Breast cancer Flashcards

1
Q

Anatomy

A

Can be divided into two regions:
- Circular body
- Axillary tail - runs into axillary fossa
Can also be divided structurally:
- Mammary glands - consists of the functional apparatus of the breast in branched structure:
= Lactiferous ducts - one per lobe, exiting at the nipple
= Lobes - 15-20 per breast, each containing 20-40
= TDLUs: terminal duct lobular unit. Functional and histological unit of the breast. Made up of glandular tissue producing milk.
- Stroma: fibrous connective tissue, supports the structure of the breast and forms the suspensory ligaments of Cooper. Each lobule is demarcated by Cooper ligament.

Drainage system:
- Lobule
- Terminal duct
- Collecting duct
- Taking milk to the nipple

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2
Q

Where do most cancers and benign lesions occur

A

TDLU

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3
Q

Lobules and ducts layers

A

Lined by an epithelium consisting of two layers:
- Inner luminal epithelial cells
- Outer myoepthithelial cells

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4
Q

Where do most cancers occur

A

upper outer quadrant

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5
Q

Lymph node drainage

A

75% = axillary lymph nodes
20% = parasternal nodes
5% = posterior and intercostal nodes

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6
Q

What is the first lymph node to which the cancer cells are most likely to spread to?

A

The sentinel lymph node is the axillary lymph node due to its proximity to the breast = has implications with regards to staging and management

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7
Q

Epidemiology

A

General risk factors
- Increasing age
- Female: 99% of cases occur in females and is the biggest risk factor for developing breast cancer
- Previous history of breast cancer
- Family history
- Proliferative lesions: atypical hyperplasia
- Alcohol
- Smoking
- Post menopausal weight gain. Aromotase in fat cells helps convert testosterone into oestrogen

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8
Q

Genetic risk factors

A

BRCA1/BRCA2:
- tumour suppressor gene involved in DNA repair
Increased risk of breast and ovarian cancer
- MC cause of hereditary breast cancer
- Male breast cancer associated with BRCA2

Li-Fraumeni syndrome: autosomal dominant p53 mutation
- Breast, brain, adrenal, leukaemia/lymphoma, osteosarcoma
- Radiosensitive - will be treated often with chemotherapy

Peutz-Jeghers syndrome
- Benign intestinal hamartomas and malignancies involving GI tract, breast, pancreas, and GU tract

Klinefelter syndrome: 47 XXY
- Increased risk of breast cancer in men

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9
Q

Hormonal

A

Increased oestrogen exposure
- Endogenous
= Obesity
= Early menarche
= Late menopause
= Late pregnancy/ nulliparity
= Breastfeeding and multiparity are protective
- Exogenous oestrogen
= HRT
= Oral contraceptive use

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10
Q

Pathophysiology

A
  • Complex series of genetic mutations and deranged cellular signalling leads to generation of malignant cells.
  • Breast cancer can be linked to inherited genetic mutation such as BRCA-1
  • Malignant cells metastasise though a 5 step process:
    1. Invasion through basement membrane
    2. Intravasation (entry into circulation)
    3. Circulation
    4. Extravasation
    5. Colonisation
    Most common mets are: Bone, brain, liver and lungs
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11
Q

Signs

A

Palpable mass
- Firm and non-tender
- Poorly defined
- Located in the upper outer quadrant most commonly
Nipple discharge
Nipple retraction
Skin changes: peau d’orange
- Tethering: mass fixes to surrounding structures, e.g. fascia, pectoral muscle, or Cooper ligaments

Evidence of metastasis:
- weight loss
- bony pain
- shortness of breath

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12
Q

Symptoms

A

Painless lump
- Breast
- Axilla
Skin changes
- Discolouration
- Erythema, swelling from oedema presenting as Peau d’orange are suggestive of inflammatory carcinoma
Nipple changes:
- Inversion
- Bloody discharge
- Eczema

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13
Q

2 week wait criteria

A
  • 30+ and have an unexplained breast lump with or without pain
  • 50+ and over with any of the following symptoms in one nipple only:
    = Discharge
    = Retraction
    = Other changes of concern
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14
Q

Considerations for 2 week wait

A
  • Skin changes that suggest breast cancer
  • 30+ with an unexplained lump in the axilla
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15
Q

A non-urgent referral

A

<30 with an unexplained breast lump with or without pain

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16
Q

Diagnosis

A

Triple Assessment:
- Clinical score 1-5 (history and examination)
- Imagining score 1-5
- Biopsy score 1-5
Imaging
= Mammography: varied appearance but include an irregular SPICULATED mass, clustered microcalcifications and linear branching calcification
= Ultrasound: adjunct to mammography esp in younger patients (< 40 years old) with denser breasts. Features include a hypoechoic irregular mass, architectural distortion, and calcification

17
Q

Types of biopsy

A

Core biopsy
Fine needle aspiration

18
Q

Staging

A

TNM Staging
T0 - No evidence primary
T1 < 2cm
T3 > 5cm
T4 - Extends to chest wall or skin or inflammatory
N0 - No nodes
N1 - Mobile nodes
N2 - Fixed/matted nodes
N3 - Internal mammary nodes
M0 - No mets
M1 - Mets

19
Q

Management

A

FIRST LINE: Surgical therapy:
- Breast-conserving: wide-local excision is indicated in localised smaller tumours
Mastectomy:
- Total mastectomy
- Skin-sparing
- Nipple-sparing
- Radical mastectomy
- Modified radical mastectomy
Axillary surgery:
- Sentinal lymph node biopsy: Px with no detectable axillary lymphadenopathy preoperativly = sentinel node identified (first node the breast cancer will metastasise to).
- Axillary lymph node dissection: Px with known axillary lymphadenopathy = multiple axillary lymph nodes are removed

20
Q

Indications for breast conserving therapy

A
  • Localised
  • Small tumour size:breast ratio
21
Q

Indications for mastectomy

A
  • Multifocal
  • Large tumour size:breast ratio
  • Breast-conserving surgery tissue removed has positive margins
  • Significant skin involvement
  • BRCA genetics - with high incidence of reoccurance
  • Previous lumpectomy + radiotherapy. Cannot irradiate the same place twice
  • DCIS > 40mm
22
Q

Adjuvent management to breast conserving surgery

A

Radiotherapy
- Indicated in those who have had breast-conserving surgery
- Considered in those who have had mastectomy if there are multiple lymph nodes positive, large tumours and/or positive margins.

23
Q

Hormone therapy

A
  • If tumour is invasive, systemic third line therapy indicated:
  • Indicated if the patient is ER-positive and continued for 5-10 years
  • Premenopausal: majority of oestrogen produced by ovaries
    = Selective oestrogen receptor modulators: e.g. tamoxifen and toremifene
    = Ovarian suppression: GnRH analogues like goserelin can also be used
  • Postmenopausal:
    = Aromatase inhibitor (prevents peripheral oestrogen synthesis): ANASTROZOLE/ LETROZOLE
24
Q

Biological therapy

A

Indicated if Human epidermal growth factor receptor 2 (HER2) positive
- Trastuzumab: also known as Herceptin, blocks HER2
- Chemo therapy given as adjuvant therapy

25
Q

Chemotherapy

A
  • Can be adjuvant or neoadjuvant:
    = TAXANE + ANTHRACYCLINE
    = taxane e.g.: paclitaxel, docetaxel
    = ACT e.g: doxorubicin, cyclophosphamide
  • Chemotherapy should be considered in the following:
    = Triple-negative disease
    = Early-stage disease and high risk of recurrence e.g. triple-negative or HER2 positive
    =Lymph node positive disease
    = Advanced disease
26
Q

Complications

A

Cancer-related
- Metastasis: bone, liver, lung, brain
- Malignant pleural effusion
- Recurrance
Treatment-related
- Surgery:
= cosmetic defect e.g. asymmetry
= seroma
= lymphoedema post-axillary node dissection
- Hormone and biologic therapy
= Tamoxifen: increased risk of endometrial cancer and VTE
= Herceptin: cardiotoxic/cardiac failure
= Aromatase inhibitor: osteoporosis - given bisphosphonates as adjuvant therapy
- Chemotherapy
= Neutropaenia
= Taxanes: peripheral neuropathy