Breast Carcinoma

Question 1

How many people are affected

Answer 1

1 in 9 females

40,000 new cases per year

Question 2

What causes it

Answer 2

• Non-invasive ductal carcinoma in-situ = premalignant
  (seen as microcalcification on mammography)
• Non-onvasive lobular = rarer + multifocal
• INVASIVE DUCTAL CARCINOMA = 70%
• Invasive lobular carcinoma = 10-15%
• Medullary cancer = 5%

Question 3

What are the risk factors

Answer 3

• FHx
• Age
• uninterrupted oestrogen exposure
• 1st pregnancy >30
• Early menarche
• Late menarche
• HRT
• Obesity
• BRCA genes
• Not breast feeding
• Past Hx

Question 4

What is the clinical presentation

Answer 4

• Stage 1 - confined to breast, mobile
• Stage 2- growth confined to breast, mobile, lymph nodes (in ipsilateral axilla)
• Stage 3 - tumour fixed to muscle (not chest wall), ipsilateral lymph nodes, skin involvement
• Stage 4 - complete fixation of tumour to chest wall, distant mets

Question 5

What type of staging do you use

Answer 5

TNM staging:

• T1 <2cm
• T2 2-5cm
• T3 >5cm
• T4 fixity to chest wall or peau d’orange
• N1 mobile ipsilateral nodes
• N2 fixed nodes
• M1 distant mets

Question 6

What investigations do you perform

Answer 6

• 60-70% breast cancers = OESTROGEN receptor +ve (best prognosis if +ve)
• 30% over-express HER2 –> worse prognosis, aggressive disease + poorer prognosis
• TRIPLE ASSESSMENT (clinical examination + histology/cytology + mammography/ultrasound)
• Sentinel node biopsy from axillary

Question 7

What is the treatment for stage 1/2 breast carcinoma

Answer 7

Surgical

• removal of tumour by wide local excision (WLE)
• mastectomy ± breast reconstruction ± axillary node sampling/surgical clearance
• sentinel node biopsy

Radiotherapy

• recommended following surgery
• risk of recurrence 30% -10%
• increase overall survival

Chemotherapy
- adjuvant chemo is for all except excellent prognosis pts

Endocrine agents:

• aim to lower oestrogen activity or progesterone +ve tumours
• ER blocker TAMOXIFEN is widely used
• Ovarian ablation or GnRH analogues lower recurrence + ^ survival.

Reconstruction options:
tissue expanders, implants, latissimus dorsi flap, TRAM (transverse rectus abdominis myocutaneous) flap.

Question 8

How do you treat stage 3/4 carcinoma

Answer 8

• Long term survival possible + median survival >2 yrs
• Staging involves: CXR, bone scan, liver USS, CT/MRI or PET-CT + LFTs & Ca2+
• Radiotherapy to painful bony lesions (bisphosphonates may reduce pain + fracture)
• Tamoxifen (for ER +ve)
• Trastuzumab should be given for HER2 +ve, in combo w/ chemo
• CNS surgery for solitary mets
• Get specialist help for arm lymphoedema.