Breast Cancer

Question 1

Triple assessment

Answer 1

1. History/Examination
2. Imaging: Mammography/ Ultrasound
3. Biopsy: Core Biopsy/ Excision Biopsy

Question 2

History

Answer 2

1. Age of patient, age at menarche, age at meopause
2. symptoms - lump, pain, nipple discharge, duration of symptoms, change in symptoms over time, previous history of breast lumps
3. Family history of breast cancer/ ovarian cancer
4. parity, breast fed children
5. present or past use of HRT, oral contraceptives

Question 3

Examination

Answer 3

Inspection

• proper exposure of both breasts + axillae
• inspection with patient lying down, sitting up, with arms up and with arms pressed onto hips
• Inspect skin contour, nipples, check for scars, pbvious deforimty, skin oedema (pea d’orange), skin puckering

Palpation

1. ask about any painful areas first
2. palpate with flat of hand entire breast. Examine nipple for discharge by squeezing gently
3. Examine axillae. Take weight of paitents arm and examine with flat of hand
4. examine supra-clavicular fossa
5. remember to examine both sides

Question 4

Skin changes

Answer 4

• Benigns skin lesions are common e.g sebacious cysts
• skin retraction/ puckering - sign of breast cancer
• red/hot skin is a sign of infection/abscess (may also be a presenation of an inflammatory cancer
• thickenened oedematous skin (peau d’oragne) may be caused by an inflamamtory breast cancer

Question 5

Nipple/ Areolar changes

Answer 5

1. Nipple inversion is common. More significant if a new symptoms
2. eczema of nipple is often simple eczema but consider pagest disease of the nipple (caused by breast cancer)
3. nipple discharge may be from a single duct or multiple ducts and may be unilater or bilater
4. colour - Green/clear/yelllow, brown (usually benign), blood (mosttly benign but possibility of underlying cancer), white/milk (often physiologically but always exclude pituitary tumour)
5. Extra nipples are not uncommon and may be mistaken for a skin mole

Question 6

Breast lump

Answer 6

1. Describe site in breast (upper outer quadrant)
2. discrete lump or generalised lumpiness
3. size in centimetres
4. hard/soft, smooth/irregular
5. mobile/fixed lump

Question 7

Mammography

Answer 7

Mammography is used for patients with a new breast symptom over the age of 35. It is performed on both breasts

Note not performed in under 35 as density of breast is different, unclear pictures may be produced

Question 8

Ultrasound

Answer 8

Used to look at specfic areas of clinical abnormality eg discrete breast lump. It is useful for distinguishing between solid and cystic lumps

Offer to women under 35

Question 9

FNA

Answer 9

Cytologcal diagnosis but often difficult to get an adequate specimen but result can be given quickly. Also cysts can be aspirated to confirm the diagnosis

Question 10

Core Biopsy

Answer 10

Histological diagnosis, more accurate but take more time to get

Question 11

Excision biopsy

Answer 11

Needs surgery leaving a scar and any risks of anaesthetic. May be needed if other technqies cannot get a diagnosis and clinical supsicion persists

Question 12

Causes of breast pain

Answer 12

• Muskuloskeletal
• Normal pre-menstrual cyclical pain
• FIbrocystic changes
• breast trauma
• infection

Question 13

Causes of Nipple discharge

Answer 13

• [regnancy/previous breast feeding- physiological
• duct ectasia
• intra-duct papilloma
• breast cancer
• Galactorrhoea

Question 14

Breast cancer epidemiology

Answer 14

1 in 11 women in UK

Question 15

Breast cancer presentation

Answer 15

1. Mostly present with a discrete lump in the breast
2. bloody nipple discharge
3. skin eryhtema, puckering
4. nipple eczema (pagets)
5. symptoms of metastatic disease e.g bone pain

Patients often detected when asymptomatic by the breast screenign programme

Question 16

Staging of breast cancer

Answer 16

1. is diseasle localised to breast or metastases present
2. CXR
3. CT chest/abdo/pelvis
4. MRI scan
5. Bone scan

Question 17

Breast surgery options

Answer 17

• Masectomy (+/- breast reconstruction)
• Wide local excision (breast conservation)

Depends on tumour size, of tumour is multifocal, patient preference

Question 18

Axilla Surgery options

Answer 18

• sentinel node bioopsy/ axillary node sample
• Axillary clearance - treatment of aximlla with involved nodes. Risk of lymphooedma

Decision depends on whether the axilla is thought to be involved with tumour at diagnosis. If it is proven that the nodes are positive then an axillary clearance is necessary

Question 19

Radiotherapy

Answer 19

• to remaining breast tissue in those having a wide local ecision
• to chest wall in those having a mastectomy with higher risk of local recurrence i.e large or multifocal tumours or those close to the chest wall

Question 20

Chemotherapy

Answer 20

For those at risk of developing metastastic disease ie large tumours, high grade tumours, involved axillary nodes or those with metastatic disease at diagnosis

Question 21

Hormonal

Answer 21

Oestrogen receptor positive patients (about 80%)

• tamoxifen
• aromatase inhibitors (post-menopausal only) - arimidex, letrozole
• ovarian suppression
  
  • Medical - zoladex
  • surgical - oopherectomy

Question 22

Monoclonal antibodies

Answer 22

Herceptic (tratuzumab) - blocks Her 2 receptors (growth factor type) which are associated with higher risk disease

Question 23

Gynecomastia causes

Answer 23

• Physiological - pubertal
• chronic liver disease
• testicular failure - usually old age
• drugs e,g bendofluazide, digoxin, spironolactone, cannabis, anti-androgens
• andrenal tumour

Question 24

Treatment of gynaecomastia

Answer 24

• physiological type often resolve spontaenously
• surgical

Question 25

Male breast cancer

Answer 25

• Uncommon <1% of all BC
• older men
• later stage than in females
• treatment very similar to female BC
• Linked ot FH in female relatives