Breast Cancer

Question 1

Features of breast cancer

Answer 1

• Hard, irregular, painless, fixed lesions
• Tethered to the skin or the chest wall
• Nipple retraction
• Skin dimpling or oedema (peau d’orange)

Question 2

Two week wait referral criteria

Answer 2

• A discrete lump with fixation, that enlarges and/or with any concerns (i.e. FHx)
• Women over 30 with a persistent breast or auxiliary lump or focal lumpiness after their menstrual period
• Previous breast cancer with new suspicious symptoms
• Skin or nipple changes suggestive of breast cancer
• Unilateral bloody nipple discharge

Question 3

Risk factors for breast cancer

Answer 3

• Female (99% of breast cancers)
• Oestrogen exposure (years of menstruation, few/no children/no breast feeding)
• Obesity
• Smoking
• FHx (first degree relatives)
• BRCA1 gene (60-80% develop breast cancer, 40% develop ovarian cancer)
• BRCA2 gene (40% develop breast cancer, 15% develop ovarian cancer)

Question 5

Breast cancer metastasis (remember 2 Ls and 2 Bs)

Answer 5

• Lung
• Liver
• Bone
• Brain

Question 6

Ductal carcinoma in situ

Answer 6

• Pre-cancerous or cancerous epithelial cells of the breast ducts
• Localised to a single area
• Often picked up by mammogram screening
• Potential to spread locally over years
• Potential to become an invasive breast cancer (around 30%)
• Good prognosis if full excised with adjuvant treatment

Question 7

Lobular carcinoma in situ

Answer 7

• Also referred to as “lobular neoplasia”
• A pre-cancerous condition occurring typically in pre-menopausal women
• Asymptomatic and undetectable on mammogram
• Usually diagnosed incidentally on breast biopsy
• Represents an increased risk of invasive breast cancer in the future (around 30%)
• Usually managed with close monitoring (i.e. 6 monthly examination and yearly mammograms)

Question 8

Invasive breast cancer

Answer 8

• NST = No Specific Type
• Also known as Invasive Ductal Carcinomas
• Originate in cells from the breast ducts
• 80% of invasive breast cancers fall into this category
• Show up on mammograms

Question 9

Invasive lobular carcinoma

Answer 9

• Around 10% of invasive breast cancers
• Originate in cells from the breast lobules
• Not always visible on mammograms

Question 10

Inflammatory breast cancer

Answer 10

• 1-3% of breast cancers
• Presents similarly to a breast abscess or mastitis
• Swollen, warm, tender breast with pitting skin (peau d’orange)
• Does not respond to antibiotics
• Worse prognosis than other breast cancers

Question 11

Paget’s disease of the nipple

Answer 11

• Looks like eczema of the nipple/areolar
• Erythematous, scaly rash
• Indicates breast cancer involving the nipple
• May represent DCIS or invasive breast cancer
• Requires biopsy, staging and treatment as with any other invasive breast cancer

Question 12

NHS breast cancer screening

Answer 12

• Offered to women aged 50 to 70
• Every 3 years
• Involves a simple mammogram
• Annual mammograms in higher risk patients:
  
  • Aged 40-49 if moderate risk
  • Aged 40-59 if high risk
  • Aged 40-69 if known BRCA positive
  • Consider offering aged 30-59 if high risk

Question 13

Triple assessment

Answer 13

• Clinical Assessment
• Breast Imaging (ultrasound or mammography)
  
  • Younger women have denser breasts with more glandular breasts
  • Ultrasound:
    
    • Typically used to assess lumps in younger women (e.g. <30)
    • Useful in distinguishing solid lumps (e.g. fibroadenoma / cancer) from cystic lumps
  • Mammogram:
    
    • More effective in older women
    • Pick up calcifications missed by ultrasound
• Biopsy (fine needle aspiration or core biopsy)

Question 14

Sentinal lymph node biopsy

Answer 14

• Performed during breast surgery for cancer
• Where no abnormal lymph nodes identified prior to surgery
• Isotope contrast and a blue dye are injected into the tumour area
• This is carried through the lymphatics to the first lymph node (the sentinel node)
• This node shows up blue and on the isotope scanner
• This node is then sampled to stage the cancer

Question 15

Receptor status

Answer 15

• Oestrogen Receptor Status (ER)
  
  • Determines whether oestrogen promotes growth of breast cancer cells
• Human Epidermal Growth Receptor 2 Status (HER2)
  
  • Determines the presence of HER2

Question 16

Surgical management of breast cancer

Answer 16

• The objective is to remove the cancer tissue along with a 2mm margin of normal breast tissue.
  
  • Breast Conserving Surgery
    
    • Lumpectomy
    • Wide Local Excision
    • Quadrantectomy (removal of a quarter of the whole breast)
  • Mastectomy (removal of the whole breast)
• Axillary clearance
  
  • Offered to patients where early invasive breast cancer has been demonstrated in axillary nodes
  • Involves removing the majority or all lymph nodes from the axilla
  • Increases risk of chronic lymphedema in that arm

Question 17

Chemotherapy for breast cancer

Answer 17

• Oestrogen Receptor Positive Women (ER +ve)
  
  • Premenopausal women should be offered Tamoxifen
  • Post-menopausal women should be offered an aromatase inhibitors (anastrozole, exemestane or letrozole)
• HER2 Positive Women (HER2 +ve)
  
  • Should be offered trastuzumab (Herceptin), a monoclonal antibody (biological therapy) that disrupts the HER2 receptor
  • Given every 3 weeks for 1 year following initial treatment
  • Impacts heart function, therefore initial and close monitoring of heart function essential
  • Contraindicated in women with congestive heart failure and certain heart conditions
• Chemotherapy - can be neoadjuvant, adjuvant or for treatment or control of metastatic or recurrent breast cancer

Question 18

Reconstructive surgery options in breast cancer

Answer 18

• Implants
• Latissimus dorsi flap - portion of the latissimus dorsi plus skin and fat tissue tunnelled under skin to the breast area
  
  • “Pedicled” refers to keeping the original blood supply and moving the tissue under the skin to a new location
  • “Free flap” refers to cutting the tissue away completely and transplanting it to a new location
• Transverse rectus abdominis flap (TRAM flap) - portion of rectus abdominis along with blood supply and skin
  
  • Either as pedicled flap (tunneled under skin) or free flap (transplanted)
  • Risk of abdominal hernia due to weakened abdominal wall
• Deep Inferior Epigastric Perforator Flap (DIEP flap) - skin and subcutaneous fat from abdomen (no muscle)
  
  • Transplanted from abdomen to breast
  • Transplant the Deep Inferior Epigastric Artery with fat and skin
  • Tissue transplanted to reconstruct breast
  • Vessels attached to branches of the internal mammary artery and vein
  • Very complex procedure with microsurgery
  • Less risk of abdominal wall hernia as muscle are intact

Question 19

Follow-up of breast cancer patients

Answer 19

• No screening for women with total mastectomies
• Yearly mammograms for 5 years in patients with early breast cancer
• After 5 years, screening frequency is based on the risk category for the individual