Breast cancer
Reference: OHCM 504, Sur Talk 180, Lec Not
Onc 75
Risk Factors
Only 15% have a risk factor other than age and gender!
-
Family history
-
Previous benign disease (especially atypical epithelial
hyperplasia)
-
BRCA 1+2
-
Estrogen (the more cycles and the later they are
interrupted by pregnancy): early menarche, late menopause,
late/low/no parity, HRT (especially estrogen only, but combined also
has double the risk)
-
OCP
-
Obesity
-
Social: high socioeconomic status, diet, alcohol
-
(Smoking is not a factor.)
Clinical
Pain, nipple discharge (especially blood), peau d'orange,
hard lumps, nipple inversion, Paget's (unilateral nipple eczema)
Factors likely to
signify
not cancer:
change in size related to
menstrual cycle
Differential
Lump:
Fibroadenoma,
cyst, fibroadenosis, mastitis, fat necrosis, abscess, lipomas/sebaceous
cysts.
Discharging lump:
Duct
ectasia (multiple colours), papilloma/adenoma/ca (bloody), lactation
Lobular carcinoma in situ (LCIS)
↑Risk of breast cancer. Incidental finding on diagnostic biopsy
requires no treatment.
Spread
Direct:
Skin/subcutaneous (dimpling, retraction of nipple, ulceration),
muscles,
chest wall
Lymph:
Axillary,
internal mammary, supraclavicular
Blood:
Lungs, liver, bones
Investigations
Triple Investigation
Treatment discussed at first visit.
-
Clinical
-
Radiological: ultrasound scan if < 35,
mammography + ultrasound scan if over (as mammography not as sensitive
in the young). Craniocaudal
and oblique XR views. Carcinoma appears as white asymmetrical
spiculated lesions with microcalcification.
-
FNA/core biopsy. Cytology stages = C1: insufficient
material, C2: benign cells, C3: uncertain: C4: probably
ca, C5: cancer
Staging
Methods:
CT
lungs/liver, bone scan, Methilin blue injection to discover sentinel
node
T0 - no evidence of primary tumour
T1 - the tumour is 2 cm or less in diameter, with no skin involvement -
except in the case of Paget's disease where confined to the nipple -
and no nipple retraction or fInvestigationsation
T2 - tumour greater than 2 cm but less than 5 cm
T3 - tumour greater than 5 cm in greatest diameter, less than 10 cm
T4 - greater than 10 cm or skin or chest wall involvement or peau
d'orange
N0 - no palpable ipsilateral axillary nodes
N1 - palpable, ipsilateral axillary nodes
N2 - ipsilateral axillary nodal metastases fInvestigationsed to one
another or to other structures
N3 - metastases to ipsilateral internal mammary nodes\
M0 - no evidence of metastases
M1 - distant metastases (includes ipsilateral supraclavicular nodes)
General Management
Early:
Surgery (Mastectomy preferred if >5cm) + radiotherapy +
neoadjuvant chemotherapy (if young) + Hormonal. Follow up with yearly
mammogram (including contralateral side)
Mets
:
Hormonal + radiotherapy + bisphosphonates + chemo (if lungs or liver)
Ca in situ:
After diagnostic WLE/mastectomy. Management with radiotherapy stops
progression
Management Details
-
Surgery
(Stages 1/2):
wide local excision (WLE/lumpectomy) or
mastectomy (± breast reconstruction) + axillary node sampling or
clearance. Can sample sentinel node instead of axillary clearance.
-
Reconstructive
surgery:
can use implant, or muscles (lat
dorsi/abdominal
recti)
-
Adjuvant
radiotherapy:
After WLE reduces recurrence to 5% (from
50%). Given daily over 6 weeks. SE: tiredness, burning, lymphoedema,
serious (damage to brachial nerve plexus/coronary vessels)
-
Adjuvant
hormonal:
Tamoxifen, a selective ERα-antagonist. Given
for 5 years if estrogen sensitive tumour, also ↑response with age. SE:
hot flushes, thrombosis, hair/nail thinning, ↓fertility.
-
Aromatase
inhibitors
, which block conversion of adrenal
precursors
to estrogen. SE: hot flushes, osteoporosis
-
Herceptin
,
an antagonist for-HER2 receptor. if HER2 positive, given in 3 weekly
intervals for 1 year or until disease recurrence for early/late stage
following other management. SE: cardiotoxicity (need pre-Management
echo), flu-like (40%), cytopenia, diarrhoea
-
Adjuvant chemotherapy
