Breast

Question 1

Causes of gynaecomastia

Answer 1

• Obesity (pseudogynaecomastia)
  ○ No glandular tissue
  • Drugs (spironolactone, digoxin, ketoconazole)
  • Endocrine
    ○ Lack of testosterone
    § Testis: Hypogonadism, Klinefelters
    § Androgen insensitivity○ Increased oestrogen
    § Chronic liver disease
    § Adrenal tumours
    Testicular tumours

Question 2

Breast cancer risk factors

Answer 2

Genetics
- BRCA (autosomal dominant, 50% chance)

Oestrogen exposure

- Physiological
         - Nulliparity
         - Early menarche
         - Late menopause

• Exogenous
  - Tamoxifen
  - Contraception/HRT

Question 3

Breast cancer screening programme

Answer 3

Mammography every 3y from 50-71

Question 4

Breast cancer Tx options

Answer 4

Surgery
WLE (lumpectomy, breast conserving) or mastectomy (+ flap) +/- adjuvant radiotherapy
- decision dependent on size of tumour, breast vol. and patient choice - generally tumours >4cm give poor cosmetic outcomes

+ Sentinel lymph node biopsy (axillary lymph node status is initially most important prognostic factor)

If triple neg disease + +ve LNs = adjuvant chemotherapy

If HER2+ = 1y adjuvant trastuzumab/herceptin

if ER+ = 5 years adjuvant Tamoxifen (pre-menopausal)/ Letrozole (post-menopausal)

Question 5

Features/signs of a cancerous lump

Answer 5

Lump characteristics

• Tethered to underlying skin
• Irregular
• Hard

Question 6

Breast lump differentials

Answer 6

Benign
Fibroadenoma
Breast cyst
Galactocele
Fibrocystic disease
Duct ectasia

Malignant
Breast cancer (DCIS, intraductal papilloma, phyllodes tumour)
Lymphoma

Question 7

At what point might you consider resection of a fibroadenoma?

Answer 7

If >3cm

Question 8

Causes of abnormal nipple discharge

Answer 8

Breast cancer
Galactorrhoea
Duct ectasia
Infection

Question 9

Other changes associated with breast cancer

Answer 9

Associated skin changes (Peau d’orange)
Associated nipple changes (Paget’s disease, nipple retraction)
Axillary lymphadenopathy

Question 10

Cancers associated with BRCA

Answer 10

BRCA = tumour suppressor genes
Gives a >50% lifetime risk of developing breast cancer

Breast
Ovarian
Several others (fallopian tube, peritoneal, pancreatic)

Question 11

Breast cancer triple assessment of a lump

Answer 11

History and clinical examination
Imaging (USS if <40, USS + Mammography if >40)
Biopsy (US-guided FNA) - biopsy rated B1-B5 after histological assessment to stratify risk of malignancy

Question 12

Complications of breast cancer treatment

Answer 12

Surgical procedural risks
Chemotherapy - side effects, immunosuppression
Radiotherapy - side effects
Recurrence
Psychological - mastectomy, whole process