Breast Cancer
last authored: Aug 09, David LaPierre
Introduction
Breast cancer is the most common cancer in women.
image by Patrick Lynch, downloaded from wikipedia
Causes and Risk Factors
BRCA is an autosomal dominant gene with a lifetime risk of 85% developing breast cancer.
Paget's disease is a desquamating, erythematous condition of the nipple, predominantly in older women. Biopsy demonstrates non-malignant pagetoid disease. It always suggests underlying ductal disease.
Obesity is a risk factor in post-menopausal women, but is protective in pre-menopausal women.
Pathophysiology
Ductal hyperplasia can be present.
Screening
Screening women ages 50-70 reduces the risk of dying.
Women between 40-50 is controversial.
Monthly breast self-exam
Clinical breast exam
Signs and Symptoms
- history
- physical exam
History
A breast lump is typically the initial presentation of breast cancer. It can be identified by screening during a clinical exam or mammogram, or by the patient her/himself.
- how has it been growing or changing?
- nipple discharge
- when and how was it noticed?
- last clinical breast exam, last mammogram
past breast history
past obstetrical history
age of menarche
Medications
- birth control pill
- hormone replacement therapy
Bone pain, weight loss
Physical Exam
breast exam
- soft vs firm
- mobile vs non
- skin changes
lymph nodes: axillary and supraclavicular
respiratory exam: pleural effusion
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
fine needle aspiration
biopsy: core, excisional, incisional
FNA has a false negative rate of ~10% and doesn't disinguish between in situ and invasive.
Core biopsy is more diagostic.
A finding of atypical ductal hyperplasia requires further excision, as malignancy could simply be adjacent to the area originally sampled.
margins
grade
lymphovascular morphology
Her2/neu
Estrogen rectpor
Diagnostic Imaging
Mammogram should be performed before biopsy of any time.
Up to 15% of breast cancers are mammographically occult.
CXR for lung mets.
Staging
Staging depends initially upon history and physical exam for
Differential Diagnosis
Treatments
Treatment depends on stage of diease and risk factors.
Early stage cancer without lymph node spread is equally treated with:
- lumpectomy plus radiation
- mastectomy
Lumpectomy is contraindicated in patients with:
- condition preventing radiotherapy (pregnancy, previous radiotherapy, inability to lie flat)
- tumour to mastectomy ratio
- multifocal disease
Surgery shouldn't be used if patients are medically unfit, in advanced or locally invasive cancers, or inflammatory conditions.
Surgery is performed to remove the tumour and to evaluate/remove lymph nodes.
Inflammatiory breast cancer
Inflammatory malignancy should NOT be treated with any type of surgery, as it will be non-curative and result in tumour growth in the would and disastrous healing. Chemotherapy is the first line.
DCIS
LCIS
almost always an incidental finding. A field effect, not being cancer itself, but predisposing for malignancy in both breasts, in all four quadrants. Can treat with increased surveillance or with bilateral mastectomy.
Adjuvant therapy
Risk factors include:
- Age under 50
- nodal status
- size >2cm
- ER +/-
BRCA1
Women should be advised to have bilateral mastectomy and oophorectomy.
There is no contraindication to pregnancy in these women.
Consequences and Course
Clinical Vignette 1
A person takes this treatment for this reason due to concerns re: condition
This happens.
How do you respond?
Clinical Vignette 2
Additional Resources
Topic Development
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