Breast Lecture 4 - Treatment of Breast Disease Flashcards
(39 cards)
what is the incidence of breast cancer?
- Affects 1 in 8 women
- Accounts for one quarter of malignancies in women
- 55,000 new cases per year in the UK;
- >490 new cases annually in Grampian
- >9,000 diagnosed each year are <50 years old
- >11 400 deaths annually
- Around 300 new cases per year in men
what are the risk facotrs for breast cancer?
- Age: Increased incidence (biggest risk factor, 25% of breast cancers are diagnosed in patients over 75)
- Previous breast cancer
- Genetic: BRCA1 and BRCA2 (5%)
- Early menarche and late menopause (exposure to oestrogen)
- Late or no pregnancy
- HRT
- Alcohol (>14 units per week)
- Weight
- Post Radiotherapy treatment for Hodgkin’s disease
what is the presentation of breast cancer?
- Asymptomatic: Breast Screening (50-70 yrs)
- Symptomatic: Outpatient Clinic
- Lump (most common presentation)
- Mastalgia (persistent unilateral 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)
- Dimpling of the breast skin
new patient clinic - one stop shop
what is it?
- CLINICAL: History and Examination
- RADIOLOGICAL: Bilateral mammograms / USS
- CYTO-PATHOLOGICAL: FNA- cells only (cytology), Core Biopsy- tissue (histo-pathology)
what information is gathered in a history?
Present Complaint (Where is the lump, how long, size, shape)
Previous Breast Problems
Family History (Previous FH of breast or ovarian cancer to know if they are high risk)
Hormonal Status
Drug History
what is checked on examination
BOTH Breasts, Axillae, SCF (supraclavicular fossa)
Signs and Symptoms - what are they?
Most common thing is a lump or thickening in the breast
Mostly painless so patients need to be breast aware
Inversion or retraction of the nipple
how is breast imaging done?
- The breast can be imaged with mammography, ultrasound or MRI
- Mammography is the most sensitive in older women
- Sensitivity is reduced in young women due to the presence of increased glandular tissue (<35yrs)
MRI is only for ladies with certain types of breast cancer and other restrictions
Cytology/Histology - how is it done?
FNA (Fine Needle Aspiration) -> Cytology
Core Biopsy -> Histo-Pathology:
- Invasive versus in-situ
- ER, PR, HER2 receptor status
How Good Are the Tests? - what is the sensitivity of each test?
Pathological types of breast cancer - what are the two classes?
invasive and non-invasive
Pathological types of breast cancer - what are some invasive types?
80% Ductal Carcinoma
10% Lobular Carcinoma
10% Others (Mucinous, Tubular, Papillary, Medullary, Sarcoma, Lymphoma)
Pathological types of breast cancer - what are some non-invasive types?
DCIS
LCIS
(Ductal Carcinoma In Situ
17% screening detected)
(Lobular Carcinoma In Situ)
Management of Cancer - whata re the key steps?
- Diagnose the disease
- Staging of the disease (Need to know how far the cancer has spread so stage the disease)
- Definitive treatment
Treatment of breast cancer - multidisciplinary approach
who is involved?
- Breast Surgeon
- Radiologist
- Cytologist
- Pathologist
- Clinical Oncologist (can give systemic therapy and radiotherapy)
- Medical Oncologist (only gives systemic therapy)
- Nurse counselor
- Psychologist
- Reconstructive surgeon
- Patient and partner
- Palliative care
Assessing the severity (“Staging”) - how is it done?
Want to know what’s going on and how far the cancer has spread
- FBC, U&Es, LFTs, Ca2+/PO2-
- Chest x ray
- Others as clinically indicated
- No reliable tumour markers
TNM classification
what is the T? - Primary Tumour
Tx Primary tumour cannot be assessed
T0 Primary tumour not palpable
T1 Clinically palpable tumour -size < 2 cm
T2 Tumour size 2-5 cm
T3 Tumour size > 5 cm
T4a Tumour invading skin
T4b Tumour invading chest wall
T4c Tumour invading both
T4d Inflammatory breast cancer
TNM classification
what is N? - Regional Lymph Nodes
N0: No Regional lymph nodes palpable
N1: Regional lymph node palpable - mobile
N2: Regional lymph node palpable - fixed
TNM classification
what is M? - Distant Metastasis
Mx: Distant metastasis cannot be assessed
M0: No distant metastasis
M1: Distant metastasis
What Management/Treatment can be done?
Surgery
+/- Radiotherapy
+/- Chemotherapy
+/- Hormonal Therapy
Neo-Adjuvant (treatment before surgery) versus Adjuvant (treatment after surgery) - All can be given in neo-adjuvant or adjuvant setting
what are the two main types of surgical procedures to the breast?
- Breast conservation surgery
- Mastectomy (breast removal)
Randomized controlled trials:
breast conservation + radiotherapy = mastectomy
for overall survival in tumours less than 4cm
But if you only do breast conserving surgery with no radiotherapy then you have an increased risk of local recurrence and does impact on survival
What patients are suitable for breast conservation surgery?
- Tumour size clinically<4cm – IN THE OLD DAYS
- Breast/Tumour size ratio
- Suitable for radiotherapy
- Single tumours – IN THE OLD DAYS
Patient’s wish – most important!!
Surgery to the AXILLA - what is its function and what does it achieve?
- Prognostic information/Staging
- Regional control of disease/eradication in the axilla
what is a Sentinel lymph node biopsy and what is tis function?
- first node to receive lymphatic drainage
- first node the tumour spreads to
- if negative, rest of nodes in lymphatic basin are negative
- Only performed when preoperative axillary USS normal/benign
