Treatment for Breast Cancer

Question 1

Who should be involved?

Answer 1

MDT of

Breast surgeons, radiologist, oncologists, pathologist

Breast cancer specialist nurses

Patient

Question 2

Types of surgery

Answer 2

Breast conserving

Mastectomy

Axillary

Question 3

What is breast conserving surgery?

Answer 3

Wide local excision with excision of the tumour + 1cm margin of normal tissue.

Question 4

Indications of WLE

Answer 4

Localised operable disease and no evidence of metastatic disease

Only suitable for focal smaller cancers

Question 5

What is mastectomy?

Answer 5

Removes all breast tissue

THe skin is then reconstructed.

Question 6

Indications of mastectomy

Answer 6

Multifocal disease

High tumour:breast tissue ratio

Disease recurrence

Patient choice

Question 7

When is axillary surgery done?

Answer 7

Alongside WLE and mastectomies in order to assess nodal status + remove any nodal disease

Sentinel node biopsy is done.

Question 8

What is sentinel node biopsy?

Answer 8

Sentinel node biopsy involves removing first lymph nodes into which the tumour drains

Nodes are identified by injecting a blue dye with associated radioisotope into the peri-areolar skin, the nodes should then become blue.

The sentinel node is removed and sent for histology.

Question 9

What is axillary node clearance?

Answer 9

Removes all nodes in the axilla and sent for histology

Question 10

Complications of axillary node clearance.

Answer 10

Paraesthesia

Seroma formation

Lymphoedema in upper limb

Question 11

What is risk-reducing mastectomy?

Answer 11

Removes healthy breast tissue in order to reduce the risk of developing breast cancer.

It is only suitable for high risk patients that wants to have it done.

Question 12

Risk factors that warrants risk-reducing mastectomy

Answer 12

Strong FH of breast or ovarian cancer

BRCA1/2, PTEN or TP53 mutations

Previous history of breast cancer

Question 13

Give examples of hormonal treatments

Answer 13

Tamoxifen

Aromatase inhibitor

Immunotherapy

Question 14

When is medical treatment used?

Answer 14

Usually after primary surgery or in elderly patients unfit for surgery.

Radiotherapy is offered to all patients after WLE in post-mastectomy cases with positive resection margins, tumour size >5 cm or 4 or more pathological nodes in axilla.

Question 15

When is tamoxifen used?

Answer 15

In pre-menopausal patients

Acts through blockade of oestrogen receptors meaning the patient must be ER+

Question 16

Risks of tamoxifen

Answer 16

Used as prophylaxis against breast cancer

But it increases risk of thromboembolism during and after surgery or period of immobility

Increases risk of uterine carcinoma as well due to its pro-oestrogenic effect on uterus.

Question 17

Give examples of aromatase inhibitors

Answer 17

Anastrozole

Letrozole

Exemestane

Question 18

How do aromatase inhibitors work?

Answer 18

Bind to oestrogen receptors to inhibit further malignant growth and prevent further oestrogen production.

Blocks conversion of androgens to oestrogen in peripheral tissues as well.

Question 19

When are aromatase inhibitors used?

Answer 19

Post-menopausal patients as adjuvant therapy

Shown to be superior in this patient subgroup to tamoxifen.

Question 20

Give examples of immunotherapies

Answer 20

Herceptin (Trastuzumab) monoclonal antibody

Question 21

When is immunotherapy used?

Answer 21

In patients whose cancers express specific growth factor receptors.

Herceptin is used in HER-2+ve malignancies

Used as adjuvant therapy or in monotherapy in patients who have received at least two chemotherapy regimen for metastatic breast cancer.

Cardiotoxicity can happen so cardiac function needs monitoring

Question 22

What is therapeutic mammoplasty?

Answer 22

WLE + breast reduction technique.

The end-result is a smaller and uplifted breast with the nipple and areola preserved.

Question 23

Give examples of flap formations

Answer 23

Latissimus Dorsi flap

Transverse Rectus Abdominal Muscle flap TRAM

Deep inferior epigastric perforator flap DIEP

Question 24

Explain lats dorsi flap

Answer 24

Part of lats dorsi muscle and its overlying skin used to reconstruct the removed breast.

This is only used to reconstruct smaller breasts because only a small bit can be used of the muscle.

Question 25

Explain TRAM flap formation.

Answer 25

Abdo msucle, skin and fat are used to reconstruct.

Removes abdo fat (usually seen as +ve) but reduces abdo muscle strength.

Question 26

Explain DIEP flap formation.

Answer 26

Uses tissue from abdomen + overlying skin to reconstruct the breast.

Advantage is that no muscle is taken so abdominal muscle strength is usually maintained.