Session 7: Breast disease

Question 1

what type of approach is required in treating patients with breast cancer?

Answer 1

holistic

Question 2

how do the patient experiences of breast cancer relate to the Kubler-Ross model of stages of grief?

Answer 2

1. denial
2. anger
3. bargaining
4. depression
5. acceptance

Question 3

summarise the UK breast screening porgramme in terms of its target population, effectiveness and challenges

Answer 3

mammogram
47-73, every 3 years
detects small impalpable cancers and pre invasive, looking for asymmetric densities, parenchymal deformities, calcifications

Question 4

describe the common clinical presentations of breast cancer

Answer 4

physiological swelling and tenderness
nodularity
breast pain
palpable lumps
nipple discharge in: galactorrhoea
breast infection and inflammation 
symtoms worse one week before menstruation and decrease when it starts
areas of nodularity and thickening, poorly differentiated from the surrounding tissue and often in upper outer quadrant of breast

Question 5

how is the diagnosis of breast cancer made?

Answer 5

mammogram (47-73) - densities: invasive carcinomas, fibroadenomas (most common benign), cysts
- calcifications: ductal carcinomas in situ,
benign changes
ultrasound
fine needle aspirations
history, exam

Question 6

define the key histological types of breast cancers

Answer 6

paget’s disease (eczematous, inflammatory conditions of nipple)
invasive adenocarcinoma ( see slide 40) v in situ - invaded beyond basement membrane into stroma, can metastasise,
invasive lobular (see slide 41) - infiltrating cells in single file, cells lack cohesion
tubular
mucinous (see slide 42)

Question 7

how are breast cancers graded and how does the impact survival of the patient?

Answer 7

classified: carcinomas divided into in situ and invasive, ductal or lobular
staged: TNM
grade (after 5 yrs, 1: 95%, to 80% for 22, 55% for grade 3)
molecular classification and gene expression profile - microarrays to examine genes to identify markers who would eventually develop metastases

Question 8

list the common presentations, histological features and implications of a diagnosis of DCIS

Answer 8

histologically - limited to ducts and lobules, myoepithelial cells preserved, does not breach basement membrane of invade into vessels, so cannot metastasise (see lecture 2 slide 34)

Question 9

how does breast cancer spread and which sites does it usually metastasise to?

Answer 9

lymph nodes via lymphatics, usually ipsilateral axilla
distant metastasis via blood vessels
usually to bone, lungs, liver, brain
invasive lobular carcinoma - peritoneum, retroperitoneum, leptomeninges, GI tract, ovaries, uterus

Question 10

what treatments are available for breast cancer?

Answer 10

breast surgery - masectomy, breast conserving
axillary surgery
post operative radiotherapy to chest and axilla
chemo
hormonal treatment - tamoxifen
herceptin treatment

Question 11

summarise the presentation and histological features of fibroadenoma

Answer 11

mobile mass
'breast mouse' - mobile and elusive
multiple or bilateral
can grow large
well circumscribed, rubbery, grey/white
mix of stromal and epithelial
localised hyperplasia 
(page 22 and 23)

Question 12

normal breast tissue histology

Answer 12

second lecture, slide 4

Question 13

what cell changes/processes take place which result in DCIS?

Answer 13

hyperplasia -> atypical hyperplasia -> ductal carcinoma in situ -> invasive