Breast Cancer

Question 1

Risk Factors (9)

Answer 1

Age
Oestrogen exposure (early menarche, late menopause, few pregnancies, no breastfeeding, COCP, HRT)
Obesity
Smoking
Low activity level
alcohol
diet
drugs-aspirin reduces, exogenous oestrogen
radiation exposure

Question 2

Genes associated with breast cancer and mode of inheritance

Answer 2

BRCA1-Auto D, also assoc. w. ovarian ca.
BRCA2-Auto D
Li fraumenti
Ataxia telangiectasia 
Cowden (hamartomas)

Question 3

Most common site for malignancies in the breast

Answer 3

upper outer quadrant

Question 4

Features of carcinoma in situ (3)

Answer 4

Tumour hasn’t invaded basement membrane of epithelium
cancer present within DUCTAL and LOBULAR structures
cancer hasn’t spread to LNs therefore curable

Question 5

Features of DCIS(7)

Answer 5

Most common non-invasive ca.
occurs in pre/post-menopausal women
usually unilateral and unifocal
can be clinically detectable (mass)
can be radiologically detectable (micro-calcifications)
histology may show comedo necrosis (assoc. w. high grade)
assoc. w. Paget’s (Paget’s +painless bloody discharge=DCIS)

Question 6

Features of Lobular carcinoma in situ (4)

Answer 6

RARE
pre-meopausal
bilateral and multifocal
not clinically or mammographically detectable

Question 7

Pathological features of invasive breast ca. (2)

Answer 7

invades basement membrane

arise at junction of extra and intralobular ducts

Question 8

Presentation of invasive breast ca. (7)

Answer 8

Hard, irregular lump
Inflammation
nipple eczema (=paget's)
peau d'orange-impaired lymph drainage but hair follicles anchored (=LN involvement)
breast pain
axillary lymphadenopathy
distant effects
(sometimes screening can detect microcalcifications which may be first presentation)

Question 9

Mammographical features of invasive ca.

Answer 9

Ill-defined calcifications

Question 10

Types of invasive breast ca. (3)

Answer 10

75% no special type
25% special type
inflammatory breast ca.

Question 11

subtypes of “no-special type”

Answer 11

infiltrating ductal-more common post-menopausal
non-otherwise specified-worst prognosis
NST

Question 12

Special type (6)

Answer 12

Lobular-multifocal, Hx of disease in other breast
ductal-unilater, unifocal, best prognosis
mucinous
tubules
papillary
medullary

Question 13

Features of inflammatory breat ca. (5)

Answer 13

impaired lymphatic drainage
progressive oedema and erythema of breast
no palpable lump
normal WCC and CRP
elevated CA 15-3

Question 14

Features of Paget’s disease of nipple (2)

Answer 14

seen in 2% of invasive breast ca.
nipple changes-ITCHY, roughened, ulcerated, red
(bilateral/nipple-sparing eczematous changes are probably just eczema)

Question 15

what does Paget’s disease of the nipple indicate?

Answer 15

underlying invasive breast ca.; most commonly high-grade DCIS

Question 16

Microscopic appearance of Paget’s nipple disease

Answer 16

Large malignant glandular cells present within epidermis of the skin of the nipple.

Question 17

Mx of Paget’s nipple disease

Answer 17

Surgical resection of ca.
if ca. can’t be located then mastectomy is indicated.
(curative)

Question 18

4 Types of breast ca.

Answer 18

Hormone sensitive-oestrogen/progesterone sensitive
HER2 overexpression-more aggressive, poorer prognosis
Triple negative (O/P/HER2-ve)- poor prognosis
BRCA1/2-inherited ca.

Question 19

Definition of T1 stage

Size of T1a,b,c tumours

Answer 19

Confined to breast
a=<5mm
b=5-10mm
c=>1cm

Question 20

Definition of T2 stage

Answer 20

spread to ipsilateral axillary LN

2-5cm

Question 21

Definition of T3 stage

Answer 21

spread to internal mammary chain

5-10cm

Question 22

Definition of T4 stage

Definition of 4a/b/c/d

Answer 22

Any distant metastases despite size/T or N stage.
Present at different sights. Bone, liver, lungs, brain and including supraclavicular LN involvement.
a=chest wall spread
b=skin
c=skin and chest wall
d=inflammatory breast ca.

Question 23

Further Staging(2)

Answer 23

Examine axilla via US: if axilla normal, remove sentinel node, if abnormal give radioactive dye+axillary node clearance.

Sentinel node biopsy(DURING OPERATION): if clear leave axillary nodes, if cancer cells>axillary node clearance.

Question 24

Methods of spread (3)

Answer 24

direct-muscle and skin
lymphatic-axillary and other LNs
blood-distant organs e.g. liver, lungs, brain

Question 25

Surgical management of stage 1/2 ca. (2)

Answer 25

removal of tumour via wide local excision>+/- mastectomy>+/-breast reconstruction

Sentinel node sampling +/- axillary node clearance

Question 26

Types of mastectomy (4)

Answer 26

simple-remove it all
completion-if previous wide local excision
skin/nipple sparing
preventative

Question 27

Radiotherapy for stage 1/2 ca. (2)

Answer 27

Recommended for all patients after wide local excision

Not used after mastectomy unless >4 LN involved, >5cm tumour or positive resection margins remain.

Question 28

Chemotherapy for stage 1/2 ca. (2)

Answer 28

Adjuvant chemo includes CMF-cyclophosphamide, methotrexate and 5-FU

Neo-adjuvant chemo DOESN’T improve survival but may be used to aid breast-conserving surgery.

Question 29

Options in ER +ve stage 1/2 ca. (3)

Answer 29

Tamoxifen-oestrogen receptor antagonist (SEs include endometrial ca., VTE and menopausal Sx)

In pre-menopausal women can do ovarian ablation or GnRH analogues e.g. goserelin

In post menopausal women can give aromatase inhibitors e.g. letrozole, anastrozole

Question 30

Pharmacological options if HER2 +ve

Answer 30

Trastuzumab (herceptin)- can temporarily reduce ejection fraction

Question 31

Management of stage 3/4 ca. (2)

Answer 31

For bony lesions-radiotherapy+bisphosphonates

if HER2+ve-trastuzumab

Question 32

Management options if BRCA1 +ve

Answer 32

PARP inhibitors-iniparib, olaparib

Question 33

What can be measured to monitor treatment

Answer 33

CA 15-3

Question 34

Breast ca. screening (3)

Answer 34

47-73
3 yrly- reported by 2 people. annually if previous ca.
mammography-calcifications and localised densities