Breast Cancer

Question 1

Risk factors for breast cancer?

Answer 1

Female (99% of breast cancers)

Increased oestrogen exposure (earlier onset of periods and later menopause)

More dense breast tissue (more glandular tissue)

Obesity and/ore high fat diet

Alcohol (More so than smoking)

Smoking

Family history (first-degree relatives)

The combined contraceptive pill gives a small increase in the risk of breast cancer, but the risk returns to normal ten years after stopping the pill.

Hormone replacement therapy (HRT) increases the risk of breast cancer, particularly combined HRT (containing both oestrogen and progesterone).

First pregnancy > 30 years

Not-breast feeding

Radiation of the chest

Question 2

Which type of HRT particularly increases the risk for breast cancer?

Answer 2

Hormone replacement therapy (HRT) increases the risk of breast cancer, particularly combined HRT (containing both oestrogen and progesterone).

Question 3

How long after stopping the COCP does the risk of breast cancer return to normal?

Answer 3

10 years

Question 4

Where is the BRACA1 gene found?

Answer 4

Chromosome 17

Question 5

Where is the BRACA2 gene found?

Answer 5

Chromosome 13

Question 6

What risks are higher in patients with the BRACA1 genes?

Answer 6

75% Breast cancer lifetime risk

Around 70% will develop breast cancer by aged 80

Around 50% will develop ovarian cancer

Also increased risk of bowel and prostate cancer

Question 7

What risks are higher in patients with the BRACA2 gene?

Answer 7

Up to 85% lifetime risk of breast cancer?

Around 60% will develop breast cancer by aged 80

Around 25% will develop ovarian cancer

In men - 6% lifetime risk for breast cancer?

Question 8

There are other rarer genetic abnormalities associated with breast cancer other than the BRACA genes, such as?

Answer 8

TP53 and PTEN genes

Question 9

What are the types of breast cancer?

Answer 9

Ductal Carcinoma In Situ (DCIS)
Lobular Carcinoma In Situ (LCIS)
Invasive Ductal Carcinoma – NST
Invasive Lobular Carcinomas (ILC)
Inflammatory Breast Cancer
Paget’s Disease of the Nipple

Rarer type: Medullary breast cancer, Mucinous breast cancer, Tubular breast cancer

Question 10

The NHS breast cancer screening program offers a mammogram to whom and when?

Answer 10

every 3 years to women aged 50 – 70 years

Also available:
- Previous breast cancer
- First degree relative with cancer < 50 years
- Have known BRACA1, BRACA2, TP53 gene

Question 11

Negatives of breast cancer screening?

Answer 11

Anxiety and stress

Exposure to radiation, with a very small risk of causing breast cancer

Missing cancer, leading to false reassurance

Unnecessary further tests or treatment where findings would not have otherwise caused harm

Question 12

There are different recommendations for screening patients with a higher risk due to a family history of breast cancer. These are in the NICE guidelines (2013, updated 2019).

There are specific criteria for a referral from primary care for patients that may be at higher risk due to their family history, such as?

Answer 12

A first-degree relative with breast cancer under 40 years

A first-degree male relative with breast cancer

A first-degree relative with bilateral breast cancer, first diagnosed under 50 years

Two first-degree relatives with breast cancer

Question 13

There are different recommendations for screening patients with a higher risk due to a family history of breast cancer. Depending on their risk factors, they may be seen in a secondary care breast clinic or a specialist genetic clinic. What may they be officered?

Answer 13

Patients require genetic counselling and pre-test counselling before performing genetic tests. This is to discuss the benefits and drawbacks of genetic testing, such as the implications for family members and offspring.

Annual mammogram screening is offered to women with increased risk, between specific age ranges, depending on their level of risk (potentially starting from aged 30, if high risk).

Chemoprevention may be offered for women at high risk, with:

Tamoxifen if premenopausal
Anastrozole if postmenopausal (except with severe osteoporosis)

Risk-reducing bilateral mastectomy or bilateral oophorectomy (removing the ovaries) is an option for women at high risk. This is suitable for only a small number of women and requires significant counselling and weighing up risks and benefits.

Question 14

Breast cancer chemoprevention: premenopausal women

Answer 14

Tamoxifen

Question 15

Breast cancer chemoprevention: postmenopausal women

Answer 15

Anastrozole

Question 16

Presentation of breast cancer?

Answer 16

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

Lymphadenopathy, particularly in the axilla

Asymmetry, or swelling,

Abnormal nipple discharge

Paget’s-like nipple changes)

Mastalgia

Ulceration

Question 17

NICE guidelines on breast lump referral

Answer 17

The NICE guidelines (updated January 2021) recommend a two week wait referral for suspected breast cancer for:

An unexplained breast lump in patients aged 30 or above
Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes)

The NICE guidelines recommend also considering a two week wait referral for:

An unexplained lump in the axilla in patients aged 30 or above
Skin changes suggestive of breast cancer

The NICE guidelines suggest considering non-urgent referral for unexplained breast lumps in patients under 30 years.

Question 18

Once a patient has been referred for specialist services under a two week wait referral for suspected cancer, they should initially receive a triple diagnostic assessment comprising of what?

Answer 18

Clinical assessment (history and examination)
Imaging (ultrasound or mammography)
Biopsy (fine needle aspiration or core biopsy)

Question 19

Imaging choice in ?breast cancer

Answer 19

Younger women generally have more dense breasts with more glandular tissue.

Ultrasound scans are typically used to assess lumps in younger women (e.g., under 30 years). They are helpful in distinguishing solid lumps (e.g., fibroadenoma or cancer) from cystic (fluid-filled) lumps.

Mammograms are generally more effective in older women. They can pick up calcifications missed by ultrasound.

MRI scans may be used:

For screening in women at higher risk of developing breast cancer (e.g., strong family history)
To further assess the size and features of a tumour

Question 20

Below which age are women with a breast lumped offered an USS over a mammogram and why?

Answer 20

Younger women generally have more dense breasts with more glandular tissue.

Ultrasound scans are typically used to assess lumps in younger women (e.g., under 30 years). They are helpful in distinguishing solid lumps (e.g., fibroadenoma or cancer) from cystic (fluid-filled) lumps.

At menopause, the breast tissue will involute - during this process, much of the glandular tissue undergoes apoptosis and is replaced by fat. The general density of the breast reduces in response to the lack of oestrogen .

Question 21

What might mammograms detect that may be missed by USS?

Answer 21

Calcifications

Question 22

Breast cancer - lymph node assessment

Answer 22

Women diagnosed with breast cancer require an assessment to see if cancer has spread to the lymph nodes.

All women are offered an ultrasound of the axilla (armpit) and ultrasound-guided biopsy of any abnormal nodes.

A sentinel lymph node biopsy may be used during breast cancer surgery where the initial ultrasound does not show any abnormal nodes.

Question 23

When is a sentinel lymph node biopsy performed and what is involved?

Answer 23

A sentinel lymph node biopsy may be used during breast cancer surgery where the initial ultrasound does not show any abnormal nodes.

Sentinel node biopsy is performed during breast surgery for cancer.

An isotope contrast and a blue dye are injected into the tumour area.

The contrast and dye travel through the lymphatics to the first lymph node (the sentinel node).

The first node in the drainage of the tumour area shows up blue and on the isotope scanner.

A biopsy can be performed on this node, and if cancer cells are found, the lymph nodes can be removed.

Question 24

What type of receptors are involved in breast cancer?

Answer 24

Oestrogen receptors (ER)
Progesterone receptors (PR)
Human epidermal growth factor (HER2)

Question 25

What receptor status carries the worst prognosis?

Answer 25

Triple negative 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 26

What are the biopsy options at triple assessment clinic?

Answer 26

fine needle aspiration or core biopsy

Question 27

Notable locations of metastasis secondary to breast cancer?

Answer 27

2 Ls and 2 Bs: L – Lungs L – Liver B – Bones B – Brain

Question 28

What is gene expression profiling, when and why is it performed?

Answer 28

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. The NICE guidelines (2018) [DG34] recommend this for women with early breast cancers that are ER positive but HER2 and lymph node negative. It helps guide whether to give additional chemotherapy.

Question 29

What is Ductal Carcinoma In Situ (DCIS) and how does it present?

Answer 29

Pre-cancerous or cancerous epithelial cells of the breast ducts Ductal carcinoma in situ (DCIS) is the most common type of non-invasive breast malignancy and currently comprises around 20% of all breast cancers diagnosed. It is a malignancy of the ductal tissue of the breast that is contained within the basement membrane Localised to a single area Often picked up on mammogram screening

Question 30

Why is DCIS treated?

Answer 30

Potential to spread locally over years Potential to become an invasive breast cancer (around 30%) Good prognosis if full excised and adjuvant treatment is used

Question 31

What is Lobular Carcinoma In Situ (LCIS) and how does it present?

Answer 31

A pre-cancerous condition occurring typically in pre-menopausal women Usually asymptomatic and undetectable on a mammogram Usually diagnosed incidentally on a breast biopsy

Question 32

How is LCIS managed and why?

Answer 32

LCIS represents an increased risk of invasive breast cancer in the future (around 30%) Low grade LCIS is usually treated by close monitoring (e.g., 6 monthly examination and yearly mammograms)rather than excision. When an invasive component is identified, it is less likely to be associated with axillary nodal metastasis than with DCIS. Bilateral prophylactic mastectomy can be potentially indicated if individuals possess the BRCA1 or BRCA2 genes.

Question 33

What is meant by 'Invasive Ductal Carcinoma – NST'

Answer 33

NST means no special/specific type, where it is not more specifically classified (e.g., medullary or mucinous) Also known as invasive breast carcinoma of no special/specific type (NST) Originate in cells from the breast ducts 80% of invasive breast cancers fall into this category Can be seen on mammograms

Question 34

Into which category do 80% of invasive breast cancers fall into?

Answer 34

Invasive Ductal Carcinoma – NST NST means no special/specific type, where it is not more specifically classified (e.g., medullary or mucinous) Also known as invasive breast carcinoma of no special/specific type (NST)

Question 35

Where does invasive ductal carcinoma - NST originate from?

Answer 35

Cells in the breast ducts

Question 36

What is Invasive Lobular Carcinomas (ILC) and how is it detected?

Answer 36

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

Question 37

How does inflammatory breast cancer present?

Answer 37

Presents similarly to a breast abscess or mastitis Swollen, warm, tender breast with pitting skin (peau d’orange) Does not respond to antibiotics

Question 38

Which breast cancer type makes up 1-3% of breast cancers and has the worst prognosis?

Answer 38

Inflammatory breast cancer 1-3% of breast cancers Worse prognosis than other breast cancers

Question 39

What does Paget’s Disease of the Nipple indicate?

Answer 39

Indicates breast cancer involving the nipple May represent DCIS or invasive breast cancer

Question 40

How does Paget's disease of the nipple appear?

Answer 40

Looks like eczema of the nipple/areolar Erythematous, scaly rash Persistent roughening, scaling, ulcerating or eczematous change to the nipple.

Question 41

What is done in order to stage breast cancer?

Answer 41

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 The TNM system is used to stage breast cancer. This grades the tumour (T), nodes (N) and metastasis (M).

Question 42

MDT role in breast cancer management?

Answer 42

All patients are discussed with the multidisciplinary team (MDT) for treatment planning: After the initial diagnosis After abnormal staging tests After further pathology and results After recurrence of the disease At any point where a treatment decision will be made

Question 43

What is involved in the surgical management of breast cancer?

Answer 43

Tumour Removal The objective is to remove the cancer tissue along with a clear margin of normal breast tissue. The options are: 1. Breast-conserving surgery (e.g., wide local excision), usually coupled with radiotherapy 2. Mastectomy (removal of the whole breast), potentially with immediate or delayed breast reconstruction Axillary Clearance Removal of the axillary lymph nodes is offered to patients where cancer cells are found in the nodes. Usually, the majority or all lymph nodes are removed from the axilla. This increases the risk of chronic lymphoedema in that arm. Patients may have adjuvant radiotherapy to the chest wall after mastectomy for tumours with a high risk of recurrence.

Question 44

Removal of the axillary lymph nodes is offered to patients where cancer cells are found in the nodes. Usually, the majority or all lymph nodes are removed from the axilla. What risk does this incur?

Answer 44

Lymphoedema is a chronic condition caused by impaired lymphatic drainage of an area. Lymphoedema can occur in an entire arm after breast cancer surgery on that side, with removal of the axillary lymph nodes in the armpit. The lymphatic system is responsible for draining excess fluid from the tissues. The tissues in areas affected by an impaired lymphatic system become swollen with excess, protein-rich fluid (lymphoedema). The lymphatic system also plays an important role in the immune system. Areas of lymphoedema are prone to infection.

Question 45

There are specialist lymphoedema services that can help manage patients. Non-surgical treatment options include what?

Answer 45

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 46

It is important to remember that you should avoid taking blood or putting a cannula in the arm on the side of previous breast cancer removal surgery. Why?

Answer 46

There is a higher risk of complications and infection due to the impaired lymphatic drainage on that side.

Question 47

What is the role of radiotherapy in the management of breast cancer?

Answer 47

Radiotherapy is usually used in patients with breast-conserving surgery to reduce the risk of recurrence. High-dose radiation is delivered from multiple angles to concentrate radiation on a targeted area. Patients will have a course of radiotherapy after surgery, for example, with a session of radiotherapy every day for 3 weeks.

Question 48

Common side effects of radiotherapy?

Answer 48

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 49

In what three scenarios is chemotherapy used to manage breast cancer?

Answer 49

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 50

Patients with oestrogen-receptor positive breast cancer are given treatment that disrupts the oestrogen stimulating the breast cancer. What are the two main first-line options for this?

Answer 50

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

Question 51

What is tamoxifen?

Answer 51

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.

Question 52

Action of tamoxifen in breast tissue?

Answer 52

Blockade of oestrogen receptors

Question 53

Action of tamoxifen on bones?

Answer 53

Stimulates oestrogen receptors

Question 54

Action of tamoxifen on endometrial tissue?

Answer 54

Stimulates oestrogen receptors

Question 55

Why does tamoxifen not increase the risk of osteoperosis?

Answer 55

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 but stimulates oestrogen receptors in the bones. This means it helps prevent osteoporosis

Question 56

What type of cancer does tamoxifen increase the risk of and why?

Answer 56

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 but stimulates oestrogen receptors in the uterus. This means it increases the risk of endometrial cancer.

Question 57

How to aromatase inhibitors work?

Answer 57

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.

Question 58

Why are aromatase inhibitors the hormonal treatment of choice in post-menopausal women with ER+ cancer?

Answer 58

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

Question 59

Pre vs post menopausal hormonal treatments for ER+ breast cancer?

Answer 59

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

Question 60

Examples of aromatase inhibitors?

Answer 60

letrozole, anastrozole or exemestane

Question 61

Options besides traditional anti-oestrogen therapy for women with oestrogen-receptor positive breast cancer, used in different circumstances include what?

Answer 61

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

Question 62

What targeted treaments may be used in HER2+ breast cancer?

Answer 62

Trastuzumab (Herceptin) Pertuzumab (Perjeta) Neratinib (Nerlynx)

Question 63

What monoclonal antibodies may be used in HER2+ breast cancer?

Answer 63

Trastuzumab (Herceptin) Pertuzumab (Perjeta)

Question 64

How does Neratinib (Nerlynx) treat breast cancer?

Answer 64

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

Question 65

What type of breast cancer does Trastuzumab (Herceptin) treat and how?

Answer 65

Trastuzumab (Herceptin) is a monoclonal antibody that targets the HER2 receptor. It may be used in patients with HER2 positive breast cancer.

Question 66

What monitoring is notably required in patients having treatment with Trastuzumab (Herceptin)?

Answer 66

Notably, it can affect heart function; therefore, initial and close monitoring of heart function is required.

Question 67

What type of breast cancer does Pertuzumab (Perjeta) treat and how?

Answer 67

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).

Question 68

Breast cancer follow up?

Answer 68

The NICE guidelines (2018) recommend all patients treated for breast cancer have surveillance mammograms yearly for 5 years (longer if they are not yet old enough for the regular breast screening programme). Patients treated for breast cancer are given an individual written care plan, including details on: Designated contacts and details Adjuvant treatment review dates Surveillance dates Advice on identifying recurrence Support service details

Question 69

Reconstructive surgery is offered to all patients having a mastectomy. What are the two options?

Answer 69

1. Immediate reconstruction, done at the time of the mastectomy 2. Delayed reconstruction, which can be delayed for months or years after the initial mastectomy After mastectomy, the options for reconstructing the breast(s) include: Breast implants (inserting a synthetic implant) Flap reconstruction (using tissue from another part of the body to reconstruct the breast)

Question 70

There are several different methods for reconstructing the breasts. The most suitable will depend on individual factors and preferences. After breast-conserving surgery, reconstruction may not be required. The standard options, if needed, are what?

Answer 70

Partial reconstruction (using a flap or fat tissue to fill the gap) Reduction and reshaping (removing tissue and reshaping both breasts to match)

Question 71

After mastectomy, the options for reconstructing the breast(s) include what?

Answer 71

: Breast implants (inserting a synthetic implant) Flap reconstruction (using tissue from another part of the body to reconstruct the breast)

Question 72

Breast reconstruction: implants - pros and cons

Answer 72

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.

Question 73

Flap reconstruction - types?

Answer 73

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.

Question 74

Which type of flap reconstruction poses a risk of developing an abdominal hernia due to the weakened abdominal wall?

Answer 74

Transverse Rectus Abdominis Flap (TRAM Flap)

Question 75

What is meant by breast carcinoma in situ?

Answer 75

Breast Carcinoma In Situ are neoplasms that are contained within the breast ducts and have not spread into the surrounding breast tissue. These carcinoma types represent a precursor to invasive breast cancer, they are typically identified solely on imaging, and are rarely symptomatic at presentation. The two main types of in situ breast carcinoma types are Ductal Carcinoma In Situ (DCIS) and Lobular Carcinoma In Situ (LCIS).

Question 76

DCIS is is categorised into what five major types based upon histological features?

Answer 76

Comedo Cribriform Micropapillary Papillary Solid Most lesions are mized?

Question 77

DCIS is often detected during screening - how?

Answer 77

Around 90% of patients with DCIS will have suspicious microcalcifications seen on mammography, with the diagnosis then subsequently confirmed via biopsy

Question 78

How is DCIS managed?

Answer 78

Any detected DCIS should be treated with surgical excision. This is done with breast conserving surgery (wide local excision) or (in cases of widespread or multifocal DCIS) with mastectomy.

Question 79

DCIS vs LCIS

Answer 79

Ductal carcinoma in situ (DCIS) is the most common type of non-invasive breast malignancy and currently comprises around 20% of all breast cancers diagnosed. It is a malignancy arising from the epithelial lining of the ducts of the breast that is contained within the basement membrane Lobular Carcinoma in Situ (LCIS) is a non-invasive lesion of the epithelial lining of the terminal ducts of the secretory lobules of the breast that is contained within the basement membrane They are much rarer than DCIS however individuals with LCIS are at greater risk of developing an invasive breast malignancy. LCIS is usually diagnosed before menopause, with only 10-20% of women diagnosed being post-menopausal. LCIS is usually asymptomatic, much like DCIS, however LCIS is not associated with microcalcifications; LCIS is usually diagnosed as an incidental finding during biopsy of the breast DCIS is often detected during screening. Around 90% of patients with DCIS will have suspicious microcalcifications seen on mammography

Question 80

Why is LCIS only usually found incidentally on biopsy?

Answer 80

LCIS is usually asymptomatic, much like DCIS, however LCIS is not associated with microcalcifications; LCIS is usually diagnosed as an incidental finding during biopsy of the breast

Question 81

Invasive carcinoma of the breast can be classified into which main 3 groups?

Answer 81

Invasive ductal carcinoma (70-80%) Invasive lobular carcinoma (5-10%) Other subtypes, such as medullary carcinoma, invasive micropapillary carcinoma, or metaplastic carcinoma

Question 82

Invasive ductal carcinoma (IDC) is the most common type of breast carcinoma, constituting 70-80% of all cases. Microscopically, IDC is composed of what?

Answer 82

nests and cords of tumour cells with associated gland formation

Question 83

Invasive lobular carcinoma (ILC) is the second most common type of breast cancer, constituting 5-10% of all cases. Microscopically, ILC is composed of what?

Answer 83

It is characterised by a diffuse (stromal) pattern of spread that makes detection more difficult.

Question 84

IDC or ILC?

Answer 84

IDC - invasive ductal carcinoma nests and cords of tumour cells with associated gland formation

Question 85

IDC or ILC

Answer 85

Invasive lobular carcinoma (ILC) diffuse (stromal) pattern of spread that makes detection more difficult.

Question 86

How can prognosis of breast cancer determined?

Answer 86

Breast cancer prognosis is influenced by nodal status, size, grade, and receptor status. The Nottingham Prognostic Index (NPI)* is a widely used clinicopathological staging system for primary breast cancer prognosis. It is calculated by: (Size x 0.2) + Nodal Status + Grade Size is the diameter of the lesion in cm, nodal status is number of axillary lymph nodes involved (0 nodes=1, 1-4 nodes=2, >4 nodes=3), and the histological grade is based on Bloom-Richardson classification

Question 87

What factors influence breast cancer prognosis?

Answer 87

Nodal status Size Grade Receptor status

Question 88

Microscopic changes in Paget's disease of the nipple?

Answer 88

Microscopically there is involvement of the epidermis by malignant intraepithelial adenocarcinoma cells within the nipple epidermis.

Question 89

How does Paget's disease of the nipple present?

Answer 89

Clinical features for Paget’s disease of the nipple include an itching or redness in the nipple and/or areola, with flaking and thickened skin on or around the nipple The area is often painful and sensitive. A flattened nipple, with or without yellowish or bloody discharge, may also be indicative of the disease.

Question 90

Paget's disease - differential diagnosis?

Answer 90

Due to its involvement of the skin of the nipple, Paget’s disease of the breast is often mistaken for dermatitis or eczema. Paget’s disease - always affects the nipple and only involves the areola as a secondary event eczema - nearly always only involves the areola and spares the nipple

Question 91

Paget's disease - investigation and management

Answer 91

A biopsy is needed to confirm diagnosis. Given its association with malignancy, a complete breast and axilla examination should also be performed; mammograms, ultrasounds, or MRI breast may also be warranted. First line management of Paget’s disease is operative, if possible. The type of surgery depends on how advanced the underlying breast cancer is, but in all cases the nipple and areola will need to be removed. In the cases associated with an underlying malignancy, radiotherapy may also be necessary.

Question 92

Breast conserving surgical management of breast cancer?

Answer 92

Breast conserving treatment is only suitable for individuals with localised operable disease and no evidence of metastatic disease. A Wide Local Excision (WLE) is the most common breast conserving treatment and involves excision of the tumour, typically ensuring a 1cm margin of macroscopically normal tissue is taken along with the malignancy. This option is typically only suitable for focal smaller cancers and will also be dependent on the location and relative size of the breast.

Question 93

What does a mastectomy involve?

Answer 93

A mastectomy removes all the tissue of the affected breast, along with a significant portion of the overlying skin (the muscles of the chest wall left intact). The amount of skin that is excised is often dependent on whether a reconstruction is planned.

Question 94

Axillary node clearance involves removing all nodes in the axilla, ensuring to not damage any associated important structures within the axilla, which are then sent for histological analysis. Common complications from this operation include what?

Answer 94

Paraesthesia Seroma formation Lymphedema in the upper limb

Question 95

Benign breast lumps

Answer 95

Fibroadenoma Adenoma Papilloma Lipoma Phyllodes Tumours

Question 96

What is the most common benign growth of the breast?

Answer 96

Fibroadenoma

Question 97

In which age group are fibroadenomas most common?

Answer 97

Women of reproductive age

Question 98

Fibroadenoma - presentation

Answer 98

highly mobile lesions (historically termed a “breast mouse'') well-defined and rubbery on palpation most less than 5cm in diameter. They can be multiple and bilateral.

Question 99

Fibroadenoma management

Answer 99

They have a very low malignant potential and can be left in situ with routine follow up appointments; over a 2 year period, up to 30% will get smaller. The main indications for potential excision are >3cm in diameter or patient preference.

Question 100

What is a ductal adenoma

Answer 100

Benign glandular tumour

Question 101

In what age group do ductal adenomas present?

Answer 101

Older females

Question 102

How do ductal adenomas present?

Answer 102

The lesions themselves are nodular and can easily mimic malignancy, therefore most cases will undergo escalation for triple assessment.

Question 103

In what age range do papillomas typical occur?

Answer 103

40-50s

Question 104

Where do papillomas usually appear?

Answer 104

Most typically occurring in the subareolar region (usually less than 1cm away from the nipple).

Question 105

What is a lipoma? Does it require management?

Answer 105

A breast lipoma is a soft and mobile benign adipose tumour that are normally otherwise asymptomatic. They have low malignant potential and are usually only removed if they are significantly enlarging or causing symptomatic compressive or aesthetic issues.

Question 106

How do papilomas present and how/why are they managed?

Answer 106

They will often present with bloody or clear nipple discharge, yet larger papillomas can also present initially as a mass typically occurring in the subareolar region (usually less than 1cm away from the nipple). They can appear similar to ductal carcinomas on imaging and therefore usually require biopsy. Some cases may be excised to ensure no atypical cells or neoplasia are present. Risk of breast cancer is only increased with multi-ductal papilloma and most are treated with microdochectomy.

Question 107

What are phyllodes tumours? How should the be managed and why?

Answer 107

Phyllodes tumours are rare fibroepithelial tumours. Phyllodes tumours are commonly larger, occur in an older age group, and are comprised of both epithelial and stromal tissue. They often grow rapidly. They are difficult to clinically and microscopically differentiate from fibroadenomas, however around one third of Phyllodes tumours have malignant potential and 10% of benign tumours will recur after excision. Consequently, most Phyllodes tumours should be widely excised (or mastectomy if the lesion is large).

Question 107

What are phyllodes tumours? How should the be managed and why?

Answer 107

Phyllodes tumours are rare fibroepithelial tumours. Phyllodes tumours are commonly larger, occur in an older age group, and are comprised of both epithelial and stromal tissue. They often grow rapidly. They are difficult to clinically and microscopically differentiate from fibroadenomas, however around one third of Phyllodes tumours have malignant potential and 10% of benign tumours will recur after excision. Consequently, most Phyllodes tumours should be widely excised (or mastectomy if the lesion is large).

Question 108

Are benign or malignant breast masses more common?

Answer 108

benign 15x more common

Question 109

Less than 1% of breast cancers occur in men, although they do tend to be more aggressive. What puts men at higher risk?

Answer 109

Gynaecomastia +/- cirrhosis FHx Hormonal disorders

Question 110

What is the physiology underlying the relationship between oestrogen exposure and breast cancer risk?

Answer 110

Glandular tissue responds to several hormones: Oestrogen, progesterone, prolactin - In response to these hormones, the alveolar cells divide and the lobules enlarge - Without these hormones, cells under go apoptosis As such, ever menstrual cycle the alveolar cells go through a period of cell division and apoptosis Every time a cell tumour divides, there is a chance of a mutation which can lead to tumour formation Thus, factors that increase the number of menstrual cycles in a womans lifetime increase the risk, as do other causes of increased oestrogen exposure

Question 111

Side effects of radiotherapy to the chest wall/axilla?

Answer 111

Pneumonitis Rib fracture Pericarditis Lymphoedema Brachial plexus injury

Question 112

When might adjuvant radiotherapy be used in management of breast cancer?

Answer 112

Tumours with high risk of reccurence Aggresive tumours inc. tripple negative Axillary if axillary lymph node involvements Chest wall if involvement of lymph nodes within chest

Question 113

Chemotherapy in breast cancer - neoadjuvant vs adjuvant

Answer 113

NEOADJUVANT - to downstage tumour size - better surgical outcomes - elimination of micrometasteses - particularly useful in TNBC, HER2+, Node + ADJUVANT - reduce risk of recurrence/mets - determined by: grade, size, node +, menopausal status, receptor status

Question 114

Breast cancer - poor prognostic factors?

Answer 114

Young age/premenopausal Large primary tumour size High grade tumour Oestrogen and progesterone receptor negativr Lymph node involvement

Question 115

Advanced breast cancer treatment -

Answer 115

Consistent chemotherapy + specific treatments depending on subtype Hormone receptor positive - Endocrine therapy HER 2 positive - HER 2 targeted therapy, commonly monocoloncal antibodis Triple negative - nil