Malignant Breast Cancer

Question 1

List the 4 types of pre-cancerous lesions in the breasts.

Answer 1

Epithelial hyperplasia
Ductal hyperplasia
Lobular hyperplasia
Carcinoma in situ

Question 2

What are the 2 types of carcinoma in situ in the breast?

Answer 2

Ductal carcinoma in situ (DCIS)

Lobular carcinoma in situ (LCIS)

Question 3

Describe the common presenting features of DCIS (ductal carcinoma in situ). (4)

Answer 3

Lump
Nipple discharge
Paget’s disease of the nipple - resembles eczema on the nipple, can indicate underlying malignancy
Micro-calcification on mammography

Question 4

How is DCIS treated? (3)

Answer 4

Complete excision
Mastectomy
Local excision and radiotherapy

Question 5

How is LCIS (lobular carcinoma in situ) detected?

Answer 5

Chance finding on biopsy

NO clinical/mammography features

Question 6

What are the features of LCIS? (4)

Answer 6

1. Multifocal lesions
2. Bilateral - check both breasts!
3. Loss of E-cadherin in lobular cells
4. x10 risk of invasive breast carcinoma in both breasts

Question 7

How is LCIS treated? (2)

Answer 7

Regular follow ups

Bilateral prophylactic mastectomy

Question 8

List the risk factors for invasive breast carcinoma. (7)

Answer 8

Age (40-70 yo)

Family history (e.g. first degree relatives with premenopausal breast cancer)

Hormone environment, e.g.

• Early menarche
• Late menopause
• Parity (children later in life; childlessness)
• Breastfeeding
• OCP/HRT

Question 9

Describe the process of axillary staging in invasive breast carcinoma.

Answer 9

Investigations needed:

1. Ultrasound of axilla
2. Core biopsy of all abnormal nodes

Results:
POSITIVE - remove all axillary nodes
NEGATIVE - do core biopsy of sentinel node (if sentinel node is +ve, may need to remove axillary nodes)

Question 10

How do you measure the hormone receptor status of breast carcinoma?

Answer 10

Allred score

0-2: hormone negative
3-5: low positive
5-8: high positive

Question 11

How do you measure the Nottingham prognostic index?

Answer 11

Cancer grade

• Grade 1: 1 point
• Grade 2: 2 points
• Grade 3: 3 points

Node status

• 0 nodes involved: 1 point
• 1-3 nodes involved: 2 points
• 4+ nodes involved: 3 points

Tumour size
-Points = size (cm) x 0.2

Question 12

Outline the 3 prognostic groups, as defined by the Nottingham prognostic index.

Answer 12

Good prognosis: <3.4 NPI

Intermediate prognosis: 3.41-5.4 NPI

Poor prognosis: 5.4+ NPI

Question 13

List the 4 types of malignant breast carcinoma.

Answer 13

Invasive ductal carcinoma (no specific type)

Lobular carcinoma

Tubular carcinoma

Mucinous/mucoid carcinoma

Question 14

How do you grade invasive breast carcinomas? (3)

Answer 14

Take into account: tubules, pleomorphisms, mitoses

Grade 1: 95% 5 yr SR
Grade 3: 50-60% 5 yr SR

Question 15

What are the histological features of invasive ductal carcinoma (no specific type)? (2)

Answer 15

Variable

Cellular infiltration in cords/sheets/tubules

Question 16

What are the features of lobular carcinoma? (5)

Answer 16

Signet ring cells (containing mucin vacuoles)
Diffuse infiltration
Multifocal
Bilateral
Oestrogen receptor (ER) positive

Question 17

What are the features of mucinous/mucoid carcinomas? (3)

Answer 17

Well-circumscribed tumours
Lakes of mucin
Well-differentiated cells

Question 18

How does malignant breast cancer spread? (2)

List some common metastases.

Answer 18

Via lymphatics:

• Axillary nodes
• Internal mammary nodes

Via blood:

• Bones
• Brain
• Lungs
• Liver

Question 19

Which genetic mutation is most commonly associated with breast cancer?

Answer 19

Her2 (human epidermal growth factor receptor)

Question 20

What is Her2 associated with in breast cancer? (3)

Answer 20

Poor prognosis
Poor response to chemotherapy
Poor response to hormonal therapy

Question 21

How would you treat invasive breast carcinoma? (6)

Where relevant, give examples of drugs.

Answer 21

Mastectomy
Lumpectomy and radiotherapy
Axillary surgery
Hormone therapy (e.g. tamoxifen)
Chemotherapy
Immunotherapy (e.g. trastuzumab)

Question 22

Which 2 drugs can be used specifically to treat breast cancer, depending on hormone status/genotype?

Answer 22

Tamoxifen (for oestrogen receptor positive carcinoma)

Trastuzumab (anti-Her2 monoclonal antibody)