Breast Ca

Question 1

List 10 differentials for breast lump/mass

Answer 1

Malignant lesions

• DCIS
• LCIS
• Invasive carcinoma
• Inflammatory breast, ‘peau d’oragnge’
• Paget’s disease of the nipple

Non malignant

• Ductal ectasia – discharge, unilateral
  
  • Risk factors = smoking
  • Refuse to operate unless they stop smoking
• Mastitis
  
  • Lactational vs non-lactational
• Intra-ductal papilloma
• Fibrocystic disease – bilateral, young women, cyclical
• Fibroadenoma

Question 2

Risk factors for breast cancer

Answer 2

• gender (99% female)
• age (80% >40yr old)
• personal history of breast cancer and/or prior breast biopsy (regardless of pathology)
• family history of breast cancer (greater risk if relative was first degree and premenopausal)
• high breast density, nulliparity, first pregnancy >30yr, menarche <12yr, menopause >55yr
• decreased risk with lactation, early menopause, early childbirth
• radiation exposure (e.g.mantleradiation for Hodgkin’s disease)
• >5yr HRT use, >10yr OCP use
• BRCA1 and BRCA2 gene mutations
• alcohol use, obesity, sedentary lifestyle

Question 3

Investigations + diagnostic investigation for breast cancer

Answer 3

IX

• mammogram
• USS - differentiate between cystic and solid
• MRI - high sensitivity, low specificity
• galactogram/ductogram

DIAGNOSTIC

• fine needle aspirate/core biopsy

Question 4

What is triple assessment?

Answer 4

1. History + examination
2. Imaging - mammogram +/- USS
3. Pathology - Fine needle biopsy/core biopsy

• FNA only provides cytology
• core needle biopsy provides full histology

Question 5

Outline the role/benefits of histology

Answer 5

• confirm tumor histogenesis
• confirm tumor subtype
• evaluation of hormone receptors/HER2 expression
• tumor margins
• grading

Question 6

What mammography findings are indicative of higher risk malignancy?

Answer 6

1. mass that is poorly defined, spiculated (spikey)
2. microcalcifications
3. architectural distortion
4. interval mammographic changes

Question 7

What kind of surgical options are there for breast lump/cancer?

Answer 7

Question 8

When should you consider genetic testing for BRCA1/2?

Answer 8

• patient diagnosed with breast AND ovarian cancer
• strong family history of breast cancer
• male breast cancer in family
• young patient (<35yo)
• bilateral breast Ca in patients <50 yo

Question 9

Contraindications for lumpectomy

Answer 9

• high risk of local recurrence
• failure to obtain tumour-free margins after re-excision
• not suitable for radiation therapy (pregnant, previous radiation)
• large tumour size relative to breast

Question 11

After breast ca has been detected + treated, how often does the pt need follow up?

Answer 11

HOW OFTEN

• 3 monthly for 2 years
• twice yearly up to 5 years
• yearly mammography, sometimes USS
• psychological support and review are essential

WHY?

• women who have had one breast cancer have a slightly increased risk of developing cancer in the same or other breast (about 1% per year)
• aim of follow up is to detect local/regional recurrence, can be treated by surgical or radiation therapy
• if metastatic disease develops - still treatable but not cureable