Breast

Question 1

Selective oEstrogen Receptor Modulators (SERM)

Answer 1

Tamoxifen

It is used in the management of oestrogen receptor-positive breast cancer in PRE-MENOPAUSAL women

Adverse effects
-menstrual disturbance: vaginal bleeding, amenorrhoea
-hot flushes - 3% of patients stop taking tamoxifen due to climacteric side-effects
-venous thromboembolism
-endometrial cancer

Question 2

Aromatase inhibitors

Answer 2

Anastrozole and letrozole are aromatase inhibitors that reduces peripheral oestrogen synthesis. This is important as aromatisation accounts for the majority of oestrogen production in POSTMENOPAUSAL women and therefore anastrozole is used for ER +ve breast cancer in this group.

Adverse effects
-osteoporosis (NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors)
-hot flushes
-arthralgia, myalgia
-insomnia

Question 3

Fibroadenoma

Answer 3

Develop from a whole lobule

On examination;
Painless
Smooth
Round
Well circumscribed (well-defined borders)
Firm
Mobile (moves freely under the skin and above the chest wall)
Usually up to 3cm diameter

12% of all breast masses
Over a 2 year period up to 30% will get smaller
No increase in risk of malignancy
If >3cm surgical excision is usual, Phyllodes tumours should be widely excised

NB- fibroadenoma is a solid structure, not cystic (ie. not fluid-filled on USS, and will not fluctuate like a cyst will)

Question 4

Breast Cyst

Answer 4

The most common breast lump
They can be painful and may fluctuate in size over the menstrual cycle.

On examination, breast cysts are:
Smooth
Well-circumscribed
Mobile
Possibly fluctuant
Small increased risk of breast cancer (especially if younger)

Cysts should be aspirated, those which are blood stained or persistently refill should be biopsied or excised

Question 5

Breast Cyst

Answer 5

7% of all Western females will present with a breast cyst
Usually presents as a smooth discrete lump (may be fluctuant)
Small increased risk of breast cancer (especially if younger)

Cysts should be aspirated, those which are blood stained or persistently refill should be biopsied or excised

Question 6

Indications for a mastectomy

Answer 6

Multifocal tumour
Central tumour
Large lesion in small breast
DCIS >4cm
Patient choice
Genetics

Question 7

Indications for a wide local incision

Answer 7

Solitary lesion
Peripheral tumour
Small lesion in large breast
DCIS <4cm
Patient choice

Question 8

Risk Factors for breast cancer

Answer 8

BRCA1, BRCA2 genes (40% lifetime risk of breast/ovarian cancer)
1st degree relative premenopausal relative with breast cancer (e.g. mother)
nulliparity, 1st pregnancy > 30 yrs
early menarche, late menopause
combined hormone replacement therapy contraceptive use
past breast cancer
not breastfeeding
ionising radiation
p53 gene mutations
obesity
previous surgery for benign disease

Question 9

Breast cancer screening

Answer 9

The NHS Breast Screening Programme is offered to women between the ages of 50-70 years. Women are offered a mammogram every 3 years. After the age of 70 years women may still have mammograms but are ‘encouraged to make their own appointments’.

NB- trans women if they have had feminising hormones for 2 years

Question 10

Subtypes of breast cancer

Answer 10

Invasive ductal carcinoma
Invasive lobular carcinoma
Ductal carcinoma in situ
Lobular carcinoma in situ
Paget’s disease of the nipple
Inflammatory breast cancer

Question 11

Invasive ductal carcinoma

Answer 11

The most common type

Question 12

Invasive lobular carcinoma

Answer 12

The 2nd most common type
May not show up on mammography

Question 13

Ductal carcinoma in situ

Answer 13

Confined to one area
Microcalcifications
Potential to become invasive
Good prognosis
Women with DCIS are usually followed up with an annual clinic appointment and an annual mammogram for five years

Question 14

Lobular carcinoma in situ

Answer 14

Asymptomatic and undetectable on mammogram
Usually diagnosed incidentally on breast biopsy
Increased risk of invasive carcinoma

Question 15

Surgical excision of axillary lymph nodes

Answer 15

USS of axilla prior to surgery- biopsy of any abnormal nodes (can then be cleared during surgery)

If no abnormal nodes detected on USS, a sentinel node biopsy can be performed (deduce whether the sentinel node has cancer cells)

NB- axillary clearance may lead to arm lymphedema and functional arm impairment

Question 16

Radiotherapy

Answer 16

Whole breast radiotherapy is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence by around two-thirds. For women who’ve had a mastectomy radiotherapy is offered for T3-T4 tumours and for those with four or more positive axillary nodes

NB- If a woman has been previously treated with radiotherapy, she cannot normally be given radiotherapy again, so if she presents with recurrence then mastectomy is usually offered

Question 17

Chemotherapy

Answer 17

Cytotoxic therapy may be used either prior to surgery (‘neoadjuvanant’ chemotherapy) to downstage a primary lesion or after surgery depending on the stage of the tumour, for example, if there is axillary node disease - FEC-D is used in this situation.

Question 18

Hormonal therapy

Answer 18

Tamoxifen is still used in pre- and peri-menopausal women.

In post-menopausal women, aromatase inhibitors such as anastrozole and letrozole are used

Question 19

Biological therapy

Answer 19

Trastuzumab (Herceptin) for tumours that are HER2 positive.

NB- Trastuzumab cannot be used in patients with a history of heart disorders (may want to do echo first)

Question 20

Fibrocystic breast disease

Answer 20

Most common in middle-aged women

Lumpiness
Breast pain or tenderness (mastalgia)
Fluctuation of breast size

The connective tissues (stroma), ducts and lobules of the breast respond to the female sex hormones (oestrogen and progesterone), becoming fibrous (irregular and hard) and cystic (fluid-filled). These changes fluctuate with the menstrual cycle.

NB- rule out cancer, supportive bra, NSAIDs, avoid caffeine

Question 21

Mammary duct ectasia

Answer 21

Dilatation of the large breast ducts
Most common around the menopause
Associated with smoking
May present with a tender lump around the areola +/- a green nipple discharge
If ruptures may cause local inflammation, sometimes referred to as ‘plasma cell mastitis’

Question 22

Duct papilloma

Answer 22

Local areas of epithelial proliferation in large mammary ducts
Hyperplastic lesions rather than malignant or premalignant
May present with wartery, blood stained discharge, lump, tenderness

NB- surgical excision

Question 23

Fat necrosis

Answer 23

More common in obese women with large breasts
May follow trivial or unnoticed trauma
Initial inflammatory response, the lesion is typical firm and round but may develop into a hard, irregular breast lump
Rare and may mimic breast cancer so further investigation is always warranted

Question 24

Breast abscess

Answer 24

More common in lactating women (and smokers)
Swollen, fluctuant, hot and tender lump (very painful)
Management- ultrasound-guided drainage (MSC of drained fluid) with ABX coverfibro

Question 25

Cyclical mastalgia

Answer 25

Benign cyclical mastalgia is a common cause of breast pain in younger females. It varies in intensity according to the phase of the menstrual cycle NB- different to fibrocystic breasts Women should be advised to wear a supportive bra Conservative treatments include standard oral and topical analgesia

Question 26

Causes of nipple discharge

Answer 26

Normal physiology Galactorrhoea (drugs, emotions) Hyperprolactinoma Carcinoma Mammary duct ectasia Intraductal papilloma NB- assessment of nipple discharge; Examine breast and determine whether there is mass lesion present All mass lesions should undergo Triple assessment.

Question 27

Reporting of breast investigations

Answer 27

Where a mass lesion is suspected or investigations are requested these are prefixed using a system that denotes the investigation type e.g. M for mammography, followed by a numerical code as shown below: 1 No abnormality 2 Abnormality with benign features 3 Indeterminate probably benign 4 Indeterminate probably malignant 5 Malignant

Question 28

Enhanced breast screening for high risk patients

Answer 28

Annual MRI and mammogram from the age of 40 NB- no screening necessary if a woman has had bilateral risk-reducing mastectomy

Question 29

Investigations for a breast lump

Answer 29

2 week wait referral Triple assessment- clinical exam, imaging (inc. axilla), and USS guided core biopsy with histology Bloods- look at calcium and ALP (metastases) Before surgery- baseline bloods During surgery- sentinel node biopsy

Question 30

Management of breast cancer

Answer 30

1. Referral to breast specialist (2 weeks if cancer suspected) 2. MDT to discuss options (surgical, chemo, radiotherapy)- use of the PREDICT tool (estimate breast cancer survival and the benefits of hormone therapy, chemotherapy) 3. Macmillan cancer support, breast cancer specialist nurse etc.

Question 31

HER2 +ve cancers

Answer 31

HER2-positive cancers demonstrate a more aggressive tumour growth and higher recurrence rates and therefore are associated with a poor prognosis

Question 32

Grading cancer

Answer 32

1-3 Grade 1 breast cancers are slower growing and have a better prognosis. Grade 3 breast cancers are faster growing and are more likely to recur after treatment, so they are associated with a worse prognosis

Question 33

USS or mammogram guided biopsy for calcifications

Answer 33

• The calcifications can't be seen on ultrasound so the biopsy would need to be guided stereotactically (by mammogram)

Question 34

Lymphoedema

Answer 34

Massage techniques to manually drain the lymphatic system (manual lymphatic drainage) Compression bandages Specific lymphoedema exercises to improve lymph drainage Weight loss if overweight Good skin care NB- it is important to remember that you should avoid taking blood or putting a cannula in the arm on the side of previous breast cancer removal surgery. This is because there is a higher risk of complications and infection due to the impaired lymphatic drainage on that side.

Question 35

Common breast radiotherapy side effects

Answer 35

General fatigue from the radiation Local skin and tissue irritation and swelling Fibrosis of breast tissue Shrinking of breast tissue Long term skin colour changes (usually darker)

Question 36

Lipoma

Answer 36

Benign tumours of adipose tissue Soft Painless Mobile Do not cause skin changes

Question 37

Galactocele

Answer 37

Galactoceles occur in women that are lactating (producing breast milk), often after stopping breastfeeding. They are breast milk filled cysts that occur when the lactiferous duct is blocked, preventing the gland from draining milk. They present with a firm, mobile, painless lump, usually beneath the areola. They are benign and usually resolve without any treatment. It is possible to drain them with a needle. Rarely, they can become infected and require antibiotics.

Question 38

Phyllodes tumour

Answer 38

They are large and fast-growing. They can be benign (~50%), borderline (~25%) or malignant (~25%). Malignant phyllodes tumours can metastasise. Surgical removal (chemo if malignant)

Question 39

Non cyclical mastalgia

Answer 39

more common in women aged 40 – 50 years. It is more likely to be localised than cyclical breast pain. Often no cause is found. However, it may be caused by: Medications (e.g., hormonal contraceptive medications) Infection (e.g., mastitis) Pregnancy The pain may not originate in the breast but instead come from: The chest wall (e.g., costochondritis) The skin (e.g., shingles or post-herpetic neuralgia)

Question 40

Gynaecomastia- Increased oestrogen

Answer 40

Obesity (aromatase is an enzyme found in adipose tissue that converts androgens to oestrogen) Testicular cancer (oestrogen secretion from a Leydig cell tumour) Liver cirrhosis and liver failure Hyperthyroidism Human chorionic gonadotrophin (hCG) secreting tumour, notably small cell lung cancer

Question 41

Gynaecomastia- reduced testosterone

Answer 41

Testosterone deficiency in older age Hypothalamus or pituitary conditions that reduce LH and FSH levels (e.g., tumours (PROLACTINOMA- the high prolactin reduces the LH/FSH), radiotherapy or surgery) Klinefelter syndrome (XXY sex chromosomes) Orchitis (inflammation of the testicles, e.g., infection with mumps) Testicular damage (e.g., secondary to trauma or torsion)

Question 42

Gynaecomastia- drug causes

Answer 42

D-digoxin I-isoniazid S-spironolactone C-cimitidine O-oestrogen K-ketoconazole DISCO King

Question 43

Management of gynaecomastia

Answer 43

Increased oestrogen- tamoxifen Otherwise, surgery

Question 44

Investigations for gynaecomastia

Answer 44

Bedside- testicular examination, Bloods- FBC UE LFT TFT hormones eg. testosterone oestrogen LH FSH prolactin AFP (testicular cancer) Imaging- breast USS, testicular USS, mammogram, biopsy NB- need to exclude cancer (even in men)

Question 45

Galactorrhoea

Answer 45

refers to breast milk production not associated with pregnancy or breastfeeding There is a long list of causes of hyperprolactinaemia, but the key causes to remember are: Idiopathic (no cause can be found) Prolactinomas (hormone-secreting pituitary tumours) Endocrine disorders, particularly hypothyroidism and polycystic ovarian syndrome Medications, particularly dopamine antagonists (i.e., antipsychotic medications) Prolactin suppresses gonadotropin-releasing hormone (GnRH) by the hypothalamus, leading to reduced LH and FSH release. Therefore, hyperprolactinaemia can also present with: Menstrual irregularities, particularly amenorrhoea (absent periods) Reduced libido (low sex drive) Erectile dysfunction (in men) Gynaecomastia (in men)

Question 46

Investigations and management of galactorrhoea

Answer 46

A pregnancy test is essential in women with childbearing potential presenting with breast milk production. Blood tests include: Serum prolactin Renal profile (U&Es) Liver function tests (LFTs) TFT's Management; Dopamine agonists (e.g., bromocriptine or cabergoline) can be used to treat the symptoms Trans-sphenoidal surgical removal of the pituitary tumour is the definitive treatment of a prolactinoma.

Question 47

Mastitis

Answer 47

Mastitis can be caused by an obstruction in the ducts or and infection (Staphylococcus aureus) Mastitis presents with: Breast pain and tenderness (unilateral) Erythema in a focal area of breast tissue Local warmth and inflammation Nipple discharge Fever Management- continue breastfeeding (affected breast), flucloxacillin, drainage of any abscesses that form

Question 48

Chemotherapy used in breast cancer

Answer 48

Node +ve disease: FEC-D Node -ve disease: FEC

Question 49

Trans women and breast cancer screening

Answer 49

A person assigned male at birth who has been taking feminising hormones for longer than 2 years can have breast screening