Treatment of breast disease Flashcards
breast cancer affects?
1 in 8 women
Risk factors for breast cancer? (8)
- increasing age
- previous breast cancer
- genetic (5%)
- Early menarche and late menopause
- Late or no pregnancy
HRT - Alcohol (>14 units per week)
- Weight
- Post Radiotherapy treatment for Hodgkin’s disease
presentation: asymptomatic
breast screening - 50-70 years
symptomatic presentation includes? (9)
- Lump
- Mastalgia (persistent unilateral pain)
- Nipple discharge (blood-stained)
- Nipple changes (Paget’s disease, retraction)
- change in colour of areola
- redness or pitting of skin- like orange skin
- Change in the size or shape of the breast
- Lymphoedema (Swelling of the arm)
- Dimpling of the breast skin
new patient clinic - radiological?
Bilateral mammograms / USS
new patient clinic - CYTO-PATHOLOGICAL?
- FNA- cells only (cytology)
- Core Biopsy- tissue (histo-pathology)
Clinical assessment - history
Present Complaint
Previous Breast Problems (prevention cysts or cancers)
Family History of breast or ovarian cancer
Hormonal Status
Drug History - blood thinning?
Clinical assessment - examination
BOTH Breasts, Axillae, SCF
most common sign and symptom
lump or thickening in breast. Often painless
how can the breast be imaged?
- what is most sensitive
mammography, ultrasound or MRI
- mammography
why is sensitivity reduced in younger women to mammography?
due to the presence of increased glandular tissue (<35yrs)
what Is FNA?
Fine Needle Aspiration
-> Cytology
what is core-biopsy
Histo-Pathology
Invasive versus in-situ
ER, PR, HER2 receptor status
most accurate test
FNA cytology
Mammography
examination/ultrasound
80 % of breast cancers are
10% can be
Ductal Carcinoma - come from the ducts
- lobular carcinoma- milk producing cells
10% = others
non invasive breast cancers?
DCIS - Ductal Carcinoma In Situ
LCIS - Lobular Carcinoma In Situ)
management of cancer (3 steps)
1 . Diagnose the disease
- Staging of the disease
- Definitive treatment
Assessing the severity (“Staging”) (4)
- FBC, U&Es, LFTs, Ca2+/PO2-
- Chest x ray
- Others as clinically indicated
- No reliable tumour markers
T - staging - T0 means?
Primary tumour not palpable
what does T1 mean?
Clinically palpable tumour -size < 2 cm
T3 means?
Tumour size > 5 cm
T4a when?
skin invasion
T4b when?
invading chest wall
T4c when?
invading both
T4d when?
inflammatory breast cancer - worst kind
N - Regional Lymph Nodes staging?
N0 - No Regional lymph nodes palpable
N1 - Regional lymph node palpable- mobile
N2 - Regional lymph node palpable- fixed
M - Distant Metastasis staging ?
Mx - Distant metastasis cannot be assessed
M0 - No distant metastasis
M1 - Distant metastasis
Management/ Treatment Neo-Adjuvant means?
treatment that has happened before surgery
Management/ Treatment -Adjuvant means?
treatment after surgery
management types?
Surgery
+/- Radiotherapy
+/- Chemotherapy
+/- Hormonal Therapy
2 main types of breast surgery?
- Breast conservation surgery
- Mastectomy
Patients suitable for breast conservation surgery?
Tumour size clinically <4cm – IN THE OLD DAYS
- Breast/Tumour size ratio
- Suitable for radiotherapy
- Single tumours – IN THE OLD DAYS
- Patient’s wish – most important!!
what node is first to receive lymphatic drainage?
sentinel
first node tumour will spread to
sentinel
is the SLN is negative..
clear of tumour)
– no further treatment required
If SLN contains tumour ..?
either remove them all surgically (clearance= ANC) or give radiotherapy to all the axillary nodes
Complications of axillary treatment? (6)
- Lymphoedema (10-17%) - can be mild or severe
- sensory disturbance (intercostobrachial n.)
- decrease ROM of the shoulder joint
- nerve damage (long thoracic, thoracodorsal, brachial plexus)
vascular damage - radiation-induced sarcoma
Factors associated with increased risk of disease recurrence?
- Lymph node involvement
- Tumour grade
- Tumour size
- Steroid receptor status (negativity- ER/PR neg)
- HER2 status (positivity- HER2 pos)
- LVI- lymphovascular invasion
Prevention - local
radiotherapy
prevention - systemic
- Hormone therapy
- Chemotherapy
- Targeted therapies
after surgery most patients will get
radiotherapy
Complications of radiotherapy (4)
Skin reaction- Skin telangiectasis
Radiation pneumonitis
Cutaneous Radionecrosis/ Osteonecrosis
Angiosarcoma
hormone therapy is only given for?
oestrogen positive receptors
2 examples of Aromatase Inhibitors
Arimidex (1mg) &
Letrozole (2.5mg)
drug you can give in hormone therapy?
Tamoxifen
chemotherapy has best benefit
young women under 50
- more higher risk cancers
- grade 3, LN pos, ER neg, HER2 pos
HER2 positivity and Anti-HER2 therapy- what drug?
Trastuzumab (Herceptin®)/Pertuzamab
why use HER2 positivity ? (4)
- Monoclonal antibody against HER-2 receptor
- Given to patients with over-expression of HER2 and chemotherapy
- 50% decrease risk of recurrence
- 33% increase in survival at 3 years!
Follow up?
- Clinical examination for 1-5 years
- Mammogram of breast(s) at yearly intervals for 3-10 years
metastatic spread? Local
Chestwall
Skin
Nipple
metastatic spread - Distant - give them in order
Contralateral Breast
Bone Lung Liver Brain Bone Marrow
