Breast

Question 1

Epidemiology of breast cancer

Answer 1

2nd most common form of cancer affecting women in the western world

Mortality decreasing, incidence increasing

1 in 7 women in the UK

Most common 40-70

Question 2

National breast screening programme

Answer 2

2-view mammography every 3yrs for women 47-73 in UK

Aims to identify DCIS (pre-cancer, microcalcifications) & small invasive carcinomas at an early stage before symptoms & signs

Reduce morbidity & mortality of cancer

Suspicious features → further assessment (imaging e.g. US, exam, FNA/core biopsy)

Question 3

Risk factors for breast cancer

Answer 3

Age >50
Female
Genetics (BRCA1/2, P53 - Li Fraumeni syndrome)
Past breast cancer 
Age at first pregnancy (>30 high risk)
Irradiation
Oestrogen exposure (obesity, late menopause/early menarche, nulliparity, no breast feeding exogenous oestrogen)
Alcohol consumption

Question 4

Protective factors against breast cancer

Answer 4

Being physically active
Breastfeeding
Diet
Aspirin
NSAIDs

Question 5

Signs and symptoms of breast cancer

Answer 5

Usually upper quadrant
Lump:
Usually painless, hard, gritty, immobile, tethered, ill-defined edges, irregular

Nipple:
Discharge, blood stained, inverted, eczema in Paget’s disease, retraction

Skin changes:
Dimpling, puckering, colour changes, peau d’orange (cutaneous oedema 2o to dermal lymphatic obstruction), ulceration

Lymphadenopathy:
Enlarged nodes

Systemic features:
Weight loss, anorexia, bone pain, jaundice, anaemia, malignant pleural & pericardial effusions

Question 6

Common sites of metastasis in breast cancer

Answer 6

Lymph nodes
Bone
Brain
Lung
Liver

Question 7

Investigations for breast cancer

Answer 7

MDT
History and exam
Imaging: US, mammogram, MRI useful in lobular cancer
Pathology: FNA and core biopsy
Staging: CXR, bone scan, liver US, CT/MRI or PET/CT, LFTs and Ca

Question 8

Importance of axillary lymph node

Answer 8

1st node draining cancer
If clear very high likelihood cancer has not spread
Prognostic info
Unnecessary risk of lymph node clearance
(lymphoedema, shoulder stiffness)

Question 9

Types of invasive adenocarcinoma in breast cancer

Answer 9

75% ductal carcinoma

10% lobular

Question 10

Ductal carcinoma subtypes

Answer 10

In situ:
Epithelial cells show cytological signs of malignant but basement membrane still in tact (pre-cancerous)

Invasive:
Tumour cells invaded through BM into adjacent tissue, meaning there is potential for metastasis
Usually presents as a palpable mass

Question 11

Lobular carcinoma subtypes

Answer 11

In situ:
Rarer, tends to be multifocal

Invasive:
Tumour cells infiltrate breast tissue as linear cord of cells pattern or as single cells which appear to be separate from one another

Question 12

Paget’s disease of nipple

Answer 12

Skin of nipple and areola
Presence of DCIS cells in epidermis
May extend along the major ducts and reach nipple
Enter deeper layers of epidermis and spread with it through nipple and areola

Question 13

Oestrogen receptor (ER) breast cancer +/-

Answer 13

+: lower grade, less aggressive, likely to respond to hormonal therapy

-: higher grade, more aggressive, unlikely to respond hormonal therapy

Question 14

HER2 (oncogene) +/-

Answer 14

+: poorer prognosis without treatment, good response to herceptin

-: less aggressive

Question 15

Medical management of breast cancer

Answer 15

Adjuvant to reduce risk of systemic relapse post surgery

Occasionally used in elderly/those unfit for surgery

Hormonal in ER+ patients (tamoxifen, letrozole)

Targeted/biological in HER2+ patients (trastuzumab)

Radiotherapy

Chemotherapy

Bisphosphonates for osteoporosis

Question 16

Surgical management of breast cancer

Answer 16

Breast conserving with wide local excision with radiotherapy

Mastectomy - non-radical preserves pec muscles

Breast reconstruction - immediate or delayed

Lymph node management - sentinel node biopsy, axillary node sampling, axillary node clearance

Metastatic disease - surgery limited to procedures for symptomatic control of local disease