Breast

Question 2

Breast cancer RFx

Answer 2

• FEMALE
• Increased OESTROGEN (early menarche + late menopase)
• More glandular tissue
• OBESITY
• ALCOHOL (metabolised into carcinogen) / SMOKING
• 1ST DEGREE RELATIVE (FHx)

cOCP + HRT (esp combined)

Question 3

Breast Cancer pathophys

Answer 3

BRCA (BReast CAncer) gene = tumour suppressor -> mutation = cancer

• BRCA1 (chromosome 17)
  
  • 70% breast cancer by 80 + 50% ovarian
  • bowel + prostate
• BRCA2 (chromosome 13)
  
  • 60% breast by 80 + 20% ovarian

Question 4

Types of breast cancer

Answer 4

• Ductal carcnioma in situ
• lobular carcinoma in situ
• Invasive ductal carcinoma (no specific type - NST)
• Invasive lobular carcinoma
• Inflam breast cancer
• Paget’s disease of Nipple

Rare:
Medullary breast cancer
Mucinous breast cancer
Tubular breast cancer
+ more

Question 5

Breast Cancer screening

Answer 5

NHS -> MAMMOGRAM every 3 YEARS for everyone 50-70 Y/O (post-menopausal typically)

Then call back + thermography if something seems unusual

Can also use a MRI in complex cases (useful in ppl with implants too)

Question 6

Downsides to breast cancer screening

Answer 6

• Anxiety and stress
• Exposure to radiation, with a very small risk of causing breast cancer
• Missing cancer, leading to false reassurance
• Unnecessary further tests or treatment where findings would not have otherwise caused harm
• Expensive

But benefits outweigh risks usually

Question 7

Which people are high-risk for breast cancer

Answer 7

People with significant FHx:

• 1st degree relative under 40
• 1st degree male relative
• 1st degree relative with bilateral breast cancer diagnosed under 50
• 2 or more 1st degree relatives

Question 8

Interventions for women at high-risk of breast cancer

Answer 8

Secondary care clinic or specialist genetic clinic

• can get genetic testing (need genetic and pre-test counselling)

Get ANNUAL mammogram

May use CHEMOPREVENTION:
- Tamoxifen (premenopause)
- Anastrozole (postmenopause - CI if severe osteoporosis)

Risk -reducing bilateral mastectomy or oophrectomy (less common)

Question 9

Clinical features suggestive of breast cancer

Answer 9

• Lumps: HARD, IRREGULAR, PAINLESS or FIXED
  
  • may be tethered to skin/chest wall
• NIPPLE RETRACTION
• Skin dimpling (peau d’orange)
• LYMPHADENOPATHY (esp axilla)

Question 10

When is a 2 week wait referral recommended for breast cancer

Answer 10

• An unexplained breast lump in patients aged 30 or above
• Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes)

Consider for:
- unexplained axilla lump in over 30s
- indicative skin changes

Question 11

What is the algorithm for once someone gets a 2 week referral for breast ca

Answer 11

Triple diagnostic assessment:

• Clinical assessment (history and examination)
• Imaging (ultrasound or mammography)
  - also of lymphnodes in the axilla + to guide biopsy of any abnormal nodes
• Biopsy (fine needle aspiration or core biopsy)

Question 12

USS vs mammography for breast cancer

Answer 12

• USS better for younger women (have more glandular tissue)
  
  • good to distinguish between solid and cystic
• Mammogram better for older
  
  • can pick up calcifications

Can also use MRI for screening high-risk or to further assess tumour dimensions

Question 13

What is a sentinal node biopsy

Answer 13

A sentinal node is the first node in the lymphatic drainage of a tumour area

Injecting isotope contrast and dye into tumour area highlights the sentinal node. A biopsy can be taken and nodes removed if cancer found.

Done if initial USS shows no abnormal nodes

Question 14

Breast Cancer Receptors

Answer 14

Oestrogen receptors (ER)
Progesterone receptors (PR)
Human epidermal growth factor (HER2)

Treatment depends on which is present. Cancer can be triple negative = worse prognosis,

Question 15

Where can breast cancer metastesise

Answer 15

Anywhere in body. But Main sides are:

• LUNGS
• LIVER
• BRAIN
• BONES

Question 16

Breast Cancer Tx

Answer 16

• Surgery
  
  • Breast conservation + radiotherapy
  • Mastectomy
  • Axillary clearance (SE: chronic Lymphoedema)
• Adjuvent Radiotherapy (SE: fatigue, irritation, fibrosis, shrinking)
• Chemo (typically if sensitive):
  
  • Neoadjuvant
  • Adjuvant
  • treat mets/recurrance
• Hormone therapy (for 5-10 years)
  
  • Tamoxifen, goserelin (- a GnRH agonist) (premonopause) (SE: risk of endometrial cancer)
  • Aromatase inhib (postmenopause)
• Adjuvent bisphosphonates in postmenopausal women

Question 17

Tamoxifen MOA

Answer 17

Selective oestrogen receptor modulator (SERM)

Blocks oestrogen receptors in breast tissue, and stimulates oestrogen receptors in the uterus and bones

helps prevent osteoporosis, but it does increase the risk of endometrial cancer

Question 18

Aromatase inhib MOA

Answer 18

Aromatase is found in fat - converts androgens to oestrogen -> primary oestrogen sourse post-menopause

Inhibs stop oestrogen production in fat

Question 19

Examples of targeted therapy for breast cancer

Answer 19

Basically just HER2 Ab

Trastuzumab (Herceptin) is a monoclonal antibody that targets the HER2 receptor. It may be used in patients with HER2 positive breast cancer. Notably, it can affect heart function; therefore, initial and close monitoring of heart function is required.

Pertuzumab (Perjeta) is another monoclonal antibody that targets the HER2 receptor. It may be used in patients with HER2 positive breast cancer. This is used in combination with trastuzumab (Herceptin).

Neratinib (Nerlynx) is a tyrosine kinase inhibitor, reducing the growth of breast cancers. It may be used in patients with HER2 positive breast cancer.

Question 20

Types of breast reconstruction

Answer 20

After breat-conserving surg:

• Partial reconstruction (using a flap or fat tissue to fill the gap)
• Reduction and reshaping (removing tissue and reshaping both breasts to match)

Mastectomy:

• Breast implants (inserting a synthetic implant)
• Flap reconstruction (using tissue from another part of the body to reconstruct the breast)

Question 21

Breast implants pros + cons

Answer 21

Pros:
- simple
- minimal scarring

Cons:
- Less natural
- Long term problems
- Hardening
- Leakage
- Shape change

Question 22

Types of flap breast reconstruction

Answer 22

• Latissimus Dorsi Flap
• Transverse Rectus Abdominis Flap (TRAM Flap)
• Deep Inferior Epigastric Perforator Flap (DIEP Flap)

Question 23

Pedicled vs Free flap

Answer 23

“Pedicled” - keeping the original blood supply and moving the tissue under the skin to a new location.

“Free flap” - cutting the tissue away completely and transplanting it to a new location.

Question 24

In situ breast carcinoma defination

Answer 24

non-invasive breast cancer that is confined to the duct or lobule in which it originated and does not extend beyond the basement membrane

Potential precursor to invasive carcinoma

Question 25

Types of breast carcinoma in situ

Answer 25

Ductal Carcinoma In Situ (DCIS) Lobular Carcinoma In Situ (LCIS) - classical - pleomorphhic - florid

Question 26

Ductal Carcinoma In Situ (DCIS)

Answer 26

- 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 and adjuvant treatment is used

Question 27

Lobular Carcinoma In Situ (LCIS)

Answer 27

- **Pre-cancerous** condition occurring typically in **pre-menopausal women** - Usually **asymptomatic and undetectable on a mammogram** - Usually diagnosed **incidentally on a breast biopsy** - increased risk of invasive breast cancer in the future (around 30%) - Often managed with close monitoring (e.g., 6 monthly examination and yearly mammograms)

Question 28

Paget’s Disease of the Nipple

Answer 28

- 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 29

Breast abscess

Answer 29

Collection of PUS within breast, usually caused by BACTERIAL INFECTION Can be lactational (related to breastfeeding) or non-lactational

Question 30

Abscess pathophys

Answer 30

Inflam -> PUS -> trapped -> abscess

Question 31

RFx for mastitis/abscesses

Answer 31

- SMOKING - Damage to nipple (eczema, piercings, candida) - Underlying breast disease (e.g. cancer) affecting DRAINAGE

Question 32

Most common causative organisms of breast absecess

Answer 32

- **Staphylococcus aureus** (the most common) - Streptococcal species - Enterococcal species - Anaerobic bacteria (such as Bacteroides species and anaerobic streptococci)

Question 33

Mastitis/breast abscess Sx

Answer 33

If **infection** is present: - Nipple changes - Purulent DISCHARGE - PAIN + TENDERNESS - Warmth, Erythema, Swelling - HARDENING OF SKIN/TISSUE KEY FEATURE of BREAST ABSCESS = swollen, tender lump which i **FLUCTUANT** (fluid moves on palpation) +/- general symps e.g. myalgia, fatigue, fever, septic

Question 34

Mastitis management

Answer 34

Lactational = conservative - continue breastfeeding - express milk - breast massage - Warm packs/showers + analgesia for symps Non-lactational - Analgesia - ANTIBIOTICS (broad spec as can be aerobic or anaerobic -> CO-AMOX or MACROLIDES AND METRONIDAZOLE) - Treat underlying causes (eczema, candida)

Question 35

Breaset abscess management

Answer 35

- Referral to the on-call surgical team - Antibiotics - Ultrasound (confirm the diagnosis and exclude other pathology) - Drainage (needle aspiration or surgical incision and drainage) - MS+C of drained fluid

Question 36

Fibroadneoma

Answer 36

Small, MOBILE benign tumours of stromal/epithelial breast duct tissue More common in 20-40 y/o (due to response to female hormones)

Question 37

On examination, fibroadenomas are:

Answer 37

Painless Smooth Round Well circumscribed (well-defined borders) Firm Mobile (moves freely under the skin and above the chest wall) Usually up to 3cm diameter

Question 38

Breast cysts

Answer 38

Benign, individual, fluid-filled lumps - most common cause of lumps. Typically in 30-50 y/o

Question 39

On examination, breast cysts are:

Answer 39

- Smooth - Well-circumscribed - Mobile - Possibly fluctuant Can be painful and fluctuate in size with menstrual cycle

Question 40

Management of breast cysts

Answer 40

further assessment to exclude cancer (may slightly increase risk), with imaging and potentially aspiration or excision. - Aspiration can resolve pain

Question 41

What is included in a triple assessment for breast cancer

Answer 41

Clinical score 1-5 (1 = norm; 5 = malignant) Imaging score 1-5 Biopsy score 1-5 Aim for concordence in MDT

Question 42

When would you do mastectomy vs Breast conservation

Answer 42

- Extensive disease through breast - THe lump is too large in relation to the breast to be able to conserve (tho can use neoadjuvent chemo to shrink first and then do conservation therapy) - preferance of the individual

Question 43

Grade vs stage

Answer 43

Grade - how abnormal cancer looks down microscope + how likely it is to progress Stage - the anatomical extent

Question 44

What genetic factors affect breast cancer Tx succes

Answer 44

- Oestrogen sensitivity - Progesteron sensitivity - Herceptin sensitivity

Question 45

Factors to consider if considering chemo for more complex breast cancer

Answer 45

- Young age - Oestrogen receptor +ve - High grade - Node positive - Ki67 pos - Tumour size -