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Breast Cancer Diagnosis and Management - Coggle Diagram
Breast Cancer Diagnosis and Management
Eight Centre Model - Symptomatic Breast
8 centres in IRE for
11,000 pt per year
Breast Check - Asymptomatic
50-70 yrs
Once every 2 years
National mobile units
Two view mammography
Epidemiology
Incidence of breast cancer increasing in western world
Hormonal risk factors - delayed birth
Postmenopausal - obesity
1 in 7 diagnosed in their lifetime
5-10% are Fhx associated
Increasing risk with age
Patterns of Breast cancers
70% sporadic
20% familial
5-10% BRACA 1/2
Breast Lump Differential Dignosis
Malignant
Carcinoma
Sarcoma
Malignannt Phyllodes tumour
Mets
Benign
Fibroadenoma
Cysr
Benign breast change
Abcess
Papilloma
Galactocoele
Fat necrosis
Phylloide tumour
Lipoma
Hamartoma
Sebaceous cyst
Breast Lump Assessment - Triple Assessment / Rapid Access cLinic (TAC/RABC)
Clinical
Hx
Exam
Radiology
Mammography
Ultrasound
Pathology
FNAC
Core Biopsy
BIRADS Score
E / S - Exam
R - Radiology
B - Biopsy
Normal / Inadequate
Benign
Indeterminate favour benign
Suspicious for malignancy
Cancer
Pruose
Accurate
TImely
Avoidance of unnecessary exision biopsy for diagnosis
MDT
All breast biopsy cases discussed
All post op breast cases discussed
Other cases for discussion / clarification
Clinical Features of Symptomatic Breast Cancer
Lump
Pain
Nipple retraction
Nipple discharge
Skin retraction
Axiallary Mass
Risk Factors
Modifiable
Nulliparity / age of first child
Hormonal replacement OCP/HRT
LAct of breastfeeding
Alcohol consumption
Obesity
Smoking
Sedentary lifestyle
Non-Modifiable
Female
Age > 45
Ethnicity
Dense breast tissue
EArly menarche
Late menopauses
Previous breast/ chest wall radiation
Fhx
Radiological Assessment
Breast Lump
. <35 y/o clinically E3
Targeted Ultrasound
May do Mammogram at E4 /E5 but not routine
. >35 y/o
Mammogram firts independent of E score
Eollowed by targeted US if >E3
.<35y/o clinically <E3
Nothing
Mammogram
Sensitivity age and density dependent
Suspicious features
Ill defined
Irregular
Spiculated mass
Calcified DCIS
Limitations
Breast density
Bilateral
Picks up undeteted cancer
Compare sides
Views
Medio-lateral oblique MLO
View of Axilla
Cranial- Caudal CC
Targeted Ultrasound Breast
Not for screening - for a located lump
USe
Distinguish solid / cystic massess
Distinguished benign / malignant masses
Core biopsy / FNA
Benefits
Young pts
Dense breast
Most sensitive independent of age group
Can diagnose > 50% of axillary mets
All pt with suspicious lumps have axallary US
Breast MRI
Not standard
Bene
Sensitive
Can detect 96% of invasive cancers & 80% of DCIS
Disadvantages
High false positive rate
Indications
Lobular cancer - more likely mammographically occult and increased risk of contralateral disease
Discordant / very dense young breast
Differentiates recurrence and scarring if done 18 months after breast conserving surgery
Screening for young women with BRCA - standard of care
Pathology
Cytology
Not done much now
Advantages
Less invasive
Quick
Same day dianosis
Accurate when preformed as part of triple assessment
Disadvantages
Only looks at cells not architecture
Use
Axillary node sampling
Core Biopsy🥇
Disadvantages
More invasive
Same day diagnosis not possible
Advantages
Differentiate between pre invasive and invasive cancer
Gives receptor status
Gives grade of cancer
LEss expertise required
VEry accurate when preformed as part of triple assessment
Epithelial Tumours
Non-invasive
Ductal carcinoma in situ (DCIS)
Lobular carcinoma in situ (LCIS)
Invasive
Ductal 80-90%
Lobular 1-10%
Mucinous 5%
Medullary 1-5%
Pathological Features
Receprot Status
ER
PR
Her2
Use
Deciding neo-adjuvant / adjuvant therapy
Prognosis / predicting disease response
Grade of tumor
Lymphovascular invasion
Clinically Staging - TNM
Unfinished
Systemic Staging Tests
No staging for T1/T2 N) unless pt have symptoms concerning for mets
Systemic staging performed if
T3
Node positive
Symptoms
Imaging
CT TAP
Bone Scan
CT PET not standard - MDT
Treatment - Operable Breast Cancer
Surgery
Chemotherapy / hormone therapy
Radioation
Neoadjuvant
Locally advanced
Aid breast conservation
Biomarkers
Role of Neoadjuvant Surgery
Locally advanced / inoperable tumour with no distance mets
Downstage tumour - allow for less morbid surgery - only if chemotherapy needed to improve survival
Stage II and Stage III chemo-responsive subtypes
HER2+ve and TNBC
Consider in node positive pdisease in pre menopausal pts
NEoadjuvant antihormonal therapy in post menopausal group to downsize primary tumour to aid tumour
40% in SJH
Surgery
Breast
Conservation surgery followed by radiation
MAstectomy
Axiall
SLNB if clinically & radiologically node neg
If SLNB (+) can consider not doing Ax clearance in breast conservation group
Axillary clearance if node pos or SLNB positive
Breast conservative Surgery
To get the same survival as mastectomy the margins around the lumpectomy must be negative and radiation usually should be given post op
Indications
Depends on lump breast ratio need to leave enough breast tissue to give good cosmesis (>20% poor outcome)
Usually unifocal lesion
Contraindications
Extensive disease through breast / multiple cancers in different quandrants
Pt preference
Relative C/i
Multifocal / multicentric disease
Hx breast radiation
Collagen vascular disease
Large or central disease in small breast
Women with strong fhx of breast cancer
Carrier if BRCA1 / BRCA2