Breast Carcinoma and Benign Breast Disease

Question 1

What is the anatomy of the breast?

Answer 1

• Made of 15-25 lobes
• Each lobe is composed of a group of lobules
• Each lobule consists of multiple acni, within which milk is produced
• The milk drains via terminal ducts into the main duct system
• The duct system opens out at the nipple

=> The entire duct and lobular system is lined by epithelium surrounded by a basement membrane

Question 2

What is the most common clinical presentation of breast cancer?

Answer 2

• Palpable lump

Question 3

What are the most likely causes of a breast lump?

Answer 3

=> Vary with age:

• Young women, fibroademona ad fibrocystic change are the most common causes
• In older women, cancer is the most important cause

Question 4

What does the Triple Assessment of Breast Lumps consist of?

Answer 4

=> Clinical
- History and Examination

=> Radiological

• Mammography (patients > 35 yrs, identifies micro calcifications and densities)
• Ultrasound (patients < 35 years, as breast tissue too dense for mammography)

=> Pathological
- Fine needle Aspiration (FNA)

Question 5

What is the most common benign tumour of the breast?

Answer 5

Fibroadenoma

=> Most commonly seen in women under the age of 30

Question 6

What is the clinical presentation of fibroadenoma?

Answer 6

• Firm, mobile, painless lump

Question 7

What is the management of Fibroadenoma?

Answer 7

• Reassurance and discharge
  OR
• Excision

Question 8

What is fibrocystic change?

Answer 8

Benign, non-neolpastic changes in the breast which are the result of minor aberrations in the normal response to cyclical hormonal changes

=> Involves:

• Fibrosis
• Cyst formation

Question 9

In what age group are fibrocystic changes most commonly seen?

Answer 9

25-45

Question 10

What is the clinical presentation of fibrocystic changes?

Answer 10

• Breast pain
• Tenderness
• Lumps/cysts

Question 11

What region of the breast do fibrocystic changes affect?

Answer 11

Terminal Duct Lobular Unit (TDLU)

Question 12

In what age group is breast cancer most likely to occur in?

Answer 12

40-70

Question 13

What are the major risk factors of Breast Cancer?

Answer 13

=> Increased lifetime oestrogen exposure through:

• Female sex
• Increasing age
• Obesity - Early menarche, late menopause, long term COCP

=> Family History:

• Germ-line mutation in BRCA 1 and BRCA 2
• Germ-line mutation in p53

=> Alcohol consumption

Question 14

What are the clinical features of Breast Cancer?

Answer 14

• Hard painless lump
• Nipple inversion and skin dumping
• Ulceration/ fungation
• Peau d’orange
• Nipple eczema
• Palpable axillary nodes
• Metastatic

Question 15

Where do half of breast cancers occur?

Answer 15

Upper outer quadrant of the breast

Question 16

What are the investigations in suspected Breast Cancer?

Answer 16

Triple Assessment

Question 17

What types of cancers are the majority of Breast Cancers?

Answer 17

Invasive adenocarcinomas

Question 18

What are the 2 most common forms of Breast Cancer?

Answer 18

• Ductal Carcinoma

- Lobular Carcinoma

Question 19

What are the 2 types of Ductal Carcinoma?

Answer 19

=> Ductal Carcinoma in situ (DCIS):

• Epithelial cells showing cytological changes of malignancy have not invaded through the basement membrane
• Unifocal lesion concentrated in one area of the breast
• Usually does not form a mass, but may be associated with micro-calcifications
• Surgically excised

Left untreated, DCIS can progress to Invasive Ductal Carcinoma (IDC)

=> Invasive Ductal Carcinoma (IDC):

• Tumour cells have invaded through the basement membrane into the adjacent tissue
• Presents as a palpable breast lump

Question 20

What is Paget’s disease of the nipple?

Answer 20

• Disease affecting the skin of the nipple and areola
• Due to presence of DCIS cells in the epidermis
• The affected skin reacts to the presence of these cells, giving the eczematous clinical appearance

=> Biopsy is required for a diagnosis

Question 21

What is the microscopic composition of Invasive Lobar Carcinoma?

Answer 21

• Tumour cells which infiltrate the normal breast tissue as linear cords of cells

Question 22

What are the other less common types of Breast Cancers?

Answer 22

• Tubular
• Cribriform
• Mucinous carcinomas

Question 23

What are the prognostic factors of Breast Cancer?

Answer 23

=> Tumour Stage - most important
TNM

=> Tumour Grade
3 tier grading system

=> Histological subtype

=> Vascular invasion

=> Excision margins

=> Oestrogen receptor and HER2 status

Question 24

What is the link between oestrogen receptors and HER2 with Breast Cancers?

Answer 24

=> Oestrogen receptor expression

• ER positive tumours are low grade and less aggressive, more likely to respond to hormonal therapy
• ER negative tumours are high grade and more aggressive, less likely to respond to hormonal therapy

=> HER2 - oncogene

• Over-expressed in breast cancer
• Poorer prognosis and good response to Herceptin

Question 25

What is the Sentinel lymph node?

Answer 25

• The first node draining a cancer
• If sentinel lymph node does not contain cancer, (not positive) then very high likelihood the cancer has not spread
• If sentinel lymph node does contain cancer, (positive), then the other axillary lymph nodes may or may not be involved

=> Postive sentinel lymph node:
- Axillary clearance required

=> Negative axillary lymph node:
- No further surgery of axilla required

Question 26

How is the sentinel lymph node identified?

Answer 26

• Dye and/or isotope is injected into the tissue around the tumour
• One or several lymph nodes take up this dye
• Tracer is used to identify these nodes
• Surgeon remove hese nodes to examine

Question 27

What is the NHS Breast Screening Programme?

Answer 27

• All women aged between 50-70 are given a mammogram screening every 3 years
• Further assessment if mammogram screening is suspect

=> Further assessment involves (Triple Assessment):

• Imaging (USS)
• Clinical examination
• FNA