Breast Cancer Flashcards
What is breast cancer?
Malignancy of breast tissue; cells in the breast grow out of control
What are the different types of breast cancers?
- Invasive ductal carcinoma (IDC): This is the most common type, accounting for about 80% of all breast cancers. It starts in a milk duct, breaks through the wall of the duct, and invades the fatty tissue of the breast.
- Invasive lobular carcinoma (ILC): This type begins in the milk-producing glands (lobules) and can spread to other parts of the body.
- Ductal carcinoma in situ (DCIS): This is a non-invasive or pre-invasive cancer where the cells are confined to the ducts in the breast and have not spread into the surrounding breast tissue.
- Lobular carcinoma in situ (LCIS): This is not a cancer but an area of abnormal cell growth that increases a person’s risk of developing invasive breast cancer later.
- Inflammatory breast cancer (IBC): This is a rare but aggressive type of breast cancer that causes the lymph vessels in the skin of the breast to become blocked.
- Triple-negative breast cancer (TNBC): This type lacks estrogen receptors, progesterone receptors, and does not have an excess of the HER2 protein on the cancer cell surfaces. It tends to be more aggressive and has fewer targeted treatments available.
- HER2-positive breast cancer: This is a cancer that tests positive for a protein called human epidermal growth factor receptor 2 (HER2), which promotes the growth of cancer cells. It tends to be more aggressive than other types of breast cancer, but it may respond well to targeted therapies that can block HER2.
- Invasive vs in-situ: whether the basement membrane has been breached
Describe the prevalence of breast cancer
- 2nd most common malignancy in women (1st= skin cancer)
- Peak incidence: 40-70 yrs, postmenopausal, incidence increases with age (50% of breast cancers are diagnosed in women >65)
- Rare in men, but possible
What are the risk factors of breast cancer?
a) Genetics (e.g. BRCA-1 and BRCA-2 genes)
b) Environmental factors:
- smoking
- Alcohol consumption
- Age
- Prolonged exposure to oestrogen:
● Nulliparity (never having been pregnant)
● First pregnancy >30 yrs
● Early menarche <13yrs
● Late menopause >51 yrs
● Obesity
● COCP
● HRT
● Not breast feeding
● Past breast cancer
- Family history of breast cancer
- Irradiation to the chest wall
What screening programme is available to detect breast cancer in the UK?
NHS Breast Screening Programme ⇒ mammogram every 3 years for women 50-70 yrs old
What are the presenting symptoms of breast cancer that can be noticed during a history?
- Breast Lump → single, non-tender, poorly defined margins, painless, hard mass usually located in upper outer quadrant
- May be fixed to deep tissue - Changes in breast shape → asymmetric breasts
- Nipple Discharge → may be bloody (single duct more concerning than multiple duct)
- Axillary Lump → due to lymphadenopathy
- Lump is firm & rigid → doesn’t change shape upon compression
- Paget’s Disease of the Nipple ⇒ eczema-like hardening of the skin on the nipple (usually caused by ductal carcinoma in situ infiltrating the nipple).
- Symptoms of malignancy:
o Weight loss
o Bone pain
o Paraneoplastic syndromes - Signs of metastasis
- Lump has been there for a while- carcinomas grow more slowly usually
What are some signs that may indicate a breast cancer has metastasized?
Bone:
- bone pain
- pathological fractures
- spinal compression
Liver:
- Abdominal pain
- Distention
- Nausea
- Jaundice
Lung:
- Cough
- Hemoptysis
- Dyspnea
- Chest pain
Brain:
- Headaches
- Seizures
- Cognitive deficits, focal neurological deficits
What signs of breast cancer can be found on physical examination?
- Breast lump:
o Firm
o Irregular
o Fixed to surrounding structures - Lymphadenopathy
- Peau d’orange (puckering of overlying skin)
- Skin tethering
- Fixed to chest wall
- Skin ulceration
- Nipple inversion
- Paget’s Disease of the Nipple ⇒ eczema-like hardening of the skin on the nipple (usually caused by ductal carcinoma in situ infiltrating the nipple).
What are the 3 types of investigations used for suspected breast cancer?
TRIPLE ASSESSMENT:
1. Clinical examination
2. Imaging:
● Ultrasound (< 35 yrs)
OR
● Mammogram (> 35 yrs)
3. Tissue Diagnosis:
● Fine Needle Aspiration (look at cells)
OR
● Core Biopsy (look at tissues) CA-15-3 marker
What is mammogram?
- X-ray image of the breast
- used to look for early signs of breast cancer (sometimes up to 3 yrs before it can be felt)
- Pt stands in front of a special X-ray machine, places breast on a plastic plate, another plate will firmly press the breast from above, the plates will flatten the breast, holding it still while the X-ray is being taken
- You will stand in front of a special X-ray machine. A technologist will place your breast on a plastic plate. Another plate will firmly press your breast from above. The plates will flatten the breast, holding it still while the X-ray is being taken
- regularly screen high risk individuals
How is a sentinel lymph node biopsy taken?
Sentinel Lymph Node Biopsy: performed for all invasive breast cancers
o A radioactive tracer is injected into the tumour and a scan identifies the sentinel lymph node
o This node is then biopsied to check the extend of spread
How are breast cancers staged?
Stage 0: abnormal cells but no spread to nearby tissue
Stage 1: confined to breast, mobile
Stage 2: growth confined to breast, mobile, lymph nodes in ipsilateral axilla may be involved
Stage 3: tumour fixed to muscle but not chest wall, ipsilateral lymph nodes matted and may be fixed, may spread to skin/ chest wall
Stage 4: complete fixation of tumour to chest wall, distant metastases
Can also do TNM staging:each ranked 0-4)
- T: size of tumour, whether it has grown to nearby areas (e.g. chest wall muscles)
- N: degree in which cancer has spread to lymph nodes
- M: degree in which cancer has spread to other sites or metastasized
How can you detect metastasis, to inform staging of the breast cancer?
Staging – commonest sites of metastasis are chest, lungs, bone and brain:
o CXR
o Liver contrast-enhanced ultrasound/CT/MRI
o Imaging of axial skeleton and long bones (bone scintigraphy or plain radiograph) and blood tests for serum calcium, phosphate and ALP.
o CT (brain/thorax)
T= core needle biopsy
N: sentinal node biopsy
M: PET scan
What bloods can be taken to inform about possible breast cancer?
Bloods: FBC, U&Es, calcium, bone profile, LFTs, ESR
When is an urgent referral required for suspected breast cancer?
Urgent Referral (2WW for triple assessment in breast clinic):
- 30 or over with unexplained breast mass
- 50 or over with nipple discharge, retraction or other concerning features (any unilateral nipple changes)
