Breast Cancer Flashcards
Basic pathology breast cancer
Sarcomas = rare cancers that arise from the stroma (connective tissue) components which include myofibroblasts and blood vessels cells and cancers arising from these “supportive” cells are phyllodes tumours and angiosarcoma.
Carcinomas = cancers from the epithelial component of the breast which consists of the cells that line the lobules and terminal ducts; under normal conditions these make milk
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In situ: no invaded breast tissue and the cancer cells grow inside of pre-eisting normal lobules or ducts. COntined within the basement membrane tissue, seen as pre-malignant condition.
- Ductal carcinoma in situ (DCIS)
- Lobular carcinoma in situ (LCIS)
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Invasive: Cancer cells infiltrated outside of normal breast lobules and grow into breast connective tissue. Have the potential to spread to other sides of the body.
- Invasive ductal carcinoma (75-80%)
- Invasive lobular carcinoma (10%)
- Other subtypes – medullary carcinoma or colloid carcinoma
- Muvinous medullary, papillary (rare)
Pagets disease
RFs invasive carcinoma of the breast
: Female sex, age, mutations to certain genes (TSG- BRCA1 BRCA2) , FH , previous benign disease obesity, alcohol consumption, geographic variation, unopposed oestrogen exposure (early menarche, late menopause, nulliparous women, oral contraceptives).
CLinical features of Invasive carcinoma of the breast
Breast lump, asymmetry, swelling, abnormal nipple discharge, nipple retraction, skin changes, mastalgia or lump in axilla.
Pagets disease of the nipple
rare condition with roughening, reddening and slight ulceration of the nipple. Most have underlying neoplasm. Involvement of epidermis by malignant ductal carcinoma cells and hypothesised they migrate or cells of nipple become malignant.
For a given patient with breast cancer, identify the prognostic factors
Nodal status is most important but size, grade and receptor status influence.
Nottingham prognostic index (NPI) = widely used clinicopathological staging system for primary breast cancer prognosis.
(Size x0.2) + Nodal status + Grade
- Size = diameter lesion in cm
- Nodal status = number axillary lymph nodes involves (0nodes=1, 1-4=2, >4=3)
- Grade = based on Bloom Richardson classification
Receptor status is key feature due to new targeted therapy. All malignancies should be checked for oestrogen receptor (ER), Progesterone receptor (PR) and human epidermal growth factor receptor (HER2) status.
Breast Examination
Triple Assessment of breast lumps and rationale
Hospital based assessment clinic to allow early and rapid detection of breast cancer. Can eb referred to this one stop clinic by GP that meet 2week wait criteria or suspicious finding on mammography. Quick and simple outpatient approach.
- History + Examination: by breast surgeon or associated specialist, PC, RFs, FH, medications.
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Imaging:
- Mammography = compression views of breat across 2 views (oblique and craniocaudal), allowing for detection mass lesions or microcalcifications
- US scanning = more useful in <35 and in men due to density of breast tissue. Routine for core biopsies too.
- MRI not used but can be used in assessment of lobular breast cancers with high sensitivity and low specificity.
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Histology or cytology: Biopsy required of any suspicious mass or lesion presenting to clinic, most commonly via core biopsy.
- Core biopsy = It provides full histology (as opposed to FNA) allowing differentiation between invasive and in-situ carcinoma. Can give info about grading an dstaging and higher sensitivity/specificity than FNA for detecting breast cancer. Can be tru cut (LA for large lump) or excision(if other investigations fail to give diagnosis) biopy too.
- If woman has recurrent cytic disease then can be aspirated with FNA to relieve symptoms
Explain the principles of surgical treatment of cancer of the breast
All discussed in MDT: breast surgeons, radiologists, oncologists, pathologists and breast cancer specialist nurses for most suitable and patient focused management plan available.
- Breast conserving: Localised operable disease and no evidence of metastatic disease. Wide local excision is most common with 1cm margin alongside tumour.
- Mastectomy: Removes all the tissue of affected breast and lots of overlying skin, indicated in multifocal disease, high tumour: breast tissue ratio, disease recurrence or patient choice.
- Reconstruciton
- No difference in 5-10year survival
Risk reducing mastectomy:
Remove healthy breast tissue to reduce risk of developing breast cancer. Only for those with high risk and requires counselling. Factors are strong FH breast/ovarian cancer, having BRCA1/ BRCA2/ PTEN/ TP53 mutations or previous history of breast cancer.
Explain the relevance of the assessment of the axilla in the management of breast cancer
Nodal status often determines need for systemic therapy, extend of surgery, reconstruction options and need for radiation therapy after surgery.
- Axillary surgery: mostly alongside WLE and mastectomies to assess nodal status and remove nodal disease.
- Sentinel node biopsy = remove 1st lymph nodes into which tumour drains (identified through blue dye) and histological analysis
- Axillary node clearance = remove all nodes in axilla ensuring to not damage any associated important structures within axilla then histological analysis. Common complications are paraesthesia, seroma formation, lymphedema in upper limb
Explain hormonal treatments for cancer of the breast. Name the commonly used hormones.
In malignant non-metastatic disease, therapy for breast cancer is adjuvant to reduce risk relapse. Hormone manipulation is the biggest contributor to improved survival (compared with chemo, radioT…)
- Tamoxifen = Typically in pre-menopausal patients, blocks oestrogen receptors and has role in prophylaxis against breast cancer. Known to increase risk of thromboembolism during and after surgery or periods immobility and increase risk uterine carcinoma.
- Aromatase inhibitors = (Like anastrozole, letrozole, exemestane) bind to oestrogen receptors and inhibit further malignant growth and preventing further oestrogen production and block conversion of androgens to oestrogen in peripheral tissues. Advised for post-menopausal patients as adjuvant therapy
- Immunotherapy – Used in patients whose cancer express specific growth factor receptors. Mostly HER-2 positive for which Herceptin (Trastuzumab) is a monoclonal antibody that targets the activity. Can be adjuvant or monotherapy who have had 2 chemo regiments for metastatic breast cancer.
Other Endocrine treatments:
- Non steroidal aromatase inhibitors – letrozole, anastrozole
- Steroidal aromatase inhibtiors – exemestane
- Selective oestrogen receptor degrader – fulvestrant
- Selective oestrogen receptor modulator – tamoxifen
- Common toxicities – nausea, hot flushes, swelling of joints, oedema, arthralgia, risk of bone loss, osteoporosis, depression
- Regular DEXA scan
Oncoplastic Management: Breast cancer
- new approach for extending technique to allow breast conserving surgery or reconstruct breast after mastectomy.
- Therapeutic mammoplasty – WLE with breast reduction technique and nipple an areola preserved with blood supply
- Flap formation = latissimus dorsi flap, transverse rectus abdominal muscle flap, deep inferior epigastric perforator flap
Describe, in general terms, adjuvant radiotherapy and chemotherapy in the treatment of breast cancer
- Adjuvant radiation therapy = eradicate any tumour deposits remaining following surgery for patients treated by either breast conserving surgery or mastectomy. Doing so reduces the risk of locoregional recurrence and improves breast cancer specific and overall survivals. Usually if cancer was large, if it spread to lymph nodes in armpit or there were cancer cells close to edge of removed breast tissue.
- Adjuvant chemotherapy = May have after to reduce the risk of breast cancer coming back. Usually offered it if it has spread to lymph nodes, large, high grade, HER2 positive, triple negative.
Neo-adj vs adj.
- No differences in long term OS, but slight increase in loco-regional occurrences in NACT
- NACT favoured as method to assess biology and guide post-operative treatment
- In HER2 and TNBC, preferred option if tumour >2 cm
- Carboplatin increases pCR rates in TNBC
- No prospective randomised data for platinum in TNBC or BRCA1/2 mutations in adjuvant setting
- Though some retrospective data and is commonly used for BRCA1/2 mutations
Identify which populations are offered breast screening
NHS breast cancer screening program 50-71years to have mammogram every 3 years if registered as female on GP and any abnormalities identified to be referred to breast clinic for triple assessment. 71 or over will not automatically be invited but can still have it every 3 years if request it. Mammography
Explain the benefits and potential drawbacks of breast screening
Research trials show women with breast screening reduce their risk of dying form breast cancer up to 20% compared to those who do not.
benefits
- Probably prevent around 1300 women in UK dying form breast cancer every year
- Cancers found at early syage so treatment more likely to be successful and 80% found then haven’t spread to lymph node.
- Of found early and small the surgeon can do breast conserving surgery instead of removing the whole breast (and then usually give radiotherapy)
Negatives
- Cannot prevent cancer
- Mammograms can be uncomfortable and involves x-rays
- Results may cause unnecessary worry (false positive)
- Mammograms may need to be repeated due to burry pc, missing part of breast tissue etc
- Cancer may be diagnosed between screenings
- May find cancer than doesn’t need treatment
Red flags for breast cancer
redness or flaky skin in nipple area, pulling of nipple or pain in the area. Discharge other than breast milk, including blood an any change in shape or size of breast
Breats anatomy
Malignant breast disease:
- DCIS – ductal carcinoma in situ. (Can be thought of as pre cancer). Low (usually revert to normal tissue after time). Intermediate and high grade (usually goes to invasive). Hence why breast screening can be overdiagnosis as surgery etc and yet don’t always develop cancer.
- LCIS – lobular carcinoma in situ
- IDC- invasive ductal carcinoma.
- ILC – invasive lobular carcinoma Lobular carcinoma more likely in both breasts vs ductal.
- Paget’s disease of the breast – looks like eczema/psoriasis. Always starts at nipple and go outwards rather than eczema is more likely if outside of the nipple. Need biopsy. If clears with steroids then its not cancer and pagets as cancer doesn’t respond to that
Breast cancer staging
Imaging one stop breats clinic
- Ultrasound is targeted investigation
- Mmamogram is screening tool (40+)
- Biopsies/cytology
- Axilla assessment
Normal on left, cancer on right
