Breast

Question 1

Breast cysts

a) What are they caused by?
b) What clinical features are seen?
c) What is seen on investigation?
d) How are they managed?

Answer 1

a) distended + involuted lobules
b) soft, fluctuant swellings

c)
- Mammography described at “halo” or Polo mint” appearance
- US to confirm fluid filled

d) aspirate + re-examine to confirm mass is gone

Question 2

What are the side effects of tamoxifen?

Answer 2

• VTE
• endometrial cancer
• hot flushes (3%)
• menstrual disturbance (vaginal bleeding, amenorrhea)

Question 3

Aromatase inhibitors

a) What will the names of these drugs end in?
b) How do they work?
c) What are their side effects?

Answer 3

a) …trozole (anastrozole, letrozole)
b) inhibit peripheral etrogen production known as aromatisation (responsible for majority of oestrogen in the body)

c)
- osteoporosis (DEXA prior to initiation recommended)
- myalgia + arthralgia
- insomnia
- hot flushes

Question 4

What can cause nipple discharge?

Answer 4

• breast feeding
• emotional events
• puberty (pale/colourless)
• histamine receptor antagonists
• hyperprolactinaemia (cream coloured)
• breast cancer
• duct ectasia
• intraductal papilloma

Question 5

Periductal Mastitis

a) What clinical features can be seen?
b) How is it treated?

Answer 5

a)
- erythema
- mammary duct fistula (abnormal tract between mammary duct and skin)
- recurrent infections
- +/- abscess

similar to duct ectasia strongly associated with smoking but in younger patients

b) co-amoxiclav

Question 6

Regarding breast cancer surgery, what are the indications for mastectomy v wide local excision?

Answer 6

mastectomy

• > 4cm
• small breast
• central lesion
• multifocal tumour

wide local excision

• <4cm
• large breast
• peripheral lesion
• solitary tumour

Question 7

How should you manage a patient with confirmed breast cancer but no palpable axillary lymphadenopathy?

Answer 7

US to confirm not present, if present carry out sentinel node biopsy

Question 8

When is radiotherapy often part of breast cancer management?

Answer 8

• wide local excision
• 4 or more positive axillary nodes
• T3 or T4 tumours

Question 9

Breast cancer referral

1. When is urgent referral made?
2. When should urgent referral be considered?
3. When is non-urgent referral made?

Answer 9

1. • > 30 unexplained breast lump
   • > 50 nipple symptoms (dischage, retraction)
2. • > 30 axillary node change
   • skin changes suggestive of breast cancer
3. <30 axillary node change

Question 10

What is the likely diagnosis in a patient with a soft breast lump and on excision is seen to have a grey, gelatinous appearance

Answer 10

mucinous carcinoma

Question 11

What should you do if the patient only wants a friend or relative as the chaperone?

Answer 11

explain that family members cannot be chaperones but they can also come in for the examination as well as a chaperone

(If still declined find a colleague who is willing to carry out without a chaperone provided it does not have negative impact on care)