Breast Cancer

Question 1

What is a bereavement?

Answer 1

A period after a loss

Question 2

What is mourning?

Answer 2

A period after a berievement

Question 3

What is grief?

Answer 3

The emotional reaction we go through during bereavement and mourning.

Question 4

What are the five stages of grief?

Answer 4

Shock and denial

Anger - at themselves and at healthcare system

Bargaining

Depression - can last a year, give hope and can make it better

Acceptance

Question 5

What three categories can breast lumps be divided into histologically?

Answer 5

Non-proliferative disorders - no increased risk

Proliferative disorders without atypia - mild to moderate risk

Atypical hyperplasias - substantial increase in risk

Question 6

When do breasts grow?

Answer 6

Puberty - Breast enlargement, sometimes initially unilateral, is the fist obvious sign of puberty in girls. Breast buds may initially be unilateral.

Puberty breast development = thelarche

Question 7

What is the most common benign breast disease?

Answer 7

Fibrocystic change.

This usually affects women aged 20-50 and appears tone hormonal in aetiology. Most often presents with pain and modularity.

Question 8

When is breast disease rarely pathological?

Answer 8

If changes are bilaterally symmetrical.
If symptoms are greatest about 1 week before menstruation and decrease when it starts.
Examination may reveal an area of thickening or nodularity, poorly differentiated from the surrounding tissue and often in the upper outer quadrant of the breast.

Question 9

What is cyclical mastalgia?

Answer 9

Tenderness and nodularity in the premenstrual phase that resolves as menstruation starts.

Breasts are active organs that change throughout the menstrual cycle. It affects 2/3 of menstruating women.

Question 10

What are most palpable benign breast lumps?

Answer 10

FIroadeomas
Cysts

A benign mass is usually three-dimensional, mobile and smooth. It has regular borders and is solid or cystic in consistency.

Question 11

In whom are cysts most common?

Answer 11

Most common between 35-50.
They are palpable as discrete lumps and may be recurrent.
They cannot be reliably be distinguished from solid tumours on examination.

Question 12

What are fibroadenomas and in who are they most common?

Answer 12

Benign tumours that are common in young women, with incidence peaking at 20-24

They are the most common type of breast lesions.

Fibroadenomas arise in breast lobules and are composed of fibrous and epithelial tissue. They present as firm, non-tender, highly mobile, palpable lumps. Hormones seem to be involved in aetiology and HRT increases incidence.

Question 13

What is mammary duct ectasia?

Answer 13

Unknown aetiology

Dilation of major ducts, filled with creamy secretion with periductal inflammation.

May be asymptomatic or -nipple discharge (bloody, serous, creamy white or yellow

• retracted nipple
• acute inflammation
• recurrent chronic inflammation with abscess formation

Treatment: Surgical excisions the major duct. Correction of nipple retraction.

Question 14

What infections could occur in breasts?

Answer 14

Mastitis
Generalised cellulitis of the breasts
Treated with antibiotics
Can be a medical emergency

Breast abscess
Present with point tenderness, erythema and fever
Generally related to lactation
Non-lactational abscess more frequent in smokers
Caused by staph or strep

Question 15

When do you refer?

Answer 15

Refer via two week wait to a breast clinic if:
Aged > 30 and unexplained breast lump with or without pain
Aged > 50 with any symptoms in one nipple only: Dischage, retraction, other changes of concern.

Consider a referral if:
skin changes that suggest breast cancer,
>30with unexplained axilla lump

Non-urgent referral if:
<30 and unexplained breast lump with or without pain.

Question 16

What physiological changes are seen in breast tissue?

Answer 16

Prepubertal breasts - few lobules

Menarche - increase in number of lobules and increased volume of interlobular stroma

Menstrual cycle - follicular phase lobules quiescent, after ovulation cell proliferation and storms oedema, with menstruation see decrease in lobules

Pregnancy - increase in size and number of lobules, decrease in stroma, secretory changes.

Cessation of lactation - atrophy of lobules but not to former level

Increasing age terminal duct lobular units decrease in number and size, interlobular stroma replaced by adipose tissue

Question 17

How can breast conditions present?

Answer 17

Pain
Palpable masses
Nipple discharge 
Skin lumps 
Lumpiness 
Mammographic abnormalities

Question 18

What breast conditions cause palpable mass?

Answer 18

Normal nodularity

Invasive carcinoma

Fibroadenomas

Cysts

Most worrying if hard, craggy and fixed

Question 19

What breast conditions can cause nipple discharge?

Answer 19

Milky - endocrine disorders. e.g. pituitary adenoma; side effects of medication e.g. OCP

Bloody or serous - benign lesions e.g. papilloma, duct ectasia; occasionally malignant lesions

Most concerning if spontaneous and unilateral

Question 20

What breast conditions cause mammography abnormalities?

Answer 20

Worrying findings include densities ad calcifications.

Densities - invasive carcinomas, fibroadenomas, cysts

Calcification - ductal carcinoma in situ. e.g benign changes

Question 21

What is fat necrosis?

Answer 21

Presents as a mass, skin changes or mammographic abnormality.
Often history of trauma or surgery
Can mimic carcinoma clinically ad mammographically.

Question 22

What physiological changes are seen in breast tissue?

Answer 22

Prepubertal breasts - few lobules

Menarche - increase number of lobules, increased volume of interlobular stroma

Menstrual cycle - follicular phase lobules, quiescent, after ovulation cell proliferation and stromal oedema, with menstruation see decrease in size of lobules.

Pregnancy - increase in size and number of lobules, decrease in stroma, secretory changes

Cessation of lactation - atrophy of lobules but not to former levels

Increasing age - terminal duct lobular units (TDLUs) decrease incumber and size, interlobular stroma replaced by adipose tissue

Question 23

How can breast conditions present?

Answer 23

Pain
Palpable mass
Nipple discharge
Skin changes
Lumpiness
Mommographic abnormalities

Question 24

Which breast conditions cause pain?

Answer 24

If cyclical and diffuse, often physiological

Non-cyclical and focal - ruptured cysts, injury, inflammation

Occasionally presenting complaint in breast cancer

Question 25

Which breast conditions cause a palpable mass?

Answer 25

Normal nodularity Invasive carcinoma Fibroadenomas Cysts Most worrying if hard, craggy and fixed

Question 26

Which breast conditions cause nipple discharge?

Answer 26

Milky - endocrine disorders e.g. pituitary adenomas; side effect of mediation e.g. OCP Blood or serous - benign lesions, e.g. papilloma, duct ectasia; occasionally malignant lesions Most concerning if spontaneous and unilateral

Question 27

Which breast conditions cause mammography abnormalities?

Answer 27

Worrying findings include: densities- invasive carcinomas, fibroadenomas, cysts Calcifications - ductal carcinoma in situ (DCIS), benign changes Found during mammography screening Women between 47-73 invited every 3 years Easier to detect lesions in breasts of older women

Question 28

Are breast conditions common?

Answer 28

Breast symptoms and signs are common Most will be benign Fibroadenomas are most common Breast cancer is most common non-skin malignancy in women Mammographic screening increases detection of small invasive tumours and in situ carcinomas.

Question 29

How do we classify pathological conditions of the breast?

Answer 29

``` Disorders of development Inflammatory conditions Benign epithelial lesions Stromal tumours Gynacomastia Breast carcinoma ```

Question 30

What inflammatory conditions can be seen?

Answer 30

Acute mastitis - occurs during lactation, Staph infection from cracks or fissures, erythematous painful breast, may produce abscesses, treated by expressing milk and antibiotics Fat necrosis - a mass, skin changes or mammography abnormalities, history of trauma or surgery, mimic carcinoma clinically and mammography

Question 31

What are phyllodes tumours?

Answer 31

Rare before 40 Present as masses or as mammography abnormalities Benign, borderline malignant types Can be very large and involve the entire breast Histology: Nodules of proliferating stroma covered by epithelium Stroma more cellular and typical than that in fibroadenomas. Need to be excised with wide margin or may recur Malignant type behave aggressively, recur locally and metastasize by blood stream.

Question 32

Why is gynacomastia?

Answer 32

Enlargement of male breast Unilateral or bilateral Often seen at puberty and in the elderly. Caused by relative decrease in androgen effect or increase in oestrogen effect Can mimic male breast cancer, especially if unilateral No increased risk of cancer

Question 33

What causes gynaecomastia?

Answer 33

Occurs in most neonates secondary to circulating lateral and placental oestrogen and progesterone. Affects more than 1/2 boys in puberty as oestrogen peaks before testosterone Klinefelter's syndrome Oestrogen excess - liver cirrhosis Gonadotrophin excess - testicular tumour (e.g. Leydig and Sertoli cells) Drug related - spironolactone, chlorpromazine, alcohol, steroids

Question 34

What are the risk factors for breast cancer?

Answer 34

``` Gender Uninterrupted menses Early menarche Late menopause Reproductive history - parity and age at first full term pregnancy Breast-feeding (protective) Obesity and high fat diet (protective up to 40) Exogenous oestrogen - HRT increases risk a bit Geography - higher in US and Europe Atypical changes on previous biopsy Previous breast cancer Radiation ```

Question 35

How do we classify breast carcinoma?

Answer 35

carcinomas can be in situ or invasive. | They can then be lobular or ductal.

Question 36

What is in situ carcinoma?

Answer 36

Neoplastic population of cells limited to ducts and lobules by basement membrane (BM), myoepithelial cells are preserved. Does not invade into vessels and therefore cannot metastasise or kill the patient.

Question 37

Why is DCIS a problem?

Answer 37

Non-obligate pre-cursor of invasive carcinoma Most often present as mammography calcifications (clusters or liner and branching) but can present as a mass. Can spread through ducts and lobules and be very extensive. Histologically often shows central necrosis with calcification

Question 38

What is Paget's disease?

Answer 38

Cells can extend to nipple skin without crossing BM Unilateral, red and crusting nipple. Eczematous or inflammatory conditions of the nipple should be regraded as suspicious and biopsy performed to exclude Paget's disease.

Question 39

How does invasive carcinoma differ from DCIS?

Answer 39

Neoplastic cells have invaded beyond the BM into stoma Can invade into vessels and can therefore metastasize to lymph nodes and other sites Usually presents as a mass or as mammography abnormalities. By the time a cancer is palpable, more than half of the patients will have axillary lymph node metastases P'eau d'orange - imvolvement of the lymphatic drainage of the skin

Question 40

How is invasive breast carcinoma classified?

Answer 40

Invasive ductal cell carcinoma Invasive lobular carcinoma Tubular carcinoma Mucinous carcinoma

Question 41

How does breast cancer spread?

Answer 41

Lymph nodes via lymphatics - usually in the ipsilateral axilla Distant metastases via blood vessels - bones, lungs, liver, brain Invasive lobular carcinoma can spread to odd sites - peritoneum, retroperitoneum, leptomeninges, gastrointestinal tract, ovaries, uterus

Question 42

What factors determine the prognosis in breast cancer?

Answer 42

In situ disease or invasive carcinoma TNM stage Tumour grade Histological subtype Molecular classification and gene expression profile

Question 43

How do we investigate and diagnose breast cancer?

Answer 43

Triple approach: Clinical - history, family history, examination Radiographic imaging - Mammogram and USS Pathology - Core biopsy, fine needle aspiration cytology

Question 44

What is mammographic screening?

Answer 44

Started in late 1980s Women ages 47-73yrs old 2 view mammogram every 3 years Aim to detect small, impalpable and pre-invasive cancers Look for asymmetric densities, parenchymaldeformites and calcofications Assess abnormality using further imaging, biopsy and FNAC

Question 45

What are the therapeutic approaches to breast cancer for local and regional control?

Answer 45

Breast surgery - mastectomy or breast conservation surgery Axillary surgery Post-operative radiotherapy to chest and axilla

Question 46

What is sentinel lymph node biopsy?

Answer 46

Reduces the risk of post-operative morbidity Intraoperative lymphatic mapping with dye and/or radioactivity of the draining or 'sentinel' lymph node(s) - one most likely to have metastasis If negative, axillary dissection can be avoided

Question 47

What are the therapeutic approaches to breast cancer for systemic control?

Answer 47

Chemotherapy -if benefits outweigh the risks Hormonal treatment - e.g. Tamoxifen (if ER positive) Herceptin - (if HER positive)

Question 48

How do we improve survival from breast cancer?

Answer 48

Early detection - awareness of disease, importance of family history, self-examination, mammography screening Neoadjuvent chemotherapy - early treatment of metastatic disease Use of newer therapies - e.g. Herceptin Gene expression profiles Prevention in familial cases - genetic screening, prophylactic mastectomies