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Breast Cancer

It's most commonly an Invasive Adenocarcinoma, and the types of this are:

  • Ductal carcinoma (75%)

  • Lobular carcinoma (15%)


The risk factors for it include:

  • Increased lifetime oestrogen exposure

    • Increasing age

    • Early menarche, Late menopause, Long-term COCP/HRT

    • Obesity - peripheral conversion of androgens to oestrogen

  • Family Hx

    • BRCA1/2 mutations

    • P53 mutations (Li-Fraumeni syndrome)

  • Alcohol and tobacco use


N.B. Women with BRCA mutations are also at high risk of ovarian ca., so a prophylactic b/l mastectomy/salpingo-oopherectomy is considered.


N.B. In men, BRCA2 mutations is associated with Prostate cancer (also pancreatic and gastric cancers).


Presentation:

  • Hard, painless lump

  • Nipple retraction

  • Skin dimpling

  • Swollen axillary lymph nodes

  • Ulceration

  • Peau d’orange - Skin dimpling or oedema

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Early signs of breast cancer - National Instituted of Health (https://commons.wikimedia.org/wiki/File:En_Breast_cancer_illustrations.png)

Investigated with a triple assessment - clinical, imaging, histology.


Ductal Carcinoma (75%)

This is an abnormal proliferation of ductal cells. It has metastatic potential as there’s invasion through the basement membrane. If there was no invasion of the basement membrane, it would called a Ductal carcinoma in situ (DCIS), which is a pre-cancer.


N.B. Invasive cancer grows through the ductal epithelium and fixes to deeper tissues → immobile mass. DCIS doesn’t invade → mobile mass.


Lobular Carcinoma (15%)

This is an abnormal proliferation of lobular cells, which arrange themselves in single rows. The tumour cells are sparsely distributed, so they’re frequently impalpable or not felt as a discrete lump.


If there was no invasion of the basement membrane, it would called a Lobular carcinoma in situ (LCIS), which is a pre-cancer.


NHS Breast Screening Programme

The aim of this is to detect DCIS and any small, early-stage invasive carcinomas.


It includes a Mammogram every 3 yrs for women 50-70 years , looking for microcalcifications.


Prognostic Factors

The most important prognostic factor is the Sentinel Lymph node. This is the first node that a cancer drains into. To check it, a dye is injected into the tissue around the tumour and the nodes that take up the dye are assessed visually with a probe. If the nodes are found +ve for cancer, the patient is given a full axillary clearance (surgical removal of the nodes).

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“Lymph nodes may become enlarged due to an infection, injury and cancer.” © www.scientificanimations.com CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0/)

Other prognostic factors include:

  • Tumour Stage + Grade

  • Histological subtype

  • Invasion

  • Completeness of excision

  • ER and HER2 Status

    • Oestrogen receptors (ER) - Negative indicates a worse prognosis

    • HER2 - Positive indicates a worse prognosis


N.B. HER2 promotes the growth of cancer cells. It tends to be more aggressive than other types of breast cancer, but it may respond well to targeted therapies that block HER2.


Management

Surgical options:

  • Wide local excision (WLE) or Mastectomy

  • Axillary node clearance if sentinal node +ve for cancer


ER+ve tumours:

  • Tamoxifen (ER antagonist) if premenopausal

    • SEs - Hot flushes, Nausea, PV bleeding, VTE, Endometrial ca.

  • Anastrozole (aromatase inhibitor) if postmenopausal

    • SEs - Hypo-oestrogenism (hot flushes, fatigue, osteoporosis)


N.B. Post-menopausal women have low oestrogen, so most of it will be made from its conversion via aromatase. This is why antagonists to this enzyme is more beneficial in these women.


HER2 +ve tumours:

  • Herceptin (Trastuzumab - monoclonal antibody)

    • SEs - Cardiac dysfunction, Teratogenicity



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