1. diagnosis 2. staging 3. definitive treatment

treatment of breast disease Flashcards by Evie withington

incidence of breast cancer

1/8 women 
account for 1/4 of malignancies in women 
55, 000 new cases p/a UK
>490 new cases p/a in Grampian 
>9000 diagnosed each year are <50y/o
>11 400 deaths p/a 
~300 new cases p/a in men

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risk factors for breast cancer

age - increased incidence
previous breast cancer
genetic: BRCA1, BRCA2 (5%)
early menarche and late menopause
late/no pregnancy
HRT
alcohol (>14 units/wk)
weight
post RT treatment for Hodgkin's disease

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why is weight a risk factor for breast cancer

increased fat

increased storage of oestrogen

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presentation of breast cancer - where would it be picked up

asymptomatic - breast screening (50-70y/o)

symptomatic - outpatient clinic

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symptomatic presentation of breast cancer

lump 
mastalgia - persistent unilateral pain 
nipple discharge - blood stained
nipple changes - Paget's disease, retraction 
change in size/shape of the breast
lymphoedema - swelling of arm
dimpling of breast skin

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new patient clinic - investigations

TRIPLE ASSESSMENT

clinical - hx and examination
radiological - bilateral mammograms/US
cyto-pathological - FNA (cells only, cytology), core biopsy (tissue, histopathology)

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triple assessment: clinical assessment

HX: 
PC
previous breast problems
FHx
hormonal status
drug Hx

examination:
BOTH breasts - start with normal breast
axillae
SCF - supraclavicular fossae

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common signs and symptoms of breast cancer

most common - lump/thickening in breast, often painless
discharge or bleeding
change in size/contours of breast
inversion - is this new or has it always been inverted
change in colour/appearance of areola
redness or pitting of skin over breast (peau d’orange) - sign of inflammatory breast cancer

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triple assessment: breast imaging

mammography, US, MRI
mammography is the most sensitive in older women
MRI - only for lobular cancer, dense breasts or other benign disease present
sensitivity is reduced in young women due to presence of increased glandular tissue (<35y/o)

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triple assessment: cytology and histology

FNA - cytology

core biopsy - histopathology, invasive VS in-situ ER/PR/HER2 receptor status

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how sensitive are the investigations

clinical examination 88%
mammography 93%
US 88%
FNA cytology 94% - diagnostic

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importance of HER2 receptor status

prognostic factor

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pathological types of breast cancer

invasive:
80% ductal carcinoma
10% lobular carcinoma
10% others - mucinous, tubular, papillary, medullary, sarcoma, lymphoma

non-invasive:
DCIS - ductal carcinoma in situ, 17% screening detected
LCIS - lobular carcinoma in situ

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management of cancer

diagnosis
staging
definitive treatment

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treatment of breast cancer - MDT approach

breast surgeon 
radiologist
cytologist
pathologist
clinical oncologist - systemic and radiotherapy
medical oncologist - systemic therapy
nurse counsellor
psychologist
reconstructive surgeon
patient and partner
palliative care

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staging of breast cancer - how do we do it

FBC, U+Es, LFTs, Ca2+/PO2-
CXR
others as clinically indicated
no reliable tumour markers

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breast cancer TNM staging - T

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TX - 1y tumour cannot be assessed
T0 - 1y tumour not palpable 
T1 - clinically palpable tumour <2cm 
T2 - 2-5cm
T3 - tumour >5cm
T4a - invading skin
T4b - invading chest wall
T4c - skin and chest wall invasion 
T4d - inflammatory breast cancer (worst type)

breast cancer TNM staging - N

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N0 - no regional LNs palpable
N1 - regional LNs palpable, mobile
N2 - regional LNs palpable, fixed

breast cancer TNM staging - M

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MX - distant mets cannot be assessed
M0 - no distant mets
M1 - distant mets

management/treatment options

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neoadjuvant (before surgery) VS adjuvant (after surgery)

surgery
+/- RT
+/- chemotherapy
+/- hormonal therapy

what are the 2 main types of surgical procedure

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breast conservation surgery
mastectomy

randomized controlled trials - breast conservation + RT = mastectomy for overall survival in tumours <4cm

patients suitable for breast conservation surgery

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previously - tumour size <4cm, single tumours
BREAST/TUMOUR SIZE RATIO
suitable for RT
patient’s wish! - most important

types of therapeutic mammoplasties

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omega shape - horizontal line across the breast, runs above the nipple
wise pattern - round the nipple then straight down

types of mastectomies

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simple

skin sparing with immediate implant reconstruction

surgery to the axilla

prognostic info/staging | regional control of disease/eradication in the axilla

sentinal LN biopsy

first node to recieve lymphatic drainage first node tumour spreads to if -ve, rest of nodes in lymphatic basin are -ve only performed when pre-op axillary US normal/benign

treatment of the axilla

if SLN is -ve = no further treatment required | if SLN contains tumour = remove them all surgically (clearance = ANC) OR give RT to all the axillary nodes

complications of axillary treatment

lymphoedema - 10-17% sensory disturbance - intercostobrachial n. decrease ROM of shoulder joint nerve damage (long thoracic, thoracodorsal, brachial plexus) vascular damage radiation induced sarcoma

factors associated with increased risk of disease recurrence

nottingham prognostic index: 1. lymph node involvement 2. tumour grade 3. tumour size steroid receptor status (ER/PR -ve) HER2 +ve LVI - lymphovascular invasion

prevention/adjuvant treatment

local RT | systemic: hormonal, chemotherapy, targeted therapies

radiotherapy - who gets it and how long for

all patients after wide local excision as adjuvant treatment over 3wks boosts reduce local recurrence (for younger patients) after mastectomy if there is local involvement/significant LN involvement

complications of RT - immediate - longterm

skin reaction - skin telangiectasis radiation pneumonitis cutaneous radionecrosis/osteonecrosis angiosarcoma

hormonal therapy - who gets it, how does it work, what are the types

only for oestrogen +ve cancers blocks stimulation of cell growth by oestrogen tamoxigen, aromatase inhibitors

tamoxifen - dose, how does it work, effectiveness, who can have it, side effects

20mg once daily for 5-10yrs blocks directly on ER receptor effective in all age groups (can be given to premenopausal women), more effective given after chemotherapy thromboembolic events - CI if prev PE/DVT low risk of endometrial cancer

aromatase inhibitors - dose, how does it work, effectiveness, who can have it, side effects

``` (arimidex 1mg and letrozole 2.5mg) once daily for 5yrs inhibiting ER synthesis should only be used in postmenopausal women improve disease free survival ``` osteoporosis

chemotherapy - where is the greatest benefit

<50y/o | pts w/ increasing adverse prognostic factor - grade 3, LN +ve, ER -ve, HER2 +ve

traditional chemotherapy

1st gen - CMF combinations, not used anymore 2nd gen - anthracycline combinations (doxorubicin or epirubicin) 3rd gen - taxane based combinations e.g. Docetaxel, more potent

oncotype Dx

21 gene assay to determine whether chemotherapy is likely to be of benefit generates recurrence score: <25 - don't benefit from chemotherapy >25 - would benefit - info is only from ER+/HER2 -, LN- pts

HER2 positivity and anti-HER2 therapy - different types

trastuzumab (Herceptin) | pertuzumab - only in neoadjuvant chemotherapy setting

HER2 positivity and anti-HER2 therapy - what is it, who gets it, benefits

monoclonal antibody against HER2 receptor pts w/ over-expression of HER2 and chemotherapy 50% decrease risk of recurrence, 33% increase in survival at 3yrs

follow up for breast cancer

many different protocols - poor evidence base clinical examination for 1-5yrs mammogram of breasts at yrly intervals for 3-10yrs patient is the best person to keep an eye on it open access to service

metastatic spread of breast cancer

local - chestwall, skin, nipple | distant - contralateral breast, bone, lung, liver, brain, bone marrow

treatment of breast disease Flashcards

(42 cards)