Breast Cancer

Question 1

What percentage of men have breast cancer?

Answer 1

Rare in men with only 1% of breast cancer occurring in men

Question 2

What are the risk factors for breast cancer?

Answer 2

Mutated BRCA1 or 2 genes which are normally tumour suppressors
Family History
Age
Uninterrupted oestrogen exposure: nulliparity, 1st pregnancy > 30yrs, early menarche, late menopause, HRT, obesity, COCP
No breastfeeding
Previous cancer

Question 3

What is the clinical presentation of breast cancer?

Answer 3

Lumps
Lump or thickening in the breast usually painless (cyclical or not)
Change in size or contours of the beast especially skin tugging
Change in colour or appearance of the areola
Redness and peau d’orange
Nipple inversion

Cancer symptoms such as breathlessness, weight loss, back pain, abdominal mass etc.

Ask about previous lumps, cancers and mammograms. Must not forget family history.

Question 4

What questions should be explored in the history of a woman suspected of having breast cancer?

Answer 4

Ask about periods and pregnancies and breast feeding

Pain
History of trauma?
Bilateral/unilateral
Related to menstrual cycle

Discharge
Discharge or bleeding
Amount, colour and consistency

Question 5

What criteria should women be referred to the 2 week wait cancer clinic for?

Answer 5

Unexplained breast lump in >30yra
Symptomatic or nipple change in >50yrs
Consider if skin changes or axillary lump in >30yrs

Question 6

How are women with suspected breast cancer investigated?

Answer 6

Clinical – inspection and examination
Radiological – Mammograms (40 and above), USS and MRIs
Pathological – Fine needle aspiration cytology, core biopsy, excisional biopsy and Vacuum assisted core biopsy

Question 7

How are breast lumps managed according to the FNA result?

Answer 7

If lump is cystic then aspiration should be done. If the fluid is clear and no lump is left then give reassurance, if there is a lump left then core biopsy and if the fluid is bloody then send for cytology.
If FNA shows a solid lump then a core biopsy is taken, if this reveals clear fluid then reassurance can be given otherwise await histology reports.

Question 8

What’s the difference between FNA and core biopsy?

Answer 8

FNA – quick less uncomfortable, lower morbidity but requires core biopsy if malignant
Core Biopsy – removes small amount of tissue, high morbidity and pain, takes longer but allows receptor status and grade of tumour

Question 9

What marker can be used to monitor breast cancer progress?

Answer 9

CA15-3 – can be used to monitor breast cancer (also found raised in hepatocellular and pancreatic cancer as well as cirrhosis, benign breast disease and normal health).

Question 10

What investigations should be done if breast cancer presents late?

Answer 10

CXR, bone scan, liver USS, CT/MRI, PET CT, LFTs and Calcium levels.

Question 11

What are the two types of non invasive breast cancers?

Answer 11

Non-invasive Ductal and Lobular Carcinoma in Situ. Most often presents as mammographic calcifications (clusters or linear and branching) but can present as a mass. Can spread through ducts and lobules and be very extensive. Histologically often shows central (comedo) necrosis with calcification. Non-obligate precursor of invasive carcinoma.

Question 12

Describe invasive ductal carcinoma?

Answer 12

Invasive ductal carcinoma, no special type – 70-80%. Well-differentiated type has tubules lined by atypical cells. Poorly differentiated type has sheets of pleomorphic cells – 35-50% 10-year survival.

Question 13

Describe invasive lobular carcinoma?

Answer 13

Invasive lobular carcinoma – 5-15% – Infiltrating cells in a single file, cells lack cohesion – Similar prognosis to IDC.

Question 14

What is Paget’s disease of the breast?

Answer 14

(Related to DCIS)
Malignant cells can extend to nipple skin via the epidermis and so without crossing BM. Paget’s disease – Unilateral red and crusting nipple, eczematous or inflammatory conditions of the nipple should be regarded as suspicious and biopsy performed to exclude. If you have Paget’s you definitely have DCIS.

Question 15

What is inflammatory breast cancer?

Answer 15

Rare rapidly progressive form caused by obstruction of the lymph drainage causing erythema and oedema. Usually a primary cancer treated with neo-adjuvant chemotherapy followed by total mastectomy +/- radiotherapy

Question 16

Where does breast cancer metastasise to?

Answer 16

Breast cancer commonly metastasises to brain, liver, lung, bone, adrenal and ovary.

Question 17

What are the 3 receptors that can be involved in breast cancer?

Answer 17

Oestrogen receptor (if positive then better prognosis)
Progesterone receptor (if positive then better prognosis) 
Herceptin over expression (aggressive disease and poorer prognosis)

Question 18

What are the 4 stages of breast cancer?

Answer 18

Stage 1 – confined to breast and mobile
Stage 2 – growth confined to breast, mobile with affected lymph nodes in ipsilateral axilla
Stage 3 – tumour fixed to muscle and skin involvement larger than tumour
Stage 4 – complete fixation of tumour to breast and distant metastasis

Question 19

Describe the TNM staging criteria for breast cancer?

Answer 19

T1 < 2cm, T2 2-5cm, T3 >5cm, T4 fixed to chest wall or peau d’orange
N1 mobile ipsilateral nodes, N2 fixed nodes

Question 20

What surgery is used to manage breast cancer?

Answer 20

Wide local excision
Mastectomy +/- breast reconstruction
Axillary node biopsy or sentinel node biopsy

Question 21

What criteria would indicate mastectomy vs wide local excision?

Answer 21

Mastectomy
Multifocal tumour
Central tumour
Large lesion in small breast
DCIS >4cm
Patient Choice

Wide Local Excision
Solitary lesion
Peripheral tumour
Small lesion in large breast
DCIS <4cm
Patient choice

Question 22

What adjuvant therapy can be given alongside surgery for managing breast cancer?

Answer 22

Radiotherapy – recommended for all patient who have WLE as it reduces recurrence and increases survival (axillary node radiotherapy if found to be involved in sampling but no surgical clearance). For mastectomy it is offered to T3-T4 and then with positive nodes.
Chemotherapy – considered in all patient as also reduces recurrence and increases survival

Question 23

What hormonal therapy is available for breast cancer?

Answer 23

Hormonal therapy

1. Oestrogen Antagonists – tamoxifen used in pre (and peri) menopausal women – increased risk of DVT, endometrial cancer and osteoporosis
2. Aromatase Inhibitors – Arimidex, letrozole and exemestane used in postmenopausal women – prevents oestrogen production in post-menopausal women. Increased risk of Osteoporosis (DEXA scan indicated before starting) and menopausal symptoms.

Biological
1. Herceptin (Trastuzumab) – contraindicated in heart disorders

Question 24

How should late stage breast cancer be managed?

Answer 24

Late stage disease – radiotherapy to painful bony lesions, (bisphosphonates can be useful). If relapse after initial success, then consider chemotherapy. Hormonal and biological treatments as usual.

Question 25

Describe the breast cancer screening programme

Answer 25

2-view mammography every 3 years for women aged 47-73 in the UK

Question 26

If someone has only 1 first degree relative or second degree relative diagnosis with breast cancer what criteria would require them to be referred to genetics?

Answer 26

If the person concerned only has one first-degree or second-degree relative diagnosed with breast cancer they do NOT need to be referred unless any of the following are present in the family history:
• 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)