18 Breast

Question 1

The Breast

Aims

Answer 1

Anatomy

Benign diseases

Tumours

Question 2

Anatomy

Answer 2

Stroma

Epithelium
ducts and lobules arranged in terminal duct lobular units

Question 3

Clinical Presentation of Breast Disease

Answer 3

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 4

Breast Cancer Screening

Answer 4

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

Question 5

Benign diseases:

Fibrocystic disease

Answer 5

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

Question 6

Benign diseases:

Fat Necrosis

Answer 6

Trauma to breast can result in localised haemorrhage and necrosis

Hard lump- mimics cancer clinically

Question 7

Breastfeeding:

Mastitis

Answer 7

Inflammatory condition

Red, tender, warm

Blocked ducts- lactation mastitis

Encourage breastfeeding.

Smoking

Question 8

Tumours

Answer 8

Benign
fibroadenoma
papilloma

Malignant
ductal carcinoma
lobular carcinoma
Paget’s disease

Question 9

Diagnosis- triple assesment

Answer 9

Clinical impression
Radiology
Cytology/histology

One-stop clinics

Question 10

Papilloma

Answer 10

Wart-like growth in ducts

Bleeding/nipple discharge

Benign

Up to 2cm

Question 11

Fibroadenoma

Answer 11

Rubbery lumps

Reproductive age

Benign- need not be removed but many prefer it

Can increase in size in pregnancy

Question 12

Malignant:

Breast Cancer

Answer 12

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 13

Risks – Modifiable and Non -modifiable

Answer 13

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 14

Diagnosis

Answer 14

Breast cancer screening programme

Mammography every 3 years

Catching cancer early improves prognosis

Surgery for pre-invasive disease possibly of questionable benefit

Question 15

Malignant

Answer 15

Ductal - DCIS, invasive ductal carcinoma

Lobular- LCIS, invasive lobular carcinoma

Paget’s disease- invasive or non-invasive

Question 16

Ductal Carcinoma in-situ

Answer 16

Abnormality of milk ducts

Pre-malignant condition

Low grade > high grade > invasive

Question 17

Invasive ductal carcinoma

Answer 17

Commonest type of breast cancer

Grades 1-3

Question 18

Treatment

Answer 18

Surgery +/- lymph node dissection

Chemo/radiotherapy

Hormone therapy s eg. Tamoxifen, Herceptin

Question 19

Surgery

Answer 19

Lumpectomy

Wide local exicion

Mastectomy

Sentinel lymph node

Question 20

Paget’s disease of the nipple

Answer 20

Affects skin of one nipple

Eczema-type rash, itchy, possible bleeding

Sign of underlying breast cancer

Question 21

Summary

Answer 21

Anatomy

Common benign conditions

Common cancer types

Breast cancer screening and treatment