What is the grading system for breast cancer + how are scores given?
Nottingham grading system - scores out of 3 for tubule formation, nuclear pleomorphism, mitotic activity
What are the stages of breast cancer?
Stage 1 = confined to breast, mobile, small, only in breast tissue or close lymph Stage 2 = confined to breast, mobile, near lymph nodes or ipsilateral axilla Stage 3 = tumour fixed to muscle, ipsilateral lymph, skin involvement Stage 4 = complete fixation of tumour to chest wall, distant mets
Describe stage 1-4 for breast cancer (in terms of TNM)
Stage 1 = T1, N0, M0
Stage 2 = T2/3, N0, M0 OR T1, N1, M0
Stage 3 = T(any), N(any), M0
Stage 4 = T(any), N(any), M1
What is DCIS?
Non invasive ductal carcinoma in situ Premalignant, seen as microcalcification on mammography
What are the types of breast cancer, how common are they + what % are ER+ + HER2+?
Invasive ductal carcinoma (70%)
Lobular (characterised by high incidence of multicentric tumours) 10%
Medullary cancer (5%) - tend to affect younger pts
Mucoid (2%) - tend to affect elderly
60-70% are oestrogen receptor positive
30% express HER2 = aggressive
Most common cancer 1 in 8 females 1 in 870 men
>50 y/o Fam hx Uninterrupted oestrogen = nulliparity, early menarche, late menopause, COCP, HRT Obesity Not breastfeeding Radiation exposure Smoking + alcohol BRCA1+2, P53
BRCA1 + 2 gene lifetime risk of breast + ovarian cancer
70% are ER negative so poorer prognosis
BRCA1 = 60-80% risk of breast, 30-45% risk of ovarian
BRCA2 = 50-70% risk of breast, 10-20% risk of ovarian
Lump, change in size + shape of breast, dimpling, inverted nipple, bloody discharge, eczema, peu d'orange, dilated veins
Liver, lungs, lymph nodes, brain, bones
What is a triple assessment?
Breast examination Bilateral mammogram US + biopsy - histology/ cytology
How do you measure treatment response?
Tumour markers Ca15.3, CEA
What staging investigations are used?
CXR, bone scan, liver USS, CT/MRI/ PET-CT, LFTs, Ca2+ IHC looking for ER+ and HER2
What is a sentinel node biopsy?
Locates sentinel node: node cancer is draining to first Inject blue dye into tumour day before surgery - look for blue node Removed + analysed - if positive then pts will have axillary clearance
Prognosis (5 year survival) for each stage of breast cancer
1 = 95%
2 = 80%
3 = 60%
4 = 25%
Treatment of early stage breast cancer
Surgery - wide local excision/ mastectomy
Radiotherapy - all invasive cancer after WLE
ER/ PR+ disease (tamoxifen for pre-menopause or aromatase inhibitors for post-menopausal)
If pre-menopausal + ER+ = ovarian ablation/ GnRH analogues
Monoclonal Ab against HER2 +
Treatment of stage 3-4 breast cancer
Radiotherapy for painful bone lesions
Tamoxifen for ER+ Trastuzumab for HER2+
Complications of radiotherapy
Radiotherapy side effects = pneumonitis, pericarditis and rib fractures, secondary cancers
Effects of hormone therapy
Increased risk of osteoporosis, vaginal dryness and irritation from lower estrogen levels.
Some increase risk of blood clots and endometrial cancer
Complications of a mastectomy
Temp swelling of breast, breast tenderness, scar tissue, infection, lymphodema, phantom breast pain.
When is MRI used in diagnosis?
If there is a discrepancy between examination, mammogram + US findings If breast density precludes mammogram If histology is lobular
When is neoadjuvant chemo used?
Initial surgery not possible due to size of tumour
Allows for breast conservation
HER2 +ve or triple negative (ER, PR + HER2 -ve)
What tools are used to help decide on adjuvant chemo?
Adjuvant online Oncotype DX (genomic test to predict benefit)
Trastuzumab use, length of treatment + SE (+ how to monitor SE)
Effective when cancer overexpresses HER2
Given for 12 months as adjuvant
Can affect cardiac function - monitor with MUGA scan
Endocrine therapy uses
Tamoxifen if ER/PR +ve for 5 years for premenopausal
Aromatase inhibitors for postmenopausal women
RT use - how long for?
All pts following conservative surgery are given RT
Given daily for 3 weeks
For young pts, given an extra week to tumour bed (a boost)
How is ovarian ablation used?
In premenopausal women, oestrogen production can be stopped by ovarian ablation (either surgially, RT or with LHRH agonists)
Best + worst cancer prognosis
Best = ER+ PR- HER2-
Worst = triple negagive or ER- PR- HER2+