Breast Cancer

Question 1

What is the most common cancer in women?

Answer 1

Breast cancer

Question 2

What is the average risk of breast cancer for women?

Answer 2

1 in 10

Question 3

What are risk factors for breast cancer?

Answer 3

Female
Increased age
Family history
Ovarian cancer
Early menopause
Late menopause
Nulliparity
Higher age at first pregnancy
Higher SE group
HRT
COCP
Not breastfeeding

Question 4

What are the main types of breast cancer?

Answer 4

Ductal carcinoma in situ
Lobular carcinoma in situ
Invasive ductal carcinoma
Invasive lobular carcinoma

Question 5

What is breast carcinoma in situ?

Answer 5

malignancy contained within the basement membrane

Question 6

What is the most common non-invasive breast malignancy?

Answer 6

Ductal carcinoma in situ (DCIS)

Question 7

What is DCIS preceded by?

Answer 7

Atypical ductal hyperplasia

Question 8

What is ductal breast cancer?

Answer 8

Malignancy of ductal breast tissue

Question 9

What is the risk with high grade DCIS?

Answer 9

Can progress to Paget’s disease of the nipple

Question 10

What is Paget’s disease of the nipple?

Answer 10

Extension of carcinoma along ducts to reach the epidermis of he nipple

Question 11

What is comedo necrosis?

Answer 11

Dead cells in the lumen of breast duct due to necrosis of inner cells caused by high grade ductal carcinoma

Question 12

How can comedo necrosis be detected?

Answer 12

Can calcify - calcification detected on mammography

Question 13

What is the risk of DCIS becoming invasive?

Answer 13

30% in 10 years

Question 14

How is diagnosis of DCIS confirmed?

Answer 14

Biopsy

Question 15

What is the second most common non-invasive breast malignancy?

Answer 15

Lobular carcinoma in situ (LCIS)

Question 16

What is LCIS?

Answer 16

Malignancy of the secretory lobules of the breast

Question 17

What is LCIS preceded by?

Answer 17

Atypical lobular hyperplasia

Question 18

What is the difference between atypical lobular hyperplasia and lobular carcinoma in situ?

Answer 18

ALH when <50% of lobule involved

LCIS when >50% involved

Question 19

What is the risk of LCIS becoming invasive?

Answer 19

20-40% in 15 years

Question 20

How is LCIS detected?

Answer 20

Not associated with micro calcification so usually diagnosed as incidental finding on breast biopsy rather than mammography

Question 21

When is carcinoma classed as invasive?

Answer 21

Once malignancy has invaded the basement membrane

Question 22

What is the most common type of invasive carcinoma of the breast?

Answer 22

Invasive ductal carcinoma (80%)

Question 23

Which type of invasive carcinoma of the breast has a better prognosis?

Answer 23

Invasive ductal carcinoma

Question 24

Where does breast carcinoma spread by local invasion?

Answer 24

Tissue of the breast
Skin
Muscles of chest wall

Question 25

Where does breast carcinoma spread by lymphatics?

Answer 25

Regional draining lymph nodes | Sentinel nodes

Question 26

Where does breast carcinoma spread by blood?

Answer 26

``` Bone Liver Brain Lungs Abdominal viscera Female genital tract ```

Question 27

What factors is breast carcinoma tumour graded on?

Answer 27

Tubular differentiation Nuclear pleomorphism Mitotic activity

Question 28

Which are the significant hormone receptors in breast carcinoma?

Answer 28

ER - oestrogen receptor PgR - progesterone receptor HER2

Question 29

What is the proportion of people that are positive for each of the hormone receptors in breast carcinoma?

Answer 29

ER - 80% PgR - 67% HER2 - 14%

Question 30

Which prognostic scores can be used in breast carcinoma?

Answer 30

Nottinham prognostic index | NHS predict

Question 31

What is the presentation of breast carcinoma?

Answer 31

``` Dimpled or depressed skin Visible lump Nipple change Bloody discharge Breast texture change Colour change Axillary lymphadenopathy ```

Question 32

What is triple assessment?

Answer 32

Clinical examination Imaging (USS, mammogram or both) Core biopsy

Question 33

Who are given USS over mammogram, and why?

Answer 33

``` Younger people (<35) Higher density of breast tissue makes mammogram appear white and makes it harder to interpret ```

Question 34

What is the staging system for breast carcinoma?

Answer 34

``` T1 - <2cm T2 - 2-5cm T3 - 5+cm T4a - invades chest wall T4b - invades skin T4c - invades chest wall and skin T4d - inflammatory breast cancer ```

Question 35

When is a sentinel node biopsy done?

Answer 35

If axillary ultrasound is positive

Question 36

Who are invited for breast cancer screening?

Answer 36

General population - age 50-70 | High risk - age 40+

Question 37

How often are people screened for breast cancer?

Answer 37

Every 3 years

Question 38

What is the preferred option for breast surgery?

Answer 38

Wide local excision and sentinel node biopsy

Question 39

Which circumstances can wide local excision and sentinel node biopsy be done?

Answer 39

Solitary lesion peripheral tumour Small lesion in large breast DCIS <4cm

Question 40

Which circumstances can mastectomy be done?

Answer 40

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

Question 41

How is reconstructive surgery done?

Answer 41

Myocutaneous flap based on the latissimus dorsi or rectus abdominis muscles

Question 42

When is axillary surgery done?

Answer 42

Almost all invasive cancers

Question 43

What are the options for axillary clearance?

Answer 43

Level 2 - includes nodes lateral and deep to pec minor | Level 3 - includes apical nodes medial to pec minor

Question 44

What does axillary node sampling involve?

Answer 44

Sampling of at least 4 random nodes | Identification of the first node draining the tumour by injecting radioactive isotope and coloured dye

Question 45

What is required if there is positive node sampling or biopsy?

Answer 45

Further axillary treatment by clearance or radiotherapy

Question 46

What is the complication of axillary clearance and radiotherapy?

Answer 46

Arm lymphoedema

Question 47

When and why is radiotherapy given as adjuvant therapy for breast carcinoma?

Answer 47

To the whole breast following wide local excision | To reduce risk of recurrence

Question 48

What are the indications for adjuvant radiotherapy in breast carcinoma?

Answer 48

Following mastectomy for T3-T4 tumours | 4 or more positive axillary nodes

Question 49

What is the hormonal therapy for ER or PgR positive tumours?

Answer 49

Tamoxifen or aromatase inhibitors

Question 50

Who are the different options for hormonal therapy for ER or PgR positive tumours given for?

Answer 50

Tamoxifen - for pre and peri-menopausal women | Aromatase inhibitors for postmenopausal women

Question 51

What are the options for aromatase inhibitors?

Answer 51

Letrozole Anastrozole Exemestane

Question 52

How long are hormonal therapies given for?

Answer 52

5 yeas after diagnosis

Question 53

What are the side effects of tamoxifen?

Answer 53

Increased risk fo endometrial cancer Venous thromboembolism Menopausal symptoms Weight gain

Question 54

What biological therapy is given in HER2 positive breast carcinomas?

Answer 54

Trastuzuman (herceptin)

Question 55

When is trastuzuman (herceptin) contraindicated?

Answer 55

History of heart disorders

Question 56

When is cytotoxic chemotherapy given in breast carcinoma?

Answer 56

For patients at high risk of recurrence - positive lymph node disease

Question 57

What are the options for cytotoxic chemotherapy in breast carcinoma?

Answer 57

Doxyrubicin Cyclophosphamide Fluorouracil Epirubicin