Breast Cancer

Question 1

Outline the causes and pathology of breast lumps

Answer 1

• Non-invasive ductal carcinoma-in-situ (CIS) is premalignant and seen as microcalcification on mammography (unifocal or widespread)
  
  • Non-invasive lobular carcinoma-in-situ is rarer and tends to be multifocal
• Invasive ductal carcinoma (~70%)
  
  • Invasive lobular carcinoma (~10-15%)
• Carcinoma (cancer from epithelium)
  
  • Often painless
  • Nipple retraction
  • Skin dimpling, peau d’orange
• Fibroadenoma (tumour formed of mixed fibrous and glandular tissue)
  
  • 15-35yrs
  • 2-3cm diameter
  • Mobile
  • Discrete
  • Firm
  • Non-tender
• Fibrocystic disease
  
  • 20-45yrs
  • Changes with hormonal environment - cystic breast pain
  • Can be multiple
  • Usually upper outer quadrant

Rarer causes;

• Phyllodes tumour (rare)
  
  • Hight cellular type of fibroadenoma
  • Can recur
• Abscess
  
  • From suppuration of acute mastitis - S. aureus
  • Painful
  • Tender
  • Red
  • Fluctuant
• Fat necrosis
  
  • Trauma and rupture of fat cells - may become calcified
• Duct ectasia
  
  • 50+ years
  • Multiparous, smoker
  • Dilatation of periareolar ducts
  • Painful
  • Nipple retraction due to fibrosis
  • Creamy/ green nipple discharge

Question 2

What are the signs and symptoms of breast carcinoma?

Answer 2

• Lump
• Nipple discharge
• Nipple inversion
• Skin change (peau d’orange)

Question 3

What are the risk factors for breast cancer?

Answer 3

• Increasing age
• Early menarche
• Late menopause
• Late pregnancies
• Combined oral contraceptive
• Extended hormone replacement therapy
• Obesity
• Alcohol
• (Not smoking)

Question 4

Outline the investigations for breast lumps

Answer 4

Triple assessment;

1. Clinical examination
2. Imagine
   
   • Mammography (>35yrs)
   • USS (only US if <35yrs, Mamo & US if >35yrs)
   • MRI
3. Tissue diagnosis
   
   • Needle Core Biopsy
   • Fine needle aspiration cytology
   • Open biopsy

Question 5

Outline the staging of breast cancer

Answer 5

Stages;

1. Confined to breast, mobile
2. Growth confined to breast, mobile, lymph nodes in ipsilateral axilla
3. Tumour fixed to muscle (but not chest wall), ipsilateral lymph nodes matted and may be fixed, skin involvement larger than tumour
4. Complete fixation of tumour to chest wall, distant metastases

TNM;

• Tumour
  
  1. <2cm
  2. 2-5cm
  3. >5cm
  4. Fixity to chest wall or peau d’orange
• Nodes
  
  1. Mobile ipsilateral nodes
  2. Fixed nodes
• Metastases
  
  1. Distant metastases

Question 6

Outline the surgical treatment for breast cancer

Answer 6

Surgical options;

1. Mastectomy
   
   • Reasons; large tumour, small breast, multifocal disease, patient choice
2. Wide local excision (breast conserving surgery)
   
   • Requires adequate margin, requires adjuvant radiotherapy

• Axilla
  
  • Node status needed for all invasive breast cancers
  • Avoid unnecessary surgery (risk of lymphoedema, sensory loss, pain)
  • Sentinel node biopsy (patent blue dye or radiocolloid injected, gamma probe/ visual inspection identify sentinel node, which is then biopsied)
  • Or axillary clearance
• Reconstruction
  
  • Implants
  • Latissimus dorsi flap
  • Transverse rectus abdominis myocutaneous (TRAM) flap
  • Free grafts
  • Contralateral reduction

Question 7

Outline the non-surgical treatment

(adjuvant and neoadjuvant)

Answer 7

Radiotherapy (adjuvant)

• Breast after WLE
• Chest wall if aggressive disease, chest wall involvement or narrow margin
• Axilla if +ve on sampling and clearance not performed
• Supraclavicular fossa

Hormonal (reduce estrogen activity) (neo & adjuvant)

• Tamoxifen (pre & post menopause)
  
  • Selective estrogen receptor modulator
  • X: hot flushes, endometrial carcinoma, thrombo-embolic problems
• Aromatase inhibitors (post menopause)
  
  • Inhibits oestrogen production
    
    • eg Anastrozole, Exemestane & Letrozole
  • X: hot flushes, joint pains, osteoporosis/ fractures
• Pure anti oestrogen
  
  • Fulvestrant

Chemotherapy

• Adjuvant
  
  • Anthacycline + 5FU + cyclophosphamide +/- methotrexate
• Neoadjuvant
  
  • Aim to reduce tumour bulk
  • Make surgery possible/ less extensive

Monoclonal antibody

• Herceptin [Trastuzumab] (interferes with Human Epidermal GF Receptor 2 (HER2))
  
  • HER2 is inc. in high grade tumours, +ve lymph nodes, shortened surivalX: Expensive, cardiac effects

Question 8

Outline the prognostic factors of breast cancer

Answer 8

• Tumour size
• Grade
• Lymph node status
• Estrogen/ progesterone receptor (ER/PR) status
• Presence of vascular invasion

Nottingham Prognostic Index (NPI)

• = 0.2 x tumour size (cm) + histological grade + nodal status
• Predicts survival/ relapse risk & select appropriate adjuvant therapy

Question 9

Outline the screening process for breast cancer

& define what lead time bias and length bias is

Answer 9

• 2-view mammography every 3 yrs for women ages 50-70 in UK
• Saves 1400 lives per year
• Cost £3000 per life saved
• For every 2000 women screened over 10 years, 1 less woman dies from brest cancer

Tumours may be screened for and found before a palpable lump would be found. If the patient death date is not affected, it would appear the screening has increased survival time, however it is simply because they found the tumour early.