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Breasts Flashcards

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1
Q

How common is breast cancer?

A

Commonest cancer in UK
11,500 deaths per year
1 woman in 8 will develop disease
90% women survive 5 years/more
5 year survival 82%

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2
Q

What can increase your risk of breast cancer?

A

Main risk factors - female, getting older, significant family history (BRCA1 or 2 or other genes)
Also…
Radiotherapy treatment < 35 years (Hodgkin’s)
Li Fraumeni syndrome
Late first childbirth (> 35)
Alcohol consumption
HRT for > 5 years
Oral contraceptive use
Obesity (post menopausal)
Not breast fed
Nulliparous
Lack of exercise
Extrogenous oestrogens
Late onset menarche

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3
Q

What genes are associated with increased breast cancer risk?

A

BRCA1 - female breast, ovarian - 40-80% lifetime risk
BRCA2 - female and male breast, ovarian, prostate, pancreatic - 20-80% lifetime risk
Li Faumeni - Tp53 - breast, sarcoma, leukaemia, brain, adrenocortical, lung - 56-90% lifetime risk
Cowdens - PTEN - breast, thyroid, endometrial - 25-50% lifetime risk
Peutz-Jeghers - STK11 - breast, ovarian, cervical, uterine, testicular, colon, small bowel - 32-54% lifetime risk
Hereditary diffuse gastric cancer - CDH1 - early onset diffuse gastric cancer, lobular breast cancer - 60%

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4
Q

What some modifiable lifestyle risk factors are there for breast cancer?

A

Weight
Exercise
Alcohol
Extrogenous oestrogens

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5
Q

What some non-modifiable lifestyle risk factors are there for breast cancer?

A

Age of menarche and menopause
Early parity and breast feeding
Breast density
Heredity

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6
Q

Who is the NHS breast screening programme offered to?

A

Women aged 47-73

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7
Q

What is the 5 year survival rate improvement from the breast cancer screening programme?

A

Rises from 80-95%

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8
Q

What is the triple assessment/fast track for breast cancer diagnosis?

A

Clinical score P1-5 (1 normal, 5 clearly malignant) (from physical examination)
Imaging score U1-5 or M1-5 (USS/mammogram)
Biopsy score B1-5
Need concordance on MDT review

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9
Q

What is MRI scanning useful for?

A

Useful for assessment of implants
Contrast enhanced high sensitivity for invasive breast carcinoma
High risk screening - inherited/iatrogenic
Evaluating response of chemotherapy

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10
Q

What are the presenting S&S for breast cancer?

A

Painless lump
- Irregular
- Hard
- Fixed
Nipple discharge (can be bloody)
Nipple in-drawing
Skin tethering
Bone pain/pathological fractures, jaundice, SOB - metastases
Pain not common

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11
Q

What surgery for operable breast cancers are available?

A

Breast conservation + radiotherapy
Mastectomy
Surgery to axilla

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12
Q

When would you do breast conservation + radiotherapy?

A

Small tumour relative to breast size < 25% volume or 25-50%
No previous radiotherapy to breast
Pre-operative chemotherapy may allow breast conservation
Patient choice
Older patient who can have GA

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13
Q

What can affect the outcome of the breast conservation surgery?

A

Tumour size relative to breast
Position of tumour in breast
Re-excision or not
Radiotherapy fibrosis

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14
Q

When would you do a mastectomy?

A

Large tumour relative to breast size
More than one cancer in same breast if in different quadrants
May have immediate or delayed reconstruction
Patient choice
BRCA genes
Inflammatory cancer

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15
Q

What options are there for breast cancer treatment?

A

Surgery
Chemotherapy - for high risk disease
Endocrine therapy
Adjuvant therapy

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16
Q

What are the risk factors for high risk breast cancer?

A

Young age
ER -ve
HER-2+ve
High grade
Node positive
Ki67 positive
Tumour size
High oncotype DX recurrence score
Complex algorithms

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17
Q

What endocrine therapy is there for breast cancer?

A

Tamoxifen
Aromatase inhibitors

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18
Q

How does tamoxifen work?

A

Inhibits oestrogen receptor on breast cancer cells
Increases survival 15-25% in women with ER+ cancer

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19
Q

What are the complications of tamoxifen treatment?

A

Hot flushes, nausea, vaginal bleeding, rarely thromboses and endometrial cancer

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20
Q

How do aromatase inhibitors work?

A

Inhibit aromatase enzyme responsible for conversion of androgens to oestrogens in post-menopausal females
Slightly better anticancer efficacy than tamoxifen

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21
Q

What are the S/E of aromatase inhibitors?

A

Hot flushes, reduced bone density and joint pains, no DVT/endometrial cancer risk

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22
Q

What is the adjuvant therapy available for breast cancer treatment?

A

Transtuzumab - 1 year, 3 weekly alongside chemotherapy
Radiotherapy

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23
Q

When should adjuvant radiotherapy be used?

A

Always after wide local excision, local recurrence rate 35% without, 10-12% with
Increased use of mastectomy wound radiotherapy for high risk cancers
May be used for axilla in low risk cases with positive SLNB where low axilla treated as part of breast irradiation or full formal axillary RT as good alternative to axillary clearance with lower rate of lymphoedema
Palliative/neoadjuvant uses

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24
Q

What is the TNM staging for breast cancer?

A

T0 no evidence primary
T1 < 2cm
T2 2-5cm
T3 > 5cm
T4 extends to chest wall or skin or inflammatory
N0 no nodes
N1 mobile nodes
N2 fixed/matted nodes
N3 internal mammary nodes
M0 no metastases
M1 metastases

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25
What do HER-2, Neu, and EGFR-2 mean for breast cancer prognosis?
Marker of poor prognosis HER-2 +ve has worst prognosis 15% of all breast cancers Penchant for the brain, 50% have metastatic
26
What are the advantages of primary reconstruction of the breast?
Increased options for skin preservation and therefore better objective cosmesis Reduced psychological trauma from disfigurement
27
What are the disadvantages of primary reconstruction of the breast?
May delay chemotherapy or radiotherapy if complications Radiotherapy may spoil result
28
What are the advantages of delated breast reconstruction?
Minimal risk of delays in other adjuvant therapies from complications Irradiated tissue may be excised when reconstructing and healthy tissue used to recreate breast
29
What are the disadvantages of delated breast reconstruction?
Loss of intra-mammary fold Limited skin preservation options Period without a breast - may never have reconstruction or face long delays as no longer urgent
30
When is radiotherapy needed for breast cancer treatment?
Difficult to predict before surgery T3 and T4 cancers usually attract a recommendation for post-operative chest wall radiotherapy High grade PLUS nodal disease may be offered radiotherapy Close margin posteriorly, careful review of imaging
31
What are the problems with radiotherapy?
High rate of capsule formation with implants Skin viability risk Wound healing Loss of elasticity Fat necrosis Fibrosis Implant extrusion
32
How can you recreate a breast?
Implant based Autologous (use of patient's own tissues) Latissimus dorsi flap
33
How can you treat locally advanced breast cancer?
Attempt to shrink with either radiotherapy, chemotherapy or hormone therapy Stage for metastases - USS liver, CXR, bone scan, bloods Very high risk recurrence/metastases Salvage surgery may be possible
34
Where does breast cancer metastasise to?
Bone 70% Soft tissue 25% Pleura 48% Lung 67% Liver 50% Brain 20%
35
How can you treat metastatic breast cancer?
Hormonal treatments - slow acting, only suitable for hormone sensitive cancers, longer lasting control Bisphosphonates and denosumab Radiotherapy - bone, brain, soft tissues, axillary nodes, palliative surgery Chemotherapy - CMF, doxorubicin, taxanes, herceptin, rapid action, high toxicity Newer agents - multiple trials Symptoms control and social/financial support
36
What is the population risk of breast cancer?
12% lifetime risk
37
What is a moderate lifetime risk of breast cancer?
17-30%
38
What is a high lifetime risk of breast cancer?
> 30% - Definite gene carriers lifetime risk up to 80%
39
What strategies are there to manage moderate risk of breast cancer?
Screening - annual mammograms 40-50 Consider prophylactic SERM Lifestyle advice
40
What strategies are there to manage high risk of breast cancer?
Enhanced screening Risk reducing mastectomy Risk reducing salpingo-oophorectomy Lifestyle advice Prophylactic SERM
41
What strategies are there to manage women with BRCA1 and 2 genes?
30-40 annual MRI 40-50 annual mammograms, annual MRI 50-60 annual mammograms, annual MRI if dense breasts 60-70 triennial mammograms, MRI if dense breasts Risk reducing surgery - 90% breast cancer risk reduction, 99% ovarian cancer risk reduction BUT complex decision
42
How common are benign breast lumps?
10 to 1 benign to malignant ratio seen in breast clinic
43
Name 4 differentials of breast lump
Benign breast change Fibroadenoma Cyst Sebaceous cyst Papilloma Fat necrosis/haematoma Mastitis/abscess Cancer Sarcoma, lymphoma, metastases Implant related (capsule, rupture, edge, crease)
44
What are the characteristics of a malignant lump?
Hard - lobular cancer/DICS may be diffuse thickening Irregular margin - high grade cancer may have pushing edge and feel and look on imaging like a fibroadenoma Skin tethering/fixation Nodal swelling Older age
45
How does age determine the management of a potentially malignant breast lump?
> 40 - mammography, USS and biopsy 25-40 - USS and biopsy < 25 - free hand biopsy
46
In whom are fibroadenomas most common?
Predominantly puberty to 25-30
47
How do fibroadenomas present?
Smooth, mobile (breast mouse), non-tender 1-3cm Giant variants and multiple juvenile FA
48
How do you treat fibroadenomas?
Leave unless increasing in size, atypical history, tender
49
In whom are breast cysts most common?
35-55
50
How do breast cysts present?
Size varies from 1mm to 20cm but on average symptomatic ones 1-2cm and often multiple May feel cystic but if tense may be hard/irregular and difficult to tell from cancer
51
How do you treat breast cysts?
Aspirate symptomatic cysts, ceases at menopause unless on HRT
52
What is a benign breast change?
Fibrocystic change
53
In whom are benign breast changes most common?
Puberty to menopause but usually younger end of range
54
How do benign breast changes present?
Often tender/painful Cyclical variation Feels like rubbery nodularity
55
How do you treat benign breast changes?
Reassure
56
What implant problems can you get?
Capsule formation affects 5% Rupture incidence relates to duration of implantation Migration Changes in body habitus and ptosis
57
What is breast sepsis?
Mastitis
58
What are the symptoms of breast sepsis?
May have associated pyrexia and flu-like symptoms May be lactational or non-lactational May progress to abscess formation
59
What can cause acute peripheral/lactation sepsis?
Age < 40 Staph aureus Cause - pregnancy and lactational blocked duct, diabetes
60
How do you treat acute peripheral/lactation sepsis?
Serial aspiration, avoid drainage surgically as may cause lactational fistula Flucloxacillin Continue to feed
61
What can cause acute peri-areolar sepsis?
Duct ectasia and periductal mastitis, smoking Age < 50 Staph aureus, step, bacteroides, enterococci
62
How can you treat acute peri-areolar sepsis?
Serial aspiration, surgical drainage, total duct excision, fistulectomy Co-amoxiclav
63
What are the indications for surgery of an abscess?
Failure of repeated aspiration and antibiotics Large multi-located collection Overlying skin necrosis Patient intolerance of aspiration Unable to aspirate
64
How is chronic periductal mastitis treated?
Total duct excision Use either radial or peri-areolar incision to resect all sub-areolar ducts
65
What are the risks of total duct excision?
Nipple numbness, nipple necrosis, recurrent sepsis
66
How does breast fistulation occur?
Recurrent bouts of sepsis/abscess formation Progressive scarring Fistulectomy and total duct excision
67
What is an important differential of mastitis?
Inflammatory breast cancer
68
How does inflammatory breast cancer present?
Breast red, oedematous, swollen, axillary lymphadenopathy, mass or thickening If fails to settle with 1-2 weeks of antibiotics always refer for imaging and biopsy
69
What does physiological nipple discharge look like?
Non-spontaneous Bilateral Yellow/creamy Reassure
70
What does hormonal nipple discharge look like?
Milky, multiduct Large volume Rarely bloody in epithelial hyperplasia of pregnancy
71
What investigations should you do for hormonal nipple discharge?
Pregnancy test Serum hormone profile If bloody, monitor
72
What does duct ectasia nipple discharge look like?
Green-ish brown Multiduct
73
How do you treat duct ectasia?
Reassure or total duct excision if volume excessive
74
What does papilloma nipple discharge look like?
Clear or bloody Uniduct
75
What investigations should you do with papilloma nipple discharge?
Imaging and proceed to microdochectomy Small mass within dilated ductal system Mass usually biopsied under USS
76
What treatment is there for papillomas?
Usually benign but generally removed Multiple associated with increased breast cancer risk
77
What does DCIS nipple discharge look like?
Clear or bloody Uniduct
78
What investigations should you do in DCIS?
Imaging and proceed to microdochectomy
79
What should you suspect with blood stained nipple discharge and what should you do?
Majority due to duct ectasia then papillomas then DCIS Rarely bilateral in pregnancy due to epithelial hyperplasia All require imaging Cytology of nipple aspirates unhelpful If imaging unhelpful, microdochectomy required
80
What is the cause of pre-menopausal cyclical breast pain?
Hormonal
81
What is the causes of pre-menopausal non-cyclical breast pain?
MSK, trauma, tender lump
82
What is the cause of post-menopausal cyclical breast pain?
On HRT - hormonal
83
What is the cause of post-menopausal non-cyclical breast pain?
MSK, trauma, tender lump
84
What is cyclical breast pain?
Breast swelling/tenderness Usually in week prior to menstruation Usually mild, self-limiting and last for a few cycles only Settles after menses commences
85
What is the aetiology of cyclical breast pain?
poorly understood, no consistent histological correlates, no endocrine correlates
86
How can you manage cyclical breast pain?
Breast pain diary Reassurance - NSAIDs, low fat diet and avoid methylxanthines Ensure has correctly fitting bra Usually settles within a few months No benefit to evening primrose oil derivates, vitamins, diuretics
87
How common is breast cancer?
Most common cancer in the UK Second biggest cause of cancer deaths in women after lung Survival higher than that for cervical cancer and much higher than that of other major cancers in women - cervical, colorectal, ovarian, lung 96% survive breast cancer for at least one year after diagnosis 85% survive for 5 years or more Earlier detection and improved treatment means survival rates have risen Survival doubled in last 40 years Risk increases with age
88
What improved chances of survival from breast cancer?
Changes in surgical management New chemotherapeutic agents Tamoxifen NHS breast screening programme
89
What can increase you risk of getting breast cancer?
Radiotherapy treatment before 35 BRCA 1 and 2 gene carriers HRT Li Fraumeni syndrome Moderate-high alcohol consumption Not breast feeding Nuliparous
90
What are the 4 stages of breast screening?
Invitation Screening mammography Assessment - average about 5% recalled, USS, biopsy Results, surgery, further treatment
91
Why might women be recalled for breast cancer screening?
Mass - may be well defined, poorly defined, spiculate Microcalcification Parenchymal deformity/distortion Asymmetric density Enlarged axillary lymph nodes Clinical recall Technical recall
92
How does imaging for breast lumps change based on age?
> 35 - mammogram and targeted USS < 35 - targeted USS then mammogram if suspicious - difficult to see cancers in under 40s a breasts denser due to more ducts
93
What anatomical structures within the breast need to be differentiated between on mammogram and how is this done?
Glandular tissue (more dense) Fatty breast tissue (less dense)
94
Where do breast cancers tend to form in the breast?
Around lobules
95
What is lymphatic drainage from the breast like?
Mostly to axillary lymph nodes 25% internal mammary lymph nodes Infraclavicular lymph nodes Supraclavicular lymph nodes
96
What positions are required for a mammogram?
Cranio-caudal (front) - entire body of gland and retromammary fat, nipple centre Medio-lateral oblique (side) - chest wall, axillary tail
97
What is a tomogram?
Mammogram but like CT - can scroll through images
98
What are the level 1 lymph nodes in breast?
Pectoral axillary lymph nodes (anterior) Subscapular axillary lymph nodes (posterior) Humeral axillary lymph nodes (lateral)
99
What are the level 2 lymph nodes in breast?
Central axillary Apical axillary Interpectoral
100
What are the level 3 lymph nodes in breast?
Apical axillary
101
What are the two different types of axilla surgery? What is the purpose of them?
Full axillary clearance - If glands clinically involved - High complication rate Limited axillary clearance - If clinically normal - No effect on mortality - Removes targeted hot nodes or samples nodes
102
What are the different types of breast cancer and how can you tell the difference?
Ductal - Hard knot in breast - Easier to see and diagnose - More common Lobular - More diffuse and spreading - More likely to be missed - Subtle thickening

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