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MBBS IV - Junior Clerkship WCS > JC76 (Surgery) - Breast cancer > Flashcards

JC76 (Surgery) - Breast cancer Flashcards

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1
Q

Modalities of breast cancer spread

A

Direct spread
•Chest wall
•Skin and subcutaneous tissues

Lymphatic spread
oLateral tumours in outer quadrant and centrally located lesions  Axillary LN
oUpper and lower inner quadrant  Internal mammary LN
oSupraclavicular LN

Hematogenous spread
•Distant metastasis to lungs, liver, bone…etc

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2
Q

Breast cancer risk factors

  • Non-modifiable RF
  • Relevant PMH
A

Non-modifiable:

  • Advanced age
  • Female gender (M : F = 1 : 2000)
  • White ethnicity
  • Inherited BRCA1 and BRCA2 mutation
  • Early menarche <12 and Late menopause >55
Medical history"
High estrogen exposure 
- Nulliparity, no breast feeding 
- Late age of first pregnancy >30 
- Estrogen-secreting ovarian tumor 
- Oral contraceptives and HRT 
- Obesity in post-menopausal

Breast diseases:

  • History of breast cancer
  • History of benign breast disease: ADH, ALH
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3
Q

Breast cancer risk factors

  • Drug hx
  • Family hx
  • Social hx
A

Drug history
• Exposure to therapeutic ionizing radiation

Family history
• History of breast cancer

• Li-Fraumeni syndrome
Germline abnormalities of TP53 gene
Tendency to develop malignancy including breast cancer, sarcoma, brain tumours,adrenocortical cancer and leukemia

• Hereditary diffuse gastric cancer
Germline mutation of CDH1 gene
Associated with development of lobular breast cancer

Social history
• Smoking
• Alcoholism

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4
Q

Ddx breast cancer

A

Benign breast lesions

Paget disease of the nipple

Phyllodes tumours

Breast sarcoma

Lymphoma - mainly non-Hodgkin lymphoma B-cell

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5
Q

Paget disease of nipple

  • Characteristic skin features
  • Disease associated
  • Clinical presentation
  • Workup
A

characterized by eczematoid changes and ulcerated lesions ofnipple-areolar complex

80% associated with HER2 +ve breast cancer

Presents with pain, burning, pruritus, palpable breast mass, bloody nipple discharge or nippleinversion

Workup:
Mammography is mandatory to look for associated mass
USG with biopsy of any mass

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6
Q

Describe structure of breast

A

Breast comprises 3 major structures including skin, subcutaneous tissue and breast tissue

Breast tissue is composed of epithelial and stromal elements
o Epithelial components include ducts that connect structural and functional units of the breast (lobules) to the nipple
o Stromal components include adipose tissues and fibrous connective tissues

Lobules are separated by suspensory ligament of breast (Cooper’s ligament)

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7
Q

Arterial supply of breast

Venous drainage of breast

A

Arterial:
 Internal thoracic (internal mammary) artery (from subclavian artery)
 Lateral thoracic (external mammary) artery (from axillary artery)
 Posterior intercostal artery
 Thoracoacromial artery
 Axillary artery

Venous 
 Internal thoracic vein
 Lateral thoracic vein
 Posterior intercostal vein
 Axillary vein
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8
Q

Lymphatic drainage of breast

A

 Axillary lymph node (75%)

 Internal mammary lymph node (20%)

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9
Q

Define the axillary lymph node levels and location

A

Level I - Inferior and lateral to pectoralis minor muscle - Anterior, posterior and lateral axillary nodes

Level II - Posterior to pectoralis minor muscle and below the axillary vein - Central axillary nodes, Interpectoral nodes

Level III - Medial to pectoralis minor extending up to apex against chest wall (Infraclavicular) - Apical axillary nodes/ Subclavian

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10
Q

List the motor nerves that supply the muscles under the breast

A

Motor nerves
o Thoracodorsal nerve > Supply latissimus dorsi muscle
o Long thoracic nerve > Supply serratus anterior muscle
o Medial and lateral pectoral nerve > Supply pectoralis major and minor muscles

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11
Q

List Non-invasive and Invasive histological types of breast cancer

List histological subtypes with good prognosis, and poor prognosis

A

Non-invasive:

  • Ductal carcinoma-in-situ (DCIS)
  • Lobular carcinoma- in-situ (LCIS)

Invasive

  • Invasive ductal carcinoma (IDC)
  • Invasive lobular carcinoma (ILC)
Good prognosis
• Tubular carcinoma
• Medullary carcinoma
• Mucinous (colloid) carcinoma
• Papillary carcinoma
poor prognosis
• Mixed ductal/lobular carcinoma
• Metaplastic carcinoma
• Micropapillary carcinoma
• Inflammatory breast cancer
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12
Q

DCIS

  • Presentation
  • Tumor characteristics
  • Treatment options
A

Presentation: asymptomatic or painless mass, incidental finding on mammography with microcalcifications

Tumor:

  • From lobules and terminal ducts of breast with ductal predominance, confined to basement membrane
  • E-cadherin + ve ***

Treatment:
Surgical:
- Partial mastectomy for unicentric lesion
- Total mastectomy for multicentric lesion

Axillary LN: DCIS is non-invasive!

  • ALND not indicated for pure DCIS
  • Sentinel LN biopsy for high-grade histology

Adjuvant radiotherapy for partial mastectomy
Adjuvant hormone therapy for ER+ve DCIS

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13
Q

LCIS

  • Presentation
  • Tumor characteristics
  • Treatment options
A

Presentation: Asymptomatic/ incidental finding by mammography

Tumor characteristics:

  • No microcalcifications (easily missed), from lobules and terminal ducts with lobule predominance
  • Non-invasive except for Pleomorphic LCIS
  • E-cadherin -VE

Treatment options: No considered cancer or pre-invasive lesion

  • Lifelong surveillance
  • Chemoprevention with Tamoxifen, Raloxifene, Aromatase inhibitor
  • Bilateral total mastectomy for strong family history
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14
Q

2 most common types of invasive breast cancer

A

Invasive ductal carcinoma (IDC)
 Accounts for 70 – 80% of invasive breast cancers (most common)

Invasive lobular carcinoma (ILC)
 Accounts for 5 - 10% of invasive breast cancers (second most common)

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15
Q

IDC vs ILC

Histological differences
- Metastasis tendencies

A

Histological differences

  • IDC: Cords and nests of cells with varying amount of gland formation
  • ILC: Smalls cells that infiltrate mammary stroma and adipose tissue in a single file pattern

Metastasis tendencies

  • IDC: A/w DCIS, Earlier than invasive lobular carcinoma (ILC)
  • ILC: Later than invasive ductal carcinoma (IDC), Metastasize to unusual location including meninges, gastrointestinal tract and peritoneum
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16
Q

Diagnostic criteria of inflammatory breast cancer

A

o Rapid onset of breast erythema, edema, peau d’ orange or warm breast with or without an underlying palpable breast mass

o Erythema occupying at least 1/3 of the breast

o Duration of history no more than 6 months

o Pathological confirmation of invasive carcinoma

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17
Q

Atypical ductal hyperplasia vs Atypical lobular hyperplasia (ADH/ ALH)

Cell origins
Treatment options

A

Proliferative lesions with cellular atypia that arises from breast ducts (ADH) and lobules (ALH) respectively

Treatment: Both with risk of malignant transformation

  • Core Biopsy for both
  • Excisional biopsy if core biopsy finds atypical hyperplasia
  • Treat like DCIS/ IDC or LCIS/ ILC if malignant
  • Or lifelong surveillance with chemoprevention (Tamoxifen) if not malignant
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18
Q

List 3 major molecular subtypes of breast cancer

Prevalence of each type?

A

Depends on ER, PR, HER2 expressions:

Luminal A and B - 70% of breast cancer

  • Luminal A: ER, PR +ve
  • Luminal B: Triple Positive

HER2 - 15% of breast cancer

Basal-like/ Triple negative: 15% of breast cancer

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19
Q

Luminal A/B, HER2, Basal-like breast cancer

Treatment choice for each

A

Luminal A/B: Hormone treatment

HER2: Anthracycline-based chemotherapy or Herceptin

Basal-like/ Triple negative: Platinum/ PARP inhibitors responsive

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20
Q

Surgical description of breast cancer mass

A
  • Site: 50% of CA breast occurs in upper outer quadrant including the axillary tail
  • Color: Discoloration (smooth and reddening) if tumour is close to overlying skin, Peau d’orange
  • Shape: Spiculated
  • Edge: Irregular or nodular
  • Surface: Dimpling, tethering, erythema
  • Consistency: Solid and stony hard
  • Tenderness: Usually non-tender
  • Mobility: Fixation of lump (Immovable)
  • Lymph nodes: May be palpable and enlarged axillary LN
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21
Q

5D for surgical description of nipple changes

A
  • Deviation/ Displacement
  • Discoloration
  • Dermatitis (Eczema in Paget’s disease of nipple)
  • Depression (Retraction/ Inversion)
  • Discharge
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22
Q

Possible skin changes over breast mass

A
  • Lump/ nodules
  • Ulceration
  • Discoloration: Erythema/ Hematoma/ Ecchymosis (in fat necrosis)
  • Puckering/ Dimpling: Underlying cancer
  • Peau d’ orange
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23
Q

How to elicit skin fixation, skin tethering or muscle fixation of breast mass on P/E

Study These Flashcards
A

o Skin fixation: Try to pick up the skin above the lump

o Skin tethering: Lump behaves as if tied to skin by a piece of string/ Remains separate from skin and can be moved independently within certain limits

o Muscle fixation: Move the lump in 2 perpendicular direction, then contract the pectoralis muscle by asking patient to press against her hip, move the lump again and observe for limited movement

24
Q

Modalities of radiological imaging for breast mass

Study These Flashcards
A

Mammogram (1st-line)

Ultrasound (2nd-line, or for younger patients with dense breasts)

MRI breast (3rd-line)

PET-CT (metastasis)

Ductoscopy

25
Mammogram - 2 standard views - Descriptors of mammogram (steps to describe) - Limitations
craniocaudal (CC) and mediolateral oblique (MLO) views - CC for inferior, medial and upper portion - MLO for axillary tail, axillar lymph nodes and upper outer quadrant Descriptors: 1. Symmetry in shape and density 2. Architecture distortions 3. Presence of lymph nodes 4. Presence of breast mass, mass density: Spiculated (stellate) mass or irregular shape for malignancy 5. Any Calcification Limitations: - NOT preferred in young women (age < 40) due to dense breast (low sensitivity) - Cannot make definitive diagnosis - Obscuration of borders and extent of primary tumour by dense breast tissues
26
Mammogram Features of benign vs malignant cancer
``` Benign:  Rim-like calcification  Large coarse calcifications  Smooth round or oval calcifications  Vascular and skin calcification ``` Malignant: Pleomorphic, linear or clustered MICROCALCIFICATIONS
27
Ultrasound for breast mass - Function
Determines whether the mass is solid or cystic Characterize solid mass as benign or malignant Identify presence of a prominent vascular supply Image-guided procedures including FNAC or core biopsy
28
Ultrasound of breast tissue Features suggesting benign lesion vs malignant lesion - Shape - Margin - Echogenicity - Calcification - Vascularity
29
MRI breast Indications Malignant breast cancer features
High risk of breast cancer Breast implants or augmentations Suspicious lesions on mammogram or ultrasound Clinically occult tumor with positive LN Neoadjuvant therapy ``` MRI abnormalities (malignant features) • Spiculated or irregular margins • Rim-like enhancement • Heterogenous internal enhancement • Enhancing internal septa • More rapid uptake of contrast ```
30
Modalities of imaging for breast cancer metastasis
```  CXR for lung metastasis  USG abdomen for liver metastasis  Bone scan for bone metastasis  CT abdomen for liver, adrenal and ovarian metastasis  CT or MRI brain for brain metastasis ```
31
Criteria and test for breast cancer HER2 expression
o Immunohistochemistry (IHC 3+) defined as uniform intense membrane staining of ≥ 10% of tumour cells by (OR) o Presence of HER2 gene amplification by fluorescence-in-situ-hybridization (FISH) defined as: - ratio of HER2/CEP17 ratio ≥ 2.0 - (OR) HER2/ CEP17 ratio < 2.0 with average HER2 copy number ≥ 6 signals/ cell
32
Prognosis of HER2+ breast cancer
* Higher risk of recurrence * Higher mortality * Relative resistance of hormonal treatment * Less benefit from some forms of chemotherapy
33
Sampling methods for palpable and non-palpable breast cancer
Methods of biopsy for palpable lumps • Fine needle aspiration (FNA) • Core biopsy (Trucut biopsy)/ Vacuum-assisted biopsy • Excisional and incisional biopsy ``` Methods of biopsy required for NON-palpable lumps = Image-guided biopsy required with Hook-wire guided excision o Stereotactic (X-ray guidance) o Ultrasound (USG) o MRI-guided ```
34
Compare FNAC and core biopsy for breast cancer - Advantages and disadvantages
35
IHC score for protein overexpression in breast cancer Scoring and histological description
36
Outline flowchart for HER2 FISH testing for breast cancer - Criteria for ISH positive or negative
37
Modalities of treatment for breast cancer
Local disease: o Surgery o Radiotherapy Systemic/ metastatic disease: o Chemotherapy o Hormonal therapy o Targeted therapy
38
Treatment options for DCIS and LCIS breast cancer
``` DCIS: Van Nuys Prognostic Index • Low score = Wide local excision • Intermediate score = Wide local excision + Radiotherapy • High score = Mastectomy Lymph node management • Sentinel lymph node biopsy (SLNB) • Axillary lymph node dissection (ALND) Systemic: Adjuvant radiotherapy or hormonal therapy ``` LCIS: Bilateral simple mastectomy with reconstruction Tamoxifen prophylaxis
39
Treatment for stage 1-3 breast cancer
Surgical approach • BCT (OR) • Mastectomy with reconstruction Lymph node management • Sentinel lymph node biopsy (SLNB) (OR) • Axillary lymph node dissection (ALND) ± Adjuvant chemotherapy ± Adjuvant radiotherapy ± Adjuvant hormonal therapy ± Adjuvant targeted therapy
40
Treatment for stage 4 breast cancer
Palliative chemo, radio, hormonal or targeted therapy
41
Modalities of breast cancer screening Which modalities are outdated/ poor detection rate
Self- breast examination - not recommended Clinical breast examination - no improvement on survival Mammogram - 20% reduction in mortality, especially pt. over 50 years old
42
Harms of mammogram screening
Over diagnosis (false positive) and over treatemtn False reassurance (false negative) Radiation exposure Pain and discomfort during scan
43
Indication for breast cancer screening in HK
Age: 44-69 Risk factors: - Family history of breast cancer (1st degree cousin) - Previous benign breast disease - Nulliparity - Late age of one live birth - Early menarche and late menopause - High BMI and low physical activity Mammogram screening every 2 years
44
Triple assessment of breast cancer | - Which 3 parts
Clinical exam: history and examination Radiological exam Pathological exam
45
Surgical mastectomy - All types
Simple mastectomy (Linear scar) Radical masectomy Modified radical masectomy Skin sparing mastectomy with reconstruction Nipple sparing mastectomy with reconstruction (low risk or prophylaxis)
46
Surgical lumpectomy | - Margin cut-off
2mm for in-situ cancer No cancer at inked margin for invasive cancer Histological margin determined intra-operatively, aim for 5-10mm margins
47
Oncoplastic breast surgery - Different surgeries are different volume displacement and replacement
Level I: <20% breast tissue removed - Local tissue rearrangement - Crescent or Doughnut mastopexy Level II: 20-50% breast tissue removed - Circumvertical mastopexy - Reduction mammaplasty Volume replacement > 50% breast tissue removed - Implant-based reconstruction - Local/ regional flap reconstruction
48
Axillary dissection for breast cancer - Indications - Levels of LN removed - Preserved structures - Complications
Indications: • Clinically +ve nodes • Sentinel lymph node +ve nodes • Inflammatory breast cancer (T4d) Level I and II axillary LN removed (≥ 10 lymph nodes) Preserved: - Long thoracic nerve - serratus anterior - winging scapula - Thoracodorsal nerve - latissimus dorsi - shoulder extension - Intercostobrachial nerve - axilla parasthesia Complications: - Seroma - Lymphedema - Nerve injury - General surgical complications (infection, pain...etc) - Shoulder dysfunction/ Restricted shoulder mobility
49
Sentinel LN biopsy - Identification methods - Indications
Identify by: - Blue dye/ Patent blue - Radioisotope - Supramagnetic iron oxide - Indocyanine green Indications: - Early breast cancer with clinical -ve nodes - DCIS with planned mastectomy - DCIS with suspicious features (> 5 cm or present with a palpable mass)
50
Breast reconstruction choices - types of surgery - Types of flaps
Autologous tissue reconstruction o TRAM flap: Transverse rectus abdominal muscle (weaken abdominal muscle) o LD flap: Latissimus dorsi muscle o DIEP flap: Deep inferior epigastric perforator (preserve abdominal muscle) Prosthetic devices o Devices include saline implants, silicone implants or tissue expanders
51
Targeted therapy for breast therapy | - Options
Trastuzumab (Herceptin) • IV infusion monthly for 12 months Lapatinib Bisphosphonates/ Denosumab (RANKL monoclonal antibody) • Osteoclast inhibitors • Indicated for palliation in patients with bone metastasis
52
Hormonal therapy options for breast cancer
Selective estrogen receptor modulators (SERMs) - Indicated in all ER or PR +ve patients Example: Tamoxifen ``` Aromatase inhibitors (AI) Non-steroidal: - Letrozole - Anastrozole Steroidal: - Exemestane ```
53
Selective estrogen receptor modulators (SERMs) MoA S/E
Mechanism of action • Antagonist of ER receptor at breast • Inhibits growth of breast cancer cells by competitive antagonism of ER ``` S/E: Thromboembolic disease* • Stroke • Deep vein thrombosis (DVT) • Pulmonary embolism ``` Endometrial cancer* • Partial agonist of ER receptor at uterus Menopausal symptoms • Hot flushes • Tachycardia and sweating Vaginal discharge, Menstrual irregularities, Sexual dysfunction
54
Aromatase inhibitor MoA S/E
Mechanism of action • Inhibits peripheral conversion of testosterone and androstenedione to estradiol Appropriate for post-menopausal women ONLY ``` S/E  Osteoporosis*  Associated musculoskeletal syndrome • Bone pain • Arthralgia • Joint stiffness ```
55
Radiotherapy for breast cancer - Types - Indications
Whole breast radiation therapy (WBRT): Indications • ALL patients undergoing breast conservation surgery (BCT) • Post-mastectomy patients with high-risk features Regional nodal irradiation Indications • Node +ve disease with ≥ 4 involved lymph node • Node -ve T2 tumour with features such as high-grade tumour, high risk receptor biology or lymphovascular invasion • T3 or T4 primary tumour
56
Complications of breast radiotherapy
Whole breast radiation therapy (WBRT) ``` Short-term complications o Breast skin fibrosis, radiation dermatitis o Arm edema Long-term complications o Rib fracture o Cardiotoxicity o Pulmonary fibrosis or pneumonitis o Secondary RT-induced malignancy ``` Regional nodal irradiation Complications • Lymphedema • Axillary fibrosis

MBBS IV - Junior Clerkship WCS (131 decks)

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