Breast Cancer

Question 1

What is the grading system for breast cancer + how are scores given?

Answer 1

Nottingham grading system - scores out of 3 for tubule formation, nuclear pleomorphism, mitotic activity

Question 2

What are the stages of breast cancer?

Answer 2

Stage 1 = confined to breast, mobile, small, only in breast tissue or close lymph Stage 2 = confined to breast, mobile, near lymph nodes or ipsilateral axilla Stage 3 = tumour fixed to muscle, ipsilateral lymph, skin involvement Stage 4 = complete fixation of tumour to chest wall, distant mets

Question 3

Describe stage 1-4 for breast cancer (in terms of TNM)

Answer 3

Stage 1 = T1, N0, M0

Stage 2 = T2/3, N0, M0 OR T1, N1, M0

Stage 3 = T(any), N(any), M0

Stage 4 = T(any), N(any), M1

Question 4

What is DCIS?

Answer 4

Non invasive ductal carcinoma in situ Premalignant, seen as microcalcification on mammography

Question 5

What are the types of breast cancer, how common are they + what % are ER+ + HER2+?

Answer 5

Invasive ductal carcinoma (70%)

Lobular (characterised by high incidence of multicentric tumours) 10%

Medullary cancer (5%) - tend to affect younger pts

Mucoid (2%) - tend to affect elderly

60-70% are oestrogen receptor positive

30% express HER2 = aggressive

Question 6

Epidemiology

Answer 6

Most common cancer 1 in 8 females 1 in 870 men

Question 7

RF

Answer 7

>50 y/o Fam hx Uninterrupted oestrogen = nulliparity, early menarche, late menopause, COCP, HRT Obesity Not breastfeeding Radiation exposure Smoking + alcohol BRCA1+2, P53

Question 8

BRCA1 + 2 gene lifetime risk of breast + ovarian cancer

Answer 8

70% are ER negative so poorer prognosis

BRCA1 = 60-80% risk of breast, 30-45% risk of ovarian

BRCA2 = 50-70% risk of breast, 10-20% risk of ovarian

Question 9

S+S

Answer 9

Lump, change in size + shape of breast, dimpling, inverted nipple, bloody discharge, eczema, peu d’orange, dilated veins

Question 10

Common mets

Answer 10

Liver, lungs, lymph nodes, brain, bones

Question 11

What is a triple assessment?

Answer 11

Breast examination Bilateral mammogram US + biopsy - histology/ cytology

Question 12

How do you measure treatment response?

Answer 12

Tumour markers Ca15.3, CEA

Question 13

What staging investigations are used?

Answer 13

CXR, bone scan, liver USS, CT/MRI/ PET-CT, LFTs, Ca2+ IHC looking for ER+ and HER2

Question 14

What is a sentinel node biopsy?

Answer 14

Locates sentinel node: node cancer is draining to first Inject blue dye into tumour day before surgery - look for blue node Removed + analysed - if positive then pts will have axillary clearance

Question 15

Prognosis (5 year survival) for each stage of breast cancer

Answer 15

1 = 95%

2 = 80%

3 = 60%

4 = 25%

Question 16

Treatment of early stage breast cancer

Answer 16

Surgery - wide local excision/ mastectomy

Radiotherapy - all invasive cancer after WLE

Adjuvant chemo

ER/ PR+ disease (tamoxifen for pre-menopause or aromatase inhibitors for post-menopausal)

If pre-menopausal + ER+ = ovarian ablation/ GnRH analogues

Monoclonal Ab against HER2 +

Question 17

Treatment of stage 3-4 breast cancer

Answer 17

Radiotherapy for painful bone lesions

Tamoxifen for ER+ Trastuzumab for HER2+

Question 18

Complications of radiotherapy

Answer 18

Radiotherapy side effects = pneumonitis, pericarditis and rib fractures, secondary cancers

Question 19

Effects of hormone therapy

Answer 19

Increased risk of osteoporosis, vaginal dryness and irritation from lower estrogen levels.

Some increase risk of blood clots and endometrial cancer

Question 20

Complications of a mastectomy

Answer 20

Temp swelling of breast, breast tenderness, scar tissue, infection, lymphodema, phantom breast pain.

Question 21

When is MRI used in diagnosis?

Answer 21

If there is a discrepancy between examination, mammogram + US findings If breast density precludes mammogram If histology is lobular

Question 22

When is neoadjuvant chemo used?

Answer 22

Initial surgery not possible due to size of tumour

Allows for breast conservation

HER2 +ve or triple negative (ER, PR + HER2 -ve)

Question 23

What tools are used to help decide on adjuvant chemo?

Answer 23

Adjuvant online Oncotype DX (genomic test to predict benefit)

Question 24

Trastuzumab use, length of treatment + SE (+ how to monitor SE)

Answer 24

Effective when cancer overexpresses HER2

Given for 12 months as adjuvant

Can affect cardiac function - monitor with MUGA scan

Question 25

Endocrine therapy uses

Answer 25

Tamoxifen if ER/PR +ve for 5 years for premenopausal

Aromatase inhibitors for postmenopausal women

Question 26

RT use - how long for?

Answer 26

All pts following conservative surgery are given RT

Given daily for 3 weeks

For young pts, given an extra week to tumour bed (a boost)

Question 27

How is ovarian ablation used?

Answer 27

In premenopausal women, oestrogen production can be stopped by ovarian ablation (either surgially, RT or with LHRH agonists)

Question 28

Best + worst cancer prognosis

Answer 28

Best = ER+ PR- HER2-

Worst = triple negagive or ER- PR- HER2+