7.1.2 Breast Cancer

Question 1

How common is breast cancer?

Answer 1

Most common cancer

1/7 women
Male breast cancer makes up 1% of all cases (increased risk with Klinefelter’s and trans women, as treated with oestrogen for prostate cancer)

Question 2

What is the most common type of breast cancer?

Answer 2

95% adenocarcinomas

Question 3

Where on the breast does cancer most commonly affect?

Answer 3

Upper outer quadrant

Question 4

What are the risk factors of breast cancer?

Answer 4

BREAST

Breast feeding
Reproductive history, partity and age at first full term pregnancy
Exogenous oestrogens (HRT)
Age
Sex- female more likely
Time of menopause, later= more risk

Question 5

What genes are involved in hereditary breast cancers?

Answer 5

10% of all breast cancers

BRCA1/2
p53 (Li-Fraumeni syndrome)

Tumour supressor genes- their proteins repair damaged DNA

Question 6

How is breast carcinoma classified?

Answer 6

In sutu and invasive

Ductal or lubular

Question 7

What is in situ carcinoma?

Answer 7

Neoplastic population of cells limited to ducts and lobules by byasement membrane

Myoepithelial cells are preserved

Does not invade into vessels, therefore cannot metastasis or kill patient

Question 8

Why is ductal carcinoma in situ a problem?

Answer 8

Non-obligate precursor of invasive carcinoma

Presents as mammographic calcifications but can present as a mass

Can spread through ducts and lobules and can be very extensive

Question 9

What is shown on histology of ductal carcinomas in situ?

Answer 9

Central (comedo) necrosis with calcification

Question 10

What is Paget’s disease?

Answer 10

Cancer cells extend to nipple skin without crossing basement membrane

Causes a unilateral red and crusting nipple

Eczematous or inflammatory nipple should be investigated and biopsied to exclude pagets

Question 11

Outline the features of invase carcinoma

Answer 11

Neoplastic cells invade beyond basement membrane into stroma

Can invade into vessels so can spread to lymph nodes and other sites

Usually presents as a mass or mammographic abnormality

By the time it is palpable patients normally have axillary lymph node metastases

Question 12

What is Peau d’orange?

Answer 12

Involvement of lymphatic drainage of the skin

Question 13

What are the different types of invasive breast carcinomas?

Answer 13

Invasive ductal carcinoma

Invasive lobular carcinoma

Other types- tubular, mucinous
(these have good prognosis, found often in older women)

Question 14

Card showing normal breast tissue vs invasive ductal carcinoma

Normal breast

Answer 14

Invasive ductal carcinoma NST

Question 15

What is this showing?

Answer 15

Invasive lobular carcinoma

Question 16

What is this showing?

Answer 16

Mucinous carcinoma

Question 17

How does breast cancer spread?

Answer 17

Via lymphatics, usually ipsilateral axilla

Distant metastases via blood vessels

Invasive lobular carcinoma can spread to odd sites- peritoneum, retropreitoneum, lemptomeninges

Question 18

What is the most common site distant metastases spread to?

Answer 18

Bones

Question 19

What is this showing?

Answer 19

Vascular invasion

Question 20

What factors determine prognosis in breast cancer?

Answer 20

In situ or invasive
TNM stage
Tumour grade (1-3)
Histological subtype
Molecular classification and gene expression

Question 21

How does grade effect survival?

Answer 21

Grade 1-90%
Grade 3- 40%

Question 22

What is a gene expression profile?

Answer 22

Analysis of genes to identify marker genes

Those with these genes would eventually develop metastases

Question 23

How many marker genes for breast cancer are there?

Answer 23

17

Question 24

What is the triple approach for breast cancer?

Answer 24

Clinical
History
Family history
Examination

Radiographic imaging
Mammogram
USS

Pathology
Core biopsy
Fine needle aspiration cytology

Question 25

What is the aim of mammoraphic screening?

Answer 25

Identify small impalpable cancers and pre-invasive cancers Done every 3 years for women 47-73

Question 26

What are the therapeutic approaches in breast cancer?

Answer 26

**Breast surgery** Mastectomy **Axillary surgery** Use sentinel node sampling to decide whether to remove all nodes or just involved **Post-operative radiotherapy to chest and axilla**

Question 27

What is sentinel lymph node biopsy?

Answer 27

**Intraoperative** lymphatic mapping with dye and/or radioactivity of the draining lymph nodes Sentinel or draining nodes are most likely to contain breast cancer metastases If negative axillary dissection can be avoided

Question 28

When is chemotherapy used?

Answer 28

If benefits thought to outweigh risks If given before surgery= neoadjuvant (basically to shrink tumour size)

Question 29

When is tamoxifen hormone treatment given?

Answer 29

Depends on the oestrogen receptor status, approximately 80% of cancer are oestrogen receptor positive (ER positive) Give tamoxifen if positive for oestrogen receptors

Question 30

When is herceptin hormone treatment given?

Answer 30

Depending on Her2 receptor status (20% of cancers are Her2 positive) If Her2 positive give Herceptin

Question 31

What is herceptin and Her2?

Answer 31

Herceptin= transtuzumab Monoclonal antibodies against the Her2 protein Her2 is human epidermal growth factor receptor

Question 32

How do we improve survival from breast cancer?

Answer 32

Early detection Awareness Neoadjuvant chemotherapy Gene expression profiles Prevention in familial cases e.g. prophylactic mastectomies

Question 33

What are molecular classifications in breast cancer?

Answer 33

Learn this generally (moved to last card so it doesn't keep popping up while learning)