Breast Cancer

Breast cancer is the commonest cancer in women all over the world. The incidence is highest in women around the age of 40 - 60 years but it may also occur at any age. The lifetime risk of developing a breast cancer in a woman is 11%.

Patients with breast cancer commonly present with:
- breast lump
- retracted nipple
- lymph node swelling in the axilla (armpits)
- ulcerated swelling on the breast
- redness & inflammation of the breast
- nipple discharge which can be blood or mucous
- incidental finding on screening by mammogram

95% of breast cancer occur sporadically while only 5% are due to genetic factors. The genes which are implicated in breast cancer are BRCA-1 and BRCA-2. Patients with BRCA genes have a 50% lifetime risk of breast cancer and a 30% risk of getting a breast cancer on the opposite breast. Women with BRCA-1 also have a 30% risk of getting ovarian cancer.

Other genetic syndromes associated with breast cancer are:
- Li Fraumeni syndrome which includes brain tumours, sarcomas and leukaemias
- Cowden syndrome which includes thyroid tumours and skin lesions
- Peutz-Jaghers syndrome which includes gastro-intestinal tract polyps, pigmentation of the lips and increased risk of gastro-intestinal cancers.

To confirm the diagnosis of breast cancer, 'Triple Assesment' is recommended. This includes:
- breast examination by the doctor
- tissue biopsy with Fine Needle Aspiration Cytology (FNAC) or Core Biopsy
- radiological investigations with a Mammogram or Ultrasound or MRI

Mammogram

Patients with strong family history of breast cancer should undergo genetic testing for BRCA-1 and BRCA-2 genes.

Once the diagnosis of breast cancer is confirmed, a patient is counselled on her diagnosis and the plan of management. The management will depend on the stage of the cancer, type of cancer (DCIS vs Invasive Ductal/Lobular Cancer) and patient's Estrogen/Progestrone Receptor (ER/PR) status.

For patients with non-metastatic (have not spread beyond the breast) cancer, the initial treatment is mastectomy (breast removing surgery) with removal of lymph nodes. The indications for mastectomy are:
- Invasive breast cancer more than 3cm
- multifocal DCIS
- patients with recurrent cancer after breast conserving surgery
- young patients who have a high risk of cancer recurrence (BRCA carriers)
- old patients who do not want to undergo further surgery
- male patients with breast cancer

Patients with DCIS (ductal carcinoma in situ) or Invasive breast cancer less than 3cm can undergo Breast Conserving Surgery (BCS) with post-operative radiotherapy. However, there is a 10% chance that further surgery might be required with BCS.

Removal of lymph node is needed for control of loco-regional disease and for more accurate staging of the disease. A few techniques commonly used are lymph node dissection or sampling or Sentinel Lymph Node Biopsy.

Post mastectomy, if the patient has got lymph node involvement or the tumour is bigger than 1.5cm, it is necessary for the patient to undergo chemotherapy which will further destroy the cancer cells in the body. The common regime used is a combination of 5-FluoroUracil, Epirubicin and Cyclophosphamide.

Patients who have ER/PR positive should be started on Tamoxifen tablets (20mg daily) which will reduce the level of estrogen in the body and reduce the risk of recurrence of the cancer. Post menopausal patients can be started on aromatase inhibitors such as anastrozole or letrozole which also reduces estrogen levels.

Patients who are HER-2 (human epidermal growth factor receptor-2) positive can be started on trastuzumab which is shown to improve disease  free survival. However, this drug is contraindicated in women with heart failure.

Patients with locally advanced breast cancer (size more than 5cm or with involvement of chest wall or skin) should undergo pre-operative chemotherapy to reduce the size of the cancer. The regime is the same as the post-operative one or a taxane based (docetaxel) chemotherapy can also be used.

Post-mastectomy, patients who are keen for reconstruction of their breast should be referred to a Plastic Surgeon for reconstructive surgery. The breast can be reconstructed with the patients own muscles and skin (free or pedicled flap reconstruction) or with a prosthetic breast implant.

What is a Cancer?

A Cancer is defined as an abnormal mass of tissue, growth of which is uncoordinated and exceeds that of normal tissue which persists even after cessation of the stimuli which provoked it. The main hallmarks of cancer are that it is purposeless, it preys on its host and it is autonomous.

The biology of Cancer growth are:
- Self sustained growth signals
- Insensitivity to inhibitory growth signals: Normal cells respond tumour suppressor genes.
- Limitless growth potential: It does not stop growing unlike normal cells.
- Evasion of apoptosis (programmed cell death): Normal cells have a fixed life-span.
- Ability to metastasise and invade
- Ability to produce own blood supply (angiogenesis)

The common causes of cancer can be divided into:
- Radiation eg UV light, ionising radiation, nuclear radiation exposure
- Infection eg H.Pylori (stomach cancer), schistosomiasis (bladder cancer), Hepatitis B & C (liver cancer)
- Genetic abnormalites eg Familial Adenomatous Polyposis, Li Fraumeni Syndrome
- Chemicals eg aniline dye (bladder cancer), cigarette smoking
- Others eg diet, chronic irritation (Marjolin's ulcer)

Treatment options for Cancers include:
- Radiotherapy
- Chemotherapy
- Surgery
- Hormonal Therapy
- Molecular Targeted Therapy

Deep Venous Thrombosis

Deep Venous Thrombosis (DVT) is a commonly discussed medical condition. It is a condition where a blood clot forms in the deep venous system of the lower legs. DVT is the third commonest cardiovascular disease. Around 20% of DVTs occur post surgery. 25% of DVTs are associated with cancers and 50% happen due to unknown reasons.

Anatomy of Deep Venous System

The aetiology of DVT is summarised by Virchow's triad of:
-Hypercoagulability (increased tendency to form blood clots)
-Venous Flow Stasis
-Vessel wall damage


Patients who have DVT usually complain of:
-calf pain
-calf swelling
-redness around the lower leg
-unilateral pitting oedema
-low grade fever


Sometimes the lower leg can be bluish (cyanotic), severely painful and swollen in a condition described as Phlegmasia Caerulia Dolens. Phlegmasia Alba Dolens describes a pale, painful, swollen limb.


Conditions which increase the risk of DVT are:
-increasing age
-immobility
-pregnancy
-patients who are diagnosed with cancers
-patients who are on oral contraceptive pills (combined progestrone & oestrogen)
-patients who are on hormone replacement therapy
-obesity
-patients with inflammatory bowel disease
-patients who are planned for knee, pelvic & hip surgeries
-patients with heart failure


Investigations for patients with DVT include:
-Duplex ultrasound scans: - 95% sentitive & specific
-Venography: - can be both diagnostic & therapeutic
-Magnetic Resonance Venography
-Impedence Pletysmography
-Spiral CT-scan / CT Pulmonary Angiography: to rule out Pulmonary Embolism

Image at Left: Deep Vein Thrombosis

Image at Right: Embolus propagating

Treatment for DVT aims to stop further clot formation, to break down the existent clot (fibrinolysis) and to prevent pulmonary embolism. Pulmonary embolism is the propagation of a blood clot from the lower leg into the smaller veins of the lungs. This is a potentially deadly complication of DVT where 10% of patients with symptomatic pulmonary embolism die within the first hour. 


Treatment options include:
-intravenous Heparin infusion
-oral Warfarin tablets
-subcutaneous Low Molecular Weight Heparin (eg enoxaparine) injection
-percutaneous mechanical thrombectomy
-catheter directed thrombolysis
-insertion of an Inferior Vena Cava filter: for prevention of pulmonary embolism in high risk patients


The complications of DVT are:
-pulmonary embolism
-propagation of clot
-chronic venous insufficiency
-varicose veins
-venous ulcers

Varicose Veins

Varicose veins are common among the general population. It is defined as tortuous, dilated, abnormal veins of the lower limbs. The other variants of these unsightly veins are reticular veins (superficial, prominent veins) and thread veins (fine, thin cutaneous veins).

Varicose veins are more common in women, caucasians and in those with a family history. The risk factors are:

-obesity

-pregnancy

-prolonged stationary standing

-women taking oral contraceptive pills or hormone replacement therapy

The aetiology of varicose veins can be due to:

-venous valve insufficiency which is either congenital or acquired. Congenital insufficiency occurs in patients who are born with weakness of the venous valves. Acquired insufficiency is secondary to thrombosis (blood clots) occuring around the valves.

-perforator (the connecting veins between the deep venous & superficial venous systems) insufficiency

-disturbance to venous flow such as deep venous thrombosis (DVT), pelvic vein thrombosis and vascular malformations.

Patients who have varicose veins usually present with:

-unsightly dilated veins

-itchiness around the veins

-aching sensation of the lower llimbs

-swelling of the lower limbs

-throbbing pain of the lower limbs

The complications of varicose veins are:

-bleeding (usually due to accidental trauma)

-ulceration of the lower limbs

-thrombophlebitis (obstruction & inflammation of the veins)

-skin changes ie. pigmentation (haemosiderin extravasation), eczema, inverse 'beer bottle deformity' of the lower leg (lipodermatosclerosis)

Investigations for patients with varicose veins include:

-Duplex/Doppler Ultrasound Scans: to assess the site of incompetence and the patency of the deep venous system

-Magnetic Resonance Venography: to assess for pelvic/abdominal vein patency

Patients with varicose veins can be managed medically or surgically.

Medical management for these patients include:

-regular exercise

-elevate lower limbs when resting

-graduated compression stockings

-compression sclerotherapy (injection of sclerosants into the veins under ultrasound guidance)

-pulsed laser therapy (for thread veins only)

Surgical management is indicated for patients with more severe symptoms. These include:

-disconnection of the sapheno-femoral junction or sapheno-popliteal junction

-long saphenous vein stripping

-phlebectomy

Recent advances in surgery include endovascular procedures such as:

-endovascular laser or radiofrequency

-endovascular foam sclerotherapy

All the surgical procedures can be done under local anaesthesia and as day cases. Post surgery, patients will need to be on graduated compression stockings for at least 1 month. Patients are given regular pain-killers, encouraged to walk and advised to elevate their legs when sitting down.