Breast - Breast Cancer: Pathology, Presentation And Assessement

Question 1

Epidemiology

Answer 1

• Affects 1/10 women
• 20 000 cases/year in UK
• Commonest cause of cancer death in females 15-54
• Second commonest cause of cancer deaths overall

Question 2

Aetiology and risk factors

Answer 2

• Family Hx: one 1st degree relative is 2x risk and/or 5% associated with BRCA mutations
• Oestrogen exposure: early menarche/late menopause, HRT, OCP, first child >35/nulliparity, obesity
• Others: previous Ca breast, increasing age (rare <30), proliferative breast disease with atypia
• Breast feeding is protective

Question 3

-Pathology: how do we classify breast carcinoma?

Answer 3

• Approx 95% are adenocarcinomas
• Adenocarcinomas divided into in situ (DCIS) and invasive
• DCIS: non invasive pre-malignant conditions 10x increase risk of invasive CA
• Invasive: commonest (70%), feel hard (scirrhous) and is classified by histological subtype (lobular, medullary, colloid/mucinous, inflammatory, papillary)

Question 4

What is Paget’s disease?

Answer 4

• Eczematoid change of the nipple associated with an underlying breast malignancy and it is present in 1-2% of pts with breast cancer
• Associated with underlying mass lesion and 90% of these patients will have an invasive carcinoma.
• Cells can also extend to nipple skin without crossing basement membrane (DCIS)
• Get unilateral red and crusting nipple (differs from nipple eczema which usually affects areolae first and then spreads to nipple)

Question 6

How does invasive carcinoma differ from DCIS?

Answer 6

• Neoplastic cells have invaded beyond BM in stroma
• Can invade into vessels: mets in lymph nodes or other places
• Usually present as mass/mammogram abnormality
• by the time cancer is palpable, more than half of pts will have auxiliary lymph node mets.
• Peau d’orange: involvement of lymphatic drainage of skin

Question 7

What are the possible avenues of spread of breast cancer?

Answer 7

• Direct extension: muscle and or skin
• Lymph: peau d’orange and arm oedema
• Blood: bones (bone pain and increase serum Ca2+), lungs (dyspnea and pleural effusion), liver (abdo pain, hepatic aimparment), brain (headache and seizures)

Question 8

What is the breast cancer screening tool?

Answer 8

• Every 3 years from 47-73: pt gets 2 view mammogram
• Craniocaudal and oblique vibes
• have decreased Ca deaths by 25%
• 10% false neg rate

Question 9

What signs can be found on patient upon presentation?

Answer 9

• Lump: commonest presentation, usually painless, 50% in upper outer quadrant +/- axillary nodes
• Skin changes: Paget’s (persistent and unilateral eczema) + peau d’orange (localised lymphoedema)
• Nipple: discharge or inversion
• Mets (previous card)
• May present through screening

Question 10

Breast cancer differential

Answer 10

• Cysts
• Fibro-adenomas
• DCIS
• Duct entasis

Question 11

What is the triple assessment approach?

Answer 11

• Hx and clinical examination
• Radiology (don’t do mammography in <35 ya b/c can’t see much) mammography and US
• Pathology: solid lump (tru-cut core biopsy) OR cystic lump do fine needle aspirate (clear = reassure, bloody = sent to cytology, do a core biopsy if residual mass or +ve cytology)

Question 12

Other Ix: bloods and imaging

Answer 12

• Bloods: FBC, LFTs, ESR, bone profile
• Imaging (helps with staging): CXR, liver US, CT scan, breast MRI (multi focal disease or with breast implants), bone scan and PET CT
• May need wire-guided excision biopsy

Question 13

Clinical staging:

Answer 13

• Stage 1: confined to breast, mobile, no lymph nodes
• Stage 2: stage 1 + nodes in ipsilateral axilla
• Stage 3: stage 2 + fixation to muscle (not chest wall), LNs matted and fixed, large skin involvement
• Stage 4: complete fixation to chest wall + mets

Question 14

TNM staging for breast cancer

Answer 14

• T(is): no palpable tumour - CIS
• T1: <2cm, no skin fixation
• T2: 2-5 cm, skin fixation
• T3: 5-10 cm, ulceration + pectoral fixation
• T4: >10 cm, chest wall extension, skin involved
• N1: mobile nodes
• N2: fixed nodes

Question 15

Give a feature of each invasive subtype

Answer 15

• Invasive lobular: 20% of cancers
• Medullary: affects young pts, feels soft
• Colloid/mucinous: occur in elderly
• Inflammatory: poor prognosis, often don’t feel mass, pain, erythema, swelling and peau d’orange