Breast

Question 1

Describe the ‘triple assessment’ approach to investigation of a breast lump.

Answer 1

• Clinical - history and examination
• Radiological (mammography, ultrasound)
• mammography (usually in older patients >35yr).
- identifies microcalcifications and densities.
• ultrasound (usually in younger patients <35y because their breast issue is too dense for mammography)
- it is good for distinguishing solid and cystic lesions, and it can guide a needle test.
• Pathological - a needle test: FNA and/or core biopsy.
• When all three modalities concur, the pre-op diagnostic accuracy is approx. 99.9%

Question 2

Describe the pathology of fibrocystic change

Answer 2

Variety of benign, non-neoplastic changes in the breast which are the result of minor aberrations in the normal response to cyclical hormonal changes. It is typically seen in women aged between 25 and 45yrs.

The changes affect the TDLU and are characterised by fibrosis (scarring) and cyst formation.

Question 3

Describe the pathology of fibroadenoma.

Answer 3

commonest benign tumour of the breast. The tumour is well circumscribed and is composed of well differentiated glands embedded in a well differentiated connective tissue stroma.

Question 4

Describe important risk factors for developing breast cancer (7)

Answer 4

Increased lifetime E2 exposure- early menarche/ late menopause
Obesity
Prolonged HRT
COCP
Age
FHx- BRCA1/2
alcohol consumption

Question 5

Identify the most common type of invasive breast cancer

Answer 5

invasive ductal carcinoma

Question 6

Identify the second most common types of invasive breast cancer

Answer 6

invasive lobular carcinoma

Question 7

Explain the concept of the ‘sentinel’ node in breast cancer

Answer 7

The sentinel node is the first node draining a cancer.

If the sentinel node does not contain cancer, then there is a very high likelihood that the cancer has not spread to any other nodes or elsewhere (since the cancer has to pass through the sentinel node first).

If the sentinel node does contain cancer, then the other axillary nodes may or may not be involved. We cannot be sure.

Question 8

Indicate how the status of the axillary sentinel node affects the management of the axilla and the patient’s prognosis.

Answer 8

If the sentinel node(s) is ‘positive’ (ie. it contains metastatic tumour) then the patient will have an axillary clearance ie. removal of all the axillary nodes. [since we cannot be sure whether the other nodes in the axilla are involved or not - the only way to determine whether they are involved or not is to remove them and examine them pathologically]

If the sentinel node(s) is ‘negative’ (ie. no metastatic tumour is present in the node) then no further surgery in the axilla is required [since there is a very high likelihood that the cancer has not spread to any other axillary nodes ie. we regard them as uninvolved. Therefore the nodes do not need to be removed]

Question 9

Tx of fibrocystic change (3)

Answer 9

reassurance, analgesics, cyst aspiration and (rarely) excision.

Question 10

Px of fibroadenoma (3)

Answer 10

firm, mobile, painless lump

Question 11

Px of breast cancer (7)

Answer 11

• hard, painless lump; maybe fixed to chest wall or overlying skin.
• nipple inversion and skin dimpling.
• ulceration/fungation.
• peau d’orange (cutaneous oedema secondary to dermal lymphatic obstruction).
• nipple eczema in Paget’s disease (see pg 6).
• palpable axillary nodes, suggesting spread of tumour to these nodes.
• metastatic disease eg. weight loss, pleural effusion.

Question 12

How is the sentinel node identified?

Answer 12

Dye and/or isotope (TechneMum-99m) is injected into the tissue around the tumour. The surgeon visually inspects the nodes for staining and uses a Gamma probe to assess which nodes have taken up the radionuclide.

Question 13

Explain how DCIS is a precursor (precancer) of invasive breast cancer

Answer 13

Ductal carcinoma in situ (DCIS), epithelial cells showing cytological changes of malignancy (pleomorphism, hyperchromasia, increased nuclear:cytoplasmic ratios, mitotic activity - see pg 3 of the Principles of Tumour notes) are present in the TDLU.

However, the basement membrane is intact ie. the cells have not invaded into the surrounding tissue. This is a form of carcinoma in situ. DCIS has not invaded into the adjacent breast tissue and does not have the potential to metastasise.

it is often (but not always) associated with microcalcifications and so may be detected on mammography

Question 14

outline how its detection is a key aim of the breast screening programme

Answer 14

All women aged between 50-70 are invited for a screening mammogram every 3 years. This age range is currently being extended to those aged 47-73.

If suspicious features are detected on the screening mammograms (eg. microcalcifications and densities), the woman is called back for further assessment of the abnormality.

Further assessment usually involves:

• imaging eg. ultrasound.
• clinical examination.
• a needle test, usually a core biopsy.

Question 15

Role of oestrogen receptor in breast cancer prognosis?

Answer 15

• ER positive tumours:
- tend to be lower grade and less aggressive.
- likely to respond to hormonal therapy.
• ER negative tumours:
- tend to be higher grade and more aggressive.
- unlikely to respond to hormonal therapy.

Question 16

What is Her2?

Answer 16

an oncogene that encodes a transmembrane tyrosine kinase receptor

Question 17

How is Her2 associated with prognosis?

Answer 17

• poorer prognosis.

* good response to Herceptin (a monoclonal antibody against the HER2 receptor).

Question 18

prognostic factors in breast cancer

Answer 18

stage, tumour grade, histological subtype, vascular invasion, excision margins, oestrogen receptor and HER2 status

Question 19

What is paget’s disease?

Answer 19

Paget’s disease is a disease affecting the skin of the of the nipple and areola. Paget’s is due to the presence of DCIS cells in the epidermis - DCIS cells may extend along the major ducts and reach the nipple, they may then enter the deeper layers of the epidermis and spread within it through the nipple and areola. The affected skin “reacts” to the presence of the DCIS cells and results in the characteristic eczematous clinical appearance.

The main clinical differential diagnosis of Paget’s disease of the nipple is eczema. A biopsy is required to provide a definitive diagnosis.