Malignant Breast Disease

Question 1

Name the most common breast malignancy

Answer 1

Carcinoma

Question 2

Name three metastatic malignancies that can occur in the breast

Answer 2

Carcinoma - bronchial, ovarian serous, clear cell of kidney
Melanoma
Soft tissue

Question 3

Name three miscellaneous malignant diseases

Answer 3

Malignant phyllodes tumour - stromal component
Angiosarcoma - post radiotherapy
Lymphoma - breast, lymph nodes

Question 4

Define breast carcinoma

Answer 4

A malignant tumour of breast epithelial cells that arises in the glandular epithelium of the terminal duct lobule unit

Question 5

What are the two vague types of precursor lesion?

Answer 5

Ductal

Lobular

Question 6

Name four ductal precursor lesions

Answer 6

Epithelial hyperplasia of usual type
Columnar cell change
Atypical ductal hyperplasia
Ductal carcinoma in situ

Question 7

What are the two types of lobular precursor?

Answer 7

Atypical lobular hyperplasia

Lobular carcinoma in situ

Question 8

Define in situ carcinoma

Answer 8

Confined within basement membrane of acini and ducts

Question 9

What is the difference between atypical lobular hyperplasia and lobar carcinoma in situ?

Answer 9

ALH - <50% lobule involved

Lobular carcinoma in situ >50% lobule involved

Question 10

What does a lobular carcinoma in situ look like?

Answer 10

Interlobular proliferation of characteristic cells, small/intermediate nuclei, solid proliferation, intra-cytoplasmic lumen/vacuoles

Question 11

Are lobular carcinoma in situ ER positive or negative?

Answer 11

Positive

Question 12

What staining can help identify lobular carcinoma in situ?

Answer 12

E-cadherin negative - deletion and mutation of CDH1 gene on chromosome 16

Question 13

Describe the clinical features of lobular carcinoma in situ?

Answer 13

Multifocal and bilateral, incidence decreases after menopause not palpable or visible but may cacify and be seen on mammogram. Usually incidental

Question 14

What is the risk of invasive carcinoma with lobular carcinoma in situ?

Answer 14

8 times higher

Question 15

How is lobular carcinoma in situ managed?

Answer 15

Core biopsy - excision/vacuum biopsy to exclude high grade

Follow up

Question 16

What are the three classifications of DCIS?

Answer 16

Low
Intermediate
High grade

Question 17

How are most cases of DCIS detected?

Answer 17

Breast screening

Question 18

Define DCIS

Answer 18

Cytologically malignant epithelial cells confined within the basement membrane of the duct

Question 19

What can occur as DCIS starts to spread?

Answer 19

Paget’s Disease of Nipple

Question 20

Describe Paget’s Disease of Nipple

Answer 20

High grade DCIS extends along the ducts to reach the epidermis of the nipple - non-invasive carcinoma in situ causing ulceration and discolouration

Question 21

How is DCIS classified?

Answer 21

Cytological grade
Histological type
Presence of necrosis

Question 22

How is DCIS managed?

Answer 22

Surgery
Adjuvent Radiotherapy
Chemoprevention

Question 23

Define malignant breast carcinoma

Answer 23

Malignant cells that have breached the basement membrane

Question 24

Name the different types of breast carcinoma

Answer 24

Tubular
Lobular
Ductal (G1, G2, G3)
Pleo lobular

Question 25

State the risk factors for breast carcinoma

Answer 25

``` Age Reproductive History Hormones (OCP, HRT) Previous breast disease Geography Lifestyle Genetics ```

Question 26

What genetic mutations predispose to breast cancer?

Answer 26

``` BRCA1 BRC2 TP53 PTEN STKII/LKBI ATM ```

Question 27

What percentage of the population have a BRCA mutation?

Answer 27

0.1%

Question 28

Describe the staging of breast carcinoma

Answer 28

T0-4 - local invasion (stroma, skin, chest wall muscle) N0-N3 - lymphatics M0-M1 - blood borne

Question 29

Where does breast carcinoma tend to spread?

Answer 29

Bone, liver, brain, lungs, abdomen, female genital tract

Question 30

Describe the grading of breast carcinoma

Answer 30

Differentiation - tubular (1-3) - nuclear (1-3) - mitotic (1-3)

Question 31

What differentiation scores correspond to which grade?

Answer 31

``` 3-5 = grade 1 6/7 = grade 2 8/9 = grade 3 ```

Question 32

What is intrinsic profiling based on?

Answer 32

Genes

Question 33

What types are ER negative?

Answer 33

Basal-like HER2+ Normal

Question 34

What types are ER positive?

Answer 34

Luminal subtypes A - low proliferation | B and C - high proliferation

Question 35

Name three hormone receptors

Answer 35

Oestrogen receptor Progesterone receptor HER2

Question 36

Describe the oestrogen receptor and associated treatment

Answer 36

Expression predicts response to anti-oestrogen therapy - oophorectomy, tamoxifen, aromatase inhibitor (letrozole), GnRH antagonist (goserilin)

Question 37

Describe HER2

Answer 37

Human epidermal growth factor receptor 2 - over expression or amplification - responds to trabtuzamab (herceptin)

Question 38

What is herceptin?

Answer 38

Monoclonal antibody that blocks the receptor

Question 39

Which receptor profile has worst prognosis?

Answer 39

Triple negative

Question 40

What does NHS PREDICT include and determine?

Answer 40

Histopathology, ER, Clinical factors (age and menopause), HER2, mode of detection Calculates survival table