Breast

Question 0

Breast lumps

Answer 0

Cyst (female >35)
Fibroadenoma (female <35)
Carcinoma

Question 1

Breast examination - triple assessment

Answer 1

Examination
Imaging - us, mammography
Fine needle aspiration (cytology) or core biopsy (histology)

Question 2

Mammography in premenopausal women

Answer 2

Not useful due to ‘white-out’ of breast tissue due to high levels of oestrogen

Question 3

NICE guidelines for MRI use in breast ca

Answer 3

MRI may be used:
In addition if high tissue density on mammography
If discrepancy between clinical assessment and mammography
When planning breast conserving surgery

Question 4

Three important outcomes for breast ca

Answer 4

Psychological morbidity
Local recurrence
Mortality, micro metastasis

Question 5

NICE guidelines for investigations in breast ca

Answer 5

All women with cancer should have an us of axilla
Needle biopsy of axillary node if positive
Sentinel node biopsy if negative

Question 6

Surgery breast options

Answer 6

Wide local excision - lumpectomy with free margin
Partial mastectomy - at least 20cm normal surrounding tissue plus segment from periphery to nipple (eg quadrantectomy)
Simple mastectomy: total mastectomy
Radical: include pectorals and axillary contents (no additional benefit)
Supraradical: plus internal mammary chain

Question 7

Bone metastases typically due to

Answer 7

Breast
Bronchus
Thyroid
Kidney
Prostate

Question 8

Chemotherapy after breast ca

Answer 8

Greatest advantage in pre-menopausal node positive women
Monthly cycles for 4-6 months
No benefit from giving for longer

Question 9

Radiotherapy after breast ca

Answer 9

Routinely used after wide local excision or partial mastectomy
Reduces risk of local recurrence but no effect on mortality
Allows breast conserving surgery to achieve similar results as simple mastectomy

Question 10

10 yr survival rates in breast ca

Answer 10

50% in node positive
70% in node negative

Chemotherapy improves this by 5-10%

Question 11

Reason for peau d’orange appearance

Answer 11

Due to obstruction of dermal lymphatics

Question 12

Breast reconstruction surgery

Answer 12

Use latissimus dorsi flap

Question 13

Paget’s disease of the nipple

Answer 13

Spread from intraductal carcinoma

Question 14

Terminal care sequence

Answer 14

Analgesic ladder
Syringe driver
Transdermal opiate patches

Question 15

Sentinel node

Answer 15

The first node which drains an area of tissue, giving access to the local lymphatic basin
Tumours progress in an orderly way (“skip nodes” are rare)

Question 16

Sentinel node identification

Answer 16

Operative injection of vital blue dyes plus technetium labelled colloids - gamma probe
Possible to identify the sentinel node >90%
Intensive histology on single node better than quick check on 15 nodes from axillary clearance

Question 17

Sentinel node biopsy

Answer 17

Easily identifiable - highly predictive of axillary status
Helps with prognosis and decisions about chemotherapy
If positive, most surgeons would undertake axillary clearance
Saves 80% of N0 women from this procedure

Question 18

Herceptin (Transtuzumab) (anti-HER2)

Answer 18

25% of women with breast ca over-express human epidermal growth factors, type 2 (HER2) on the surface of tumour cells
Herceptin blocks cell growth and division
It blocks the binding of endogenous oestrogen to the cell and helps attract NK cells (Ab dependent cytotoxicity)

Results:
Immunotherapy with herceptin can improve survival by 3-6 months in HER2 positive women with late metastatic disease
Increase in disease-free survival and a reduction in distant metastasis in early HER2 positive breast ca

Regime: every 3 weeks for 1 year, ECHO every 3 months

Serious side effect of cardiomyopathy and CCF

Question 19

Tamoxifen

Answer 19

SERM selective estrogen receptor modulator
Blocks breast, receptors, causes hot flushes and vaginal dryness
Stimulates bones and endometrium

Reduces both recurrence and death rates
5% benefit at 10 years if node negative, 10% benefit at 10 years if node positive
Increased risk of thromboembolic events and endometrial ca (1/500)

Question 20

Aromatase inhibitors

Answer 20

Selective aromatase inhibitors used in post menopausal women
E.g. Anastrozole

MOA: block peripheral conversion of andostendione (adrenals) to oestrogen 
Results: as effective as tamoxifen in controlling metastatic disease, fewer thromboembolic events and endometrial ca, but more osteoporosis. Hot flushes and vaginal bleeding less common. 
ATAC trial (arimidex / tamoxifen alone or in combination)