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3RD YEAR SYSTEMS: Repro > Breast cancer + cytology/histology > Flashcards

Breast cancer + cytology/histology Flashcards

1
Q

Incidence of Breast Cancer

A
  • High - affects 1 in 8 women
  • 55,000 new cases per year in the UK
  • Around 300 new cases per year in men
  • Screening from age 50-70
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2
Q

Risk factors

A
  • Age - breast cancer is multi-factorial
  • Previous breast cancer
  • Genetic: BRCA1 and BRCA2 (only 5%)
  • Early menarche (periods) and late menopause - due to exposure to oestrogen
  • Late or no pregnancy
  • HRT - over 10 years on it
  • Alcohol >14 units per week
  • Weight
  • Post Radiotherapy treatment for Hodgkin’s disease
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3
Q

Presentation of Breast cancer

A
  • Asymptomatic - incidental on breast screening (50-70 years)
  • Symptomatic - outpatient clinic
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4
Q

Symptoms of breast cancer

A
  • Lump
  • Mastalgia (persistent unilateral breast pain)
  • Nipple discharge (blood-stained)
  • Nipple changes (Paget’s disease, retraction)
  • Change in the size or shape of the breast
  • Lymphoedema (Swelling of the arm - if cancer is already advanced - lymph cannot drain properly)
  • Dimpling of the breast skin
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5
Q

What 3 things are done when a patient comes to a clinic with suspected breast cancer?

A

Called the ‘triple assessment’:

  • History and clinical examination
  • Radiology - Bilateral mammogram / USS
  • Cyto-pathological - FNA (cells only - cytology) or core biopsy (tissue - pathology)
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6
Q

What do you want to find out from the history from your patient?

A
  • Presenting complaint
    • symptoms etc
  • Previous breast problems
    • Cysts
    • Fibroadenoma
    • Previous cancer
  • Family history
    • Ovarian or breast cancer
    • Have they already had genetic testing? Are they BRCA1 or BRCA2 positive?
  • Hormonal status
    • Previous pregnancies?
    • Menopause
    • HRT/Contraception
  • Drug history/allergies
    • Blood thinning - need to consider if taking biopsy etc
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7
Q

What does a clinical examination in a breast clinic involve?

A

Chaperone is required - intimate procedure

  • Examine both breasts - start with normal breast
  • Axillae, supraclavicular region and internal mammary
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8
Q

How can the breast be imaged? (3)

A
  • Mammography
  • USS
  • MRI - only for lobular type of breast cancer or dense breasts or ladies with other benign diseases (in order to distinguish between them and the cancer)
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9
Q

Which imaging modality is the most sensitive in older women?

A

Mammography

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10
Q

Why is the sensitivity of mammography reduced in younger women?

A

Due to increased glandular tissue. For this reason, it is not routinely done in women younger than 35

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11
Q

What can doing a core biopsy tell you?

A
  • About cells and tissue structures
    • Malignant cells breach the basement membrane and these are classed as invasive breast cancer
    • If within the basement membrane then classed as in-situe disease
  • Oestrogen, progesterone and HER2 receptor status
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12
Q

What technique is used to obtain cells for cytology in breast cancer?

A

Fine needle aspiration

Can also use: direct smear from nipple discharge or scrape of nipple with scalpel (not pleasant)

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13
Q

FNA vs Core biopsy

  • When are each of them used?
  • What are they useful for?
A

FNA:

  • Gives an immediate confirmation if the lesion is benign.
  • Useful in assessing enlarged lymph nodes (solid or fluid filled) or satellite lesions/diffuse area of thickening
  • It is done as part of the triple assessment when women attend the breast clinic.
  • If inpalpable area then do US-guided FNA

Core biopsy:

  • Done in all symptomatic cases where there is either clinical/radiological/cytological suspicion
  • Doesn’t give immediate diagnosis
  • It is essential for pre-operative classification
  • If the clinical and radiological findings are suspicious of malignancy then tend to go straight to core biopsy
  • If abnormality detected from breast screening in asymptomatic women then core biopsy is used as it is better at showing micro-calcification or architectural distortion.
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14
Q

Breast cancer is categorised into invasive and non-invasive types.

What are the different types of breast cancer within these categories?

A

Invasive

  • Ductal carcinoma (80%)
  • Lobular carcinoma (10%)
  • Others (10%)

Non-invasive - commonly picked up from screening as does not form a palpable tumour. Risk of invasion depending on grade (low or high grade)

  • Ductal carcinoma in-situ
  • Lobular carcinoma in-situ
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15
Q

How is breast cancer staged? i.e what investigations are done to work out the stage of cancer

A
  • Blood tests! - FBC, U+E
  • LFT
  • Checking for Bone metastases - Ca2+ and PO2-
  • Chest x-ray - lung metastases?
  • CT chest/abdo/pelvis
  • No reliable tumour markers for breast cancer
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16
Q

TNM staging in breast cancer

A

REMEMBER 2 NUMBERS: 2 and 5

  • T1 = tumour size is <2cm
  • T2 = 2-5cm
  • T3 = >5cm
  • T4
    • a = tumour invading skin
    • b = tumour invading chest wall
    • c = tumour invading both
    • d = inflammatory breast cancer - most severe
  • N0 = no regional lymph nodes palpable
  • N1 = regional lymph node palpable - mobile
  • N2 = regional lymph node palpable - fixed
  • M X – distant metastasis cannot be assessed
  • M0 – no distant metastasis
  • M1 – distant metastasis
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17
Q

Management/treatment of breast cancer

A
  • Surgery
    • +/- radiotherapy
    • +/- chemotherapy
    • +/- hormonal therapy
18
Q

What are the 2 main types of surgical procedures done for breast cancer?

A
  • Breast conservation surgery (need radiotherapy too to have the same survival as mastectomy)
  • Mastectomy
19
Q

Who is suitable for breast conservation surgery?

A

Depends on:

  • Breast size/tumour size ratio
  • Breast ptosis/sagging or hanging of breasts (occurs when supporting structures of the breast fail)
  • If patient is fit enough to have radiotherapy afterwards
  • Patient’s choice
20
Q

Why is axillary dissection/surgery done?

A
  • To examine or remove lymph nodes
  • Prognostic information / staging
  • Regional control of disease / eradication in the axilla
21
Q

What is the importance of the Sentinel lymph node?

A
  • First node to receive lymphatic drainage so the first node the tumour spreads to
  • If no cancer detected there then reassured that there is no further disease in the armpit – helps stage cancer
22
Q

When is a Sentinel lymph node biopsy performed?

A
  • Done after cancer diagnosis to help with staging of cancer
  • Only performed when pre-operative axillary USS is normal
  • If negative = clear of tumour – no spread to lymph nodes
23
Q

What happens if cancer is detected in the SLN?

A

Remove all axillary lymph nodes surgically or give radiotherapy to all the axillary nodes

24
Q

What are the complications of axillary surgery?

A
  • Lymphoedema (10-17%) – mild or severe
  • Sensory disturbance (intercostobrachial n.)
  • Decrease ROM of the shoulder joint
  • Nerve damage (long thoracic, thoracodorsal, brachial plexus)
  • Vascular damage
  • Radiation-induced sarcoma
25
Q

What factors increase the chance of breast cancer coming back?

A
  • Lymph node involvement
  • Tumour grade
  • Tumour size
  • Steroid receptor status (er/pr negative)
  • HER2 positive
  • LVI – lymphovascular invasion
26
Q

What is the Nottingham prognostic index (NPI)?

A

A tool used to determine prognosis following surgery for breast cancer.

  • Its value is calculated using 3 pathological criteria:
    • the size of the tumour
    • the number of involved lymph nodes
    • the grade of the tumour.
27
Q

What local and systemic therapies are used for prevention of breast cancer relapse?

A

Local - radiotherapy

Systemic - hormone therapy, chemotherapy, targeted therapies

28
Q

Radiotherapy

A
  • Given to all patients after wide local excision (breast conserving) as adjuvant treatment – over 3 weeks
  • Boosts given to younger patients – reduce local recurrence
  • Only given to women after having mastectomy if there is local or significant lymph node involvement
  • Complications
    • Immediate – skin reaction
    • Radiation pneumonitis
    • Osteonecrosis
    • Angiosarcoma
29
Q

Hormone therapy

A
  • Can only be given to women with oestrogen receptor positive cancers
  • Blocks stimulation of cell growth by oestrogen
  • 2 main groups: Tamoxifen or aromatase inhibitors (arimidex, letrozole)
    • Tamoxifen – blocks the receptor by sitting on it - effective in all age groups
    • Aromatase – can’t be given pre-menopausal women, inhibits oestrogen synthesis
30
Q

Chemotherapy

A

Greatest benefit in higher risk cancers or younger women

Taxane based combinations – latest drugs

Oncotype DX - tool used to determine whether chemo is likely to benefit

31
Q

Who is HER2 positivity and anti-HER2 therapy given to?

A
  • Given to patients with over-expression of HER2 and given with chemotherapy
32
Q

Where does breast cancer spread to?

A

Local

  • Skin
  • Pectoral muscles
  • Contralateral breast

Lymphatic

  • Axillary nodes
  • Internal mammary nodes

Haematogenous/blood

  • Bone
  • Lung
  • Liver
  • Brain
  • Bone marrow
33
Q

Which cells does breast carcinoma arise from?

A

Epithelial cells of glandular tissue

34
Q

Benign cytology

A
  • Low/ moderate cellularity
  • Cohesive groups of cells (joined together to form the regular layer of epithelial layers and linings)
  • Flat sheets of cells
  • Bare oval (bipolar) nuclei in background
  • Cells of uniform size
  • Uniform chromatin pattern - DNA in nucleus is even
35
Q

Malignant cytology

A
  • Highly cellular - proliferation
  • Crowding/overlapping of cells
  • Loss of cohesion - dissociated cells
  • Nuclear pleomorphism - enlarged and variation
  • Hyperchromasia - increased nuclear DNA - stains darker
  • Absence of bipolar nuclei - tumour cells wipe out myoepithelial cells
36
Q

What is the role of cytology in clinic?

A

To determine whether benign or malignant

Rarely specific

37
Q

What is the cytology scoring system?

A

C1-5

  • C1 Unsatisfactory/ Insufficient cells for diagnosis
  • C2 Benign
  • C3 Atypia (probably benign)
  • C4 Suspicious (probably malignant)
  • C5 Malignant
38
Q

Look

A

If a breast lump turns out to be a cyst then aspiration is curative. The fluid is discarded unless:

  • It is bloodstained - then examined under microscope
  • There is residual mass - examine fluid and aspirate residual lump
39
Q

Cytology is used for nipple lesions too. What are some common diagnoses?

A
  • Duct ectasia - macrophages only
  • Intraduct papilloma - benign cells in papillary groups
  • Intraduct carcinoma - malignant cells
  • Eczema - squamous cells from epidermis only
  • Paget’s disease - squamous cells and malignant cells
40
Q

Screening for breast cancer

A
  • Mammogram every 3 years
  • Women 50-70 years old

3RD YEAR SYSTEMS: Repro (34 decks)

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