Breast Carcinoma

Question 1

How common is it?

Answer 1

Affects 1 in 9 women. Rare in men (~1% of all breast cancers)

Question 2

Who does it affect?

Answer 2

Women mainly, rare in men.

Question 3

Pathology?

Answer 3

• Non-invasive ductal carcinoma in situ (DCIS) is premalignant and seen on mammography. Non-invasive lobular CIS is rarer.
• Invasive ductal carcinoma is most common (~70%) – invasive lobular carcinoma accounts for 10-15%.
• Medullary cancers (~5%) tend to affect younger patients. Colloid/mucoid tend to affect elderly.
• Others: papillary, tubular, adenoid-cystic and Paget’s.
• 60-70% of breast cancers are oestrogen receptor +ve = better prognosis.
• ~30% over-express HER2 (growth factor receptor gene) associated with aggressive disease and poorer prognosis.

Question 4

Risk factors?

Answer 4

• Family history
• Age
• Uniterrupted oestrogen exposure (1st pregnancy >30yrs old, early menarche, late menopause, HRT, obesity)
• BRCA genes
• Not breastfeeding
• Past breast cancer

Question 5

How does it present?

Answer 5

Painless increasing mass, which may also be associated with nipple discharge, skin tethering, ulceration.
- In inflammatory cancers oedema and erythema may be present also (peau d’orange)
• Recent nipple inversion
• Bloodstained nipple discharge - uncommon
• Non-cyclic breast pain - usually, a late sign
• Disseminated disease:- bone pain, pathological fracture, dyspnoea, pleural effusion hepatomegaly, jaundice.

Question 6

Similar presentations?

Answer 6

• Breast abscess

- Fibrocystic disease

Question 7

Investigations?

Answer 7

• All lumps should undergo ‘triple assessment’:
  1. Clinical examination/history
  2. Radiology – US for 35yrs.
  3. Histology/cytology (FNA or core biopsy; US guided core biopsy best for new lumps)

Question 8

Staging?

Answer 8

Stage 1 – confined to breast, mobile.
Stage 2 – Growth confined to breast, mobile, lymph nodes in ipsilateral axilla.
Stage 3 – Tumour fixed to muscle (but not chest wall), ipsilateral lymph nodes matted and may be fixed, skin involvement larger than tumour.
Stage 4 – complete fixation of tumour to chest wall, distant metastases.

Also, TNM staging:

• T: T1 5cm, T4 fixity to chest wall or peau d’orange.
• N: N1 mobile ipsilateral nodes N2 fixed nodes.
• M: M1 distant metastases.

Question 9

Treatments?

Answer 9

Surgical
- Removal of tumour by wide local excision (WLE) or mastectomy +/- breast reconstruction and axillary node sampling/surgical clearance or sentinel node biopsy.

Radiotherapy
- Recommended for all breast ca. Risk of recurrence decreases, increases overall survival.

Chemotherapy
- Adjuvant chemo improves survival and reduces recurrence in most groups of women.

Endocrine agents

• Aim to reduce oestrogen activity and are used in oestrogen receptor (ER) or progesterone receptor (PR) +ve disease.
• ER blocker Tamoxifen is widely used (e.g. 5 yrs post op).
• Aromatase inhibitors (eg. Anastrazole) targeting peripheral oestrogen synthesis are also used – only used if post-menopausal.
• If pre-menopausal and an ER+ve tumour, ovarian ablation (via surgery or radiotherapy) or GnRH analogues (eg goserelin) reduce recurrence and increase survival.