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Year 3 Surgery > 9 - Breast Cancer > Flashcards

9 - Breast Cancer Flashcards

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1
Q

Which is the most common cancer in women?

A

Breast cancer

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2
Q

In the UK - women are assessed in specialist one stop clinics - what happens here? What is this called?

A

They get clinical, radiological and pathological evaluation

Called = triple assessment

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3
Q

What are red flags for breast cancer?

A

Inc / dec in size or symmetry
New or persistent skin changes
New nipple inversion or discharge
Breast pain or mass / lump
Hx of trauma to the breast

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4
Q

What Qs should you ask Ps about oestrogen exposure?

A

Age of menarche / menopause
Parity
Breastfeeding
Oral contraception
HRT
IVF

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5
Q

Who can have a mammogram?

A

Ps aged 40+ = skin too dense in younger Ps

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6
Q

What other imaging is used for breast cancer?

A

USS - inc imaged guided nodal biopsy
MRI

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7
Q

When is MRI used for breast cancer?

A

Women who have breast implants
Women who have dense breasts

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8
Q

What do we look for with breast histology?

A

Grade of cancer
DCIS - if high, low or intermediate
ER / PR / HER2 status (receptor)
Lymphovascular invasion
Lymph node assessment

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9
Q

What can breast pain be divided into?

A

Cyclical
Non-cyclical
Extramammary

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10
Q

Is pain a common feature of breast cancer?

A

No - <3% of breast cancers present with pain

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11
Q

What can extramammary pain be caused by?

A

MSK conditions - e.g. costo-chondritis

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12
Q

What percentage of palpable breast lumps in 20s-50s are benign?

A

> 90%

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13
Q

What a common cause of firm and mobile masses in the breast, mostly in younger Ps?

A

Fibroadenoma

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14
Q

What do fluid-filled masses tend to be?

A

Cysts

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15
Q

What changes can make breasts mildly tender and nodular in premenopausal women?

A

Fibrocystic changes

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16
Q

What is a milk retention cyst (cyst filled with milk) that is common in breastfeeding women?

A

Galactocele

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17
Q

Blunt trauma to the breast can cause?

A

Fat necrosis - can be difficult to distinguish from malignancy on mammogram

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18
Q

What is a fluctuant, tender, palpable mass with skin change likely to be?

A

Breast abscess

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19
Q

How are breast cysts ruled out as being malignant?

A

Usually USS sufficient but if in doubt - biopsy

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20
Q

What is the age of peak incidence of breast cysts?

A

35-50

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21
Q

How are breast cysts treated?

A

Often resolve within 5 years
If Sx can be aspirated but recurrence is common

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22
Q

When is nipple discharge more likely to be cancer?

A

In older Ps?
Only a sign in 3% of Ps <40 with cancer
10% 40-60
32% 60+

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23
Q

What can medications can cause nipple discharge?

A

Warfarin - can cause brown/ blood stained discharge
APs - can cause milky discharge
Smoking - can cause green/grey discharge

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24
Q

Persistent discharge for how long is more likely to be associated with a neoplastic lesion?

A

More than 2 weeks

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25
What are the signs of galactorrhea?
Bilateral discharge Pale milky colour From multiple ducts
26
What should you check if galactorrhea is suspected?
Prolactin levels - if >1000 - is more likely to be secondary to medication or a pituitary tumour
27
What can produce serosanguinous or bloody discharge?
Duct papillomas Epithelial hyperplasia DICS or Invasive carcinoma
28
What colour discharge can duct ectasia produce?
Thick yellow
28
What investigations are done for duct discharge?
Cytology not done Mammogram if >40 USS if nothing seen on mammogram
29
Which hormones can you test for in gynaecomastia?
LH FSH Testosterone Prolactin Α Fetoprotein βHCG
29
Which drugs can cause gynaecomastia?
Digoxin Amiodarone Spironalactone TCAs Haloperidol
29
How is gynaecomastia Rx?
Often conservatively - reassure and explain. Remove cause if any.
30
What causes gynaecomastia in men?
Imbalance of androgen and oestrogen - idiopathic 58% - hypogonadism 25% - hyperprolactinemia - 9% - chronic liver disease 4% - drugs - testicular cancer
31
What can cause mastitis?
Lactation (75%) Inflammatory cancer Infected foreign body (implant)
31
What are the RF for mastitis?
Smoking DM Immunosuppression Sore/cracked nipples IBD
32
What is the Rx for mastitis
Abx
33
What complication can mastitis cause?
10% will develop breast abscess
34
What is the most common bacteria that causes breast abscess?
Staph aureus
35
What are the RF for mastitis?
>30 First pregnancy Smoking DM, RA, Steroid Rx and trauma
36
What do you need to check if a P has a non-lactating abscess?
Check for cancer - <1% of cancers can cause this but they trend to be aggressive ones.
37
How do breast abscesses present?
Localised, painful inflammation Fever malaise Fluctuant, tender, palpable mass
38
How is breast abscess confirmed?
USS - often combined with needle aspiration
39
What percentage of cancers in F are breast cancer?
15%
40
What are the RF for breast cancer?
Young menarche Old first birth Old menopause Past use contraceptive pills HRT Alcohol Dense breasts Obesity
41
Which familial cancers are relevant to increasing a P's chance of getting breast cancer?
Ovarian or breast cancer in the family are relevant - look at number of cases, relationship, age at diagnosis
42
Which race has a higher risk of getting breast cancer?
Ashkenazi Jews
43
Which genetic mutations are linked to inc risk of breast cancer?
BRACA1 BRACA2 TP53 80-90% Li Fraumeni 80-90%
44
How do BRACA genes cause an inc risk of breast cancer?
BRACA1 & 2 are tumour suppressor genes - AD inheritance - mutations mean that tumours are not suppressed as well
45
What does being BRACA1 or 2 positive do to your risk of (1) breast cancer (2) ovarian cancer?
Breast = x5 higher than normal pop Ovarian = 10-30x higher than normal pop
46
How are Ps with BRACA gene mutations managed?
Annual breast MRI 30-49 Mammography from 40
47
What is the current screening for breast cancer in the UK?
Mammography from 50-70 every 3 years
48
What are the classic characteristics of a cancerous breast lesion?
Hard Immoveable Single dominant lesion with irregular borders
49
What is it called when you have eczematous change to the nipple-areolar complex (that is 80% associated with cancer)
Paget's disease
50
What breast findings can indicate locally advanced disease?
Axillary adenopathy Erythema Thickening of skin Peau d'orange Function of tumour Distant disease - bone pain, pathological fractures, hepatomegaly
51
52
What surgical management is done for DCIS?
Wide local excision + radiotherapy Axillary node biopsy - can do sentinel lymph node biopsy using radioisotope.
53
What complications can arise from axillary node clearance?
Lymphodema of the arm
54
What are poor prognostic factors for chemo?
High grade tumour Negative receptor cancer
55
Which Rx is given for HER-2 positive cancer?
Herceptin
56
What possible hormone receptors are linked to breast cancer?
ER = oestrogen receptor PR = progesterone receptor HER2 = Human Epidermal Growth Factor 2
57
What are poor prognostic factors for breast cancer surivial?
Advanced stage - esp involving axilla High grade Inflammatory cancer = poor prognosticator Young diagnosis Triple negative - HER2, ER and PR negative
58
What is used to block ER receptors?
If a cancer is ER +ve = it receives signals from oestrogen to grow Can use SERMS = selective ER modulators - these block the ER receptors and prevent hormones from binding to them SERDS = selective ER degraders - block and damage ER receptors Can also use aromatase inhibitors - stops conversion to oestrogen.
59
What is it called when cells grow and divide more than they should, or do not die when they should, creating an abnormal mass of tissue?
Neoplasia
60
Where do the majority of breast cancers arise?
In the terminal duct lobular units
61
What is the breast?
A modified exocrine gland
62
What is the breast microbiome? Why do we have it?
Breast has more diverse bacterial populations living in it than then skin - over 200 species. Have it to establish gut microbiome of breastfeeding babies and infants
63
Which chromosomes have BRACA 1 and 2 on them?
1 = Chr 17 2 = Chr 13
64
Which ethnic groups have persistent mutations of the BRACA gene?
Ashkenazi Jews Icelanders
65
Apart from BRACA, which other gene mutations are linked to inc breast cancer risk?
CHEK2 PALB2 ATM TP53
66
What does SNP stand for?
Single nucleotide polymorphism - give small but cumulative risk of developing BC
67
What is it called when cells have the hallmarks of breast cancer but have not broken through the walls of the duct?
Pre-invasive breast cancer - DCIS or pleomorphic lobular carcinoma in situ
68
How does invasive cancer differ from pre-invasive?
Cancer cells have breached the basement membrane to invade local tissues - can enter BVs and lymph
69
What are Risk Lesions?
Aka Cellular Atypia Disorder where the cells look abnormal, but not sufficiently to be called pre-invasive breast cancer. Is a risk that they can increase risk of BC. Different types of these lesions inc - Atypical intraductal epithelial proliferation - ALH or LCIS etc
70
What is then most common type of breast cancer?
Invasive ductal carcinoma of no special type = 75%
71
What types of breast cancer are there?
72
How is breast cancer graded?
Score each of these - Look at the nucleus compared to normal cells = nuclear grade Mitotic rate Tubule formation Combine the scores 3-5 = low grade (1) 6-7 = intermediate grade (2) 8-9 = high grade (3)
73
How are lymph node mets classified?
Isolated tumour cells Micromets <2mm Macromets >2mm Extracapsular spread - has pushed through the capsule of the lymph node
74
How are isolated tumour cells treated?
Dealt with as a negative lymph node finding but indicate the need for more treatment
75
How is breast cancer staged?
Stage 1 = confined to breast 2 = breast and regional (axilla) lymph nodes 3 = skin or muscle + regional lymph 4 = mets to other parts of the body
76
How does TNM staging work?
T = size N = nodes involved M = mets
77
What percentage of breast cancers are picked up via screening?
1/3 = from screening 2/3 = from symptomatic presentation
78
What is the aim of breast screening?
To detect cancers at an early stage before they are big enough to be felt - this allows inc survival but also less invasive Rx.
79
How much radiation in a mammogram?
7 weeks background 20 CXR
80
Due to screening - in 1000 Fs how many will be diagnosed with cancers that would not have caused harm?
17
81
What do we look for on mammogram?
Masses Microcalcifications Distortion Asymmetry
82
What percentage of breast cancers are DCIS?
20%
83
How is DCIS seen on mammogram?
Microcalcification
84
How many women will develop cancer between mammograms? What percentage of these were missed cancers?
3 in 1000 20% were subtly seen on first mammogram
85
What happens in triple assessment?
86
Are mammograms effective in dense breasts?
The are less accurate in dense breasts. Normally - 80-85% accurate But in dense tisse - only 60% Dense breasts are also MORE likely to develop breast cancer!
87
What imaging can you do for very dense breasts?
Contrast enhanced mammogram 3D mammogram
88
If a P is under 40 - what first test should they have when presenting with a breast lump?
USS

Year 3 Surgery (15 decks)

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