Breast Cancer

Question 1

Describe how breast cancers are categorised based on the area in which they arise from?

Answer 1

Most breast cancers are either:
-Ductal (arise from the epithelial lining of the duct)
OR
-Lobular (arising from the epithelium of the terminal ducts of the lobules)

1% are infiltrating carcinomas of the nipple epithelium. (Paget’s disease of the breast)

Question 2

Breast cancer stats:

1) Lifetime risk for women
2) Percent attached to genetic abnormality

Answer 2

1) 1/8

2) 5%

Question 3

Describe the common genetic abnormality associated with breast cancer?

Answer 3

BRCA1/2 genes

Question 4

Describe the important of ER/HER/PR receptors when working our breast cancer prognosis?

Answer 4

ER +ve has a better prognosis than ER -ve (oestrogen receptor)
PR +ve has a better prognosis than PR -ve (progesterone receptor)
Her-2 +ve has worse prognosis than HER-2 -ve

Question 5

What causes these breast cancer associated skin changes?

1) Peau d’orange
2) Skin tethering
3) Eczema around the nipples
4) Nipple retraction

Answer 5

1) Cancer spread to the lymph system and prevents lymph drainage
2) Local spread of cancer into overlying skin
3) Padgets disease. Intra-ductal carcinoma of the breast spreads to the nipple
4) Local spread of cancer into overlying skin

Question 6

Name the risk factors for carcinoma of the breast

Answer 6

• Genetics: FH, BRCA
• Smoking
• Age

Increased oestrogen exposure:

• Early menarche/ late menopause
• Nulliparity
• Not breast feeding
• HRT
• Obesity

Question 7

Describe the triple assesment

Answer 7

• Clinical examination
• Imaging (USS +/- mammogram)*
• Biopsy and cytology

Biopsy is most reliable e.g. if USS -ve but biopsy +ve then rely in biopsy result.
If the USS is +ve and biopsy -ve then the patient requires more tests

*Those under 40 get just an USS, over 40 get USS and mammogram

Question 8

Describe the national screening programme for mammography.

Answer 8

Women aged 47-73 are offered mammography every 3 years

Question 9

In which population group is mammography not appropriate?

Answer 9

Don’t do in pregnancy.
Dont usually do in women under 35 as there breast are much more dense with fibroglandular tissue, therefor the mammogram just appears white (also radiation risk). Older adults have more fat (black)

NB// if suspect malignant cancer may need to do a mammography before surgery to help guide treatment, even if <40y.

Question 10

What does a cancerous breast lump feel like?

What does a cancerous breast lump look like on mammography?

Answer 10

Lump
o Hardness, Irregularity, Focal nodularity, Asymmetry with the other breast, Fixation to skin or muscle

Other visible changes
o Change in breast size or shape
o Skin: dimpling, thickening, swelling, redness, tethering, peau d’orange
o Nipple abnormalities: inversion, ulceration, retraction, or spontaneous bloody discharge, padgets disease of the nipple
o Axillary lump

Spiculated mass lesion with associated microcalcfication

Question 11

Describe symptoms of possible metastatic spread of breast disease and common metastatic sites?

If breast mets are suspected what tests are done to investigate

Answer 11

Common:

• LUNG: Breathing difficulties, cough
• BONE: Bone pain, hypercalcaemia symptoms
• LIVER: Jaundice, abdominal distention

Other:
- Neurological signs or altered cognitive function, headache

Tests: Liver USS, CXR, and bone scan

Question 12

Describe the different types of biopsies used in breast cancer

Answer 12

FNAC

Core biopsies

Question 13

Describe the clinical staging of breast cancer

Answer 13

T1 <2cm, T2 2-5cm, T3 >5cm, T4 fixed to chest wall or peau d’orange
N0 no nodes, N1 mobile ipsilateral nodes, N2 fixed nodes
M0 no distant mets, M1 distant mets

Question 14

Describe the options and indications for the different types of breast cancer surgery.

Answer 14

Wide local excision: If tumour not central. Need adjuvant radiotherapy

Mastectomy: Preferred for large tumours/ small breasts/ if tumour is a central location. +/- Radiotherapy

Senital node biopsy: +/- Radiotherapy

Axillary node clearance: done if SNB is positive. Don’t do radiotherapy as well!! (high lymphoedema risk)

Breast reconstruction can be done at the same time or at a later stage

Question 15

What is a Sentinal node biopsy and when is it indicated?

Answer 15

Dye is injected into the tumour to identify the first 1/2 nodes that drain the tumour. Remove these nodes and analyse them histologically.
If histology negative then we can presume no nodal involvement
If histology positive then full axillary clearance is required

Question 16

When is chemotherapy indicated in breast cancer treatment?

What adjuvants can you use if the tumour is ER or HER positive

Answer 16

Chemo: if there is nodal disease, high grade tumours

ER +ve: Tamoxifem is given for 5 years (oestrogen antagonist breast selective)
Aromatase inhibitors are given instead if post menopausal (stop peripheral oestrogen conversion)

HER+ve: Herceptin + chemotherapy

Question 17

What factors affect breast cancer prognosis?

What scoring system is used to assess prognosis?

Answer 17

Tumour size, Tumour grade, nodal status, ER/HER/PR status, vascular invasion, metasteses

Nottingham Prognostic Index
(Tumour size in cm x 0.2 ) + histological grade (1-3) + nodal status (1-3)

No nodes = 1, 1-3 nodes = 2, >3 nodes =3

Question 18

Describe the different types of discharge.

Answer 18

Clear - normal
Milky - pregnancy, hyperprolactinaemia
Green - duct etasia around menopause (psyiological) or fibroadenotic cyst
Worrying = blood staines, single duct.
Purulent discharge = periductal mastitis, more common in smokers, nipple piercings, pregnant women,