What are the different types of breast cancer? Which is most common?
Usually adenocarcinomas:
- ductal carcinoma in situ (23%): 20-30% go on to develop invasive disease
- invasive ductal carcinoma (54%): most common form
- lobular carcinoma in situ (6%): less common than DCIS but greater risk of invasive disease
- invasive lobular carcinoma (7%): more aggressive than IDC
Suggest possible risk factors for breast cancer
- female gender
- increasing age
- increased oestrogen exposure e.g. early menarche, late menopause, nulliparity, 1st child 30+, obesity, COCP and HRT
- FHx of breast/ovarian cancer (BRCA1/2 mutation)
- previous breast, ovarian, endometrial or bowel cancer
- radiation exposure
A 65yo lady presents with a breast lump to the one stop breast clinic. Describe the features of the ‘triple diagnosis’.
- clinical examination: P1 normal, P2 benign, P3 uncertain, P4 suspicious, P5 malignant
- imaging:
- USS (U1-5): for women <35yrs - hypoechoic mass, irregular mass with internal calcifications, enlarged axillary LNs
- mammopgrahy (M1-5): irregular spiculated mass, clustered microcalcifications and linear branching lesions - biopsy (B1-5):
- FNA: for rapid Dx of malignancy
- core biopsy: effectively differentiates between pre-invasive and invasive disease and enables assessment of receptor status
Which further tests would be performed on a breast lump core biopsy sample?
- immunohistochemistry: for oestrogen + progesterone receptor status
- FISH: HER2 testing
- gene expression assays: calculate recurrence score + relative benefit of adding chemo to hormone Tx in pts with hormone R positive early stage cancer
A 56yo lady has just been diagnosed with breast following her biopsy results. Which further Ix might be performed for disease staging?
- CXR: ?lung mets
- LFTs + liver USS (+ abdo palpation): ?liver mets
- serum Ca2+/phosphate + isotope bone scan or MRI: ?bone mets
- CT head: if symptoms of brain mets
What is your differential diagnosis for a breast lump?
- breast cancer
- fibrocystic changes: symmetrical, associated with cyclical breast pain. Usually resolves at menopause.
- fibroadenoma: smooth, well-demarcated, mobile mass.
What are the different categories of treatment options for breast cancer?
- surgery e.g. WLE, mastectomy
- chemotherapy
- hormone therapy
- immunotherapy
- radiotherapy
What are the different types of hormone therapy for breast cancer? What is their MOA? When is each indicated?
- AROMATASE INHIBITORS: anastrazole, letrozole, exemestane
- bind oestrogen receptors to prevent oestrogen production + inhibit further malignant growth (also block conversion of androgens to oestrogen in peropheral tissue)
- adjuvant in non-metastatic bCa to decrease risk of relapse OR primary Tx in elderly pts or those unfit for surgery
- avoid in pre-menopausal women due to risk of osteopenia and fractures - TAMOXIFEN:
- selective oestrogen receptor blocker
- adjuvant in non-metastatic bCa to decrease risk of relapse OR primary Tx in elderly pts or those unfit for surgery
- typically used in premenopausal women
- continue for 5 yrs - GOSERELIN
- gonadorelin analogue: continued administration causes down regulation of GHRH receptors and thus decreased FSH + LH release and thus decreased androgen + oestrogen production
- same indications as tamoxifen
Give an example of a tyoe of immunotherapy used in breast cancer Tx.
HERCEPTIN (trastuzumab)
- mAb targeting HER-2 receptor
- adjuvant in 20-25% ob bCa +ve for HER-2
Suggest possible adverse effects/complications of aromatase inhibitors.
- osteopenia/osteoporosis (consider bisphosphonates)
- arthralgia
- hypercholesterolaemia and CVD
Suggest possible adverse effects/complications of tamoxifen.
- VTE
2. endometrial cancer (is an endometrial Oe R agonist)
Suggest possible adverse effects/complications of Herceptin.
- cardiotoxicity (dilated cardiomyopathy)
What is Paget’s disease of the breast? How would it present?
Ductal carcinoma that infiltrates the nipple + areola.
- erythematous, scaly or vesicular rash affecting the nipple + areola
- pruritis, burning sensation
- lesion eventually ulcerates causing bloody nipple discharge
Which Ix would you perform on someone presenting with ?Paget’s disease of the breast?
- nipple scrape cytology: large round cells with prominent nuclei
- punch or wedge biopsy
- USS/mammogram
What is inflammatory breast cancer? How would it present?
Rare form of advanced invasive carcinoma (usually ductal carcinoma), characterised by dermal lymphatic invasion of tumour cells. 25% have invasive disease at time of presentation.
- erythematous + oedematous (peau d’orange) skin plaques over a rapidly growing breast mass
- tenderness, burning sensation
- bloody nipple discharge
- axillary lymphadenopathy
