476885
Breast Cancer
- History
- Ask about: previous lumps, family history, pain
(rarely in cancer), nipple discharge/inversion,
change in size related to menstrual cycle, number of
pregnancies, first/last/latest period, drugs ie HRT
- Ask about: previous lumps, family history, pain
(rarely in cancer), nipple discharge/inversion,
change in size related to menstrual cycle, number of
pregnancies, first/last/latest period, drugs ie HRT
- Examinations
- Inspect (arms up and down), note position, size,
consistency, mobility, fixity, local
lymphadenopathy. Any nipple
discharge/inversion? Skin involvement: dimpling,
ulceration, peau d’orange?
- Inspect (arms up and down), note position, size,
consistency, mobility, fixity, local
lymphadenopathy. Any nipple
discharge/inversion? Skin involvement: dimpling,
ulceration, peau d’orange?
- Differentials of lumps
- Common lumps: fibroadenoma, cyst, cancer,
fibroadenosis (focal or diffuse nodularity)
- Rare lumps: periductal mastitis, fat necrosis, galactocoele, abscess,
‘non-breast’ eg lipoma or sebaceous cyst
- Common lumps: fibroadenoma, cyst, cancer,
fibroadenosis (focal or diffuse nodularity)
- Investigation
- All lumps should undergo quadruple assessment: clinical
examination+histology/cytology (FNA or core
biopsy)+mammography+USS if >35 or just USS if <35. If cystic
lump then aspirate: residual lump = core biopsy, clear fluid =
discard and reassure, bloody fluid = send for cytology. If solid
lump then core biopsy: benign = reassure and tx mastalgia,
malignant = plan tx
- Sentinel node biopsy
- Decreases needless axillary clearance in LN
–ve pts thus decreasing post-op morbidity.
Patent blue dye +/or radiocolloid is injected
perioperatively into periareolar area or area of
primary tumour. Incision made in axilla and
gamma probe/visual inspection used to
identify sentinel node, which is biopsied and
sent for histology.
- Decreases needless axillary clearance in LN
–ve pts thus decreasing post-op morbidity.
Patent blue dye +/or radiocolloid is injected
perioperatively into periareolar area or area of
primary tumour. Incision made in axilla and
gamma probe/visual inspection used to
identify sentinel node, which is biopsied and
sent for histology.
- TMN staging
- T1: <2cm, T2: 2-5cm, T3: >5cm, T4: fixity to
chest wall or peau d’orange. N1: mobile
ipsilateral nodes, N2: fixed nodes, M1 distant
metastases
- T1: <2cm, T2: 2-5cm, T3: >5cm, T4: fixity to
chest wall or peau d’orange. N1: mobile
ipsilateral nodes, N2: fixed nodes, M1 distant
metastases
- All lumps should undergo quadruple assessment: clinical
examination+histology/cytology (FNA or core
biopsy)+mammography+USS if >35 or just USS if <35. If cystic
lump then aspirate: residual lump = core biopsy, clear fluid =
discard and reassure, bloody fluid = send for cytology. If solid
lump then core biopsy: benign = reassure and tx mastalgia,
malignant = plan tx
- Nipple discharge
- Causes: duct ectasia (green/brown/red, often multiple
ducts and bilat), intraductal
papilloma/adenoma/carcinoma (bloody often single duct),
lactation. Management: Diagnose cause (mammogram,
USS, ductogram) then tx appropriately. Smoking cessation
reduces duct ectasia. Consider microdochectomy/total
duct excision if other measures fail
- Causes: duct ectasia (green/brown/red, often multiple
ducts and bilat), intraductal
papilloma/adenoma/carcinoma (bloody often single duct),
lactation. Management: Diagnose cause (mammogram,
USS, ductogram) then tx appropriately. Smoking cessation
reduces duct ectasia. Consider microdochectomy/total
duct excision if other measures fail
- Risk factors
- FH, increasing age, uninterrupted oestrogen
exposure (ie nulliparity, 1st pregnancy >30yrs,
early menarche, late menopause, HRT,
obesity, BRCA genes, not breast feeding, the
pill (possibly), past breast cancer.
- FH, increasing age, uninterrupted oestrogen
exposure (ie nulliparity, 1st pregnancy >30yrs,
early menarche, late menopause, HRT,
obesity, BRCA genes, not breast feeding, the
pill (possibly), past breast cancer.
- Treatment
- Early cancer: Surgery: Wide local excision or mastectomy +/- breast reconstruction + axillary node
sampling or surgical clearance. WLE + radiotherapy gives equal survival to mastectomy but higher local
recurrence rates. Radiotherapy: if high chance of local recurrence give radiotherapy to the breast wall
following mastectomy to reduce risk of recurrence and possibly increase overall survival. Give
radiotherapy to breast following WLE to reduce risk of recurrence. Give radiotherapy to axilla if lymph
node positive on sampling but complete surgical clearance was not performed. SE’s: pneumonitis,
pericarditis, rib fractures, lymphoedema, brachial plexopathy. Chemotherapy: improves survival esp if
younger/node +ve. Ie an anthracycline + 5FU + cyclophosphamide+/-methotrexate. Trastuzumab has a
role. Endocrine therapy: to reduce oestrogen activity, used in all oestrogen receptor or progesterone
receptor positive disease ie tamoxifen for 5 years post op or aromatase inhibitors ie anastro
- Distant disease: Assess LFT, calcium, CXR,
skeletal survey, bone scan, liver USS, CT.
Tamoxifen if ER +ve. If relapse after initial
success consider chemotherapy. Tumours +ve
for HER2 protein may respond to monoclonal
antibody tratuzumab (Herceptin)
- Preventing mortality: Promote breast awareness.
Mammography every 3yrs if 50-70 yrs old,
screening reduces breast cancer deaths by 25% in
this group. 2 view mammograms are used.
Negligible radiation risk.
- Tumour size, grade, LN status, ER/PR
status, presence of lympho-vascular
invasion. NPI predicts survival and risk of
relapse. NPI= 0.2 x tumour size (cm)
+histological grade + nodal status. If
treated with surgery alone then 10yr
survival rates are NPI <2.4: 95%, NPI
>5.4: 20%
- Early cancer: Surgery: Wide local excision or mastectomy +/- breast reconstruction + axillary node
sampling or surgical clearance. WLE + radiotherapy gives equal survival to mastectomy but higher local
recurrence rates. Radiotherapy: if high chance of local recurrence give radiotherapy to the breast wall
following mastectomy to reduce risk of recurrence and possibly increase overall survival. Give
radiotherapy to breast following WLE to reduce risk of recurrence. Give radiotherapy to axilla if lymph
node positive on sampling but complete surgical clearance was not performed. SE’s: pneumonitis,
pericarditis, rib fractures, lymphoedema, brachial plexopathy. Chemotherapy: improves survival esp if
younger/node +ve. Ie an anthracycline + 5FU + cyclophosphamide+/-methotrexate. Trastuzumab has a
role. Endocrine therapy: to reduce oestrogen activity, used in all oestrogen receptor or progesterone
receptor positive disease ie tamoxifen for 5 years post op or aromatase inhibitors ie anastro
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