Breast Carcinoma

Question 1

Definition?

Answer 1

Malignancy of epithelial cells originating in breast and nodal basins.
Can be confined to the basement membrane (carcinoma in-situ)
Can be squamous or glandular (adenocarcinoma)

Question 2

Risk factors?

Answer 2

• Old age
• Female
• Ethnicity
• Family history
• Genetic mutations
• Oestrogen/progestogen exposure
• Alcohol
• Radiation
• High SE class
• Benign breast disease
• Increased breast density

Question 3

Differentials?

Answer 3

• Benign breast disease
• Fibrocystic changes-symmetrical, pain worse in second half of cycle, younger
• Fibroadenoma-smooth, well-circumscribed mobile mass-worse in high oestrogen levels
• Mastitis-lactating or breastfeeding-inflamed and signs of infection

Question 4

Epidemiology?

Answer 4

Age: Older
Sex: Women
Ethnicity: White
Prevalence:

Question 5

Aetiology?

Answer 5

• Genetics-BRCA1 and 2 mutations-5-10% cancers

Exogenous sex hormone exposure

Question 6

Clinical Presentation?

Answer 6

• Asymmetrical breasts
• Mass-non-tender/painless , poorly defined margins in upper outer quadrant
• Retractions/dimpling
• Peau d’orange
• Blood-white nipple discharge
• Axillary lymphadenopathy

Question 7

Pathophysiology?

Answer 7

• In the menstrual cycle, there are increases mitoses of myoepithelial cell/glandular tissue in the alveoli lining, which increases teh risk of mutations
• Mutations in TSG’s are AD-can increase risk of familial cancer-lack of homologous recombination of double-stranded breaks
• Mutations in EBB2 increases HER2-gorwth factor of cell division
• Rapid and uncontrolled cancers
• DCIS-ductal carcinoma in situ-hasn’t crossed basement membrane
• Paget’s disease/inflammatory carcinoma-cells break off and migrate via lactiferous ducts onto the skin and settle between squamous cells and causes an inflammatory response-exudate dries on skin as crusts
• LCIS-local
• Lobular carcinoma-alveoli and lobules
• Infiltrates into pec muscles-immobile
• Fibrosis of ligaments-retraction
• PDO-lymph build up in interstitial spaces stretching skin on top

Question 8

Investigations-first line?

Answer 8

• Breast examination and history
  
  • Asymmetry, masses, nipple deviation/retraction/scaling, scars, axillary lymph nodes, nipple discharge, skin changes, peau d’orange

Question 9

Investigations-second line?

Answer 9

• Mammogram-
  
  • screening for over40’s/suspected pts
  • High specificity and sensitivity
  • Assessed by 2 readers

Question 10

Investigations-third line?

Answer 10

MRI
US
Biopsy
genetic/receptor testing

Question 11

MRI?

Answer 11

• High sensitivity but medium specificity

* For known mutation, first-degree relative with it or have lifetime risk >20%, radiation or TP53 mutation

Question 12

US?

Answer 12

• Eliminates fibrocystic disease, other masses and lymph nodes
  
  • Assess response in neoadjuvant chemo

Question 13

Biopsy?

Answer 13

• Core-specific and can assess receptor status
  
  • FNA-rapid, high sensitivity an specificity if done by experienced clinician
  • Invasive ductal
  • Invasive lobular
  • Medullary
  • Mucinous
  • metaplastic

Question 14

Genetic/hormone testing?

Answer 14

• OR and PR using immunohistochemistry assay
  
  • HER2 testing -positive means can be given Herceptin
  • ER testing-positive means can be given oestrogen-antagonising therapy