Breast Cancer

Question 1

Most common type of breast cancer

Answer 1

Invasive ductal carcinoma
(aka. No Special Type)

Question 2

4 indications for mastectomy

Answer 2

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

Question 3

4 indications for wide local excision

Answer 3

Solitary lesion
Peripheral lesion
Small lesion in large breast
DCIS <4cm

Question 4

Genetic risk factors for breast cancer

Answer 4

BRCA1: 70% lifetime risk
BRCA2: 55% lifetime risk
p53 gene
1st degree premenopausal relative with breast cancer (e.g. mother)

Question 5

4 risk factors related to oestrogen exposure for breast cancer

Answer 5

Early menarche
Late menopause
Nulliparity, 1st pregnancy >30y
COCP/ combined HRT

Question 6

3 Non modifiable risk factors for breast cancer

Answer 6

Age (strongest)
Previous breast cancer
Dense breast tissue

Question 7

2 modifiable risk factors for breast cancer

Answer 7

Obesity
Alcohol

Question 8

Breast screening programme age and frequency

Answer 8

50-70y
Offered mammogram every 3y

> 70y may still have mammogram, but make own appointments

Question 9

Patients with one first degree relative with breast cancer should be referred for screening if…

Answer 9

Age of dx <40y
Bilateral breast cancer
Male breast cancer
Ovarian cancer

Question 10

4 common types of breast cancer

Answer 10

Invasive ductal carcinoma (most common)
Invasive lobular carcinoma (aka Special type)
Ductal carcinoma in-situ
Lobular carcinoma in-situ

Question 11

What is inflammatory breast cancer?

Answer 11

Where cancerous cells block the lymph drainage resulting in an inflamed appearance of the breast.
Accounts for~1 in 10,000 cases of breast cancer.

Question 12

What is Paget’s disease of the nipple?

Answer 12

Eczematoid change of the nipple a/w an underlying breast malignancy
Present in 1-2% of patients with breast cancer. In half, is a/w an underlying mass lesion + most have an invasive carcinoma.
30% of patients without a mass lesion will still be found to have an underlying carcinoma. The remainder will have carcinoma in situ.

Question 13

Which patients should be referred on the 2ww pathway for breast cancer?

Answer 13

> ,30 + unexplained breast lump +/- pain
OR
,50 with discharge, retraction of other changes in 1 nipple only

Question 14

In which patients should a 2ww referral for breast cancer be considered?

Answer 14

With skin changes that suggest breast cancer
>,30 with unexplained lump in axilla

Question 15

In which patients should a non-urgent referral be made?

Answer 15

<30 with an unexplained breast lump +/- pain

Question 16

Prior to surgery describe management of women with no palpable axillary lymphadenopathy at presentation?

Answer 16

Perform pre-op axillary US before their primary surgery

If -ve: sentinel node biopsy to assess nodal burden

Question 17

Describe management of women who present with clinically palpable lymphadenopathy

Answer 17

Axillary node clearance is indicated at primary surgery

Question 18

Give 2 complications of axillary node clearance

Answer 18

Arm lymphedema
Functional arm impairment

Question 19

Describe use of radiotherapy in women who have had a wide local excision

Answer 19

Whole breast radiotherapy recommended
Reduces risk of recurrence by 2/3

Question 20

Describe use of radiotherapy in women who have had a mastectomy

Answer 20

Ipsilateral radiotherapy offered for T3-4 tumours + for those with >,4 positive axillary nodes

Question 21

Hormonal therapy for oestrogen receptor positive tumours

Answer 21

Pre/peri-menopausal: Tamoxifen
Post-menopausal: Anastrozole

Question 22

MOA of Tamoxifen

Answer 22

Selective Oestrogen Receptor Modulator (SERM)
Acts as oestrogen receptor antagonist + partial agonist

Question 23

4 side effects of Tamoxifen

Answer 23

Increased risk endometrial cancer
Increased risk VTE
Hot flushes
Menstrual disturbance: PV bleeding, amenorrhoea

Question 24

MOA of Anastrozole and another drug in its class

Answer 24

Aromatase inhibitor
Reduces peripheral oestrogen synthesis (aromatisation accounts for majority of oestrogen production post-menopause)
Letrozole

Question 25

4 side effects of aromatase inhibitors

Answer 25

Osteoporosis (DEXA on starting)
Hot flushes
Arthralgia, myalgia
Insomnia

Question 26

Biological therapy for HER2 positive breast cancer

Answer 26

Trastuzumab (Herceptin)

Question 27

In which patients is Trastuzumab contraindicated?

Answer 27

Hx of heart disorders

Question 28

Describe use of chemotherapy in breast cancer

Answer 28

Neoadjuvant: to downstage primary lesion
OR
After surgery depending on stage of tumour e.g. if axillary node disease, use FEC-D

Question 29

How does Paget’s disease differ from eczema of the nipple?

Answer 29

Pagets involves nipple primarily + only latterly spreads to the areolar
(opposite to eczema)

Question 30

Diagnosis of Paget’s disease of the nipple

Answer 30

US, mammography + punch biopsy

Question 31

Describe the axilla if there are axillary lymph nodes involving only isolated tumour cells or micrometastases

Answer 31

Axilla is considered clear

Question 32

BRCA gene mutation inheritence

Answer 32

Autosomal dominant

1 parent with the mutation= 50% chance of passing on to a child.