Breast - Breast Cancer Management

Question 1

Explain the Aetiology of breast cancer

Answer 1

• Most breast cancers arise from duct tissue (ductal) or lobular tissue (lobular) and are carcinomas
• Carcinoma in situ: cancer has not spread beyond local tissue- can be lobular or ductal
• Invasive: cancer spread to surrounding tissue -can be lobular or ductal
• Invasive ductal carcinoma is the most common type (has recently been renamed to No Special type)

Question 2

When should you consider referring someone to the 2 week pathway?

Answer 2

• Age 30 and over and have unexplained breast lump with or without pain
• Age 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other concerning change

Question 3

Outline the 5 options available for breast cancer treatment

Answer 3

• Surgery
• Radiotherapy
• Hormone therapy
• Biological therapy
• Chemotherapy

Question 4

Surgery: who is offered surgery?

Answer 4

• Vast majority of women with breast Ca are offered surgery
• Exception: elderly very frail lady who may be better managed with hormonal therapy
• 2/3 of tumours can be removed with WLE

Question 5

What features are used to determine whether a mastectomy or WLE is performed?

Answer 5

Mastectomy

• Multifocal tumour
• Central tumour
• Large lesion in small breast
• DCIS >4cm

WLE

• Solitary lesion
• Peripheral tumour
• Small lesion in large breast
• DCIS <4cm

*All women should be offered breast reconstruction to achieve cosmetically suitable result, regardless of type of operation they have

Question 6

What is a sentinel node biopsy?

Answer 6

• Surgical procedure to determine whether cancer has spread from primary tumour into the lymphatic system. Gold standard
• Sentinel node: first node that a section of a breast drains into
• If the node is negative, there is no need for further dissection
• If the node is positive, axillary clearance and radiotherapy will be offered to the patient.

Question 7

Outline the axillary clearance levels

Answer 7

1. Up to axillary vein level
2. Up to medial border of pectoralis minor
3. Up to border of first rib

Question 8

Outline surgical complications

Answer 8

• Haematoma or seroma
• Frozen shoulder
• Long thoracic nerve palsy (winged scapula)
• Lymphoedema

Question 9

When do we offer radiotherapy?

Answer 9

Whole breast radiotherapy is recommended for:

• Women who has had WLE: reduces risk of recurrence by 2/3
• Mastectomy patients for T3/T4 tumours
• Patients with 4 or more positive axillary nodes

Question 10

What hormonal therapy is offered to patients?

Answer 10

• Tamoxifen: ER+ve cancer - offered to both pre and peri menopausal women and for 5 years after diagnosis. Works as oestrogen receptor block
• Anastrozole: ER+ve cancers in post-menopausal women - work as aromatisation inhibitors (aromatisation accounts for the majority of estranged production in post-menopausal women)

Question 12

What are important side effects of tamoxifen?

Answer 12

• Increased risk of endometrial cancer
• Venous thromboembolism
• Menopausal symptoms

Question 12

What biological therapies are offered to breast cancer patients? What important C/I is there?

Answer 12

Trastuzumab: HER2 +ve patients (only useful 20-25% these tumours). Works by binding to the HER2 receptor and slowing down cell duplication

S/E: fever, infection, insomnia, rash, heart failure, allergic reactions and lung disease

CI: cannot be used in patients with history of heart disorders or heart failure

Question 13

What is the Nottingham Prognostic index?

Answer 13

Index used to give an indication of survival

Question 14

What are borders of the axilla?

Answer 14

• Anterior border: pectoralis major and minor
• Lateral border: intertubercular sulcus of humerus
• Medial border: serrated anterior and thoracic wall
• Posterior border: scapularis, teres major and latissimus doris

https://teachmeanatomy.info/wp-content/uploads/Transverse-View-of-the-Borders-of-the-Axilla.jpg