Breast Cancer

Question 1

Types

Answer 1

Ductal carcinoma in situ
Invasive ductular carcinoma (80%)
Invasive lobular carcinoma
Paget's disease of the breast (inflitrating carcinoma of the nipple)
Inflammatory cancer

Question 2

Risk factors

Answer 2

Female
Increasing age
First degree family history
BRCA1/2 or TP53
Nulliparous/first child after 30
Not breastfeeding
Early menarche, late menopause
Chest radiation
HRT/COCP
Obesity, increased alcohol intake, physical inactivity
PMH atypical ductal hperplasia, lobular carcinoma in situ

Question 3

Presentation

Answer 3

With a lump or by screening
Painless
Skin changes
Discharge
Nipple changes

Question 4

Screening

Answer 4

Mammogram every 3 years from 47 - 73

May screen earlier if strong family history

Question 5

Assessment of breast lump

Answer 5

Triple assessment
History and examination
Imaging
Biopsy

Question 6

Referral

Answer 6

2ww: >30 with unexplained breast lump; >50 with unilateral nipple retraction or discharge; >30 with unexplained axilla lump
Routine: <30 with unexplained lump

Question 7

Imaging

Answer 7

<35: US
>35: US and mammogram (looking for masses and microcalcifications)
Mammographically occult/ILC/breast too dense/US and mammogram disagree: MRI

Question 8

Biopsy options

Answer 8

FNA: less traumatic, results immediately, cannot determine invasiveness
Core: more traumatic, differentiate between pre-invasive and invasive cancer, type of cancer, ER status

Question 9

Sentinel LN biopsy

Answer 9

To avoid full axillary clearance

To look for LN involvement

Question 10

Classification

Answer 10

TNM:
T1 <2cm; T2 2-5cm; T3 >5cm; T4 fixed to chest wall or skin
N0 no nodal involvement; N1 mobile nodes; N2 matted nodes
M0 no mets; M1 mets
Also BI-RADS - at clinical assessment, each of the stages is given 1-5 (5=most likely to be malignant)

Question 11

Surgical options

Answer 11

Mastectomy

Lumpectomy (wide local excision) plus radiotherapy

Question 12

Mastectomy indications

Answer 12

Multifocal tumour
Large lesion, small breast
Centrally located
Inflammatory cancer
DCIS >4cm
Previous lumpectomy and radiotherapy (on same breast - recurrence)
Patient choice
Must discuss reconstruction options

Question 13

Lumpectomy indications

Answer 13

Note: must have radiotherapy
Solitary lesions
Small tumour, large breast
Peripherally located
DCIS <4cm
Patient choice

Question 14

Adjuvent therapy options

Answer 14

Radiotherapy
Chemotherapy
Hormonal therapy
Herceptin

Question 15

Radiotherapy

Answer 15

Indications:
Following lumpectomy
Following mastectomy if tumour >5cm (ie T4)
If >4 LN involved

Question 16

Chemotherapy

Answer 16

Under 70yrs and:
High grade/LN positive/ER negative cancers/Her2 positive and tumour >1cm
First line in metastatic disease
FEC: 5 flourouracil, epirubicin, cyclophosphamide

Question 17

Hormonal therapy

Answer 17

Tamoxifen: blocks ER in breast cells, inhibiting their growth - pre and peri menopausal women (and some post)
Aromatase inhibitors: aromatases convert androgens to oestrogens. Give to post-menopausal women

Question 18

Herceptin

Answer 18

AKA trastuzumab (anti-HER 2-monoclonal Ab)
20-30% cancers over express HER-2 (measured using IHC/FISH)
Also give chemo - improves survival

Question 19

Pagets disease of the nipple

Answer 19

Eczematoid change of the nipple associated with an underlying breast malignancy (of various types - most commonly invasive carcinoma)
1-2% of patients with breast cancer
Pagets: starts in nipple, spreads to areolar; eczema: starts in areolar, spreads to nipple
Punch biopsy, mammography and US
Treatment depends on underlying lesion.

Question 20

Inflammatory cancer

Answer 20

Symptoms resemble inflammatin (hot, red breast)
Cancer cells block smallest lymph channels in breast
Imaging may be normal
Punch biopsy of skin diagnostically reliable
Chemo +/- radio before mastectomy