Breast Cancer — SAQ

Stem

A 52-year-old postmenopausal woman presents with a 2-month history of a painless left breast lump. Examination: 2.5 cm hard, irregular, fixed mass in the upper outer quadrant with skin tethering. A 1.5 cm hard mobile axillary node is palpable. Core biopsy confirms invasive ductal carcinoma, ER-positive, PR-positive, HER2-negative. [1]

Questions

a) Define triple assessment and explain why core biopsy is preferred to FNA alone. (3 marks) [1]

Triple assessment = (1) clinical examination of both breasts and regional nodes, (2) imaging (mammography ± ultrasound; MRI in selected cases), (3) tissue diagnosis. Accuracy approaches ~98% when concordant.
Core needle biopsy preserves architecture, allows grade, and provides ER/PR/HER2 (and often Ki-67) essential for systemic therapy planning. FNA cytology alone cannot reliably deliver this modern molecular information and risks inadequate sampling of architecture. [1]

b) Surgical options for breast and axilla, including a key complication to counsel. (4 marks) [1]

Breast: breast-conserving surgery (wide local excision) + adjuvant whole-breast radiotherapy if tumour-to-breast ratio and multicentricity allow clear margins and acceptable cosmesis; or mastectomy (± immediate/delayed reconstruction) if multicentric disease, contraindications to RT, patient preference, or inflammatory sequence after neoadjuvant therapy. Survival is equivalent for BCS+RT vs mastectomy in appropriate candidates when RT is given.
Axilla: clinically/radiologically node-positive pathways may need staging/ALND or targeted axillary management per MDT; clinically node-negative invasive disease uses sentinel lymph node biopsy. Counsel lymphoedema, seroma, shoulder stiffness, intercostobrachial numbness. [1]

c) Endocrine therapy choice with dose and two toxicities; one trial principle. (4 marks) [1]

Postmenopausal ER-positive disease: aromatase inhibitor e.g. letrozole 2.5 mg oral once daily, anastrozole 1 mg OD, or exemestane 25 mg OD, typically 5 years with consideration of extended therapy in higher-risk disease (ATAC/AI superiority principles over tamoxifen in postmenopausal women).
Toxicities: arthralgia, accelerated bone loss/osteoporosis/fracture, urogenital symptoms; monitor bone density and offer calcium/vitamin D/bisphosphonate strategies as indicated.
(Premenopausal standard remains tamoxifen 20 mg OD, ± ovarian suppression in higher risk — VTE and endometrial cancer are key tamoxifen risks.) [1]

d) How would management differ if this were inflammatory breast cancer or male breast cancer? (4 marks) [1]

Inflammatory (T4d): erythema, warmth, peau d'orange from dermal lymphatic invasion — biopsy including skin, stage systemically, neoadjuvant chemotherapy first, then surgery (usually mastectomy) ± RT; do not treat as simple mastitis.
Male breast cancer: usually mastectomy + axillary staging; almost always ER-positive → tamoxifen 20 mg OD; offer genetic testing (BRCA2 especially); reconstructive and psychosocial counselling. [1]

Additional teaching points (mark-scoring phrases)

Referral red flags (2-week pathway language): hard fixed mass, skin tethering/ulceration, new nipple retraction, bloody spontaneous unilateral discharge, inflammatory breast picture, axillary nodes with breast signs. [1]

Receptor panel on every invasive cancer: ER, PR, HER2 (IHC ± ISH). Therapy is illegal without this in modern viva terms. [1]

Radiotherapy after BCS: whole-breast RT is standard; partial-breast RT selected low-risk protocols; omit RT only in highly selected elderly low-risk pathways — know the principle that RT underpins BCS oncologic safety. [1]

Trastuzumab cardiotoxicity: baseline and serial LVEF; hold/stop if significant drop; higher risk with prior anthracyclines. [1]

OlympiAD pearl: olaparib 300 mg BD in germline BRCA-mutated HER2-negative advanced disease after chemotherapy exposure. [1]

References

1. [1]Leon-Ferre RA, Goetz MP. Advances in systemic therapies for triple negative breast cancer BMJ, 2023.PMID 37253507
2. [2]Hassett MJ, Somerfield MR, Baker ER, et al. Management of Male Breast Cancer: ASCO Guideline J Clin Oncol, 2020.PMID 32058842
3. [3]Waks AG, Winer EP. Breast Cancer Treatment: A Review JAMA, 2019.PMID 30667505
4. [4]Darby S, McGale P, Correa C, et al. Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials Lancet, 2011.PMID 22019144
5. [5]Modi S, Jacot W, Yamashita T, et al. Trastuzumab Deruxtecan in Previously Treated HER2-Low Advanced Breast Cancer N Engl J Med, 2022.PMID 35665782
6. [6]Robson M, Im SA, Senkus E, et al. Olaparib for Metastatic Breast Cancer in Patients with a Germline BRCA Mutation N Engl J Med, 2017.PMID 28578601
7. [7]Taylor C, Correa C, Duane FK, et al. Estimating the Risks of Breast Cancer Radiotherapy: Evidence From Modern Radiation Doses to the Lungs and Heart and From Previous Randomized Trials J Clin Oncol, 2017.PMID 28319436