Week 7 - D - Breast conditions - DCIS, Cancer - Tx (Breast conservation & mastectomy) and symptoms, Benign conditions, screening

Question 1

What is the most common cancer among women?

Answer 1

The most common cancer among women is breast cancer

Question 2

Is the incidence of breast cancer changing? Is the mortality of breast cancer changing?

Answer 2

The incidence of breast cancer is steadily increasing and the mortality rates are steadily decreasing

Question 3

What are the risk factors for breast cancer?

Answer 3

• Increasing age and females
• Uninterrupted unopposed oestrogen exposure - early menarch, nullparity, age at first parity >30, not breastfeeding, late menarch, Hormones - being on the OCP or HRT
• Previously having had breast cancer or a family history of breast cancer - first degree relative, Having genetic mutations - BRCA1or2 Lifestyle - smoking, alcohol, obesity (adipocytes secrete oestrogen), physical inactiviy ,
• Lobular/ductal carcinoma in situ

Question 4

How much does having a first degree relative increase the rates of breast cancer?

Answer 4

Having a 1st degree relative doubles the risk of breast cancer

Question 5

If breast cancer is not asymptomatic, what are common presenting symptoms?

Answer 5

Might have blood nipple discharge Nipple inversion Depressed or dimpled skin A painless visible nipple lump Also colour or texture change of the breast

Question 6

What is the most common histological type of breast cancer?

Answer 6

Ductal carcinoma is the most common histological type of breast cancer

Question 7

When a woman presents to the doctor with a painless breast lump, usually an xray is taken (depending on the womans age) What might be seen in a woman with a ductal carcinoma in situ?

Answer 7

Usually the DCIS takes up a single ductand can have either: linear microcalcifications usually with casting and pleomorphic or appear as a stellate solid mass on xray Linear distribution is typically seen when DCIS fills the entire duct and its branches with calcification The calcification is usually described as pleomorphic - ie they have a sort of crushed stone like appearance

Question 8

The calcifications on the mammogram are often described as casting pleomorphic linear calcifications and sometimes can look different ie stellate solid mass LEFT: Lobular calcifications: punctate, round or ‘milk of calcium’ RIGHT: Intraductal calcifications: pleomorph and form casts in a linear or branching distribution.

How is definitive diagnosis of breast cancer achieved?

Answer 8

Definitive diagnosis is achieved via a needle core biopsy - usually image guided Picture shows the casting microcalcificiations If looking closely can see it is almost linear

Question 9

If the xray shows a stellate architectural mass and after taking the core needle biopsy and it comes back negative for malignant cells, what would you presume was the cause of the mass?

Answer 9

Would assume the cause was a radial scar A radial scar is a benign hyperplastic proliferative disease of the breast

Question 10

INvasive lobular carcinoma spreads diffusely, what is the pattern of spread typically described on histology for this type of invasive cancer? Is the cancer typically unilateral or bilateral in presentation?

Answer 10

INvasive lobular carcinoma is typically described by its Indian file pattern spread on histology - this is because the cells are single cellular and linear when invasive

Typically the cancer is bilateral (just as the lobular in situ neoplasia is bilateral)

Question 11

Lobular carcinoma in situ (LCIS) is thought to be a tumor marker with associated increased risk of eventual invasive carcinoma that usually is of the ductal type. What does lobular carcinoma in situ test negative for on immunohistocehmistry? (helps to differentiate LCIS from DCIS)

Answer 11

It is E-cadherin negative on immunohistochemistry

Question 12

Surgery is the preferred treatment for breast cancer What are the types of surgery? Which type of surgery would you then carry out breast reconstruction surgery?

Answer 12

Wide local excision or Mastectomy Most women who require or request mastectomy are candidates for breast reconstruction. This option should be presented to the patient when she is making her treatment choice.

Question 13

What does a modified radical mastectomy involve the removal of?

Answer 13

This involves the removal of the breast, including the overlying skin and the axillary lymph nodes

Question 14

What is the difference between modified radical and radical mastectomy?

Answer 14

Modified radical mastectomy does not involve the removal of the pectoralis major muscle and this potentially facilitates wound healing and perhaps even helps with reconstruction

Question 15

The choice of the reconstruction method depends upon the patient’s body habitus, co-morbidity, smoking history, size and shape of her breasts, her preference and the surgeon’s experience. What are some options for the breast reconstruction? What can immediate or delayed breast reconstruction following a modified radical mastectomy cause? (this is non skin sparing mastectomy NSSM)

Answer 15

Non-skin sparing mastectomy (NSSM) often results in scars on the new breast and a paddle of sin that is a different color

Usual options are

• A breast prosthesis
• Lattisimus dorsi myocutaneous flap
• Transversus abdominus myocutaenous (TRAM) flap

Question 16

What is the next most essential component of treatment for breast cancer? When is this treatment given in patients for whom have had a mastectomy?

Answer 16

This would be treating the patient with radiotherapy This is very important in patients who have had wide local excision and isnt usually used in mastectomy cases unless: Indications for post-mastectomy RT include involvement of more than three nodes, positive surgical margins and/or tumors larger than 5 cm

Question 17

What TNM score is it when radiotherapy is given in mastectomy? What stage is this generally?

Answer 17

Given when T >5cm (T3) and when 3 or more nodes are involved (N3) This is T3 N3 M0 disease Stage 3 breast cancer

Question 18

When is chemotherapy given in breast cancer?

Answer 18

It is usually given as an adjuvant in early stage (Stage 1 and 2) but used more in advanced stage breast cancer

Question 19

What is the most commonly used hormonal therapy in breast cancer? When is trastuzamab given?

Answer 19

Tamoxifen - the selective oestrogen receptor modular (SORM) is given in oestrogen receptor positive breast cancer - 1st line in premenopasual women Trastuzamab (Herceptin) is given in HER2 over expressing breast cancers and is generally given in combo with chemo

Question 20

What is the first line oestrogen receptor positive hormone drug for postmenopasual women with breast cancer?

Answer 20

This would be an aromatase inhibitor - eg anastrazole or letrozole

Question 21

What is carried out preoperatively to measure tumour extent into axilla?

Answer 21

Pretreatment ultrasound examiantion of the axilla and if there is morphological anomaly then USS guided biopsy Sentinel lymph node biopsy (SLNB) is the preferred technique if required

Question 22

What is the usual treatment for early and late disease breast cancer? Define early and advanced staging also

Answer 22

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Question 23

What is the most common benign neoplasm of the breast and what causes it?

Answer 23

This is a fibroadenoma It is due to the overgrowth of collagenous mesenchyme of one breast lobule resulting in a lump formation

Question 24

How does fibroadenoma usually present? How are fibroadenomas usually managed?

Answer 24

Usually present as a painless smooth lump which is non tender and very mobile Usually around age 30 in females and is mostly unilateral

Question 25

When definitely diagnosed, fibroadenomas need not be removed, because they tend to to remain unchanged or decrease in size approaching the menopause and usually become nonpalpable after the menopause. However, some women prefer to have such breast lumps excised. How are fibroadenomas diagnosed?

Answer 25

usually they are diagnosed on USS as the woman is below 40 and then a core biopsy to confirm

Question 26

some women prefer to have fibroadenomas excised. This performed electively in the form of open lumpectomy or percutaneous vacuum-assisted core biopsy as an outpatient procedure under local anesthesia. What are fibrocystic breasts? What age range does it typically affect and how does it present?

Answer 26

These are breasts where there is the excess of fibrous tissue and cysts Typically affects woman in their 20s-50s and occurs as multiple and often bilateral cysts in the breasts that range from 1mm to several cm Patients usually present with breats tenderness and pain in one or both breasts

Question 27

Which type of woman does fibrocystic change typically affect?

Answer 27

Fibrocystic change typically affects woman who have gone through early menarche or late menopuse It is thought to be hormone dependent as it has a cyclical change

Question 28

What is mastalgia? How can it present?

Answer 28

Many women have breast tenderness and pain It can present as cyclical mastalgia where the tenderness and pain occurs with the change in hormones ie in fibrocystic breast changes or non-cyclical Noncyclic mastalgia is usually localized, often persistent, and less responsive to treatment than cyclic mastalgia. Clinically, it is imperative to be certain the pain is within the breast and not of a nonbreast etiology affecting the anterior chest wall

Question 29

One of the main types of papillary breast lesion is an intraductal papilloma How does intraductal papilloma present? How is it diagnosed?

Answer 29

It is a benign proliferation of epithelial tissue within the lactiferous ducts of the breast which can often be associated with a bloody discharge from the breast Diagnose via US guided core biopsy

Question 30

Nipple discharge, usually clear, yellow, and watery, can be elicited from the nipples of most women of reproductive age. This is physiologic. Bloody nipple discharge, particularly from a single duct is pathologic and should be evaluated. The most common etiology of spontaneous nipple discharge is an intraductal papilloma or papillomas. These are benign lesions. Nipple discharge is rarely a sign of malignancy unless there is an associated palpable mass. What is the type of benign growth that is smotth and palpable and reveals adipose tissue only on histology?

Answer 30

This would be a lipoma

Question 31

What is a galactocele? When is it common? What can be used to diagnose and manage it?

Answer 31

A gactocele is a milk-filled cyst most commonly assoicated with pregnnacy and lactation FNA can be used for its diagnosis and treatment

Question 32

Fat necrosis of the breast can mimic cancer by examination but has a distinct mammographic appearance What is this usually caused by? How does it present?

Answer 32

This typically occurs when there is damage to the adipocytes during trauma causing fomay macrophages recruitment - this leads to fibrosis and scarring Presents as a tender firm mass in the breast - breast often has bruising due to the trauma

Question 33

What percentage of breast cancer patient are picked up on screening?

Answer 33

50% of asymptomatic patients are picked up on screening 50% of patients present symptomatically and half of these patients also have a lump as a symptom

Question 34

What is the triple assessment in breast lump presentation?

Answer 34

Clinical History + Examination Morphological - ultrasound or Mammorgram Pathology - cytopathology - fine needle aspiration mainly, histopathology - core-biopsy mainly

Question 35

What age cut off determines the first line radiological investigation for a women presenting with a breast lump?

Answer 35

Age 40 - carry out a mammogram It is usual practice for patients over 35 years with discrete breast lumps to undergo mammography and ultrasound. In patients under 35 years, ultrasound is the first line investigation

Question 36

Why is a mammogram not as effective in patients under the age of 40?

Answer 36

Younger woman have denser breasts and therefore mammograms arent as effective as ultrasound in detecting cancer

Question 37

What is the current screening programme for breast cancer in woman?

Answer 37

Breast cancer screening is currently offered to woman who are aged between 50-70 years of age every 3 years But NHS trying to extend this programme from 47-73 years of age