Breast Cancer

Question 1

What are the different types of breast cancer?

Answer 1

1. Invasive ductal carcinoma (most common. Starts in milk ducts)
2. Invasive lobular carcinoma (starts in milk lobules)
3. Ductal carcinoma in situ (non invasive - doesn’t extend past basement membrane)
4. Lobular carcinoma in situ
5. Inflammatory breast cancer

Question 2

what are some rarer types of breast cancer?

Answer 2

• Medullar cancer
• Mucinous
• Phyllodes

Question 3

What are the risk factors for breast cancer?

Answer 3

• Increased hormone exposure: Early menarche or late menopause. OCP or HRT
• Genetic mutations (BRCA)
• Advancing age
• Caucasion ethnicity
• Obesity and lack of physical activity
• Alcohol and tobacco use
• History of breast cancer
• Previous radiotherapy treatment
• Not breastfeeding

Question 4

What are the signs and symptoms of breast cancer?

Answer 4

• Unexplained mass in patient > 30
• Nipple discharge, retraction in patient > 50
  -Skin changes: Puckering, dimpling, peau d’orange, rash, redness
• Axilliary lymphadenopathy

Question 5

Which patients are referred for an appointment within 2 weeks?

Answer 5

• Age 30+ with an unexplained lump
• Age 50+ with nipple symptoms
• Consider referring in patients with skin changes or lumps in axilla

Question 6

What are the differentials for breast cancer?

Answer 6

Fibroadenoma - Solitary, painless, well-circumscribed lump
Cyst: Well defined movable mass which can vary with size with menstrual cycle
Mastitis: Typically in breastfeeding women
Lipoma - Soft, mobile and painless lump

Question 7

What is the breast cancer screening?

Answer 7

Women between ages 50-70 are given a mammogram every 3 years

Question 8

What is involved at a triple assessment?

Answer 8

1. Clinical examination
2. Imaging: Mammogram or ultrasound. MRI for lobular breast cancer
3. Biopsy. Core needle biopsy is better but can use FNA

Question 9

What is Paget’s disease of the nipple?

Answer 9

Persistent roughening, scaling, ulcerating and ecxematous changes to the nipple. Majority have underlying neoplasm

Question 10

What is the clinical presentation of Paget’s disease of the nipple?

Answer 10

• Itching or redness in the nipple and/or areola with flaking or thickened skin
• Area is often painful and sensitive with or without discharge
• Can look like eczema so biopsy needed

Question 11

What is the surgical treatment for breast cancer?

Answer 11

Wide local excision if - Solitary lesion, tumour is peripheral, lesion is small.
Mastectomy - Multifocal lesion, lesion is central and large.
If no palpable axillary lymphadenopathy - US ans sentinel node biopsy
If palpable lymphadenopathy then axillary clearence.

Question 12

What are the risks of axillary clearence?

Answer 12

It can cause lymphoedema and functional arm impairment

Question 13

What non surgical treatment is offered for breast cancer?

Answer 13

Radiotherapy - Recommended after wide local excision.
Hormonal therapy - If oestrogen or progesterone +
Biological therapy - If HER2+
Chemotherapy - Neoadjuvant or adjuvant

Question 14

What is used in oestrogen positive breast cancers

Answer 14

• If premenopausal then tamoxifen (increases risk of endometrial cancer)
• If postmenopausal then aromatase inhibitors

Question 15

What drug is given for HER2+

Answer 15

Trastuzumab. Contraindicated in patients with heart disorders

Question 16

WHat is the importance of endocrine treatment?

Answer 16

Chemo can’t prevent metastatic relapse but endocrine treatments can

Question 17

What are the pathological prognostic factors?

Answer 17

Carcinoma grade
Carcinoma stage

Question 18

What are the side effects of transtuzumab?

Answer 18

Diarrhoea, liver disease, heart issues, mouth sores and hypertension

Question 19

What is inflammatory breast cancer?

Answer 19

Cancerous cells block lymph drainage resulting in inflamed appearance of the breast. Very aggressive

Question 20

What is the management of ductal carcinoma in situ or lobular carcinoma in situ?

Answer 20

DCIS - Surgical excision
LCIS - Monitoring unless BRCA+ then prophylaxtic mastectomy is recommended

Question 21

What is ductal carcinoma in situ?

Answer 21

Pre-cancerous/cancerous epithelial cells.
It is localised to a single area and often picked up via mammogram

Question 22

What is lobular carcinoma in situ?

Answer 22

Pre cancerous lesion which is usually asymptomatic and undetectable on mammogram.

Question 23

What are the most common sites of breast cancer metastasis?

Answer 23

Lung, liver, bones and brain

Question 24

What are the non surgical management of lymphoedema?

Answer 24

• Massage techniques to drain lymph,
• Compression bandages,
• Weight loss,
• Good skin care

Question 25

Describe features of tamoxifen

Answer 25

It acts as an oestrogen antagonists and partial agonist; Meaning it can be protective again osteoporosis but increases the risk of endometrial cancer

Question 26

What are the adverse effects of Tamoxifen?

Answer 26

Menstrual disturbances, hot flushes, VTE and endometrial cancer
It is an oestreogen antagonist and partial agonist

Question 27

What are the side effects aromatase inhibitors?

Answer 27

Osteoporosis, hot flushes, arthralgia, myalgia and insomnia

Question 28

What is the nottingham prognostic index?

Answer 28

Tumoir size, lymph node score and grade.