Breast (3) (Malignant conditions) Flashcards
(49 cards)
1
Q
Carcinoma in situ
A
Malignancies that are contained within the basement membrane tissue.
2
Q
invasive
A
any type of breast cancer that has spread (invaded) into the surrounding breast tissue.
3
Q
carcinoma in situ is seen as
A
- pre-malignant condition, typically found on imaging and are rarely symptomatic at presentation
4
Q
two types of carcinoma in situ
A
- Ductal carcinoma in situ (DCIS)
- Lobular carcinoma in situ (LCIS)
5
Q
ductal carcinoma in situ (DCIS)
A
- Most common non-invasive breast malignancy (20%)
- Malignancy of ductal tissue of the breast- contained within basement membrane
- 20-30% of cases will develop invasive disease
-
Subtypes
- Comedo (microcalifcations), cribriform (multifocal), micropapillary (multifocal) and solid types, most are mixed
6
Q
presentation of DCIS
A
- Usually asymptomatic
- Microcalcifications on mammography
7
Q
investigations for DCIS
A
- Detected during screening
- Confirmed by biopsy
8
Q
management of DCIS
A
- Completely wide excision, ensuring surrounding tissue of all margins have no residual disease
- Widespread or multifocal DCIS – complete mastectomy
9
Q
lobular carcinoma in situ
A
Is a malignancy of the secretory lobules of the breast that is contained within the basement membrane.
They are much rarer than DCIS however individuals with LCIS are at greater risk of developing an invasive breast malignancy
10
Q
RF for LCIS
A
before menopause
11
Q
presentation of LCIS
A
asymptomatic
12
Q
investigations of LCIS
A
- Incidental finding during biopsy of breast
13
Q
management of LCIS
A
- Depends on extent of disease
- Low grade LCIS
- Monitoring rather than excision
- If invasive component and BRCA1 or BRCA2 positive à bilateral prophylactic mastectomy
14
Q
invasive cancer can be classified into
A
Carcinoma most common in western world. Classification
- Invasive ductal carcinoma (80%)
- Invasive lobular carcinoma
- Other subtypes
- Medullary carcinoma
- Colloid carcinoma
15
Q
RF for invasive cancer
A
- Female sex
- Older (doubles every 10 years until menopause)
- BRCA1 and BRCA2 mutation
- Family history
- Previous bening disease
- Obesity
- Alcohol
- Degree of exposure to oestrogen
- Early menarche
- Late menopause
- Nulliparous women
- First pregnancy after 30 years age
- Oral contraceptive or hrt
16
Q
presentation of invasive cancer
A
- Can present symptomatically or asymptomatically via screening(particularly for ILC).
- Breast lump
- Asymmetry
- Swelling
- Abnormal nipple discharge
- Nipple retraction
- Skin changes (dimpling/peau d’orange or Pagets-like change)
- Mastalgia
- Palpable lump in axilla
17
Q
investigations for invasive cancer
A
- Triple assessment:
- Clinical – history, family history, examination
- Radiographic imaging – mammogram (in older) and ultrasound scan (in younger)
- Pathology – core biopsy and fine needle aspiration cytology (FNAC)
- Receptor status
- Oestrogen, progesterone, human epidermal growth factor
18
Q
prognosis of invasive cancer
A
Nodal status is the most important prognostic factor in breast cancer- size, grade and receptors status also influence prognosis
19
Q
invasive ductal carcinoma
A
- Most common type of breast carcinoma, constituting 80% of all cases.
-
Further classified into
- tubular, cribriform, papillary, mucinous (/colloid), or medullary carcinomas, all showing distinct patterns of growth*.
- Most commonly incidental finding during screening
*Tubular, cribriform and papillary subtypes are well circumscribed and show the most favourable prognoses
20
Q
what does an IDC look like
A
- Irregular
- Condensed part which tugs other tissue in e.g. inverted nipple or breast dimple
21
Q
Invasive lobular carcinoma (ILC)
A
- Constituting 10% of all invasive breast cancers.
- RF more common in older women.
- It is characterised by a diffuse (stromal) pattern of spread that makes detection more difficult. By the time of diagnosis, tumours are often quite large.
22
Q
staging- nottingham prognostic index
A
Nottingham prognostic index
It is calculated by:
- (Size x 0.2) + Nodal Status + Grade
Size is the diameter of the lesion in cm, nodal status is number of axillary lymph nodes involved (0 nodes=1, 1-4 nodes=2, >4 nodes=3), and grade is based on Bloom-Richardson classification
23
Q
how does breast cancer spread
A
- Lymph nodes via lymphatics– usually in the ipsilateral axilla
- Distant metastases via blood vessels – bones (most frequent site), lungs, liver, brain
- Invasive lobular carcinoma can spread to odd sites – peritoneum, retroperitoneum, leptomeninges, gastrointestinal tract, ovaries, uterus
24
Q
molecular classification of breast cancer
A
basically if you are receptor positive, then your prognosis is better
- Oestrogen receptor positive= better prognosis
- Her2 positive and oestrogen positive= better prognosis (can have Herceptin)
- Oestrogen receptor negative and HER2 negative = poor prognosis and usually BRCA1
25
treatment of breast cancer involves
* **Surgical**
* **Hormone treatment**
* **Oncoplastic management**
26
surgical management
* breast conserving
* mastectomy
* axillary surgery
27
breast conserving surgery
* Indication
* Localised operable disease with no evidence of metastatic disease
* Focal smaller cancers
* Dependent on location and size of breast
* Wide local excision (WLE) most common treatment
* Excision of tumour with 1cm margin of macroscopically normal tissue
28
mastectomy
* Removes all of the tissue of the affected breast along with signif portion of overlying skin (muscles of the chest wall left intact)
* Indication
* Multifocal disease
* High tumour: breast tissue ration
* Disease recurrence
* Patient choice (or in risk-reducing cases)
29
axillary surgery
* Why? Most commonly performed alongside WLE and mastectomies in order to asses **nodal status** and **removal of nodal disease**
30
sentinel node biopsy (nodal status)
* Removing first lymph node into which the tumour drains
* Method: blue dye (with associated radioisotope) is injected into the peri-areolar skin
* The sentinel node is identified by its radioactivity and visual assessment (as node becomes blue)
* Node removed and sent for histological analysis
31
axillary node clearance
* (removal of nodal disease)
* Removing all nodes in the axilla
32
complications of axillary node clearance
* Complications
* Paraesthesia
* Seroma formation
* Lymphedema in upper limb
33
**A risk-reducing mastectomy is**
an operation to remove healthy breast tissue in order to reduce the risk of developing breast cancer.
Risk-reducing mastectomy is only suitable for patients with a high risk of developing breast cancer and requires appropriate counseling to reach this difficult decision. In cases of suspected genetic risks, then patients are often referred to a genetic counsellor.
34
when to consider risk reducing mastectomy
* A strong family history of breast or ovarian cancer
* Testing positive for genetic mutations, such as BRCA1 or BRCA2, PTEN, or TP53 mutations
* Previous history of breast cancer
35
systemic control of invasive disease includes
chemotherapy
hormonal treatment
herceptin
36
chemotherapy
if benefits thought to outweigh the risks; if given before surgery = neoadjuvant
37
hormonal treatment
e.g. tamoxifen – depending on oestrogen receptor status (approximately 80% of cancers are ER positive)
38
herceptin treatment
* depending on Her2 receptor status (approximately 20% of cancers are Her2 positive)
* Her2 is a member of the human epidermal growth factor receptor family
* Encodes a transmembrane tyrosine kinase receptor
* Herceptin = trastuzumab = humanised monoclonal antibodies against the Her2 protein
39
indication of hormonal treatments
Although several treatments options e.g. chemo, radiotherapy and immunotherapy, hormone manipulation is the biggest contributor to improved survival
**Indication**
* In **malignant non-metastatic disease,** therapy for breast cancer is adjuvant so as to reduce the risk of relapse.
* **Medical treatment** is commenced usually after primary surgery
* It can often be the treatment of choice in elderly patients or in those **unfit for surgery.**
40
tamoxifen
**Indication**
* Pre-menopausal women
**MOA**
* SERM- selective oestrogen receptor modulator
* converse effects in breast and endometrial tissue
* in endometrium = ER agonist
* in breast = ER antagonist
* cell cycle arrest
* Blockage of oestrogen receptor in breast tissue
**ADR**
* Risk of thromboembolism during and after surgery or during periods of immobility
* Uterine carcinoma (due to pro-oestrogenic effect on the uterus)
41
aromatase inhibitors
**Aromatase Inhibitors (post-menopausal)**
e.g such as Anastrozole, Letrozole, or Exemestane
**Indication**
* **Post-menopausal patients** as adjuvant therapy, shown to be superior in this patient subgroup to Tamoxifen, however are more expensive.
**MOA**
* Act through **binding to oestrogen receptors** to inhibit further malignant growth and preventing further oestrogen production, as well as blocking the conversion of androgens to oestrogen in peripheral tissues.
42
pre-menopausal women
tamoxifen
43
post menopausal women
aromatase inhibitors
44
immunotherapy for breast cancer eg
herceptin
45
Herceptin
**Indication**
* Immunotherapy may be used in patients whose cancers express specific growth factor receptors.
* 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\*.
**MOA**
* One of the most common targets is the **human epidermal growth factor recepto**r(HER-2 positive malignancies) for which **Herceptin** (Trastuzumab) is a monoclonal antibody that targets its activity.
46
side effect of herceptin
*\*A common side-effect of treatment is **cardiotoxicity**, hence cardiac function must be monitored before and during treatment*
47
oncoplastic management- surgical reconstructive techniques
Several surgical reconstructive techniques in oncoplastic treatment of breast malignancy. Broadly divided into
* Mammoplasty
* Flap formation
48
mammoplasty
* A therapeutic mammoplasty involves a WLE combined with a breast reduction technique.
* The end-result is a smaller and uplifted breast, with the nipple and areola preserved along with their blood supply and the nipple relocated to suit the new breast.
49
flap formation can use
Latissimus dorsi
Transverse rectus abdominal muscle (TRAM) flap
Deep inferior epigastric perforator (DIEP) flap
