Session 11 - Breast Disease

Question 1

Describe the incidence of different breast conditions overall and in relation to age

Answer 1

Fibroadenoma - mobile mass (breast mouse), multiple, bilateral, mimic hyperplasia, any age during reproductive period, often

Question 2

Describe the risk factors of breast cancer

Answer 2

Hormone exposure - gender, interrupted menses, early menarche, late menopause, reproductive history, breast feeding, obesity and high fat diet, exogenous oestrogen (HRT/OCP)
Geographic influence - higher in US+Europe
Previous breast cancer
Radiation e.g. mantle for Hodgkin’s lymphoma)
Hereditary - BRCA 1/2, p53

Question 3

Describe the different types of breast cancer

Answer 3

In situ/invasive
Ductal/lobular
In situ - neoplasm limited to ducts and lobules no basement membrane, myoepithelial cells preserved, cannot metastasise
Ductal carcinoma in situ (DCIS) - presents as mammographicmcalcification/mass, can spread through ducts and lobules, shows central necrosis with calcification, non obligate precursor of invasive carcinoma
Invasive - invaded beyond basement membrane into stoma, can metastasis to lymph nodes, may have axillary lymph node metastases

Question 4

Describe the patterns of metastasis of breast cancer

Answer 4

Lymph - ipsilateral, axilla
Blood - bone, liver, lung, brain
Vascular invasion
Distant –> peritoneum, GIT, ovaries, uterus

Question 5

Describe the principles of treatment of breast cancer

Answer 5

Mastectomy/lumpectomy
Axilla surgery
Sentinel lymph node biopsy
Post operative radiotherapy 
Systemic - chemotherapy, tamoxifen, herceptin

Question 6

State what factors determine the prognosis of breast cancer

Answer 6

In situ/invasive
Histological subtype
Tumour grade
Tumour stage - size, metastases 
Gene expression profile

Question 7

Identify what factors can help in predicting response to therapy and state how survival from breast cancer can be improved

Answer 7

Early detection
Newer therapies
Neoadjuvant chemotherapy
Gene expression profiles 
Prevention with familial breast cancer - screening, mastectomies

Question 8

Explain the ‘triple approach’ to breast cancer

Answer 8

Clinical - examination, history
Radiography - mammogram, USS
Pathology - biopsy, fine needle aspiration

Question 9

Explain the appearance of peau d’orange breast cancer

Answer 9

Looks like the skin of an orange
Involvement of lymph drainage of skin –> oedematous skin, hair follicles remain down, breast swells up
Invasive ductal, no specific type, invasive lobular, mucinous, tubular

Question 10

Describe the clinical presentation of different breast conditions

Answer 10

Pain:
Cyclical, diffuse - physiological
Non-cyclical, focal - ruptured cysts, injury, inflammation
Palpable mass:
May represent normal nodularity
Worry if craggy, fixed, hard - invasive carcinoma, fibroadenoma, cysts
Nipple discharge:
Concerning if spontaneous and unilateral
Milky - endocrine disorder e.g. pituitary adenoma, side effect of OCP
Bloody/serous - benign lesions e.g. papilloma, duct ectasia
Skin changes:
Peau d’orange - breast cancer
Lumpiness
Mammographic abnormalities:
Densities - invasive carcinoma, fibroadenoma, cysts
Calcifications - ductal carcinoma in situ, benign changes

Question 11

Explain Paget’s disease of the breast

Answer 11

Cells extend to nipple skin without crossing basement membrane