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

 

 

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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.

 

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Pathophysiology

Ductal hyperplasia can be present.

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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

 

 

 

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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

 

 

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Differential Diagnosis

 

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Treatments

Treatment depends on stage of diease and risk factors.

 

Early stage cancer without lymph node spread is equally treated with:

 

Lumpectomy is contraindicated in patients with:

 

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:

 

BRCA1

Women should be advised to have bilateral mastectomy and oophorectomy.

There is no contraindication to pregnancy in these women.

 

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Consequences and Course

 

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Additional Resources

 

 

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