Breast cancer

Question 1

What is breast cancer?

Answer 1

Malignancy originating in the breasts, usually either in a duct or a lobule.

Question 2

What are types of breast cancer?

Answer 2

Invasive ductal

Invasive lobular

Medullary/colloid carcinoma are rare

Question 3

What are pre-cancerous lesions in breast?

Answer 3

Ones which haven’t breached the basement membrane.

DCIS = precursor to ductal

LCIS = precursor to lobular

Question 4

How does DCIS look on imaging?

Answer 4

Microcalcifications

Question 5

What are risk factors for breast cancer?

Answer 5

• Increasing age
• Family history
○ BRCA1 and BRCA2

	• Prolonged oestrogen exposure 
		○ Nulliparity, early menarche, late menopause
		○ OCT and HRT
	• Alcohol 
	• Existing benign breast disease 
	• Not breastfeeding 
Previous breast cancer

Question 6

What are Sx of breast cancer?

Answer 6

Often present asymptomatically through screening

Lump in breast or axilla

Breast asymmetry, swelling

Nipple retraction or discharge

Skin changes

Question 7

What is Paget’s disease of the nipple?

Answer 7

an eczematoid change of the nipple associated with an underlying breast malignancy

Question 8

What are DDx for breast cancer?

Answer 8

Benign tumours, breast cysts, or infective causes are all potential differentials, the majority of which are identified following suitable imaging and histology.

Question 9

What is triple assessment in breast lumps?

Answer 9

1. Examination
2. Radiology (<35 US, >35 mamogram)
3. Biopsy (FNA or core, guided by US)

Grade as E, U, M 0-5.

Do histology of cells, cytology of any fluid aspirated/nipple discharge

IHC and FISH

Question 10

What may be seen in imaging in cancer?

Answer 10

Ductal is often calcifications in one breast

Lobular is often bilateral changes

Question 11

What are IHC and FISH used for?`

Answer 11

OR, PR, and Her2 status (FISH)

Question 12

What is used to stage the prognosis of breast cancer?

Answer 12

Nottingham prognostic index

(Size x 0.2) + Nodal Status (how many lymph nodes) + Grade

Question 13

What is management of breast cancer?

Answer 13

Surgery - lumpectomy or WLE, or mastectomy, with sentinel node biopsy +/- axillary clearance

Chemo given neo/adjuvant

Radio given as neo/adjuvant

Question 14

What is WLE used for?

Answer 14

Small or peripheral cancers, no evidence of mets.

Excision of the tumour, typically ensuring a 1cm margin of macroscopically normal tissue is taken along with the malignancy.

Done for DCIS < 4cm

Question 15

What is mastectomy used for?

Answer 15

Multifocal or central cancer, large

DCIS > 4cm.

Question 16

When should lymph node biopsy and clearance be done

Answer 16

If no axilla lump, do US. If +ve, do sentinel node biopsy to assess nodal status.

If axilla lump, do axillary clearance

Question 17

What are side effects of axillary node clearance?

Answer 17

Paraesthesia, lymphoedema seroma

Question 18

What is sentinel node biospy

Answer 18

Involves injecting dye into tumour which goes into sentinel node
Then remove it and biopsy. if no cancer, don’t need axillary clearance which avoids pointless surgery

Question 19

When is chemo given neo/adjuvantly?

Answer 19

To downsize prior to surgery.

Also given a as adjuvant to reduce risk of recurrence.

Question 20

When is radiotherapy given?

Answer 20

To all patients after WLE and mastectomy with positive margins.

Question 21

What hormone treatments are there for breast cancer

Answer 21

For ER positive

Tamoxifen (pre-menopause)

Aromatase inhibitors (post-menopause)

Herceptin if Her-2 positive

Question 22

What types of reconstructive surgery can be done?

Answer 22

Flap formation: lat dorsi, transverse rectus

Question 23

What other drugs should be given to patients?

Answer 23

Bisphosphonates