Approach to a breast mass

Question 1

Differential diagnosis

Answer 1

Fibroadenoma
Fibrocystic changes
Fat necrosis
Intraductal papilloma
Breast abscess
Atypical ductal/lobular hyperplasia
DCIS
Invasive breast cancer

Question 2

Percentage of women presenting with a breast mass that are malignant

Answer 2

10%

Question 3

Triple test

Answer 3

Physical examination
Imaging
Biopsy

Question 4

Most common cause of breast mass

Answer 4

Fibroadenoma

Question 5

Risk of breast cancer in women with fibroadenomas

Answer 5

Twice the risk

Question 6

What does fibrocystic disease encompass, and when is it more common

Answer 6

Pre/perimenopauses

Question 7

Are breast cysts common in post-menopausal

Answer 7

Cysts
Epithelial hyperplasia
Apocrine metaplasia
Cystic dilation
Fibrosis

Question 8

Bloody nipple discharge, typical of what lesion

Answer 8

Intraductal papilloma

Question 9

When are breast abscess more common

Answer 9

Breastfeeding

Question 10

Types of premalignant breast lesions

Answer 10

Atypical ductal hyperplasia

Atypical lobular hyperplasia

Question 11

What causes dimpling of the skin in breast cancer

Answer 11

Malignant infiltration of fibrous contraction of coopers ligaments

Question 12

Arterial supply of the breast

Answer 12

Axillary artery

Internal thoracic

Question 13

Lymphatic drainage of the breast

Answer 13

Axillary:
Apical= infraclavicular
Anterior= pectoralis major
Posterior= subscapular
Lateral= axillary vein
Cantral= axillary fat

Internal mammary:
Drains medial breast

Question 14

Proliferative (non-neoplastic) changes in breast

Answer 14

Metaplasia
Adenosis
Simple cysts
Diabetic fubrous matopathy
Fibrocystic

Question 15

Management of likely benign lesion on USS

Answer 15

Clinical and ultrasonographic surveillance every 6 months for 2 years, to document stability
Core needle biopsy to make a definitive diagnosis while leaving the lesion in situ
Surgical removal of the mass, particularly if the lesion is bothersome to the patient.

Question 16

Benign neoplastic proliferations

Answer 16

Fibroadenoma
Atypical ductal/lobular
Sclerosing adenosis
Ductal papilloma

Question 17

What imaging method is preferred in women >30 and

Answer 17

Mammography preferred in women >30 yo

USS preferred in women

Question 18

BIRADS categories, description and recommmendation

Answer 18

0= need more info, further imaging
1= normal, routine screening mammography
2= benign, routine screening mammography
3= probably benign, short term f/u in 6 months
4= highly suspicious, biopsy
5= malignant, biopsy
6= known cancer, treat malignancy

Question 19

Algorithm for breast USS

Answer 19

Solid–>

1. Suspicious= biopsy
2. Probably benign= biopsy or f/u

Cystic–>

1. Simple= follow or aspirate
2. Complex= biopsy

Question 20

Main types of biopsy

Answer 20

FNA
Core needle
Excisional

Question 21

FNA advantages and disadvantages

Answer 21

A: easy, painless, office, small needle
D: expert cytopathologist, cannot evaluate histology

Question 22

Core needle advantages and disadvantages

Answer 22

A: easy, painless, office, histopathology, tissue, receptor status
D: slightly larger needle

Question 23

Excisional advantages and disadvantages

Answer 23

A: histopathology, tissue architecture, receptor status
D: need OT, larger incision, painful

Question 24

When would cystic fluid be sent for cytology

Answer 24

When blood

Question 25

Investigations for fibroadenoma

Answer 25

In women physical | In >35-> U/S, biopsy

Question 26

Biopsy in fibroadenoma, when to review and management if stable vs growing

Answer 26

Review in 3 months Stable->USS and review in 12/12->stable = d/c. Growth->refer for surgical Growth->surgical opinion

Question 27

Progress of fibroadenoma

Answer 27

Usually doesn't change Hormone responsive Not in itself pre-malignant

Question 28

What is phylloides tumor

Answer 28

Intralobular stroma, leaf like protrusions +Cellularity, mitosis, pleomorphism, +infiltration Does not regress 8% malignant

Question 29

Causes of nipple discharge

Answer 29

``` Physiologic->pregnancy, lactation Galactorrhea Duct ectasia Ductal papilloma Cyst Malignancy Idiopathic ```

Question 30

Relative risk of malignant breast disease when presenting with benign breast disease

Answer 30

Moderately increased risk (4–5×) Atypical ductal hyperplasia Atypical lobular hyperplasia Radial scar Slightly increased risk (1.5–2.0×) Moderate or florid hyperplasia Multiple papilloma ``` No increased risk Cysts Fibroadenoma Duct ectasia Mild hyperplasia Sclerosing adenosis Apocrine change ```

Question 31

When is nipple discharge likely to represent a physiologic process

Answer 31

Clear Yellow or green Multiple ducts On nipple stimulation

Question 32

When is nipple discharge more suggestive of a pathalogic process and common etiologies

Answer 32

Spontaneous Persistent Bloody Associated with a mass 1. Ductal papilloma 2. Ductal ectasia 3. Cancer 4. Infection

Question 33

Definition of galactorrhea

Answer 33

Discharge of milk/serous fluid in the abscence of parturition or beyond 6 months post partum in a non-breast-feeding woman

Question 34

Etiology of galactorrhea

Answer 34

stress, physical irritation, hypothyroidism, chronic renal failure, hypothalamic-pituitary disorders, hormone-secreting neoplasms (most commonly pituitary adenomas), or may be idiopathic but is not associated with breast cancer. can block dopamine and histamine receptors, deplete dopamine stores, inhibit dopamine release, and stimulate lactotrophs. Common medications and classes of medications: SSRIs, TCAs, atenolol, verapamil, antipsychotics, H2 histamine blockers (cimetidine), and opiates, Estrogen in oral contraceptives can cause galactorrhea by suppressing the hypothalamic secretion of prolactin inhibitory factor and by direct stimulation of the pituitary lactotrophs

Question 35

Investigations in galactorrhea

Answer 35

``` Discontinue offending agents UEC TSH Prolactin Pregnancy test in reproductive age MRI if ++prolactin ```

Question 36

Management of glactorrhea

Answer 36

Manage underlying conditions | Bromocriptine is preferred treatment for hyper-prolactin induced anovulatory infertility