4. Breast Lump

Question 1

What is the most common benign breast lump?

Answer 1

fibroadenoma

Question 2

1. What is a fibroadenoma
2. describe its features on examination
3. Is it likely to transform to malignancy?

Answer 2

1. proliferation of stromal and epithelial tissue of the duct lobules
2. highly mobile; well defined and rubbery. may be multiple and bilateral
3. very low malignant potential

Question 3

1. What is an adenoma?
2. In what women do they typically occur?
3. Describe features in examination

Answer 3

1. benign glandular tumour of the ductules
2. older women
3. nodular (easily mimic malignant lesions)

Question 4

1. what is a papilloma?
2. in what women do they occur?
3. Where in the breast do they occur?
4. How do patients often present?

Answer 4

1. benign breast lesion within the breast ducts
2. females around 40-50 yrs
3. subareolar region
4. bloody/clear nipple discharge. Appear similar to ductal carcinomas

Question 5

1. What is a phyllodes tumour?
2. What other benign breast lesions are they difficult to differentiate from?
3. What is their malignant potential?

Answer 5

1. rare tumours of fibroepithelial origin - comprised of both epithelilal and stromal tissue
2. fibroadenomas
3. 1/3 have malignant potential, therefore most phyllodes tumours should be widely excised.

Question 6

In general, on examination, how do benign breast lumps differ from malignant lesions?

Answer 6

• more mobile

- smoother borders

Question 7

1. What is gynaecomastia?
2. What is the finding on examination?
3. What other examination is essential?

Answer 7

1. development of breast tissues in males
2. rubbery, firm mass that starts from underneath the nipple and spreads outwards over the breast region
3. testicular examination (testicular tumours can cause gynaecomastia)

Question 8

1. What is the underlying mechanism of gynaecomastia

2. Name some causes

Answer 8

1. changes in oestrogen and androgen activity
2. • lack of testosterone - androgen insensitivity; testicular atrophy
     - increased oestrogen levels - liver disease, hyperthyroidism, adrenal tumours; testicular tumours
     - medication - spironolactone, antipsychotics, anabolic steroids, cannabis

Question 9

1. What are breast cysts?
2. In which age group do they usually form?
3. Common examination findings

Answer 9

1. epithelial lined fluid filled cavities
2. perimenopausal women
3. smooth mass; may be tender; may be multiple and bilateral

Question 10

1. What is mammary duct ectasia?
2. in which age group is it common?
3. How do women present/examination findings
4. what is a complication of mammary duct ectasia?

Answer 10

1. dilatation and shortening of the major lactiferous ducts
2. peri-menopausal women
3. green/yellow nipple discharge; palpable mass; nipple retraction
4. non-lactational mastitis

Question 11

1. What is fat necrosis?

2. What is the most common cause?

Answer 11

1. acute inflammatory response in the breast leading ischaemic necrosis of fat lobueles
2. trauma

Question 12

where do the majority of breast cancers arise from?

Answer 12

epithelial cells of the milk ducts

Question 13

What is the term given for cancers arising from:

1. ducts
2. lobules

Answer 13

1. ductal carcinomas

2. lobular carcinomas

Question 14

1. What does carcinoma in situ mean?

2. What does primary invasive cancer mean?

Answer 14

1. confined to the duct/lobule in which it originated, and does not extend beyond the basement membrane
2. penetrated past the basement membrane of the duct/lobule and has invaded surrounded tissues (but still confined within the breast)

Question 15

Name risk factors for breast cancer (9)

Answer 15

1. obesity
2. lack of physical exercise
3. alcohol consumption
4. HRT
5. exposure to ionising radiation
6. early age of first menstruation
7. late pregnancy or nuliparous
8. older age
9. fam hx

Question 16

1. What is the most common presentation of breast cancer?

2. Describe significant breast changes that could indicate cancer

Answer 16

1. painless lump
2. nipple discharge (blood or clear; spontaneous)
   skin tethering
   ulceration
   oedema
   erythema

Question 17

What is the gold standard assessment for ?breast cancer

Answer 17

TRIPLE ASSESSMENT

• hx and examination
• imaging - US and mammography
• histology

Question 18

what radiological investigations are useful for breast cancer? (3)

Answer 18

• Ultrasound
• Mammography
• MRI

Question 19

What does triple negative breast cancer mean?

Answer 19

• negative for oestrogen receptor, progesterone receptor and HER2
• cancer is more aggressive, harder to treat, more likely to metastasise and more likely to reoccur

Question 20

What is the general management of breast cancer?

Answer 20

• Surgery - local excision or mastectomy + sentinal lymph node biopsy or axillary clearance
• adjuvant radiotherapy
• hormonal treatment

Question 21

Name 3 indications of:

1. local excision
2. mastectomy

Answer 21

1. small tumour relative to breast size
   no previous radiotherapy to chest
   patient choice
2. large tumour relative to breast size
   multifocal cancer
   patient choice

Question 22

1. What anti-oestrogen treatment is given to pre-menopausal women?
2. What anti-oestrogen treatment is given to post-menopausal women?

Answer 22

1. GNRH agonists

2. tamoxifen or aromatase inhibitors (letrozole, anastrozole)