Home

Recent Notes

Breast carcinoma

Feb 23, 20245 min read

Most common form of breast cancer in the UK - around 1 in 8 lifetime risk for women (1% of UK cases are male)

Types

Non-invasive ductal carcinoma in situ (DCIS)

  • Pre-malignant cancer of epithelial cells of breast ducts
  • Localised to a single area
  • Often picked up by mammogram screening
  • Potential to spread locally over years
  • 30% become invasive
  • Good prognosis if excised and adjuvant treatment

Lobular carcinoma in situ (LCIS)

  • Pre-malignant typically in pre-menopausal women
  • Rarer and tends to be multifocal
  • Increased risk of invasive breast cancer in the future (~30%)
  • Often managed conservatively with monitoring (6 monthly exam and yearly mammogram)

Invasive ductal carcinoma - NST

  • Most common invasive carcinoma (80%)
  • NST - means no specific type and its not specifically classified (eg medullary or mucinous)
  • Originate in cells from the breast ducts
  • Can be seen on mammograms

Invasive lobular carcinomas

  • Around 15% of invasive breast cancers
  • Originate in cells from the breast lobules
  • Not always visible on mammograms

Inflammatory breast cancer

  • 1-3% of carcinomas
  • Presents similarly to a Breast abscess or mastitis
  • Swollen, warm, tender breast with pitting skin (peau d’orange)
  • Does not respond to antibiotics
  • Worse prognosis than other breast cancers

Paget’s Disease of the Nipple

  • Looks like eczema of the nipple/areolar
  • Erythematous, scaly rash
  • Indicates breast cancer involving the nipple
  • May represent DCIS or invasive breast cancer
  • Requires biopsy, staging and treatment, as with any other invasive breast cancer

Rarer Types of Breast Cancer

  • Medullary breast cancer
  • Mucinous breast cancer
  • Tubular breast cancer
  • Multiple others

Causes/Factors

  • Family history - first degree (BRCA1/2 gene)
    • BRCA1 gene on chromosome 17
      • Around 70% will develop breast cancer by 80
      • Around 50% will develop Ovarian Cancer
      • Also increased risk of bowel and prostate
    • BRCA2 gene on chromosome 13
      • Around 60% will develop breast cancer by aged 80
      • Around 20% will develop Ovarian Cancer
  • Increased oestrogen exposure (earlier onset of periods and later menopause; nulliparity; 1st Pregnancy 30>yrs old)
  • More dense breast tissue - more glandular tissue
  • Obesity
  • Smoking

Presentation

  • Lumps that are hard, irregular, painless or fixed in place
  • Lumps may be tethered to the skin or the chest wall
  • Nipple retraction
  • Skin dimpling or oedema (peau d’orange)
  • Lymphadenopathy, particularly in the axilla

Referral Criteria

Two week wait referral for:

  • Unexplained breast lump in patients aged 30 or above
  • Unilateral nipple changes in patients aged over 50 or above
  • Unexplained lump in the axilla in patients aged 30 or above
  • Skin changes suggestive of breast cancer

Investigations

Triple assessment

  • Clinical assessment (history and examination)
  • Imaging (ultrasound or mammography)
  • Biopsy (fine needle aspiration or core biopsy)

  • Ultrasound scans are typically used to assess Lumps in younger women - distinguish solid Lumps from cystic fluid

  • Mammograms are generally more effective in older women - can find calcifications

  • MRI for screening women in higher risk groups or to further assess the size and features of a tumour

  • Sentinel lymph node biopsy may be used during breast cancer surgery where the initial ultrasound does not show any abnormal nodes.

    • Contrast in injected into the tumour area and travels through the lymphatics to the first lymph node - sentinel.

  • Cancer histology - may have receptors:

    • Oestrogen receptors (ER)
    • Progesterone receptors (PR)
    • Human epidermal growth factor (HER2) Triple-negative breast cancer is where the breast cancer cells do not express any of these three receptors. This carries a worse prognosis, as it limits the treatment options for targeting the cancer.

Breast cancer screening

The NHS breast cancer screening program offers a mammogram every 3 years to women aged 50 – 70 years.

Screening aims to detect breast cancer early, which improves outcomes. Roughly 1 in 100 women are diagnosed with breast cancer after going for a mammogram.

High risk patients

There are different recommendations for screening patients with a higher risk.

  • Genetic Counselling
  • Annual mammogram
  • Chemoprevention
    • Tamoxifen (ER modulator) if premenopausal
    • Anastrozole (prevents conversion of androgens to oestrogen) if post (except with severe osteoporosis)

Management

TNM staging:

All patients are discussed with the multidisciplinary team (MDT) for treatment planning

Surgery

  • Tumour removal
  • Axillary clearance
  • Reconstructive - immediate or delayed. Can be partial or reduce and reshape both breasts to match

Radiotherapy

Chemotherapy

  • Neoadjuvant therapy – intended to shrink the tumour before surgery
  • Adjuvant chemotherapy – given after surgery to reduce recurrence
  • Treatment of metastatic or recurrent breast cancer

Drug treatment

  • Tamoxifen for premenopausal
  • Aromatase inhibitors for post

ER positive

  • Fulvestrant (selective ER down regulator )
  • GnRH (Gonadotropin releasing hormone)

HER2 positive

  • Herceptin (trastuzumab) - monoclonal antibody targets HER2 receptor. Can also affect heart function so initial heart monitoring is required
  • Perjeta (pertuzumab) for HER2 receptor can be used in combination with herceptin
  • Nerlynx (neratinib) - tryosine kinase inhibitor reducing the growth of breast cancers

Complications/red Flags

Metastasis

  • Lungs - Liver
  • Bones
  • Brain

Chronic lymphoedema = impaired drainage in that area

Cannulas and bloods

Avoid taking blood or putting a cannula in the arm on the side of previous breast cancer surgery. Higher risk of complications and infections due to the impaired lymphatic drainage on that side

Graph View

Backlinks