Breast Cancer

Risk Factors:

  • Strongest risk factor for breast Ca? female gender, then age
  • Incidence of breast Ca in men? Female-to-male ratio is 1:100
  • Male pts do worse, why? not b/c biology (they have same biology of breast Ca as in females), but b/c of late dx and small breast parenchyma -> easier invasion
  • Probability of malignant breast mass in an 80 yo is 1:290
  • Probability of malignant breast mass in a 30 yo is 1:6000
  • Third risk factor is FHx
  • In FHx, ask about # of relatives, degree of relation, pre or post menopause, unilateral or bilateral

CASE: A 30 yo pt, has a sister w/ bilateral breast ca + pre menopause, what’s the pt’s cumulative risk? Her cumulative risk by the age of 70 yo is 55%. However, if her sister has unilateral + post menopause breast ca, her cumulative risk by the age of 70 yo is 8%

  • Most genetic syndromes w/ breast ca are autosomal dominant (e.g.: li fraumeni). It can also be recessive (e.g.: ataxia telangiectasia(
  • Most significant genetic mutation is BRCA 1 and BRCA 2
  • If a family with BRCA 1 mutation, the cumulative risk by the age of 70 yo is 37-87% and the risk of ovarian ca is 11-42% -> prophylactic mastectomy, pharmaceutical prophylaxis, ovarian radio-ablation
  • BRCA 2 has less risk, associated more with male breast ca

1. Endogenous endocrine risk factors: 

  • Exposure to oestrogen for more than 30 yrs is what matters
  • Early menarche (before the age of 13, and having regular periods=ovulatory) has double the risk than after the age of 13 yrs
  • Late menopause (after 44-55 yo)
  • Nulliparity:
    • First child before the age of 19 = half the risk
    • First child between 30-34 yo = exact same risk as nulliparous
    • First chid after the age of 35 = higher risk of breast ca

2. Exogenous endocrine risk factors:

  • HRT: (but benefit outweighs risk: increases bone density, decreases stroke and MI); however, prolonged use (more than 5 yrs) carries more risk
  • OCP: (but risk of unplanned pregnancy outweighs the minimal increase in breast ca risk), however; prolonged use (more than 10 yrs) carries more risk
  • Exposure to radiation: ionising radiation exposure as in NHL. The risk in the first 15 yrs is less than the risk of the following 15 yrs

3. Other risk factors:

  • Obesity: the risk is more apparent post menopause (but if chemotherapy-induced amenorrhea in a 35 yo, then it applies the same as ‘post menopause’).
  • Weight loss decreases the risk (one of the indications of bariatric surgery in a diagnosed breast ca pt is to decrease risk in contralateral breast)
  • Alcohol and smoking has weak association
  • Personal Hx of ca -> increased risk of ipsilateral recurrence and contralateral occurrence
  • Hx of benign breast ds (b/c of unstable breast parenchyma)

 

Benign Breast Diseases:

  • Non-proliferative (e.g.: cysts, duct ectasia): doesn’t increase the risk of breast ca by pathology
  • Proliferative w/out atypiag.: ductal hyperplasia -> associated w/ a 1.5-2 folds increased risk of breast ca
  • If w/ atypia -> associated with a 4-5 folds increased risk of breast ca
  • If LCIS -> 8-10 folds increased risk of breast ca

 

Differentiation Between DCIS and LCIS:

  • DCIS: it’s a disease worse than cancer, treated sometimes more aggressively than its invasive counterparts, it’s not a premalignant lesion
  • LCIS: not a disease, doesn’t need treatment, considered as a risk marker, and the risk is equal in both breasts

CASE: Pt w/ a breast mass removed and the histo shows duct ectasia + incidental finding of DCIS -> “you’re faced with a problem” and you have to treat the DCIS. But if it were incidental LCIS -> you only need close surveillance

 


Approach to A Breast Mass:

While taking Hx and PE of breast ca, think of it as an organ w/ 3 components:

  1. Nipple-areolar complex: discharge? Colour? bloody? Spontaneous or expressed? Coming out of the same orifice all the time? Nipple retraction (vs. has it been retracted since childhood)? Excoriation? Paget disease of the breast (which can be mistreated as eczema)?
  2. Breast parenchyma: lumps? Pain? Are those symptoms cyclic or not?
  3. Skin: redness? peau d’orange? Ulceration? Dimpling? Sinuses? Inflammatory breast ds (e.g.: TB)?
  • While investigating a pt w/ breast ca, make sure you cover 3 areas: local (breast), regional (LN), and systemic (for mets)
  • CAP imaging (chest, abdomen, pelvis), sometimes brain CT, sometimes bone scan
  • If you base your management on FNA, then it’s THE END OF YOUR CAREER! We need tissue!!
  • If LN is negative -> still do CAP (b/c of lymphatic and hematogenic spread of breast ca; so your LN might have strong immunity which controlled the lymphatic spread, but you can still present w/ mets b/c of hematogenic spread)

CASE: a 24 yo lady comes w/ 3 mo Hx of a 2 cm breast mass, looks like fibroadenoma -> no need to operate, only do imaging and FNA. But if the same pt w/ a 6 cm breast mass -> then don’t bother w/ a biopsy b/c it’s indicated for removal

CASE: a 35 yo lady with a 3 cm mass in upper outer quad of the breast, not fixed, hard, skin is normal, nipple area normal, contralateral breast is normal, what to do? Triple assessment:

  1. Clinical: Hx and PE
  2. Imaging: if younger than 40 go for US b/c of increased breast parenchymal density, if older than 40 go for mamogram
  3. Biopsy: FNA or true cut (= core biopsy)

 

 

  • So the imaging will be reported as BI-RADS (breast imaging reporting and data system):
    • BI-RADS 1 = negative; recommendation is to discharge to appropriate screening program
    • BI-RADS 2 = benign; recommendation is to discharge to appropriate screening program
    • BI-RADS 5 = malignant; recommendation is to stage and treat accordingly
    • BI-RADS 3 = undetermined, probably benign ( has a lot of features of benign w/ slightly malignant feastures); recommendation is to follow up w/ imaging in 6 mo, unless higher risk (family or personal Hx of breast ca(
    • BI-RADS 4 = suspicious, has more malignant features; recommendation is to biopsy
    • BI-RADS 6 = for already diagnosed breast ca (biopsy-proven carcinoma), referred in the case of neo-adjuvant follow up or contralateral breast
  • Why is radiology done before biopsy, ideally?
    • Breast structure is not effected by external force (hematoma might lead to calcification)
    • You may find other lesions in imaging that you need to target with biopsy
  • So if the biopsy comes back as invasive ductal carcinoma -> then go for regional examination of LN
  • If enlarged LN either by PE or imaging -> biopsy that LN:
    • If inconclusive -> repeat
    • If positive -> axillary LN dissection
    • If negative -> sentinel LN
  • Then complete the staging with CT
  • Then do TNM classification (memorise the TNMs but not the stages)

 

Treatment Options:

  • Radical mastectomy: removes everything, no one does it nowadays
  • Modified radical mastectomy (MRM): removes the breast and associated LN and leaves skin flap, nerves, and muscles
  • Breast conserving therapy (BCT): has 3 components:
    1. lumpectomy with wide margin
    2. Ipsilateral axillary dissection
    3. Ipsilateral whole breast radiation
  • Things to consider in BCT:
    • Tumour-to-breast ratio; if small tumour size compared to breast size -> do BCT
    • Number of lesions; if multiple/multifocal lesions -> do MRM
    • Location of tumour; if retro-areolar -> do MRM
    • Contraindication to radiation; pt already radiated (e.g. for thymoma or NHL) you can’t radiate that region again, active skin lesions, pregnancy -> do MRM
    • I the pt won’t accept the increased recurrence rate after BCT -> do MRM (lower recurrence rate)
  • If recurrence after BCT -> do another lumpectomy or salvage mastectomy
  • Axillary LN dissection was used to be done for everyone, but how many pts will actually benefit from axillary dissection? 20% actually have axillary LN involvement, but the rest 80% are for staging (but not for therapeutic(
  • If 1% of the tumour cells is ER/PR positive then it’s still considered positive and given therapy but won’t have the same response
  • If same scenario but w/ strong FHX -> she gets the same treatment

Neo-adjuvant:

  • Neo-adjuvant can be given when the size of the tumour borderline -> shrinks the size so it becomes legible for BCT, but need to put coils in the breast around the tumour, in case it “disappears” after neo-adjuvant -> you still need to resect the margins
  • When to use neo-adjuvant first then MRM?
    1. If borderline/larger tumour size
    2. Bulky axilla (here, neo-adjuvant is used to “melt” the tumour cells, and therefore; prevent nerve injury
    3. Lung or bone mets (usually, in a case of met -> we never operate. But it has been recently documented that it can improve life expectancy, but not for everyone)

 

Random notes:

  • Breast feeding is protective against breast ca (2 yrs of lactation)
  • Right breast ca is more prevalent than left breast ca

 


Download the PDF version: here


References:

  • Dr Alabeidi’s lecture
  • Surgical recall

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