Breast pathology treatment

Question 1

TNM staging T

Answer 1

Tx: primary tumour cannot be assessed
T0: not palpable
T1:Clinically palpable tumour -size < 2 cm 
T2: Tumour size 2-5 cm
T3: tumour size>5cm
T4: Tumour invading skin
o	T4b: Tumour invading chest wall
o	T4c: Tumour invading both
o	T4d :Inflammatory breast cancer

Question 2

TNM staging N

Answer 2

N0: no regional lymph nodes palpable
N1: regional lymph nodes palpable- mobile
N2: regional lymph nodes palpable- fixed

Question 3

TNM staging M

Answer 3

Mx: Distant metastases cannot be assessed
M1: No distant metastasis
M1: Distant metastasis

Question 4

Surgery

Answer 4

• Mastectomy
• Breast conserving surgery
• Surgery to axilla

Question 5

Who is eligible for breast conserving surgery

Answer 5

• Tumour size<4cm
• Breast/tumour ratio
• Suitable for radiotherapy
• Single tumours- OLD DAYS
• Patients wish

Question 6

What does axillary surgery involve?

Answer 6

• Sentinel node lymph node biopsy: first node to receive lymphatic drainage
• First node to receive tumour spread if it spreads
• If negative rest of nodes are negative
• If positive: remove all surgically and give radiotherapy to rest of axillary nodes
• Only performed when pre-op axilla USS is normal/benign

Question 7

complications of surgery to axilla

Answer 7

• Lymphodema
• Sensory disturbance
• Decrease ROM of the shoulder joint
• Nerve damage
• Vascular damage
• Radiation induced sarcoma

Question 8

Radiation

Answer 8

o All patients after Wide Local Excision as adjuvant treatment
o 40gy-50Gy over 3 weeks
o Boosts reduce local reccurence
o After Mastectomy if thes is LN involvement

Question 9

complications of radiation

Answer 9

• Skin reactions
• Radiation pneumonitis
• Cuteneos radionecrosis/ osteonecrosis
• Angiosarcoma

Question 10

Hormone therapies available?

Answer 10

Tamoxifen 
•	20mg once daily over 5-10yrs
•	Blocks directly on ER receptor
•	Effective in all age groups
•	More effective given after chemotherapy
•	!Thromboembolic events

Aromatase inhibitors
• Once daily for 5 years
• Inhibiting ER synthesis
• Should only be used in postmenopausal women
• Improve disease free survivial (switch thx)
• !Osteoporosis

Question 11

Different types of chemotherapy?

Answer 11

• CMF Combinations (1st generation)
• Anthracycline Combinations
• Taxane based Combinations

More modern :
“Oncotype DX” – 21 gene assay to determine whether chemotherapy likely to be of benefit

Question 12

Targeted therapies available?

Answer 12

Trastuzumab (Herceptin®)
•Monoclonal antibody against Her-2 receptor
•Given to patients with over-expression of Her2 and chemotherapy
•50% decrease risk of recurrence
•33% increase in survival at 3 years!

Question 13

Factors associated with increased risk of reoccurence

Answer 13

• Lymph node involvement
• Tumour grade
• Tumour size
• Steroid receptor status
• HER2 status
• LVI

Question 14

Follow up

Answer 14

oClinical examination for 1-5 years
oMammogram of breasts at regular intervals for 3-10 years
oPatient to keep eye on it
oOpen Access to service