Breast Disease

Question 1

What is a carcinoma in situ?

Answer 1

This is when the carcinoma is maintained within the basement membrane and is classified as a pre-malignant condition.

Question 2

What are the two main types of carcinoma in situ, in breast disease?

Answer 2

Ductal carcinoma in situ - 20% of all breast cancers

Lobular carcinoma in situ

Question 3

What are the four different classifications of carcinoma in situ and which presentation is most common?

Answer 3

Solid

Micropapillary

Cribriform

Comedo

Nb. Lesions are most commonly mixed

Question 4

On screening, what will each disease show?

• DCIS
• LCIS

Answer 4

DCIS will show microcalcifications on mammography, confirmation of diagnosis on biopsy

LCIS doesn’t show calcifications and is usually diagnosed as an incidental finding on the breast.

Question 5

Which type of DCIS is most likely to form microcalcifications?

Answer 5

Comedo will most likely form calcifications.

Question 6

Which type of DCIS will show focal lesions on mammography?

Answer 6

Cribriform and micropapillary

Question 7

What is the management for DCIS?

Answer 7

Localised lesion - A wide local excision

Widespread or multifocal - complete mastectomy

Question 8

Which type of carcinoma in situ (in breast disease) is more likely to develop invasive cancer?

Answer 8

Lobular carcinoma in situ - although they are not as common as DCIS.

Question 9

What is the management for LCIS?

Answer 9

Low grade LCIS - monitor

Bilateral prophylactic mastectomy can be indicated in patients who have the BRCA1/2 genes.

Question 10

How can invasive breast cancers be classified?

Answer 10

1) Invasive ductal carcinoma - 80% of carcinomas
2) Invasive lobular carcinoma - 10% of carcinomas
3) Other subtypes - e.g. medullary and mucinous (aka colloid).

Question 11

Which patient demographic does invasive lobular carcinoma affect?

Answer 11

Older women.

Question 12

How does age affect the likelihood of someone getting breast cancer?

Answer 12

It doubles the likelihood of getting breast cancer every ten years until the menopause

Question 13

What are some of the risk factors for developing breast cancer?

Answer 13

• Female
• Older age
• Nulliparous
• Early menarche/late menopause
• First pregnancy after 30 years old
• Obesity
• Positive family history
• Genes - BRCA1/2, PTEN, TP53
• Geographic variation - more common in developed countries
• Oral contraceptives/HRT

Question 14

What are some of the clinical features of invasive breast cancer?

Answer 14

• Nipple changes - redness, retraction, abnormal discharge
• Skin changes - peau d’orange or Paget’s
• Lump in breast
• Lump in axilla
• Mastalgia

Question 15

Which tool is used to work out the prognosis of a patient with invasive breast cancer?

Answer 15

The Nottingham prognostic index

Question 16

Which tool is used to grade an invasive breast cancer?

Answer 16

The Bloom-Richardson scale

Question 17

Which receptors should be tested for in breast cancer?

Answer 17

ER - Oestrogen receptor

PR - Progesterone receptor

HER2 - Human epidermal growth factor 2 receptor

Question 18

Who qualifies for the breast screening programme? How often are they screened?

Answer 18

Women aged 50-70 years old, who are screened every 3 years

Question 19

How does Pagets disease present?

Answer 19

Roughening, reddening and hardening of the nipple, painful around the area. It is different to eczema as there is also nipple involvement as well as the areola. 97% of cases have underlying breast disease (whether in situ or invasive)

Question 20

How do you diagnose Paget’s disease?

Answer 20

A biopsy of the nipple is taken for histological analysis and in some cases the entire nipple is taken.

Question 21

What is the management for Paget’s disease?

Answer 21

In all cases the nipple and areola needs to be removed.

Radiotherapy may be necessary if there is an underlying malignancy.

Question 22

Describe breast conserving treatment in breast cancer?

Answer 22

The most common type is a wide local excision where the tumour is resected with a 1cm margin.

Question 23

What is a mastectomy?

Answer 23

This is removal of all of the breast tissue on the affected side/both sides alongside a significant portion of the overlying skin (dependent on whether a reconstruction will be carried out).

Question 24

When is a mastectomy indicated?

Answer 24

• Recurrent disease
• High tumour to breast tissue ratio
• Multifocal disease
• Patient choice

Question 25

What are the two main types of axillary surgery?

Answer 25

* Sentinel node biopsy - Blue dye injected into peri-areolar skin, sentinel nodes will become blue and are excised and sent for histological analysis * Axillary node clearance - All lymph nodes are removed and are sent for histological analysis. Common complications include lymphoedema, paraesthesia and seroma formation.

Question 26

When is medical management used in breast cancer?

Answer 26

As adjuvant therapy in a malignant non-metastatic breast cancer following WLE. In elderly women or those deemed unfit for surgery

Question 27

Tamoxifen - Mechanism of action - Patient demographic - Risks of treatment

Answer 27

- MOA: Oestrogen receptor blockade - Patient demographic: pre-menopausal women - Risks of treatment: uterine cancer risk increased, menopausal symptoms, increased risk of thromboembolic event

Question 28

Aromatase inhibitors Examples? MOA? Patient demographic? Risks?

Answer 28

Examples: Anastrozole, Letrozole MOA: Bind to oestrogen receptors to prevent further growth and oestrogen production. Also blocks conversion of androgens to oestrogens in peripheral tissue. Patient demographic: post-menopausal patients. They are shown to be more effective in these patients even though they are more expensive

Question 29

What is Herceptin? Clinical indication?

Answer 29

Trastuzumab - a monoclonal antibody that targets the activity of the HER2 receptor. It can be used as an adjuvant therapy or monotherapy in HER2 positive patients who have had at least 2 chemotherapy regimens for metastatic breast cancer.

Question 30

What is a common side effect of Herceptin?

Answer 30

Cardiotoxicity - therefore cardiac health has to be carefully monitored whilst patients are taking this medication.

Question 31

What is the procedure called whereby you will remove a tumour on the affected breast (WLE) and carry out a breast reduction on the contralateral side?

Answer 31

This is called a therapeutic mammoplasty.

Question 32

Name the three different flap formations that can be carried out in Oncoplastic surgery?

Answer 32

Latissimus dorsi flap - a free or pedicle flap. Only a small amount of muscle can be used so this technique is suited to smaller breasts. Transverse rectus abdominal muscle flap - use of muscle, fat and skin as a free or pedicle flap. This reduces fat on the abdomen but makes muscles weaker. Deep inferior epigastric perforator flap - a free flap using abdominal skin and tissue. No muscle is used so abdominal strength is maintained.