Breast cancer

Question 1

What are the risk factors for breast carcinoma?

Answer 1

• Age
• HRT
• Obesity
• BRCA genes
• Family history
• Nulliparity, 1st pregnancy >30 yrs old, not breastfeeding
• Early menarche, late menopause

Question 2

Describe the pathology of Non-invasive ductal carcinoma in situ (DCIS)?

Answer 2

• Premalignant
• Seen as microcalcification on mammography
  
  • unifocal or widespread

Question 3

Describe the pathology of Non-invasive lobular CIS?

Answer 3

• Rare
• Tends to be multifocal

Question 4

Describe the pathology of Invasive ductal carcinoma?

Answer 4

• Most common breast carcinoma
• Further classified:
  
  • tubular, cribiform, papillary, mucinous, medullary

Question 5

Describe the genetics of breast carcinoma?

Answer 5

• 60-70% oestrogen receptor positive
  
  • => better prognosis
• 30% over-express HER2
  
  • => aggressive disease and poor prognosis
• Gene abnormalities: BRCA1/2, Li-Fraumeni, Cowden

Question 6

Describe Invasive lobular carcinoma?

Answer 6

• More common in older women
• Diffuse (stromal) pattern of spread => makes detection more difficult
• Tumours are often large at time of diagnosis

Question 7

Describe Fibrocystic change?

Answer 7

• Lumpy bump breast tissue
• May be a discrete focal area of fibrosis that is more dominant

Question 8

Differentials for breast cancer?

Answer 8

• Benign tumours
• Breast cysts
• Breast abscess

Question 9

Describe the prognosis in breast cancer?

Answer 9

• Nodal status is most important prognositc factor
• Size, grade, receptor status also important
• Nottingham prognostic index can be used

Question 10

Describe the Nottingham prognostic index (NPI)?

Answer 10

• (Size x 0.2) + Nodal status + Grade
  
  • Grade is based on Bloom-Richardson classification

Question 11

Describe the breast screening programme in the UK?

Answer 11

• Women 50-70 years old
• Mammogram every 3 years
• Abnormalities referred to breast clinic for clinical assessment

Question 12

Describe the staging of breast cancer?

Answer 12

• Stage 1: Confined to breast, mobile
• Stage 2: Growth confined to breast, mobile, lymph nodes in ipsilateral axilla
• Stage 3: Tumour fixed to muscle, fixed lymph nodes, skin involvement
• Stage 4: Complete fixation to chest wall, distant mets
• Also TNM staging:
  
  • T1(<2cm), T2(2-5cm), T3(>5cm) T4(fixity to chest wall or peau d’orange)
  • N1 (mobile ipsilateral nodes), N2 (fixed nodes)
  • M1 (distant mets)

Question 13

Describe the treatment for local breast cancer?

Answer 13

• Surgery
  
  • Wide local excision (WLE) or mastectomy +/- reconstruction
  • Axillary node sampling/surgical clearance or sentinal node biopsy
• Radiotherapy
  
  • All patients with invasive cancer after WLE
• Chemotherapy
  
  • Improves survival and reduces recurrence
  • Epirubicin + CMF
• Endocrine agents
  
  • Reduces oestrogen activity in ER and PR positive disease

Question 14

Side effects of radiotherapy in breast cancer?

Answer 14

• Pneumonitis
• Pericarditis
• Rib fractures

Question 15

What are the chemotherapy drugs often used in breast cancer?

Answer 15

• Epirubicin + CMF
• CMF:
  
  • Cyclophosphamide
  • Methotrexate
  • 5-FU

Question 16

Describe the use of endocrine agents as a treatment for breast cancer?

Answer 16

• Reduce oestrogen activity in ostrogen and progesterone receptor positive disease
• Tamoxifen: ostrogen receptor blocker
  
  • (risk of uterine cancer)
• Aromatase inhibitors: target peripheral oestrogen synthesis
  
  • (only used if post-menopausal)
• If oestrogen receptor positive and pre-menopausal:
  
  • Ovarian abaltion via surgery or radiotherapy

Question 17

Name some surgical options for breast reconstruction?

Answer 17

• Tissue expandors
• Implants
• Nipple tattoos
• Latissimus dorsi flap
• TRAM flap
  
  • (transverse rectus abdominis myocutaneous)

Question 18

Describe the treatment for distant breast cancer disease?

Answer 18

• Painful bony lesions:
  
  • Radiotherapy
  • Bisphosphonates (reduce pain and fracture risk)
• ER+ve tumours:
  
  • Tamoxifen
• HER2+ve tumours:
  
  • Trastuzuman + chemotherapy

Question 19

Flow chart for the management of a breast lump

Answer 19

Question 20

Describe the process of a sentinal node biopsy?

Answer 20

• Decreases needless axillary clearances in lymph node negative patients
  
  • Dye is injected into periareolar area
  • Sentinal node is biopsied
    
    • Histology +/- immunohistochemistry
  • Axillary clearance if node positive

Question 21

Describe Paget’s disease of the nipple?

Answer 21

• Roughening, reddening and slight ulceration of the nipple
• The majority of people will have an underlying neoplasm
• Microscopically:
  
  • Involvement of the epidermis by malignant carcinoma cells

Question 22

How can Paget’s disease be differentiated from dermatitis?

Answer 22

• Paget’s
  
  • Affects nipple then areola secondary
• Dermatitis
  
  • Only involves areola

Question 23

Describe the difference between a screening and diagnostic mammogram?

Answer 23

• Screening:
  
  • Asymptomatic women to look for occult breast cancer
  • 2 views of each breast are obtained
• Diagnostic:
  
  • Pays attention to area of clinical concern
  • Additional views at multiple angles or compressions

Question 24

Techniques available for diagnosis of a palpable, solid breast mass?

Answer 24

• Fine needle aspiration (FNA)
• Core biopsy
• Excisional biopsy

Question 25

Describe FNA?

Answer 25

* Recovers cells from the mass * Requires cystopathologist for interpretation * Cannot discriminate between invasive and in-situ

Question 26

Describe core biopsy?

Answer 26

* Removes 14- to 18-gauge pieces of tissue * Risk of missing the lesion and obtaining a false-negative

Question 27

Describe an excisional biopsy?

Answer 27

* Completely removes the target lesion * Provides the mos ttissue for evaluation * Can be diagnostic and therapeutic

Question 28

Where can invasive breast cancer spread to?

Answer 28

Bones, brain, liver, lung

Question 29

Chemotherapy regimes for breast cancer?

Answer 29

* Node positive disease * FEC-D chemotherapy * Node negative disease * FEC chemotherapy

Question 30

Differences between the use of mastectomy of wide load excision

Answer 30

Question 31

A 74 year old oman presents with a breast lump. On examination, it has a soft consistency. The lump is removed and sliced apart. Macroscopically there is a grey, gelatinous surface. What is the most likely cause of the lesion?

Answer 31

Mucinous carcinoma

Question 32

A 74 year old woman presents with a erythematous rash originating in the nipple. It is spreading to the surrounding areolar area and the associated normal tissue. What is the most likely cause of the lesion?

Answer 32

* Paget's disease of the nipple * usually diagnosed by punch biopsy

Question 33

A 53 year old woman presents with a bloody nipple discharge. On mammogrpahy there is calcification behind the nipple areolar complex. A core biopsy shows background benign change but cells that show comedo necrossis which have not breached the BM What is the most likely cause of the lesion?

Answer 33

* Ductal carcinoma in situ (DCIS) * Comedo necrosis is a feature of high . nuclear grade DCIS * High risk of being associated with foci of invasion

Question 34

A 57 year old woman with a recent diagnosis of breast cancer is found to be positive for a BRCA1 gene mutation on genetic screening. She has a strong family history of breast . cancer, with both her mother and aunt receiving treatment for the condition at a young age. She is concerned that she has passed the gene onto her son and daughter and is also worried about her sister having the gene. What is the likelihood of her son, daughter and sister having the gene?

Answer 34

Both children and her sister have a 50% chance of inheriting the gene