Breast cancer

• Breast cancer is the most common form of cancer in the UK. Around 1 in 8 women will develop breast cancer in their lifetime.
• What are the RFs for breast cancer?

  Female

  Increased oestrogen exposure

  More dense breast tissue

  Obesity

  Smoking

  Alcohol

  FHx (BRCA1/2)

  HRT (esp combined)
• What are BRCA gene?

  Tumour suppressor genes

  Mutations -> increased risk of breast cancer
• Where are the BRCA genes located?

  BRCA1 -> chromosome 17

  • also has role in ovarian, bowel & prostate cancer

  BRCA2 -> chromosome 13

  • also have role in ovarian cancer
• What are the different 'types' of breast cancer?

  Invasive ductal carcinoma (IDC)

  Invasive lobular carcinoma (ILC)

  Ductal carcinoma in situ (DCIS)

  Lobular carcinoma in situ (LCIS)

  Paget's disease of breast
• What is ductal carcinoma in situ?

  Pre-cancerous or cancerous epithelial cells of breast ducts

  Localised to a single area

  Often picked up by mammogram screening

  Potential spread to locally over yrs

  Can become invasive breast cancer (around 30%)

  Good prognosis (if full excised & adjuvant treatment is used)
• What is lobular carcinoma in situ?

  Pre-cancerous

  Typically occurs in pre-menopausal women

  Usually asymptomatic & undetectable on mammogram

  Usually diagnosed incidentally on breast biopsy

  Increased risk of invasive breast cancer in the future (around 30%)

  Often managed with close monitoring (examination & mammograms)
• What is invasive ductal carcinoma?

  Most common type

  80% of invasive breast cancers

  Originate in cells from the breast ducts, breaks through wall of duct & invades fatty tissue of breast

  Can be seen on mammograms
• What is invasive lobular carcinoma?

  Around 10% of invasive breast cancers

  Originates in cells from the breast lobules

  Not always visible on mammograms
• What is Paget's disease?

  Infiltrating carcinoma of nipple epithelium

  Looks like eczema of the nipple/areolar

  Erythematous, scaly rash

  Indicates breast cancer involving nipple

  Requires biopsy, staging & treatment
• Breast Cancer Screening

  Mammogram every 3 yrs to women aged 50-70
• What are the high-risk pts for breast cancer?

  A first-degree relative with breast cancer under 40 years

  A first-degree male relative with breast cancer

  A first-degree relative with bilateral breast cancer, first diagnosed under 50 years

  Two first-degree relatives with breast cancer
• Fill in the blanks

  A) chest wall

  B) pectoralis muscles

  C) lobules

  D) nipple

  E) areola

  F) milk duct

  G) fatty tissue

  H) skin

  
• What are the signs & symptoms of breast cancer?

  Painless lump

  Skin changes (erythema, ulceration, dimpling, peau d'orange)

  Nipple changes (inversion, deviation, eczema-like changes, discharge)

  Axillary lymphadenopathy
• What is the referral criteria for breast cancer?

  Unexplained breast lump in pts aged 30 or above

  Unilateral nipple changes (discharge, retraction or other changes) in pts aged 50 or above
• What are the Inx for breast cancer?

  Full Hx & examination

  Bloods (FBC, LFTs, U&Es, CEA, CA-153)

  USS/mammogram (dependent on age, over 40 = mammogram) -> also USS of axilla + biopsy of abnormal nodes

  Biopsy (fine needle aspiration, core)

  MRI/CT
• What is a sentinel lymph node biopsy?

  Done during breast surgery for cancer

  Isotope contrast & blue dye injected into tumour area -> travel to lymphatics to 1st lymph node

  This node is biopsied & if cancer cells are found, lymph nodes can be removed
• What is triple-negative breast cancer?

  Breast cancer that does not express...

  • oestrogen receptors
  • progesterone receptors
  • human epidermal growth factor (HER2)
• What are the common locations for breast cancer metastasis?

  2 Ls & 2 Bs

  Lungs

  Liver

  Bones

  Brain
• What is the management of breast cancer?

  Surgery

  • wide local excision
  • mastectomy w/sentinel node biopsy

  Radiotherapy (adjuvant)

  Chemotherapy

  • Trastuzumab (HER2-positive)
  • Abermaciclib (HER2-negative, hormone receptor-positive)
  • Pembrolizumab (triple-negative)
  • Olaparib (BRCA positive, HER2-negative)

  Hormone therapy (oestrogen-positive)

  • Anastrozole (post menopausal)
  • Tamoxifen (pre menopausal)
  • Bisphosphonates (reduce occurrence in node-positive)
  • Zoledronic acid (improve disease-free survival in post menopausal)
• Invasive lobular carcinoma is hard to visualise on mammogram.