Breast cancer

Question 1

RF

Answer 1

• Female
  -Increased oestrogen exposure
  -more glandular tissue
  -Obesity
  -Smoking
  -Family history (first-degree relatives)
  -HRT
  -COCP
  -Genetics- BRACA 1 and BRACA 2

Question 2

Ductal carcinoma in situ?

Answer 2

-Pre cancerous or cancerous
-localised to a single area
- 30% chance of being invasive

Question 3

Lobular carcinoma in situ?

Answer 3

-Pre-cancerous typical in premenopausal women
-often asymptomatic
-Diagnosed on breast biopsy incidentally

Question 4

Invasive ductal carcinoma?

Answer 4

-80% of invasive breast cancers are these
-Can be seen on a mammogram
-No specific type

Question 5

Invasive lobular carcinoma?

Answer 5

Around 10% of invasive breast cancers
Originate in cells from the breast lobules
Not always visible on mammograms

Question 6

Inflammatory Breast Cancer ?

Answer 6

1-3% of breast cancers
Presents similarly to a breast abscess or mastitis
Swollen, warm, tender breast with pitting skin (peau d’orange)
Does not respond to antibiotics
Worse prognosis than other breast cancers

Question 7

Paget’s Disease of the Nipple?

Answer 7

Looks like eczema of the nipple/areolar
Erythematous, scaly rash
Indicates breast cancer involving the nipple
May represent DCIS or invasive breast cancer
Requires biopsy, staging and treatment, as with any other invasive breast cancer

Question 8

Screening?

Answer 8

The NHS breast cancer screening program offers a mammogram every 3 years to women aged 50 – 70 years.

Question 9

Presentation?

Answer 9

Lumps that are hard, irregular, painless or fixed in place
Lumps may be tethered to the skin or the chest wall
Nipple retraction
Skin dimpling or oedema (peau d’orange)
Lymphadenopathy, particularly in the axilla

Question 10

Two week referral?

Answer 10

An unexplained breast lump in patients aged 30 or above
Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes)
An unexplained lump in the axilla in patients aged 30 or above
Skin changes suggestive of breast cancer

Question 11

What is the triple diagnostic assessment ?

Answer 11

Imaging- US in young women as more dense breast with glandular tissue. Mammograms in older women to pick up calcifications. MRI- for high risk people and to see size of tumour
Lymph node- sentinel lymph node biopsy. Isotope contrast

Question 12

Breast cell receptors?

Answer 12

Oestrogen receptors (ER)
Progesterone receptors (PR)
Human epidermal growth factor (HER2)
Triple-negative breast cancer is where the breast cancer cells do not express any of these three receptors. This carries a worse prognosis, as it limits the treatment options for targeting the cancer.

Question 13

How is gene expression profiling used?

Answer 13

• Gene expression profiling involves assessing which genes are present within the breast cancer on a histology sample. This helps predict the probability that the breast cancer will reoccur as a distal metastasis (away from the original cancer site) within 10 years.
  -recommend this for women with early breast cancers that are ER positive but HER2 and lymph node negative.

Question 14

Metastasis ?

Answer 14

2 Ls and 2 Bs:

L – Lungs
L – Liver
B – Bones
B – Brain

Question 15

How do we stage breast cancer?

Answer 15

The first step in staging is with triple assessment (clinical assessment, imaging and biopsy). Additional investigations may be required to stage the breast cancer:

Lymph node assessment and biopsy
MRI of the breast and axilla
Liver ultrasound for liver metastasis
CT of the thorax, abdomen and pelvis for lung, abdominal or pelvic metastasis
Isotope bone scan for bony metastasis

Question 16

Surgery

Answer 16

-breast conserving surgery with radiotherapy
- mastectomy
-lymph node removal

Question 17

What is chronic lymphoedema ?

Answer 17

-Chronic condition caused by impaired lymphatic drainage of an area
-Can occur in an entire arm after breast cancer surgery
There are specialist lymphoedema services that can help manage patients. Non-surgical treatment options include:

Massage techniques to manually drain the lymphatic system (manual lymphatic drainage)
Compression bandages
Specific lymphoedema exercises to improve lymph drainage
Weight loss if overweight
Good skin care

Question 18

Radiotherapy ?

Answer 18

Usually in breast conserving surgery to reduce the risk of recurrence.
Common side effects:
General fatigue from the radiation
Local skin and tissue irritation and swelling
Fibrosis of breast tissue
Shrinking of breast tissue
Long term skin colour changes (usually darker)

Question 19

Chemotherapy?

Answer 19

Neoadjuvant therapy – intended to shrink the tumour before surgery
Adjuvant chemotherapy – given after surgery to reduce recurrence
Treatment of metastatic or recurrent breast cancer

Question 20

Hormone treatment?

Answer 20

Patients with oestrogen-receptor positive breast cancer are given treatment that disrupts the oestrogen stimulating the breast cancer.

There are two main first-line options for this:

Tamoxifen for premenopausal women
Aromatase inhibitors for postmenopausal women (e.g., letrozole, anastrozole or exemestane)

Question 21

How do tamoxifen and aromatase inhibitors work?

Answer 21

Tamoxifen is a selective oestrogen receptor modulator (SERM). It either blocks or stimulates oestrogen receptors, depending on the site of action. It blocks oestrogen receptors in breast tissue, and stimulates oestrogen receptors in the uterus and bones. This means it helps prevent osteoporosis, but it does increase the risk of endometrial cancer.

Aromatase is an enzyme found in fat (adipose) tissue that converts androgens to oestrogen. After menopause, the action of aromatase in fat tissue is the primary source of oestrogen. Aromatase inhibitors work by blocking the creation of oestrogen in fat tissue.

Tamoxifen or an aromatase inhibitor are given for 5 – 10 years to women with oestrogen-receptor positive breast cancer.

Other options for women with oestrogen-receptor positive breast cancer, used in different circumstances, are:

Fulvestrant (selective oestrogen receptor downregulator)
GnRH agonists (e.g., goserelin or leuprorelin)
Ovarian surgery

Question 22

What is a targeted treatment?

Answer 22

Trastuzumab (Herceptin) is a monoclonal antibody that targets the HER2 receptor. It may be used in patients with HER2 positive breast cancer. Notably, it can affect heart function; therefore, initial and close monitoring of heart function is required.

Pertuzumab (Perjeta) is another monoclonal antibody that targets the HER2 receptor. It may be used in patients with HER2 positive breast cancer. This is used in combination with trastuzumab (Herceptin).

Neratinib (Nerlynx) is a tyrosine kinase inhibitor, reducing the growth of breast cancers. It may be used in patients with HER2 positive breast cancer.

Question 23

What are the types of reconstructive surgery?

Answer 23

-Immediate reconstruction, done at the time of the mastectomy
-Delayed reconstruction, which can be delayed for months or years after the initial mastectomy
Implants

Inserting an implant is a relatively simple procedure (compared with a flap) with minimal scarring. It gives an acceptable appearance but can feel less natural (e.g., cold, less mobile and static size and shape). There can also be long-term problems, such as hardening, leakage and shape change.

Latissimus Dorsi Flap

The breast can be reconstructed using a portion of the latissimus dorsi and the associated skin and fat tissue. The tissue is tunnelled under the skin to the breast area.

“Pedicled” refers to keeping the original blood supply and moving the tissue under the skin to a new location.

“Free flap” refers to cutting the tissue away completely and transplanting it to a new location.

Transverse Rectus Abdominis Flap (TRAM Flap)

The breast can be reconstructed using a portion of the rectus abdominis, blood supply and skin. This can be either as a pedicled flap (tunnelled under the skin) or a free flap (transplanted). It poses a risk of developing an abdominal hernia due to the weakened abdominal wall.

Deep Inferior Epigastric Perforator Flap (DIEP Flap)

The breast can be reconstructed using skin and subcutaneous fat from the abdomen (no muscle) as a free flap. The deep inferior epigastric artery, with the associated fat, skin and veins, is transplanted from the abdomen to the breast. The vessels are attached to branches of the internal mammary artery and vein. This is a complex procedure involving microsurgery. There is less risk of an abdominal wall hernia than with a TRAM flap, as the abdominal wall muscles are left intact.