid cystic
What’s the most common type of non-invasive breast cancer?
Ductal Cell Carcinoma
20% of all breast cancers
What happens in Ductal Carcinoma in-situ?
Malignant cells have not penetrated the epithelial basement membrane → so have not yet extended out of the breast duct system
- 20-30% of patients who do not receive the treatment will develop invasive disease
Investigations for Ductal Carcinoma in situ
- often detected during screening → appears as microcalcifications on mammography
- biopsy → to confirm
Management of Ductal Cell Carcinoma In Situ (DCIS)
- Any detected localised DCIS should be treated with complete wide excision, ensuring the surrounding tissue of all margins have no residual disease
- Cases of widespread or multifocal DCIS normally requires complete mastectomy
Possible modes of management (general types of treatment) for breast cancer
- Surgery
- Radiotherapy
- Chemotherapy and targeted therapy
- Endocrine therapy
Who does Breast Cancer MDT consist of?
- all patients diagnosed with breast cancer should be discussed within the multidisciplinary team (MDT) meeting
- includes breast surgeons, radiologists, oncologists, pathologists, and breast cancer specialist nurses
When us ‘curative’ approach used and when is ‘palliative’ approach used?
- curative → either no lymph node involved or only axillary node is involved
- palliative → symptoms relief when distant metastases are present
Name (2) surgical options with a curative approach in breast cancer
- mastectomy
- breast-conserving surgery
When are they used (criteria):
- mastectomy
- breast-conserving surgery
- Breast-conserving → suitable for smaller tumours (<5cm) or if patient prefers minimal surgery, suitable for patients with localised disease with no evidence of metastases
- Mastectomy → suitable for large (<5 cm), central or multifocal tumours, recurrance of the cancer, patient choice
What happens during breast-conserving surgery?
Wide Local Excision (WLE) → lump is removed with a wide margin and followed by radiotherapy
*typically ensuring a 1cm margin of macroscopically normal tissue is taken along with the malignancy
What happens during a mastectomy?
- removes all the tissue of the affected breast, along with a significant portion of the overlying skin (the muscles of the chest wall left intact)
- the amount of skin that is excised is often dependent on whether a reconstruction is planned.
What is the aim of axillary surgery?
- most commonly performed alongside WLE and mastectomies
- to assess nodal status and remove any nodal disease
What is sentinel lymph node biopsy?
How is it performed?
Sentinel node biopsy:
- involves removing first lymph nodes into which the tumour drains
- The nodes are identified by injecting a blue dye with associated radioisotope into the peri-areolar skin → radioactivity detection and / or visual assessment (as the nodes become blue) can then identify → the sentinel nodes can then be removed and sent for histological analysis
The possible outcomes of sentinel nodes biopsy (2)
- negative → rest of the lymphatic trunk is probably free of metastases *
- positive → all nodes are removed from the axilla
*false-negative ratio is about 5%
What happens in axillary node clearance?
Complications
Axillary node clearance:
- involves removing all nodes in the axilla, ensuring to not damage any associated important structures within the axilla, which are then sent for histological analysis
- Common complications from this operation include paraesthesia, seroma formation, and lymphedema in the upper limb.
Who medical treatment for breast cancer is offered to?
- in non-metastatic malignant cancer, after primary surgery→ as therapy adjuvant
- in the elderly or people not fit for the surgery
What’s the importance of Oestrogen Receptor (ER) expression?
A tumour that expresses ER is dependant on oestrogen → susceptible to hormonal therapies
- status is determined histologically
- ER positive tumours (common) have better prognosis
Tamoxifen
- used in what group of patients
- MoA
Tamoxifen
- used typically in pre-menopausal patients
- acts through blockade of oestrogen receptors, therefore also has a role in prophylaxis against breast cancer
Side effects of Tamoxifen
Tamoxifen increases the risk of:
- thromboembolism during and after surgery or periods of immobility
- uterine carcinoma (due to its pro-oestrogenic effect on the uterus)
Aromatase inhibitors
- names (3)
- group of patients used on
Aromatase inhibitors
- advised for post-menopausal patients
- as adjuvant therapy
- however are more expensive than Tamoxifen (but superior to Tamoxifen in these groups of patients)
MoA of Aromatase inhibitors (2)
- binding to oestrogen receptors to inhibit further malignant growth and preventing further oestrogen production
- also blocking the conversion of androgens to oestrogen in peripheral tissues
What group of patients is immunotherapy used in?
In patients whose cancers express specific growth factor receptors.
What is HER-2
What is the treatment
Human epidermal growth factor receptor (HER-2)
- positive malignancies for HER-2 treated with Herceptin (Trastuzumab)*
*is a monoclonal antibody that targets its activity → immunotherapy
*It can be used either as adjuvant therapy or as a monotherapy in patients who have received at least two chemotherapy regimens for metastatic breast cancer
Common side effect of Herceptin treatment
cardiotoxicity → hence cardiac function must be monitored before and during treatment
What is oncoplastic management? (in general)
- oncoplastic surgery → a new approach for either extending techniques to allow breast-conserving surgery or to reconstruct the breast following mastectomy
- there are several surgical reconstructive techniques in the oncoplastic treatment of breast malignancy, broadly divided into mammoplasty and flap formation
Paget’s Disease
- what’s that
- what to do
- it is a skin manifestation (patch of eczema around the nipple)
- suggestive of underlying malignancy (1% of cancers may present like that)
- underlying malignancy may be palpable (not always)
- need to perform mammography/ultrasound and nipple biopsy (punch biopsy)
How to differentiate Paget’s Disease of the Nipple from Eczema of the Nippe?
Paget’s disease differs from eczema of the nipple in that it:
- involves the nipple primarily and only later spreads to the areolar (the opposite occurs in eczema)
What timescale of nipple retraction do we worry about?
If it’s short onset e.g. less than 3 months
Family history of what cancers do we consider as relevant to tisk of breast cancer (4)?
- breast
- ovarian
- prostate
- pancreas
What does score 1 mean and what does sore 5 mean?
1 - not cancer; benign disease e.g. fibroadenoma
2
3
4
5 - definitely cancer
What age do we consider mammogram and at what age do we do USS?
- mammogram → age 40 or more
- USS → less than 40
What does C1 (cytology result mean)?
What does B1 (biopsy) mean?
C1 = inadequate sample to perform scoring !
B1 = normal
What do we do for a persistent and/or bloody discharge?
Surgical excision of the duct
How do we manage (at GP setting) a patient presenting with abscess or mastitis? When do we refer?
- History + examination
- Give antibiotics
- See in 2 weeks → if the infection still there → refer for triple assessment*
* this is to role out inflammatory cancer
What’s the difference between staging and grading?
Staging → how much tumour is there in an axilla, breast, body (e.g. metastases)
Grading → change in tissue e.g. hyperplasia, metaplasia (how different is a lump from normal tissue)
*the higher grade, the more different
Breast screening programme in the UK
- to include women aged 47-73 years
- mammogram every 3 years
- after the age of 70 years women may still have mammograms but are ‘encouraged to make their own appointments’
When does a patient who had one 1st or 2nd-degree relative with breast cancer must be referred?
If the person has only one first-degree or second-degree relative diagnosed with breast cancer they do NOT need to be referred unless any of the following are present in the family history:
- age of diagnosis < 40 years
- bilateral breast cancer
- male breast cancer
- ovarian cancer
- Jewish ancestry
- sarcoma in a relative younger than age 45 years
- glioma or childhood adrenal cortical carcinomas
- complicated patterns of multiple cancers at a young age
- paternal history of breast cancer (two or more relatives on the father’s side of the family)
How to differentiate fibrocystic change from fibroadenoma?
- Fibrocystic change → no definitive lump
- Fibroadenoma → definitive lump
What does it mean ‘triple-negative breast cancer’ and what group of patients it tends to occur in?
- Cancer that is: oestrogen, Herceptin and progesterone negative
- Tends to occur in BRACA mutations
*use chemotherapy as systemic treatment
