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Breast cancer

Reference: OHCM 504, Sur Talk 180, Lec Not Onc 75

Risk Factors

Only 15% have a risk factor other than age and gender!

Clinical

Pain, nipple discharge (especially blood), peau d'orange, hard lumps, nipple inversion, Paget's (unilateral nipple eczema)
Factors likely to signify not cancer: change in size related to menstrual cycle

Differential

Lump: Fibroadenoma, cyst, fibroadenosis, mastitis, fat necrosis, abscess, lipomas/sebaceous cysts.

Discharging lump: Duct ectasia (multiple colours), papilloma/adenoma/ca (bloody), lactation

Lobular carcinoma in situ (LCIS)

↑Risk of breast cancer. Incidental finding on diagnostic biopsy requires no treatment.

Spread

Direct: Skin/subcutaneous (dimpling, retraction of nipple, ulceration), muscles, chest wall
Lymph:  Axillary, internal mammary, supraclavicular
Blood: Lungs, liver, bones

Investigations

Triple Investigation

Treatment discussed at first visit.
  1. Clinical
  2. Radiological: ultrasound scan if < 35, mammography + ultrasound scan if over (as mammography not as sensitive in the young). Craniocaudal and oblique XR views. Carcinoma appears as white asymmetrical spiculated lesions with microcalcification.
  3. FNA/core biopsy. Cytology stages = C1: insufficient material, C2: benign cells, C3: uncertain: C4: probably ca, C5: cancer

Staging

Methods: CT lungs/liver, bone scan, Methilin blue injection to discover sentinel node
T0 - no evidence of primary tumour
T1 - the tumour is 2 cm or less in diameter, with no skin involvement - except in the case of Paget's disease where confined to the nipple - and no nipple retraction or fInvestigationsation
T2 - tumour greater than 2 cm but less than 5 cm
T3 - tumour greater than 5 cm in greatest diameter, less than 10 cm
T4 - greater than 10 cm or skin or chest wall involvement or peau d'orange
N0 - no palpable ipsilateral axillary nodes
N1 - palpable, ipsilateral axillary nodes
N2 - ipsilateral axillary nodal metastases fInvestigationsed to one another or to other structures
N3 - metastases to ipsilateral internal mammary nodes\
M0 - no evidence of metastases
M1 - distant metastases (includes ipsilateral supraclavicular nodes)

General Management

Early: Surgery (Mastectomy preferred if >5cm) + radiotherapy + neoadjuvant chemotherapy (if young) + Hormonal. Follow up with yearly mammogram (including contralateral side)
Mets : Hormonal + radiotherapy + bisphosphonates + chemo (if lungs or liver)
Ca in situ: After diagnostic WLE/mastectomy. Management with radiotherapy stops progression

Management Details

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