Breast

Question 1

Breast cancer screening

Answer 1

NHS Breast Cancer Screening (mammogram):

Offered to women aged 50 to 70 (±3 years), every 3 years

High risk patients →annual screening mammograms between ages of:
Aged 40-49 if moderate risk
Aged 40-59 if high risk
Aged 40-69 if known BRCA positive
Consider offering aged 30-59 if high risk

Question 2

Tripple Assessment

Answer 2

• Clinical Assessment = history + examination
• Breast Imaging = USS ± biopsy (if younger age) or mammogram (if older age)
• Biopsy = fine needle aspiration or core biopsy. Confirms diagnosis + assess for receptor status of tissue (to guide hormonal Tx). Senital lymph node biopsy may be performed in breast cancer surgery.

Question 3

Breast cancer types

Answer 3

Ductal = arising from duct tissue of breast. 2 types based on spread:
 In-situ ductal carcinoma = has not spread beyond local tissue. 30% become invasive.
 Invasive ductal carcinoma = spread beyond local tissue. Most common type. A.k.a. “no-special type” (all other breast cancers called “special type”)
Lobular = arising from lobular tissue of breast. 2 types based on spread:
 In-situ lobular carcinoma = has not spread beyond local tissue. 30% become invasive (Tx = monitor).
 Invasive lobular carcinoma = spread beyond local tissue. 10%. Often missed on mammogram.
o Note: in-situ lobular/ductal carcinomas are considered pre-cancerous lesions

Rarer types of special type = medullary + mucinous + tubular + adenoid cystic carcinoma + metaplastic + lymphoma + basal type + phyllodes + papillary

Question 4

Complications of breast cancer

Answer 4

Paget’s disease of nipple = eczematoid changes (itchy) to nipple secondary to breast cancer (invasive carcinoma in 90%). Seen in 1-2% of breast cancer. Ix = punch biopsy.

Inflammatory breast cancer = blocks lymph drainage → breast appears inflamed (peau d’orange = tender + pitting skin). 1-3% of breast cancer. Poor prognosis. Ix shows raised Ca15-3 levels.

Question 5

Risk factors for breast cancer

Answer 5

Genetic / FMH Hx:
BRCA1 (chromosome 14) → 70% develop breast cancer, 50% develop ovarian cancer. Increased risk of bowel and prostate cancer.
BRCA2 genes (chromosome 13) → 60% breast cancer. 20% ovarian cancer.
p53 / PTEN gene mutation
1st degree relative premenopausal relative with breast cancer (e.g. mother)

Excessive oestrogen exposure / Lack of progesterone exposure:
Nulliparity + 1st pregnancy > 30 yrs (twice risk of other women)
Early menarche + late menopause
COCP / combined HRT
Not breast feeding

Other: ionising radiation + obesity + previous surgery for benign disease

Question 6

Breast cancer symptoms and referral criteria

Answer 6

Symptoms:
o Lumps that are hard, irregular, painless or fixed in place
o Lumps may be tethered to the skin or the chest wall
o Nipple retraction
o Skin dimpling or oedema (peau d’orange)
o Lymphadenopathy, particularly in the axilla

Referral criteria:
o Must perform 2WW if:
 Unexplained breast lump + age 30+
 Unilateral nipple changes (discharge / retraction / concerning change) + aged 50+
o Consider 2WW if:
 An unexplained lump in the axilla + age 30+
 Skin changes suggestive of breast cancer
o Routine referral if: unexplained lump (with/without pain) + age < 30

Question 7

Investigations for suspected breast cancer

Answer 7

Confirm diagnosis = triple assessment ± MRI
Ca15-3 = tumour marker for breast cancer

Assess for lymph node involvement = axilla USS + biopsy. May consider sentinel lymph node biopsy during surgery (if no lymph node involvement detected on USS).

Test for breast cancer receptors → if ER positive but HER2 and lymph node biopsy negative do genetic expression profiling for prognostic markers.

Investigations for TMN staging – consider:
MRI of the breast and axilla
Liver ultrasound for liver metastasis
CT TAP for lung, abdominal or pelvic metastasis
Isotope bone scan for bony metastasis

Hormonal receptors = all breast cancers tested for receptor status (to guide hormonal Tx). 3 types of receptor: oestrogen receptor (ER) + progesterone receptor (PR) + human epidermal growth factor (HER2). Triple negative = no receptors present (worst prognosis).

Question 8

Treatment for breast cancer

Answer 8

Surgery – offered to majority (unless very elderly with metastatic disease):
Prior to surgery → palpate for axillary lymphadenopathy:
No palpable lymphadenopathy → axillary USS. If positive → sentinel lymph node biopsy to assess for nodal involvement.
Palpable lymphadenopathy → axillary node clearance required during surgery, this may cause arm lymphedema / functional impairment.

Types of surgery
Wide local excision = performed in 66% of cases. Indications: solitary lesion + peripheral location + small sized tumour (<4cm) + large breast + DCIS < 4cm
Mastectomy = indications: multifocal tumour + central tumour + large lesion + small breast + DCIS < 4cm.
All woman should be offered breast reconstruction can be immediate (during surgery) or delayed and partial (using flap / fat tissue / breast implants) or reduction/reshape (reshaping or removing both breast to match).

Whole breast Unilateral Radiotherapy = recommended after wide local excision (reduces recurrence by 2/3rds) + T3/4 tumour after mastectomy

Hormonal therapy → offered if oestrogen receptor positive (continue for 5-10yrs):
Pre- or peri-menopausal → tamoxifen. Side effects = endometrial cancer + VTE + menopausal Sx.
Postmenopausal → aromatase inhibitor (e.g. anastrozole / letrozole). This is because post menopause action of aromatase in adipose tissue is responsible for production of majority of oestrogen from androgens.

Biological therapy – used in HER2 positive cancer (20-25%). Usually trastuzumab (Contraindications = heart disorders) / pertuzumab / neratinib.

Chemotherapy = indications: prior to surgery to downstage lesion + after surgery + axillary node disease