Breast Disease

Question 1

What are the risk factors for breast cancer?

Answer 1

As age increases, previous breast cancer, BRCA1 and BRCA2, early menarche, late menopause, late or no pregnancy, HRT, alcohol, weight and post radiotherapy for Hodgkin’s

Question 2

What is the lifetime risk of breast cancer?

Answer 2

Affects 1 in 7 women

Question 3

What is the presentation of breast cancer?

Answer 3

Lump, mastalgia, nipple discharge, nipple retraction, Paget’s disease of nipple, change in size or shape, lymphoedema and dimpling

Question 4

What is the 3 steps of diagnosis?

Answer 4

Clinical - history and examination
Radiological - bilateral mammograms/ USS
Cyto-pathological - FNA cells and core biopsy

Question 5

What is used for breast imaging?

Answer 5

Mammography, US or MRI
Mammography is most sensitive in older women - sensitivity reduced in younger women as increased glandular tissue

Question 6

What is the invasive types of breast cancer?

Answer 6

80% ductal carcinoma
10% lobular carcinoma
10% others - mucinous, tubular, papillary, medullary, sarcoma and lymphoma

Question 7

What is the non-invasive types of breast cancer?

Answer 7

DCIS - ductal carcinoma in situ
LCIS - lobular carcinoma in situ

Question 8

What is investigations are used for staging of breast cancer?

Answer 8

FBC, U+Es, LFTs, Ca2+/PO2-
CXR

Question 9

Describe T in TNM classification of breast cancer

Answer 9

T1 - size less than 2cm
T3 - more than 5cm
T4 - invading

Question 10

What is the management/ treatment used for breast cancer?

Answer 10

Surgery
Radiotherapy
Chemotherapy
Hormonal therapy
Neoadjuvant and adjuvant

Question 11

What are the 2 main types of breast surgery?

Answer 11

Breast conservation surgery
Mastectomy

Question 12

What patients are suitable for breast conservation surgery?

Answer 12

Breast/ tumour size ration
Suitable for radiotherapy
Patients wish

Question 13

Why might there be surgery to the axilla?

Answer 13

Prognostic information and staging
Regional control of disease/ eradication in the axilla

Question 14

Describe sentinel lymph node (SLN) biopsy

Answer 14

First node to receive lymphatic drainage so first node for tumour spread
If negative then other nodes are negative
Preoperative axillary USS

Question 15

What happens when the SLN contains tumour?

Answer 15

Remove them all surgically or give radiotherapy to all axillary nodes

Question 16

What are the complications of axillary treatment?

Answer 16

Lymphoedema
Sensory disturbance
Decreased ROM
Nerve damage
Vascular damage
Radiation-induced sarcoma

Question 17

What factors are associated with increased risk of disease recurrence?

Answer 17

Lymph node involvement, tumour grade and size
Steroid receptor status
HER2 status
LVI - lymphovascular invasion

Question 18

What is the prevention/ adjuvant treatment for breast cancer?

Answer 18

Local - radiotherapy
Systemic - hormone therapy, chemotherapy and targeted therapies

Question 19

Describe RT in breast cancer

Answer 19

All patients after WLE as adjuvant treatment over 3 weeks
Boosts reduce local recurrence
After Mx if there is local involvement or LN involvement

Question 20

What are the complications of radiotherapy?

Answer 20

Skin reaction - skin telangiectasias
Radiation pneumonitis, cutaneous radionecrosis and angiosarcoma

Question 21

What is the action of oestrogen receptor positive (ER+)?

Answer 21

Blocks stimulation of cell growth by oestrogen
Tamoxifen and aromatase inhibitors

Question 22

Describe tamoxifen

Answer 22

20mg daily for 5-10 years
Blocks directly on ER receptor
All age groups
More effective after chemo
Side effect - thromboembolic

Question 23

Describe aromatase inhibitors

Answer 23

Arimidex and Letrozole
Once daily more 5 years
Inhibiting ER synthesis
Used in post-menopausal women
Improves disease free survival
Side effect -osteoporosis

Question 24

When does chemotherapy have the greatest benefits?

Answer 24

Younger women and patients with increasing adverse prognostic factors
Anthracycline and taxane

Question 25

What is oncotype DX?

Answer 25

21 gene assay to determine whether chemo is likely to benefit

Question 26

What is Trastuzumab?

Answer 26

Monoclonal antibody against HER-2 receptor
Given when overexpression of HER2 and chemo
50% decrease in recurrence
33% increase in survival

Question 27

What is the local spread of breast cancer?

Answer 27

Chest wall, skin and nipple

Question 28

What is the distant spread of breast cancer?

Answer 28

Contralateral breast
Bone, lung, liver, brain and bone marrow