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REGUB Surgery: Breast Cancer & Screening (i) (Symptoms (more rarely…
REGUB Surgery: Breast Cancer & Screening (i)
Intro
commonest cause of death in middle aged-women in western countries
1 in 10 lifetime risk
incidence increasing
tx evolved significantly
screening done in asymp pop
Risk factors
age - rare before 25
family hx
risk increases 2-fold with affect 1st degree relative <50y/o
up to 10% due to genetic predisposition
BRCA1 mutations - chromo 17
BRCA2 mutations - chromo 13
looking for 3rd gene
gene +ve: bilat masectomy +/- ovary removal or 6 monthly mammogram
hormonal
age @ menarche + menopause - increased lifetime oestrogen exposure
age @ 1st pregnancy
before 18 = protective
increased risk with nulliparity + older age
OCP (not so much anymore as oestrogen dose has decreased since 1st gen OCP)
HRT (post-menopausal oestrogen therapy)
radiation
lifestyle
alcohol
smoking (mild, will usually die from heart/lung disease 1sst)
obesity (oestrogen from fat)
Breast cancer classifications
anatomical location
ductal
lobular
10% occurs in contralat breast too
pathological characteristics
invasive
80% ductal
10% lobular - more diffuse, harder to detect, presents later as lump
non-invasive
Carc in situ
duct full of cells but no spread
DCIS has potential to become invasive over time
many subtypes exist
comedo necrosis - worse prognosis
hyperplasia -> atypia -> in situ -> invasive (escaping duct)
better prognosis a/w...
invasive carc with tubular features
mucinous (2%)
Paget's disease of nipple
form of ductal carc arising in the excretory ducts
a/w DCIS or less commonly invasive cancer
nipple ulceration, surrounding hyperaemia (redness), excoriation (skin picking due to itch), underlying lump in 50%
Symptoms
most patients present with palpable breast lump (may be a visible mass)
change in breast size/shape
nipple inversion (retraction)
skin change (e.g. dimpling, ulceration if advanced)
nipple asymmetry
nipple discharge (esp bloody)
arm swelling
peau d'orange - lymphatic infiltration
pain usually NOT a feature
inflamm tumour: redness + swelling of breast - a/w poor prognosis
more rarely patients present with features of mets
breathing difficulties
bone pain + pathological fractures (esp lower back)
hypercalcaemia
abdo distension
jaundice
localising neurologic signs - rare
altered cognitive function
Staging
based on clinical findings, pathological analysis, imaging studies assessing met disease (CXR, liver US, bone scan)
TNM
T1 < 2cm
T2 2-5cm
T3 >5cm
T4 involves local structures - skin or chest wall
N0 no palpable axillary nodes
N1 ipsilat nodes contain tumour
N2 fixed (matted, stuck together, hard to remove) ipsilat nodes
M0 no mets
M1 distant mets/supraclav node
Staging classification
I: <2cm, no spread
II: 2-5cm, mobile payable nodes
III: >5cm, locally advanced disease (chest wall, skin, fixed axially nodes)
IV: mets
Surgery
mainstay of tx for invasive cancer
breast: conserving vs mastectomy
patient preference
tumour size
tumour location (central tumour a/w worse cosmetic outcome in breast conserving surgery)
presence of multifocal disease
axilla
for staging
reduces risk of recurrence in axilla
sentinel node bx
1st node which drains tumour
identified with blue due + radiolabelled isotope
analysed by pathologist
if +ve further surgery
avoids unnecessary axially clearance (no further nodal dissection)
axillary clearance
removal of all axillary nodes
75% of patients node -ve
SEs
lymphoedema in 20-40% (no cure)
arm/axilliary numbness in 80%