Breast carcinoma

Question 1

Define a breast carcinoma.

Answer 1

Malignancy originating in the breasts and nodal basins that may be classified into 3 stages which are defined by the extent of disease.

Question 2

How common is it?

Answer 2

· Most common female malignancy. 1 in 10 new cancers diagnosed each year is breast cancer.

· Decline in incidence due to breast screening and reduction in the use of HRT.

Question 3

Who is most commonly affected?

Answer 3

· Incidence is higher for women aged 50 and over.
· White people have higher incidence rates as they get older.
· Death rates in black people are higher though.

Question 4

What is the pathophysiology of a breast carcinoma?

Answer 4

· Malignant cells result from a cascade of genetic events involving the uncontrolled expression of endogenous growth factors and signalling pathways.
· This has led to innovations in targeted therapy of the disease.
· Also, loss of tumour suppressor genes has been associated with familial syndromes.

Question 5

How do co-morbidities affect the prognosis of a breast carcinoma?

Answer 5

Co-morbidities exert a significant negative influence on patient outcome.

Question 6

What is the aetiology of a breast carcinoma?

Answer 6

· Genetic - lifetime incidence of breast cancer in BRCA mutation carriers is 87%.

· Hormonal - oestrogen plays a role in the stimulation of mammary tumours.

Question 7

List the most common risk factors.

Answer 7

· Increasing age. 
· Female. 
· Ethnic origin - white/caucasian has the most risk then black, then Asian/Latin/Native Americans. 
· High socioeconomic class.
· Positive FH/Genetic disposition. 
· High levels of alcohol consumption. 
· Radiation exposure. 
· Benign breast disease.

Question 8

What are the most common presenting signs and symptoms?

Answer 8

· Breast mass.
· Nipple discharge.
· Axillary lymphadenopathy.
· Skin changes - peau d’orange, tethering.
· Retraction or scaling of the nipple (may be related to Paget’s disease of the breast).

Question 9

What investigations would you request to confirm the diagnosis?

Answer 9

· Mammogram.
· Breast USS. 
· Breast MRI. 
· Biopsy. 
· Hormone receptor testing. 
· HER2 receptor testing.

Question 10

Suggest some differential diagnoses.

Answer 10

· Fibrocystic changes.
· Fibroadenoma.
· Mastitis.

Question 11

What 4 treatment options are available?

Answer 11

· Surgery.
· Chemotherapy.
· Radiotherapy.
· Osteoporosis prophylaxis and bisphosphonates.

Question 12

What complications can arise?

Answer 12

· Chemotherapy - related N&V.
· Chemotherapy - related neutropenia/neutropenic fever. Occurs 10-14 days following chemo.
· Aromatose inhibitor - related osteopenia/osteoporosis.
· Drug-related vasomotor syndrome. Menopause symptoms.
· Lymphoedema. Following axillary node dissection.

Question 13

What is the treatment option for a patient who is node-negative + HER2 negative?

Answer 13

Surgery (1st line) + chemo + radiotherapy.

Question 14

What is the treatment option for a patient who is node-positive + HER2 negative?

Answer 14

Surgery (1st line) + chemo (plus taxane-based chemo) + radiotherapy.

Question 15

What is the treatment option for a patient who is node positive or negative + HER2 positive?

Answer 15

Surgery (1st line) + herceptin/trastuzumab-based chemo + radiotherapy.