Breast CA

Question 1

commonest type of breast CA?

Answer 1

• invasive ductal (70 percent)

Question 2

pre-malignant types?

have not breached the basement membrane

Answer 2

• ductal carcinoma in situ (DCIS)
• lobular carcinoma in situ (LCIS)
• atypical ductal hyperplasia

Question 3

Ex findings?

Answer 3

• majority have palpable lump in breast
other Ex:
• skin changes (dimpling, ulcer)
• breast pain
• change in size or shape
• nipple changes (inversion, discharge, rash)
• ↑ lymph nodes

Question 4

Hx: patient comes in with eczematoid skin and painful itching in breast, bloody nipple discharge and a lump?

Answer 4

ΔΔ
• unilateral = Paget’s disease of the breast (half are malignant)
• if bilateral, then consider breast eczema

Question 5

Hx: patient presents with peau d’orange (skin like the surface of an orange), itch, inflammation (pain, swelling, warmth) and nipple inversion?

Answer 5

• inflammatory breast CA

Question 6

what ↑ risk of breast CA?

Answer 6

• age
• O exposure (HRT, OCP, nulliparous, BMI)
• white ethnicity
• alcohol
• radiotherapy
• GENES: BRCA, p53, PTEN mutation

Question 7

when and how often is breast CA screening?

Answer 7

• age 50-70

* every 3 years

Question 8

if positive for BRCA, what age and how screened?

Answer 8

age 30-49

annual MRI

Question 9

Ix breast ca?

Answer 9

TRIPLE ASSESSMENT

1) Hx and Ex
2) Imaging (mammagram, US if <35, +/- MRI if discrepancy
3) Histology (FNA cytology +/- core needle biopsy)

• also bloods (FBC, LFTs, Ca++ - looking for mets)
• CXR, abdo US, bone scan, CT (mets again)
• screening for mets happens if stage 3-4 or large tumour etc

Question 10

Hx: patient with breast lump also presents with SOB, bone pain, neuro Sx and hepatomegaly?

Answer 10

breast CA mets

Question 11

Tx breast CA?

Answer 11

SURGERY + RADIO + CHEMO + HORMONAL

conservative:
• MDT approach
• annual mammogram for 5 years
• CA15-3 can be used to monitor Tx response in metastatic CA

medical:
• radio adjuvant if bad
• chemo if young or high grade
• endocrine therapy if ER +ve (for years)
- tamoxifen (1st line premenopausal)
- aromatase inhibitors - anastrozole (1st line postmenopausal)
• Herceptin if Her2/EGFR2 +ve
• bisphosphonates

surgical:
• stage 1-2 operable, 3-4 less so
• wide local excision
• mastectomy
• (*blue dye injected for sentinel node)

Question 12

complications breast CA?

Answer 12

• mets
- bone (pain, pathological #, Tx with bisphos and radio)
- **spinal cord compression (2’ to bone mets)
- liver (hepatomegaly)
- lung (pleural effusion)
- CNS (headache, neuro Sx)
- **carcinomatous meningitis (patchy CN lesions, headache)
• lymphoedema (from node removal)
• ↑↑Ca++

Question 13

when to urgently refer?

Answer 13

• >30yrs with unexplained breast lump
• >50yrs with Sx or changes to one nipple
+/- • skin changes, >30 years with axillary lump