Breast Cancer

Question 1

Describe breast cancer findings on examination

Answer 1

• May be hard, irregular, painless, fixed lesions
• May be tethered to the skin or the chest wall
• May cause nipple retraction
• May cause skin dimpling or oedema (peau d’orange)

Question 2

Two week urgent referral criteria

Answer 2

• A discrete lump with fixation, that enlarges and/or with any concerns (e.g. family history)
• Women over 30 with a persistent breast or auxiliary lump or focal lumpiness after their menstrual period
• Previous breast cancer with new suspicious symptoms
• Skin or nipple changes suggestive of breast cancer
• Unilateral bloody nipple discharge

Question 3

Breast Cancer RF

Answer 3

• Female (99% of breast cancers)
• Oestrogen Exposure (years of menstruation, few/no children/no breast feeding)
• Obesity
• Smoking
• Family history (first degree relatives)

Question 4

Genetic predisposition

Answer 4

•BRCA genes are tumour suppressor genes
•Faulty BRCA1 gene
◦Chromosome 17
◦Around 60% (to 80%) will develop breast cancer
◦Around 40% will develop ovarian cancer
◦Also increased risk of bowel and prostate cancer

•Faulty BRCA2 gene
◦Chromosome 13
◦Around 40% will develop breast cancer
◦Around 15% will develop ovarian cancer

•Many other rarer genetic abnormalities are associated with breast cancer (e.g. TP53 and PTEN genes)

Question 5

Where are breast cancer metastasis?

Answer 5

• Lungs
• Liver
• Bones
• Brain

Question 6

Ductal Carcinoma in Situ

Answer 6

• Pre-cancerous or cancerous epithelial cells of the breast ducts
• Localised to a single area
• Often picked up by mammogram screening
• Potential to spread locally over years
• Potential to become an invasive breast cancer (around 30%)
• Good prognosis if full excised with adjuvant treatment

Question 7

Lobular Carcinoma in Situ

Answer 7

• Also referred to as “lobular neoplasia”
• A pre-cancerous condition occurring typically in pre-menopausal women
• Asymptomatic and undetectable on mammogram
• Usually diagnosed incidentally on breast biopsy
• Represents an increased risk of invasive breast cancer in the future (around 30%)
• Usually managed with close monitoring (e.g. 6 monthly examination and yearly mammograms)

Question 8

Invasive Breast Cancer (NST)

Answer 8

• NST = No Specific Type
• Also known as Invasive Ductal Carcinomas
• Originate in cells from the breast ducts
• 80% of invasive breast cancers fall into this category
• Show up on mammograms

Question 9

Invasive Lobular Breast Cancer

Answer 9

• Around 10% of invasive breast cancers
• Originate in cells from the breast lobules
• Not always visible on mammograms

Question 10

Inflammatory Breast Cancer

Answer 10

• 1-3% of breast cancers
• Presents similarly to a breast abscess or mastitis
• Swollen, warm, tender breast with pitting skin (peau d’orange)
• Does not respond to antibiotics
• Worse prognosis than other breast cancers

Question 11

Paget’s Disease of The Nipple

Answer 11

• Looks like eczema of the nipple/areolar
• Erythematous, scaly rash
• Indicates breast cancer involving the nipple
• May represent DCIS or invasive breast cancer
• Requires biopsy, staging and treatment as with any other invasive breast cancer

Question 12

NHS BC screening

Answer 12

• Offered to women aged 50 to 70 (extended in some areas)
• Individual offered screening every 3 years
• Involves a simple mammogram

Question 13

Limitations of Screening

Answer 13

• False positives and negatives

* Exposure to radiation (causes around 5 cancers per 10,000 women who undergo full screening)

Question 14

High Risk Screening

Answer 14

•Patients should be offered genetic counselling and pre-test counselling prior to testing
•Tests available for BRCA1, BRCA2, TP53 and PTEN genes
•Screening for breast cancer in high risk patients consists of annual mammograms ◦Aged 40-49 if moderate risk
◦Aged 40-59 if high risk
◦Aged 40-69 if known BRCA positive
◦Consider offering aged 30-59 if high risk

Question 15

Triple diagnostic assessment

Answer 15

Once a patient has been referred for specialist services under a two week wait referral for suspected cancer they should initially receive triple diagnostic assessment comprising of:
•Clinical Assessment
•Breast Imaging (ultrasound or mammography)
•Biopsy (fine needle aspiration or core biopsy)

Question 16

Ultrasound vs Mammogram

Answer 16

• Younger women have denser breasts with more glandular breasts
• Ultrasound:

◦Typically used to assess lumps in younger women (e.g. <30)
◦Useful in distinguishing solid lumps (e.g. fibroadenoma / cancer) from cystic lumps

•Mammogram:

◦More effective in older women
◦Pick up calcifications missed by ultrasound

Question 17

Assessing Lymph Nodes

Answer 17

• Before surgery: everybody offered axillary ultrasound and ultrasound guided biopsy of any abnormal nodes
• During surgery: where no abnormal lymph nodes are found using Sentinal Lymph Node Biopsy

Question 18

Sentinal Node Biopsy

Answer 18

• Performed during breast surgery for cancer
• Where no abnormal lymph nodes identified prior to surgery
• Isotope contrast and a blue dye are injected into the tumour area
• This is carried through the lymphatics to the first lymph node (the sentinel node)
• This node shows up blue and on the isotope scanner
• This node is then sampled to stage the cancer

Question 19

Types of Surgery

Answer 19

•Breast Conserving Surgery ◦Lumpectomy
◦Wide Local Excision
◦Quadrantectomy (removal of a quarter of the whole breast)

•Mastectomy (removal of the whole breast)

Question 20

Axillary Clearance (when offered and complication)

Answer 20

• Offered to patients where early invasive breast cancer has been demonstrated in axillary nodes
• Involves removing the majority or all lymph nodes from the axilla
• Increases risk of chronic lymphedema in that arm

Question 21

Chronic Lymphodema following axillary node clearance

Answer 21

• Can occur in the ipsilateral arm to the breast undergoing surgery
• This can have a large impact on the patient’s quality of life
• Patients should be informed of the risk of lymphoedema prior to surgery
• Resting the arm post operatively, certain exercises and avoiding injury or infection reduces the risk of developing lymphoedema
• Specialist lymphoedema services available

N.B. Do not take bloods from this arm

Question 22

When is radiotherapy offered?

Answer 22

Offered following Breast Conserving Surgery with Clear Margins

Question 23

Describe why radiotherapy and why its offered

Answer 23

• Radiotherapy allows for breast conserving surgery with equal outcomes to full mastectomy in patients with early breast cancer
• Radiotherapy post-surgery reduces local recurrence
• Involves radiotherapy delivered from multiple angles to concentrate radiation on targeted area
• Usually involves daily treatments for 3-5 weeks

Question 24

Side effects of radiotherapy in breast cancer

Answer 24

• General fatigue from the radiation
• Local skin and tissue irritation and swelling
• Fibrosis of breast tissue
• Shrinking of breast tissue
• Long term skin colour changes (usually darker)

Question 25

What should oestrogen receptor positive women be offered?

Answer 25

* Premenopausal women should be offered Tamoxifen | * Post-menopausal women should be offered an aromatase inhibitors (anastrozole, exemestane or letrozole)

Question 26

What should HER2 positive women be offered

Answer 26

* Should be offered trastuzumab (Herceptin), a monoclonal antibody (biological therapy) that disrupts the HER2 receptor * Given every 3 weeks for 1 year following initial treatment * Impacts heart function, therefore initial and close monitoring of heart function essential * Contraindicated in women with congestive heart failure and certain heart conditions * Common side effects: Diarrhoea, tumour pain, headaches.

Question 27

Chemotherapy

Answer 27

•Used in one of three scenarios: ◦Neoadjuvant therapy – intended to shrink the tumour prior to surgery ◦Adjuvant chemotherapy – after the surgery to reduce recurrence ◦For treatment or control of metastatic or recurrent breast cancer

Question 28

When is reconstructive therapy offered

Answer 28

* Offered to all patient having a mastectomy * Immediate reconstruction done at the same time as the mastectomy * Reconstruction can be delayed for years after initial mastectomy * May not be possible due to required chemo or radiotherapy or comorbidity

Question 29

Implants

Answer 29

* Simple procedure with minimal scarring * Reasonable appearance but less natural feel (cold, less mobile and static size and shape) * Long term problems include hardening, leakage, and shape change

Question 30

Latissimus Dorsi flap

Answer 30

* Portion of the latissimus dorsi plus skin and fat tissue * Tunnelled under skin to the breast area * “Pedicled” refers to keeping the original blood supply and moving the tissue under the skin to a new location * “Free flap” refers to cutting the tissue away completely and transplanting it to a new location

Question 31

Transverse rectus abdominus flap

Answer 31

* Portion of rectus abdominis along with blood supply and skin * Either as pedicled flap (tunneled under skin) or free flap (transplanted) * Risk of abdominal hernia due to weakened abdominal wall

Question 32

Deep Inferior Epigastric Perforator Flap

Answer 32

* Skin and subcutaneous fat from abdomen (no muscle) * Transplanted from abdomen to breast * Transplant the Deep Inferior Epigastric Artery with fat and skin * Tissue transplanted to reconstruct breast * Vessels attached to branches of the internal mammary artery and vein * Very complex procedure with microsurgery * Less risk of abdominal wall hernia as muscle are intact

Question 33

Surveillance Mammography

Answer 33

* No screening for women with total mastectomies * Yearly mammograms for 5 years in patients with early breast cancer * After 5 years, screening frequency is based on the risk category for the individual