Breast cancer (SURG) Flashcards
(53 cards)
1
Q
How common is breast cancer?
A
Second most common malignancy in women
2
Q
When is the peak incidence for breast cancer? (2)
A
- postmenopausal
- incidence increases with age - 50% of breast cancers are diagnosed in women >65
3
Q
What are some risk factors for breast cancer? (7)
A
- increased exposure to oestrogen:
- not having kids
- early menarche <13y
- late menopause >51y
- obesity
- COCP
- HRT
- smoking
- alcohol consumption
- Fx of breast cancer
- hereditary breast ovarian cancer syndrome (mutations in BRCA1/2)
- increasing age
- radiation exposure
4
Q
What can cause increased exposure to oestrogen, increasing risk of breast cancer? (6)
A
- not having kids
- early menarche <13y
- late menopause >51y
- obesity
- COCP
- HRT
5
Q
Name two genes associated with breast cancer.
A
- BRCA-1
- BRCA-2
6
Q
What are the different types of breast cancer?
A
- invasive ductal carcinoma - most common
- non-invasive breast cancer:
- ductal carcinoma in situ (DCIS)
- lobular carcinoma in situ (LCIS)
7
Q
What is non-invasive breast cancer?
A
- does not extend beyond basement membrane and cannot spread through lymphatics or bloodstream
- ductal carcinoma in situ (DCIS) - increased risk of invasive ductal carcinoma at that site
- lobular carcinoma in situ (LCIS) - increased risk of ductal OR lobular carcinoma developing in either breast
- higher grade DCIS/LCIS may progress to high-grade invasive breast cancer
8
Q
Describe the continuum of progression of breast cancer.
A
Typical hyperplasia –> atypical hyperplasia –> ductal carcinoma in situ (DCIS) –> invasive ductal carcinoma
9
Q
What does the NHS breast screening programme include?
A
Mammogram every 3 years for women 50-70 years old
10
Q
When should we refer women for suspected breast cancer?
A
Refer women aged >30 with an unexplained breast lump using a suspected cancer pathway referral
Aged >50 with nipple discharge, retraction or other concerning features
11
Q
What are the clinical features of breast cancer? (6)
A
- breast lump - non-tender, poorly-defined margins, painless, hard mass in upper outer quadrant, may be fixed to deep tissue, smooth or nodular, firm and rigid, does not change shape upon compression
- change in breast shape - asymmetry
- nipple discharge - unilateral, may be bloody (intraductal papilloma or neoplastic)/watery/serous/milky
- axillary lymphadenopathy
- skin thickening/discolouration/ulceration
- Paget’s disease of the nipple - usually caused by DCIS infiltrating nipple
12
Q
Describe the breast lump in breast cancer. (7)
A
- non-tender
- poorly-defined margins
- painless
- hard mass in upper outer quadrant
- may be fixed to deep tissue
- smooth or nodular
- firm and rigid, does not change shape on compression
13
Q
Describe the nipple discharge in breast cancer.
A
- unilateral (more concerning than bilateral)
- may be bloody (intraductal papilloma or neoplastic)
- or watery, serous or milky
14
Q
What is Paget’s disease of the nipple (breast cancer)?
A
- eczema-like hardening of skin on nipple
- bleeding and excoriation
- retraction or scaling of the nipple
- usually caused by ductal carcinoma in situ (DCIS) infiltrating nipple
15
Q
What might you see on examination of breast cancer? (3)
A
- irregular, firm, fixed mass
- peau d’orange (orange peel apprarance)
- axillary lymphadenopathy
16
Q
Where does breast cancer commonly metastasise? (4)
A
- bone
- liver
- lung
- brain
17
Q
What are the signs of bone metastases in breast cancer? (3)
A
- bone pain
- pathological fractures
- spinal compression
18
Q
What are the signs of liver metastases in breast cancer? (3)
A
- abdominal pain and distension
- nausea
- jaundice
19
Q
What are the signs of lung metastases in breast cancer? (4)
A
- cough
- haemoptysis
- SOB
- chest pain
20
Q
What are the signs of brain metastases in breast cancer? (3)
A
- headaches
- seizures
- cognitive deficits / focal neurological deficits
21
Q
How do we investigate a breast lump?
A
Triple assessment:
- clinical examination
- radiology - US for <35y, mammography AND US for >35y
- histology/cytology (FNA or core biopsy: US-guided core biopsy is best for NEW lumps)
22
Q
What is the main investigation for breast cancer, depending on age?
A
- women <35y: breast ultrasound (mammogram difficult due to denser breast tissue)
- women >35y: mammography (and US)
23
Q
What might mammography show in breast cancer?
A
Calcifications
24
Q
What are the two ways of taking a biopsy in breast cancer?
A
- fine needle aspiration –> cytological information
- core needle biopsy –> histological and cytological information
25
What investigation do we do for all invasive breast cancers?
Sentinel lymph node biopsy
26
Which investigations are used to stage breast cancer? (3)
TNM:
- core needle biopsy (T)
- sentinel lymph node biopsy (N)
- PET scan (M)
27
How else can we check for metastases in breast cancer? (7)
- PET scan
- bone scan
- CXR
- FBC
- LFTs
- calcium
- CT CAP
28
Name a marker for breast cancer.
CA15-3
29
Which patients do we refer on urgent 2WW pathway for suspected breast cancer? (2)
- >30y with unexplained breast mass
- >50y with nipple discharge, retraction or other concerning features
30
What are some differential diagnoses for breast cancer? (6)
- locally invasive breast cancer (lump +/- nipple inversion, discharge or tenderness)
- atypical hyperplasia (progresses to invasive breast cancer)
- fibroadenoma (freely mobile, sharp edges for calcifications)
- breast cyst (tenderness, cyclical with menstruation, sharp edges for calcifications)
- mastitis (lactating women, systemic Sx)
- fat necrosis
31
How do we stage breast cancer?
- IA, IB, IIA, IIB, IIIA, IIIB, IIIC
- stages IA, IB & IIA are early-stage
- stages IIIA, IIIB & IIIC are locally-advanced
32
What classification can we use for ductal carcinoma in situ (breast cancer)?
Van Nuys score for DCIS: size, margin, age, pathological classification
33
What is triple-negative breast cancer?
- characterised by 3 negative biomarkers: oestrogen receptors (ER), progesterone receptors (PR), HER2
- highly heterogenous = difficult diagnosis
- limited response to hormonal and immune therapies & very aggressive = difficult treatment
34
What is the first-line treatment most of the time for breast cancer?
Surgery
35
What is a mastectomy?
Removal of the entire breast and possibly other structures e.g. lymph nodes and muscles
36
List indications for a mastectomy. (4)
- ductal carcinoma in situ (high-grade DCIS)
- multifocal tumour
- central tumour
- large lesion in small breast
37
What is a wide local excision (breast cancer)?
Removal of just the area of cancer, aims to keep most of the breast tissue
Whole breast radiotherapy recommended after - may reduce risk of recurrence by 2/3
38
In which patients with breast cancer do we do a wide local excision?
For smaller, solitary lesions which are peripherally located
Low-grade DCIS
39
What is recommended after a woman has had a wide local excision for breast cancer?
Whole breast radiotherapy recommended after - may reduce risk of recurrence by 2/3
40
What is the treatment for clinical (palpable) axillary lymphadenopathy in breast cancer?
Axillary lymph node clearance - can cause lymphoedema and functional arm impairment
If no surgery wanted: axillary radiotherapy
41
Who is hormonal therapy offered to in breast cancer?
Adjuvant therapy to women who are oestrogen receptor (ER) positive
42
Which hormonal therapies are offered for breast cancer?
- pre-menopausal (or >60): Tamoxifen (oestrogen receptor modulator/antagonist)
- side effect: VTE
- post-menopausal: Anastrozole (aromatase inhibitor)
- side effect: osteoporotic fractures due to reduced E2
43
Who is biological therapy offered to in breast cancer?
If HER2 positive --> Trastuzumab (Herceptin)
Can cause cardiac toxicity - do echo first
44
What systemic therapy can be done for breast cancer?
Chemotherapy - can be given as neoadjuvant or adjuvant
45
What do we give for chemotherapy-induced N&V in breast cancer?
5HT-3 antagonist e.g. ondansetron (+ metronidazole)
46
How do we manage low-grade ductal carcinoma in situ (breast cancer)?
Surgical excision (wide local excision)
47
How do we manage high-grade ductal carcinoma in situ (breast cancer)? (4)
- mastectomy +/- breast reconstruction
- axillary node sentinel biopsy and staging --> axillary node clearance
- radiotherapy (treat microscopic disease and reduce risk of ipsilateral recurrence)
- hormonal therapy (tamoxifen or anastrozole depending on menopause)
48
How do we manage lobular carcinoma (breast cancer)?
- low risk: observation + hormonal Rx
- high risk: double mastectomy
49
How do we manage early-stage breast cancer (stage I to IIB) and locally advanced breast cancer (stage IIB to III)? (3+2)
- mastectomy +/- breast reconstruction
- SNLB + axillary lymph node dissection (ALND)
- neoadjuvant or adjuvant chemotherapy (ACT - doxorubicin + cyclophosphamide + paclitaxel)
- (HER2: +trastuzumab)
- (hormonal Rx depending on pre/post menopause: tamoxifen/anastrozole)
50
How do we manage metastatic breast cancer? (4)
- oestrogen receptor positive: tamoxifen (pre-menopause) or anastrozole (post-menopause, aromatase inhibitor)
- HER2 +ve: trastuzumab
- PD-L1: atezolizumab
- triple negative: chemotherapy
51
When is mastectomy vs wide local excision done in breast cancer? (4)
- multifocal vs solitary lesion
- central vs peripheral tumour
- large lesion in small breast vs small lesion in large breast
- DCIS>4cm vs DCIS<4cm
52
What are some complications of breast cancer? (6)
- pleural effusion
- paraneoplastic syndromes
- high recurrence rate
- lymphoedema of arm
- progression into invasive carcinoma
- chemotherapy-related neutropenia or N&V
53
What is the most important factor for breast cancer prognosis?
Stage at time of diagnosis - earlier stages have significantly better prognosis due to less spread
