17. The Breast

Question 1

Anatomy

Answer 1

Stroma

Epithelium
ducts and lobules arranged in terminal duct lobular units

Question 2

Clinical Presentation of Breast Disease

Answer 2

Pain- less than 2% have cancer

Palpable mass- cysts, benign tumours, cancer

Nipple discharge- benign 95% of cases 5% malignant.

Mammographic abnormality- 2% screened asympmtomatic population

Question 3

Breast Cancer Screening

Answer 3

50-70 yrs (extension underway to age range 47-73)
Mammography
3 yearly

Question 4

Fibrocystic disease

Answer 4

Very common
Lumpiness in one or usually both breasts
Pain/tenderness in breasts
Hormone related changes
Cumulative process >30 years old
Calcification

Question 5

Fat Necrosis

Answer 5

Trauma to breast can result in localised haemorrhage and necrosis

Hard lump- mimics cancer clinically

Question 6

Mastitis

Answer 6

Inflammatory condition

Red, tender, warm

Blocked ducts- lactation mastitis

Encourage breastfeeding.

Smoking

Question 7

Tumours

Answer 7

Benign
fibroadenoma
papilloma

Malignant
ductal carcinoma
lobular carcinoma
Paget’s disease

Question 8

Diagnosis- triple assesment

Answer 8

Clinical impression
Radiology
Cytology/histology

One-stop clinics

Question 9

Papilloma

Answer 9

Wart-like growth in ducts

Bleeding/nipple discharge

Benign

Up to 2cm

Question 10

Fibroadenoma

Answer 10

Rubbery lumps

Reproductive age

Benign- need not be removed but many prefer it

Can increase in size in pregnancy

Question 11

Breast Cancer

Answer 11

Most common cancer in the UK
Incidence increases with age (average age at diagnosis 64yrs)

Hereditary breast cancer- BRCA mutation
x5 risk of breast cancer, x10 risk of ovarian cancer
Accounts for 5% of breast cancer

Question 12

Risks – Modifiable and Non -modifiable

Answer 12

Age, Height -17%

Oestrogen
Early menache
Parity down 7%
Breastfeeding (down per 12mth) 4%

Lifestyle
Obesity -30%, physical activity dwn 20%, alcohol 10%, dietary fat 10%.

Question 13

Diagnosis

Answer 13

Breast cancer screening programme

Mammography every 3 years

Catching cancer early improves prognosis

Surgery for pre-invasive disease possibly of questionable benefit

Question 14

Malignant

Answer 14

Ductal - DCIS, invasive ductal carcinoma

Lobular- LCIS, invasive lobular carcinoma

Paget’s disease- invasive or non-invasive

Question 15

Ductal Carcinoma in-situ

Answer 15

Abnormality of milk ducts

Pre-malignant condition

Low grade > high grade > invasive

Question 16

Invasive ductal carcinoma

Answer 16

Commonest type of breast cancer

Grades 1-3

Question 17

Treatment

Answer 17

Surgery +/- lymph node dissection

Chemo/radiotherapy

Hormone therapy s eg. Tamoxifen, Herceptin

Question 18

Surgery

Answer 18

Lumpectomy

Wide local exicion

Mastectomy

Sentinel lymph node

Question 19

Paget’s disease of the nipple

Answer 19

Affects skin of one nipple

Eczema-type rash, itchy, possible bleeding

Sign of underlying breast cancer