breast cancer

Question 1

peak age for incidence of breast cancer?

Answer 1

women aged 60-70

Question 2

where do most breast cancers arise from ?

Answer 2

duct tissue followed by lobular tissue

Question 3

4 common breast cancers?

Answer 3

invasive ductal carcinoma
invasive lobular carcinoma
ductal carinoma in situ
lobular carinoma in situ

Question 4

what is pages disease of the nipple?

Answer 4

an eczematoid change of the nipple associated with an underlying breast malignancy and it is present in 1-2% of patients with breast cancer.

Question 5

what percentage of patients with breast cancer have pages disease of the nipple?

Answer 5

1-2%

Question 6

when should a patient with one first-degree or second-degree relative diagnosed with breast cancer be referred?

Answer 6

age of diagnosis < 40 years
bilateral breast cancer
male breast cancer
ovarian cancer
Jewish ancestry
sarcoma in a relative younger than age 45 years
glioma or childhood adrenal cortical carcinomas
complicated patterns of multiple cancers at a young age
paternal history of breast cancer (two or more relatives on the father’s side of the family)

Question 7

most common type of cancer in the breast ?

Answer 7

carcinoma

Question 8

what are the two most common precursors to carcinoma ?

Answer 8

DCIS 70%

LCIS 10%

Question 9

how are breast cancers staged?

Answer 9

carrying out
bloods (FBC, U and E, LFT, bone)
axillary ultrasound
CXR / CTCAP / bone scan

Question 10

how are breast cancers staged?

Answer 10

TNM

Question 11

what are the two positive and one negative receptors for effect on prognosis ?

Answer 11

Oestrogen
Positive
Progesterone. 
Positive
HER 2
Negative.

Question 12

the best combination of receptor expression ?

Answer 12

ER positive
PR positive
HER 2 negative

Question 13

worst prognosis combination of receptor expression ?

Answer 13

all negative

Question 14

poor prognostic indicator for breast cancer?

Answer 14

less than 35
her 2 positive
oestrogen receptor negative
lymph node positive

Question 15

risk factors for breast cancer?

Answer 15

over 55
early menarche 
late menopause 
nullparity 
late age of first born (>35) 
no breast feeding of infants 
History of breast cancer
history of radiotherapy 
current or previous use of HRT 
long term use of COCP 
obesity 
smoking 
alcohol 
breast cancer 
ovarian cancer
BRCA 1/2 and p53 mutations

Question 16

DCIS usually develops in women

Answer 16

over 50

Question 17

what percentage diagnosis does it represent?

Answer 17

25%

Question 18

how does DCIS present?

Answer 18

breast lump
nipple discharge
pages disease of nipple (eczema of the nipple that doesn’t respond to steroids)

Question 19

can DCIS be asymptomatic ?

Answer 19

yes can be detected by screening

Question 20

what found on MXR is pathognomonic of DCIS?

Answer 20

microcalcifications

Question 21

diagnosis of DCIS?

Answer 21

diagnostic investigation: core biopsy

Question 22

management of DCIS?

Answer 22

WLE and radiotherapy

radical mastectomy

Question 23

LCIS - what age group of women ?

Answer 23

younger (usually in 40s)

Question 24

prognosis?

Answer 24

increased risk of invasive carcinoma but not to same event as DCIS

Question 25

management of LCIS?

Answer 25

excision biopsy at time of triple assessment

Question 26

invasive carcinoma - what kind of lump?

Answer 26

irregular, tethered and non fluctuating.

Question 27

nipple signs in invasive carcinoma ?

Answer 27

Unilateral blood stained nipple discharge, retraction, pagets.

Question 28

general management of invasive carcinoma ?

Answer 28

• Surgery +/- axillary clearance, radiotherapy, chemotherapy, endocrine or immunotherapy and reconstruction.

Question 29

two surgical options available ?

Answer 29

o reast conserving: WLE + radiotherapy. | Non breast conserving: radical mastectomy +/- radiotherapy

Question 30

what surgical option in generally preferred ?

Answer 30

WLE

Question 31

general rule - WLE can only be carried out if less than ?

Answer 31

2cm in size

Question 32

tumours can be shrunk with ? in order to achieve WLE

Answer 32

adjuvant chemo

Question 33

when is axillary clearance carried out ?

Answer 33

only when clinically indicated

Question 34

when can reconstruction be carried out?

Answer 34

at time of surgery or later date

Question 35

reconstruction options ?

Answer 35

o Implants. o Tissue flaps. o +/- nipple reconstruction and future fat remodeling to achieve best cosmetic outcome.

Question 36

implants - where are they fitted?

Answer 36

underneath the pec major muscle.

Question 37

implants associated with more/less problems than tissue flaps?

Answer 37

more

Question 38

common problems ?

Answer 38

o rippling, migration and capsular contraction of the implant.

Question 39

what are the three tissue flaps used?

Answer 39

``` latissimus dorsi o TRAM / DIEP (tissue from abdomen) o IGAP (skin and fat flap from buttocks) ```

Question 40

what is the artery used in lat dorsi reconstruction

Answer 40

thoracodsorsal

Question 41

why is the procedure known as a pedicle?

Answer 41

artery is not dissected out, it is kept intact

Question 42

tram / diep - both involve tissue from the ?

Answer 42

abdomen

Question 43

what is IGAP?

Answer 43

skin and fat flap from the buttocks

Question 44

what can be used as adjuvant to reduce the rate of local recurrence?

Answer 44

radiotherapy

Question 45

whats the typical regimen of radiotherapy?

Answer 45

o 45 – 50 Gy for 3 or 5 weeks, starting within a month from surgery.

Question 46

who give chemo to?

Answer 46

• Adjuvant in women with poor prognostic indicators: o <35. o ER negative, HER2 positive. o >4 lymph nodes involved.

Question 47

what sort of chemtherapy agents would be used

Answer 47

♣ Cyclophosphamide, methotrexate, 5FU.

Question 48

what is tamoxifen?

Answer 48

partial oestrogen agonist

Question 49

who is tamoxifen used in ?

Answer 49

pre and post menopausal women

Question 50

what is letrozole?

Answer 50

aromatase inhibitor

Question 51

who is letrozole used in ?

Answer 51

post menopausal women

Question 52

endocrine therapy includes tamoxifen and letrozole. what sort of tumours can these be used in ?

Answer 52

oestrogen receptor positive tumours

Question 53

when is immunotherapy used? (trustuzimab)

Answer 53

post operatively in HER2 positive tumours

Question 54

what can be used to prolong life in metastatic disease

Answer 54

radiotherapy, chemotherapy and hormonal therapy