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Flashcards in Breast cancer Deck (45):
1

Types of breast cancer

DCIS

LCIS

Medullary

Peu de orange

Invasive Metastatic

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What is DCIS

neoplastic proliferation atypical features contained by basement membrane

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Epidemiology of DCIS, detection, presentation

1. Age: 50-59

2. Detection mammogram: microcalcifications, soft tissue densities

3. Dense, irregular, lumpy area

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Morphological types of DCIS

1. Commedo carcinoma->central necrosis, fibrosis, calcifciations

2. Non-commedo

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Management of DCIS

1. Excision/mastectomy

2. Radiotherapy

3. If receptor +ve->tamoxifen

6

Risk factors for DCIS

Strong

1. FHx of breast cancer

2. benign breast disease on prior biopsy

3. hereditary breast ovarian cancer syndrome

4. Li-Fraumeni syndrome Cowden's syndrome Klinefelter's syndrome

Weak

1. older age at menopause

2. older age at first full-term pregnancy

3. nulliparity

4. low physical activity

5. high vitamin A intake

6. ataxia telangiectasia

7. Peutz-Jeghers syndrome

7

What is pagets disease

1. Unilateral, erythematous, crusting, pruritic, eczema like

2. Malignant cells from DCIS within ductal system to nipple skin via lactiferous ducts xcross BM

3. Disrupt the barrier->EC fluid seeps onto skin= irritation

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What is medullary type carcinoma

1. Inflammatory Ca

2. Less common More aggressive

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Molecular testing and prognostic value in invasive carcinoma

1. Luminal A: ER+ve HER2-ve

Most in post menopausal

2. Luminal B: ER+ve HER2+ve

poor differentiation +metastasis

Respond to chemotherapy

3. Basal like: Triple negative

Markers of myoepithelial= basal keratoms. Pcadherin, laminin +in BRCA1 Her2/neu +ve: Trastuzumab (clonal antibody against HER2/Neu Poor differentiation, ++proliferation

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Prognostic factors

1. Axillary node status

2. Tumor size

3. Histological grade

4. Hormone receptor status

5. Vascular invasion, menopausal, HER 2++ expression

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Staging Manchester`

1. Stage I

Tumour confined to the breast with skin involvement less than the size of the tumour

2. Stage II Tumour confined to the breast with palpable mobile axillary lymph nodes

3. Stage III Locally advanced breast cancer with skin fixation larger than the tumour. Cutaneous ulcers or fixity to pectoralis fascia may be present. Peau d’orange or satellite chest wall nodules. Fixed axillary nodes, supraclavicular nodal involvement

4. Stage IV Distant metastases

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What is peu de organge

1. Malignant cells embolise to lymphatics: occlude causing lymphoedema retraction of skin= orange peel appearance

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Screening with mammogram, outcomes

1. for every 2000 women screened one will avoid dying of breast cancer

2. 10 healthy women will be treated unnecessarily.

3. >200 experience distress due to false positive findings.

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Treatment options for breast Ca

1. Surgical

2. Adjuvant radiotherapy

3. Adjuvant chemotherapy

4. Hormone therapy

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Surgical options

1. Partial mastectomy

2. Total mastectomy

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Indications for partial mastectomy

1. If can achieve good cosmetic result with clear margins

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What is partial mastectomy usually followed by

Radiotherapy

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Indications for total mastectomy

1. Large tumor relative to Breast

2. Involves overlying skin/ nipple

3. Multifocal/extensive intraductal

4. Prior breast irradiation

5. Chooses this option

6. Usually breast reconstruction follow

19

Risks of surgery

1. Breast haematoma

2. Wound infection

3. Seroma of the skin flap

4. Psychological effects on body image and self esteem

5. Brachial plexus

6. Lymphadema

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When can radiotherapy generally be ommitted

1. In elderly

2. Low histologic grade ++abundant hormone receptors

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Side effects of radiotherapy

Side effects of radiotherapy to the chest wall / axilla:

1.Pneumonitis 

2. Rib fracture

3. Pericarditis

4. Lymphodema

5. Brachial plexus injury

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Options for ovarian ablation in pre-menopausal women

1. Surgical oophrectomy

2. Ovarian irradiation

3. LHRH analogues- goserelin (reversible medical oophrectomy)

23

Commonly used chemotherapy regimens

1. Adriamycin and cyclophosphamide

2. Methotrexate and 5FU 6 months

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Systemic therapy in node +ve

1. Premenopausal--> Doxorubicin + cyclophosphamide 4 cycles

2. Post-menopausal--> Receptor + tomoxifen 5 years

Receptor -ve Combo chemoT

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Systemic therapy for node -ve

1. Pre-menopausal--> chemotherapy if poor prognostic factors

2. Post-menopausal--> Rec +ve Tamoxifen 5 years -ve same

Risk of endometrial Ca

26

Aberrations or normal development and involution in early reproductive years

1. Lobar developement

Abberation= fibroadenoma Disease= giant fibroadenoma

2. Stromal development

Aberration= teenage hypertrophy Disease=giantomastia

3. Nipple eversion Abberration= Nipple inversion Disease= Subareolar abscess, mammary duct fistula

27

Aberrations or normal development and involution in mature reproductive years

1. Epithelial hyperplasia of pregnancy

2. Bloody nipple discharge

3. Nodularity

4. Phylloides tumor

5. Cyclical changes of mensturation

6. Cyclical mastalgia Incapacitating mastalgia

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Involution

35-55

Lobar involution: A: Macrocysts, sclerosing lesions ,Ductal involution, dilation, sclerosis

A: duct ectasia D: periductal mastitis and abscess Nipple retraction Epithelial turnover

A: Hyperplasia D: Hyperplasia w/ atypia

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Indications for surgery in fibroadenoma

1. Triple test discordant S

2. Symptomatic

3. Rapid growth

4. Patient request

30

TMN staging

Tumour categories

Tx Primary tumour cannot be assessed

Tis Carcinoma in situ

T1 Tumour size < 2cm

T2 Tumour size  is 2-5 cm

T3 Tumour size is >5 cm

T4 Any tumour size with fixation to chest wall or skin

Nodal categories

Nx Regional lymph nodes cannot be assessed

N0 Axillary lymph nodes not involved

N1 Ipsilateral axillary nodal metastases (mobile)

N2 Ipsilateral axillary nodal metastases (fixed)

N3 Ipsilateral supraclavicular or internal mammary nodal metastases

Metastasis categories

Mx Presence of distant metastases cannot be assessed

M0 No distant metastases

M1 Distant metastases

31

Purpose of breast USS

1. Dense breast

2. Equivocal mammography

3. Palpable mass

4. Guide biopsy

32

Staging bloods

1. full blood examination,

2. urea and electrolytes,

3. liver function tests,

4. bone scan,

5. liver ultrasound

6. chest and abdomnial CT scan.

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Is LCIS pre-malignant`

No

But has +risk for malignancy

34

Purpose of axillary dissection

1. Remove metastatic deposits

2. Assess receptor status for systemic therapy

3. Assess nodal status for prognosis

35

Reduction in recurrence and death with adjuvant therapy with tamozifen

1. Adjuvant systemic therapy with tamoxifen, with combination cytotoxic chemotherapy or, in premenopausal women, ovarian ablation, reduces the risk of recurrence and death after treatment for node-positive and node-negative breast cancer.

36

Benefits of chemotherapy increase

With decreasing age and increasing nodal status

37

Improvement in recurrence rate and death rate after ovarian ablation in pre-menopausal women

10% at 15 years in both recurrence-free and overall survival

38

Purpose of followup

1. Detect local recurrence

2. Detect distance recurrence

3. Detect new primary

4. Management of treatment toxicities

5. Psychosocial supports

39

Most important prognostic factor for metastatic breast cancer

1. disease-free interval after diagnosis of the primary breast cancer

40

Imaging in metastatic breast cancer

CXR CT abdomen/chest, brain if relevant symptoms Bone scan

41

Management of metastatic breast cancer: pre and post menopausal ER/PR +ve

1. ER/PR +ve

Post-menopausal 1st line: aromatase inhibitor (anastrazole) or tamoxifen

adjunct: bisphosphonate or denosumab

adjunct: calcium and vitamin D

2. HER-2 +ve pertuzumab plus trastuzumab plus docetaxel

3. Pre-menopausal

1st line: tamoxifen plus monoclonal antibody if HER2 +ve plus: ovarian ablation (surgical or medical) plus monoclonal antibody plus: aromatase inhibitor adjunct: bisphosphonate or denosumab adjunct: calcium and vitamin D

42

Management of metastatic breast cancer: pre and post menopausal ER/PR -ve

HER2-negative 1st line: chemotherapy adjunct: bisphosphonate or denosumab adjunct: calcium and vitamin D adjunct: palliative therapy HER2-positive 1st line: pertuzumab plus trastuzumab plus docetaxel adjunct: bisphosphonate or denosumab adjunct: calcium and vitamin D

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Treatment of choice in visceral mets

Chemotherapy

44

Treatment of cerebral mets

Radiotherapy

45

Follow up for breast cancer

1. All patients should undergo a detailed history and physical examination by a doctor who is experienced in the surveillance of cancer patients and in breast examinations.

2. Intervals between examinations should be 3 to 6 months for the first 3 years, 6 to 12 months for years 4 and 5, and yearly thereafter