Breast

Question 1

Risk factors of breast cancer?

Answer 1

Increased age
Obesity/little exercise
Family history - BRCA1/2 & 1st degree relative
Early menarche/late menopause
not breast feeding
Nulliparity, 1st pregnancy >30yrs
Combined hormone replacement therapy, COCP
Ionising radiation
p53 gene mutations
Obesity
Previous surgery for benign lumps

Question 2

Clinical features indicating malignancy?

Answer 2

Palpable lumb - painless, hard, fixed
Nipple discharge/indrawing
Skin tethering

Question 3

Indications for breast clinic referral?

Answer 3

2WW: if >30 with unexplained lump in breast or axilla +/- pain or
>50 w/ any of discharge, retraction, or other nipple changes on 1 side
Skin changes suggesting breast ca

Question 4

Common malignant breast cancers?

Answer 4

Most common: ductal carcinoma followed by lobular carcinoma
These classified into:
Invasive - spread
or carcinoma in situ - not spread
Rarer types:
Medullary breast cancer
Mucinous (mucoid or colloid) breast cancer
Tubular breast cancer
Adenoid cystic carcinoma of the breast
Metaplastic breast cancer
Lymphoma of the breast
Basal type breast cancer
Phyllodes or cystosarcoma phyllodes
Papillary breast cancer
Paget's disease of the nipple: eczematoid change associated w/ malignancy (commonly invasive ductal carcinoma) - areolar sparing initially.

Question 5

Common benign lumps of the breast? Mx?

Answer 5

Fibroadenoma - solid, mobile, firm, growths of tissue - if >3cm - excise
Cysts - smooth discrete lump - aspirate. If blood stained or persistently refill + Symptomatic? Radiological: halo sign from compression of underlying fat
Sclerosing adosis - breast lump/pain - biopsy
Fat necrosis - may mimic carcinoma - from trauma, obesity mass may increase in size - image & core biopsy
Duct papilloma - nipple discharge, bilateral bleeding, no lump - do microdochectomy

Question 6

How is a breast assessed for cancer?

Answer 6

Triple assessment:
Clinical examination - scored 1-5 (changes)
Imaging - mammogram w/ craniocaudal and mediolateral oblique - high resolution USS
If positive - core biopsy

Question 7

Surgical interventions for breast cancer?

Answer 7

Lumpectomy (wise local incision)
Mastectomy
Cosmetic options (reconstruction) prosthetic nipples, fat from abdomen, lat dorsi
Axilla surgery if axilla involvement esp if lymph node involvement

Question 8

When would you do breast conservative (lumpectomy/wide local incision) treatment?

Answer 8

Small tumour (<25% vol - small lesion in larger) breast
Solitary lesion
Peripheral tumour
DCIS <4cm
Not underneath nipple
NO previous radiotherapy

Question 9

When would you do a mastectomy?

Answer 9

Large tumour relative to breast
Tumour underneath/indrawing nipple - central
More than 1 tumour in same breast (multifocal tumour)
DCIS >4cm

Question 10

Grading in breast cancer?

Answer 10

TNM - size, nodes, metastasis
Nottingham Prognostic Index - prognosis if no treatment:
Tumour size x 0.2 + lymph node score + grade score

Question 11

How is breast cancer oncotyped for diagnosis?

Answer 11

Oestrogen/progesterone positive
HER2 positive - detected by FISH
Proliferative markers - Ki67

Question 12

What non-surgical treatment options are available for breast cancer?

Answer 12

Endocrine - If positive hormone receptors
Radiotherapy
Chemotherapy - esp if axillary disease
Trastuzumab - if HER2 positive. CI if PMH of heart disease
Bisphosphanates

Question 13

Describe endocrine measures

Answer 13

Given to all women w/ ER+ disease
Tamoxifen - inhibits oestrogen receptor - if pre/perimenopausal (risk of endometrial ca, VTE & menopausal symptoms)
Aromatase inhibitors (anastrozole) given to post menopausal women (converts androgens to oestrogen)

Question 14

When is radiotherapy indicated?

Answer 14

All women who undergo lumpectomy (whole breast)
Women w/ aggressive disease after mastectomy
- give to T3-T4 tumours/4+ positive axillary nodes

Question 15

Oncotyping reveals a HER2+/ER- cancer. Rx?

Answer 15

Chemotherapy

Trastuzumab

Question 16

When is chemotherapy used?

Answer 16

Aggressive disease
HER2+/ER-
Young age
High grade
Ki67+

Question 17

Why are bisphosphonates used?

Answer 17

Prevents bony mets

Question 18

Breast cancer screening

Answer 18

All women 47-73
Women offered mammogram every 3 years
Family history referred if: age of dx <40, bilateral disease, male breast ca, ovarian ca, jewish ancestry, sarcoma if relative <45, glioma/childhood adrenal cortical carcinomas, complicated multiple cancers - if so then referred to breast clinic for further assessment

Question 19

Non malignant breast conditions?

Answer 19

Duct ectasia - thick green nipple discharge, with list like retraction of nipple

Periductal mastitis - younger females, inflammation/mammary duct fistula, smoking is RF, Mx is continue breastfeeding is they are, abx (fluclox), abscess drainage

Breast abscess - lactational mastitis - usually s. aureus. OE tender fluctuant mass
Mx: abx, USS guided aspiration
Overlying skin necrosis is indication for surgical debridement

TB - histology & culture

Question 20

What is inflammatory breast cancer and its treatment?

Answer 20

typical Sx = progressive, erythema and oedema of the breast in the absence signs of infection such as fever, discharge or elevated WCC and CRP, and an elevated CA 15-3

IBC = rare but rapidly progressive ca due to obstruction of lymph drainage -> erythema and oedema. Usually a primary cancer.

Mx= neo-adjuvant chemotherapy first-line, followed by total mastectomy +/- radiotherapy.

Question 21

45 yr old female has known breast ca. Nipple and areola has erythematous and crusty rash. It spread out from nipple. Dx? Mx?

Answer 21

Paget’s disease of the nipple
Dx: punch biopsy, mammography, USS
Mx: Depends on underlying lesion - usually carcinoma