Breast Cancer

Question 1

Define

Answer 1

Malignancy of breast tissue

• Most common type: invasive ductal carcinoma
• Different types include
  
  • Non-invasive ductal carcinoma in situ (DCIS) – pre-malignant
  • Non-invasive lobular carcinoma - rarer
  • Invasive ductal carcinoma – 70%
  • Invasive lobular carcinoma – 10-15%
  • Medullary cancers – 5%
  • Colloid/mucoid cancers – 2%
  • Others: papillary, tubular, adenoid-cystic, Paget’s
• 60-70% are oestrogen receptor +ve – better prognosis – hormone therapy
• 30% over-express HER2 (GF receptor gene) – poorer prognosis – oxford cases says better prognosis as will respond to herceptin

Question 2

Causes

Answer 2

Genetics (e.g. BRCA-1 and BRCA-2 genes)

Environmental factors

Question 3

Risk factors

Answer 3

Age

Prolonged exposure to oestrogen

• Nulliparity (not having kids)
• First pregnancy >30 yrs
• Early menarche
• Late menopause
• Obesity
• COCP
• HRT
• Not breast feeding
• Past breast cancer

Family history of breast cancer

Question 4

Epidemiolgy

Answer 4

Most common cancer in women (1/9 women in the UK)

Peak incidence: 40-70 yrs

Rare in men

Question 5

Symptoms

Answer 5

• Breast lump – painless, irregular, indistinct border, hard, immobile, may be fixed to structures
• Changes in breast shape
• Nipple discharge (may be bloody)
• Axillary lump
• Symptoms of malignancy:

1. Weight loss
2. Bone pain
3. Paraneoplastic syndromes

Question 6

Signs

Answer 6

Breast lump

• Firm
• Irregular
• Fixed to surrounding structures

Lymphadenopathy

Peau d’orange

Skin tethering

Fixed to chest wall

Skin ulceration

Nipple inversion

Paget’s disease of the nipple - eczema-like hardening of the skin on the nipple

• Usually caused by ductal carcinoma in situ infiltrating the nipple

Question 7

Investigations

Answer 7

TRIPLE ASSESSMENT

Clinical examination

Imaging:

• Ultrasound (< 35 yrs)
  OR
• Mammogram (> 35 yrs)

Tissue Diagnosis:

• Fine Needle Aspiration
  OR
• Core Biopsy

On mammogram: cancer is suggested by increased density, irregular margins, speculation (like shards of glass) and accompanying clustered irregular microcalcifications.

Sentinel Lymph Node Biopsy

• A radioactive tracer is injected into the tumour and a scan identifies the sentinel lymph node
• This node is then biopsied to check the extend of spread

Staging – commonest sites of metastasis are chest, lungs, bone and brain

• CXR
• Liver contrast-enhanced ultrasound/CT/MRI
• Imaging of axial skeleton and long bones (bone scintigraphy or plain radiograph) and blood tests for serum calcium, phosphate and ALP.
• CT (brain/thorax)

Bloods: FBC, U&Es, calcium, bone profile, LFTs, ESR