Breast

Question 1

what stage of women is most commonly affected by breast cysts?

what are breast cysts caused by?

Answer 1

most commonly found in perimenopausal women

caused by distended and involuted lobules

Question 2

what will breast cysts show on mammogram?

Answer 2

halo appearance

Question 3

how may symptomatic breast cysts be managed?

Answer 3

aspiration and then the breast is reexamined to ensure that the lump has gone

Question 4

what Tx is required for duct ectasia?

Answer 4

no specific Tx required

Question 5

describe the drainage of lymph for 75% of lymph from the breast?

Answer 5

ipsilateral axillary node –> supraclavicular node –> thoracic duct

Question 6

name group 1, 2 and 3 axillary lymph nodes?

Answer 6

group 1: inferior and lateral to pec minor

group 2: deep to pec minor

group 3: superficial and medial to pec minor

Question 7

which part of the lobule secretes milk in response to prolactin?

Answer 7

the secretory acini

they connect to the nipples via a series of ducts

Question 8

name the 3 components of the triple assessment?

Answer 8

1. clinical: history and examination
2. radiological: mammography +/- US
3. cyto-pathological: cytology or biopsy

Question 9

describe the age categories for imaging in breast condition investigations?

Answer 9

< 35-40 = US

> 40 = mammography +/- US

Question 10

which is the only imaging technique that can reliably detect micro calcifications?

Answer 10

mammography

Question 11

name the conditions that cause these 3 benign pictures of calcification:

a) popcorn
b) tea cup
c) rod shaped

Answer 11

a) popcorn = fibroadenoma
b) tea cup= micro cyst
c) rod shaped = duct ectasia

Question 12

when would an US be requested following a mammography?

Answer 12

to characterise a lesion found on mammography

Question 13

what imaging technique gives excellent images of lesions but doesnt pick up micro-calcifications?

Answer 13

MRI

Question 14

who is duct ectasia most commonly seen in?

Answer 14

peri or post menopausal women who smoke

Question 15

if infection occurs following duct ectasia, what is it called?

Answer 15

mastitis

Question 16

how is duct ectasia managed?

Answer 16

smoking cessation

duct excision (microdochectomy)

Question 17

which condition causes multiple lumps within the breast?

Answer 17

fibrocystic change

breast described as having a ‘cobblestone’ appearance

Question 18

describe the pain felt in fibrocystic change?

Answer 18

sudden and cyclical mastalgia - pain occurs before and during the period

Question 19

which lesion is described as the breast mouse? why?

Answer 19

fibroadenoma

due to its mobility - O/Ex, the lesion is firm, discrete, painless and mobile

Question 20

which condition presents with a lump and blood stained discharge?

Answer 20

duct papilloma

in older women = it is usually a single lesion under the nipple

in younger women = multiple lesions that grow more peripherally

Question 21

name the 2 situations when mastitis is seen?

Answer 21

1. women with duct ectasia

2. women who is breast feeding

Question 22

describe presentation of mastitis?

Answer 22

erythema, swelling and tenderness of breast

an abscess, with worsening of symptoms and a rapidly growing mass

Question 23

how should mastitis be managed 1st line if women is breast feeding?

Answer 23

encourage them to continue and ensure complete draining with each feed

Question 24

what is the 1st line AB if symptoms dont improve with continued breast feeding?

Answer 24

flucloxicillin for 7-10 days

continue breast feeding through Tx

Question 25

name the 3 components that make up sinister nipple discharge?

Answer 25

unilateral

bloodstained

+/- nipple inversion and palpable mass

Question 26

what is the action of tamoxifen as a medication for breast cancer?

Answer 26

it is an oestrogen receptor antagonist

used to manage oestrogen receptor positive breast cancer

Question 27

when is the peak incidence for breast cancer?

Answer 27

60-70 y/o

Question 28

describe the breast cancer screening programme?

Answer 28

a MXR for every women aged 47-73, every 3 years

Question 29

name the 2 most common pathological subtypes of breast cancer?

Answer 29

DCIS (70%)

LCIS (10%)

Question 30

what receptor expression confers the worst prognosis?

Answer 30

triple negative

Question 31

how does the presence of HER 2 receptors in a breast cancer affect prognosis?

Answer 31

HER 2 has a negative effect on prognosis

unlike oestrogen and progesterone receptors - their presence has a positive prognosis

Question 32

name the receptor expression with the best prognosis?

ie - oestrogen, progesterone and HER2

Answer 32

oestrogen: positive
progesterone: postive

HER2: negative

Question 33

what on MXR is almost pathognomic for DCIS?

Answer 33

micro calcifications

Question 34

what is the diagnostic Ix done in DCIS?

Answer 34

core biopsy

Question 35

which has the greatest risk of invasion? DCIS or LCIS?

Answer 35

DCIS

Question 36

compare the management of DCIS and LCIS?

Answer 36

DICS: WLE + radiotherapy or mastectomy

LCIS: excision biopsy at time of triple assessment

Question 37

compare what age women tend to be who are affected by DCIS and LCIS?

Answer 37

DCIS: women >50

LCIS: women in their 40’s

Question 38

what is peau d’orange associated with?

Answer 38

most commonly associated with invasive breast cancer

Question 39

although WLE + radiotherapy, when is a mastectomy indicated?

Answer 39

mastectomy is usually needed if >4cm, central tumour or multifocal

general rule is WLE is only carried out if tumour <4cm

Question 40

name 2 complications of axillary node clearance?

Answer 40

lymphedema of arm

damage to the brachial plexus

Question 41

in which patients is chemotherapy given as an adjuvant Tx?

Answer 41

women with poor prognostic factors:

• <35
• ER negative, HER2 positive
• > 4 lymph nodes involved

Question 42

why is letrozole used as endocrine therapy in Px’s with oestrogen positive tumours only if they are post menopausal?

Answer 42

it induces the menopause

Question 43

name key side effects of tamoxifen to be aware of?

Answer 43

associated with increased risk of:
- endometrial cancer

• VTE
• menstrual bleeding
• hot flushes

Question 44

in which receptor specific breast cancers is immunotherapy used?

what is the name of the immunotherapy?

Answer 44

used post op in HER2 +ive tumours

Herceptin

Question 45

how should all women aged >30 with an unexplained breast lump be managed?

Answer 45

they should all be referred urgently to the breast clinic using a suspected cancer pathway referral

Question 46

describe Paget’s disease of the nipple?

Answer 46

an eczematous change of the nipple associated with an underlying breast malignancy

it is present in 1-2% of patients with breast cancer

Question 47

name the chemotherapy regime used in node positive breast cancer?

Answer 47

FEC-D chemotherapy

chemotherapy is usually indicated if there is nodal involvement

Question 48

compare the therapy used in women who are ER +ive and

a) pre or peri menopausal
b) post menopausal

Answer 48

a) pre/peri menopausal: tamoxifen

b) post menopausal: tamoxifen

Question 49

compare the class of drug of 
a) tamoxifen 

b) anastrozole

why is anastrozole preferred in post menopausal women?

Answer 49

tamoxifen: oestrogen receptor inhibitor in the breast
anastrozole: aromatase inhibitor

in post menopausal women, oestrogen is mainly derived from peripheral aromatisation, hence this class of drug is preferred

Question 50

as a GP, what is the best initial management option for a women <30 with a suspected fibroadenoma?

Answer 50

a non-urgent referral to the breast clinic

Question 51

what is a potential complication associated with aromatase inhibitors?

Answer 51

osteoporosis

bone mineral density should be checked prior to commencing and throughout treatment

biphosphonate prophylaxis is encouraged