How may breast cancer present
- hard craggy, non tender palpable masses
- nipple changes: inversion, puckering, dimpling, serous or blood discharges (esp if unilateral)
- breast pain
- skin changes (peau d’ orange, pagets disease of breast)
- mammogram changes
Give 5 major risk factors for breast cancer
- being female
- BRCA1/2 mutations
- uninterrupted menses
- late age of first pregnancy
- obesity and high fat diet
- never breast feeding
- late menopause
- HRT and ?long term COCP use
- radiation exposure
How is breast cancer diagnosed?
- Mammogram to screen
- USS and core needle biopsy (for very large lesions) or fine needle aspiration cytology
- excision biopsy or incisional biopsy (lesion >4cm)
What is the most common type of breast cancer? How are they subdivided?
adenocarcinoma- may be invasive (usually invasive ductal carcinoma no special type (IDC NST)) or ductal carcinoma in situ (DCIS)
What is pagets disease of the breast?
Where DCIS extends to the nipple without crossing the basement membrane and so you get eczema like changes around the affected nipple. 97% associated with breast cancer. Needs skin biopsy, breast and axilla examination and USS + mammogram
Are DCIS removed?
yes- although they do not cross the basement membrane and so cannot metastasise, they may go to become invasive carcinoma, especially if high grade
Where does invasive breast cancer (IDC NST) most commonly metastasise to?
The axillary lymph nodes.
Bone is the most common distant site, followed by lung, liver and brain.
Where does invasive lobular carcinoma spread to?
odd places- peritoneum, meninges, GI tract, ovaries, uterus
What are the NICE indications for 2WW breast cancer referal?
- age >30 and unexplained breast lump
- age >50 and unilateral discharge, retraction or other nipple changes
- consider if >30 and unexplained axilla lump or skin changes
- non urgent referal if age <30
what grading system is used for breast cancer
bloom richardson
Tnm staging used
Bcrisk score used to asses risk of the cancer
Other than biopsies and mammogram, what investigations are done for confirmed breast cancer?
- ER and progesterone receptor status with monoclonal antibody assay
- Epidermal GF and HER2 receptor status
- LFTs (?mets, drugs) and other routine bloods
- CXR for long mets
- CT scan if mets suspected
- bone scintigraphy if distant mets or bone pain
- PET scan if distant mets (wont detect if <5mm)
What surgical options are available for DCIS and IDC NST?
- mastectomy (removal of all breast tissue)
- wide local excision (breast conserving)
- Many will also get axillary lymph node clearance or at least sentinal node biopsy (inject blue dye and remove first nodes for biopsy)
How is lobar carcinoma in situ managed?
- if BRCA1/2 +ve–> bilateral prophylactic mastectomy
- if not, tends to be monitored
- these are usually only picked up incidentally on biospies as dont cause calcifications so not seen on mammogram
What non surgical treatments are available for breast cancer?
- radiotherapy (often adjuvant to chest and axilla)
- Herceptin if HER2 +ve
- Aromatase inhibitors if ER +ve, advised if post menopausal as tamoxifen will increase endometrial ca risk. Often given for a year after remission
- Tamoxifen- if ER +ve and premenopausal
Who is screened for breast cancer and how regularly?
women age 47-73, every 3 yrs
What features suggest a breast lump is benign?
- rounded
- regular
- smooth
- solid
- mobile
- pt age <40
What is the most common cause of a benign breast lump?
- fibroadenomas (age 20-25, well defined, highly mobile and rubbery)
- then cysts (age 35-50)
- fat necrosis should also be considered as a cause
What is the most likely cause of breast tenderness (worse a week before menstruation) and nodularity (usually bilateral) in pts age 20-50?
fibrocystic change/ nodularity
- thought to be hormonal in cause
- treat with pain relief and a well fitted bra, or can try hormonal contraception
How should suspected breast cysts be managed?
- usually get aspirate to check its not cancerous as they can be difficult to distinguish on examination
What is cyclical mastalgia?
normal tenderness of breasts just before mensturation
State one benign cause of nipple discharge which may be bloody
intraductal papilloma
When does mastitis tend to occur?
- in breast feeding
- non lactational mastitis usually associated with diabetes and immunocompromise
- smoking and nipple rings predispose to it
How should lactational mastitis be managed?
- admit if septic, immunocompromised, abscess
- NSAIDS
- warm compress
- continue to breast feed, if cant then use hand of breast pump to express the milk
- abx (flucloxacillin or erythromycin) if infected fissure or symptoms persist after 12 hrs despite milk removal
- can do milk cultures
How is non lactational mastitis managed?
- admit if septic, immunocompromised or abscess
- warm compress, NSAIDS
- oral abx for all pts (coamox or erythro + metronidazole)
- tell them to stop smoking and removal nipple rings as appropriate to stop recurrence
