Breast

Question 1

What happens in duct ectasia

Answer 1

dilatation of large breast ducts
common around menopause (as ducts shorten and dilate), accumulating green / yellow fluid
may cause slit like retraction of the nipple

Question 2

S/S of duct ectasia

Answer 2

tender lump near arola
green / yellow multiduct nipple discharge

Question 3

management of duct ectasia

Answer 3

generally conservative
if troublesome, consider total / partial duct excision

Question 4

presentations of nipple discharge and what condition they suggest

Answer 4

green nipple discharge > duct ectasia in smoker
yellow nipple discharge > duct ectasia in PM women
milky, multi duct > prolactinoma
Cancer, DICS, papilloma > blood stained

Question 5

what happens in fat necrosis

Answer 5

common in obese women with large breasts
after trauma

Question 6

how does fat necrosis present

Answer 6

firm, round, hard irregular lump

Question 7

what is acute mastitis

Answer 7

infection of the breast usuallly caused by staph aureus
affects 1 in 10 breastfeeding women
associated with NIPPLE INJURY and SMOKING

Question 8

what are S/S of acute mastitis

Answer 8

coryzal symptoms
nipple dischaarge
red tender breast - with cellulitis and generalised soreness

CONSIDER POSSIBILITY OF ABSCESS

Question 9

risk factors for mastitis/ abscess

Answer 9

smoker
breastfeeding
diabetic

Question 10

how do you manage acute mastitis

Answer 10

non-severe / lactational:

• simple analgesia
• warm complress
• continue breastfeeding

severe / non-lactational:
- fluclox 500mg QDS 10 days

Question 11

how does a breast abscewss present

Answer 11

discrete hot red lump
walled off collection of ppus

Question 12

how do you manage a breast abscess

Answer 12

US diagnostic - confirms walled off collection of pus
Then: US guided aspiration + antibiotics + review in 24-48h

If necrotic abscess / skin necrosis: incision and drainage + fluid culture

Question 13

what is a fibroadenoma

Answer 13

“breast mouse” (discrete, non tender, mobile)

Question 14

who is fibroadenoma common in

Answer 14

common in women <30 years old

Question 15

what is mx of fibroadenoma

Answer 15

<4cm: conservative (will shrink)
>4cm, surgical excision

Question 16

how do you investigate a fibroadenoma

Answer 16

US and biopsy

Question 17

how does fibrocystic change / fibroadenosis present

Answer 17

lumpy breast
may be painful
bilatral
changes with menstruation

in middle aged women

Question 18

how do you manage fibrocystic change

Answer 18

conservative

Question 19

who do intraductive papillomas affect

Answer 19

40-60yo
local areas of epithelial proliferation in large mammary ducts

Question 20

how doe intraductal papillomas presend

Answer 20

blood-stained discharge

Question 21

what is a phylloides tymour

Answer 21

most benigh, few very aggressive
enlarging mass in women >50

Question 22

intraductal papilloma mx

Answer 22

duct excision

Question 23

how does breast cancer present

Answer 23

POST MENOPAUSAL WOMAN

fixed mass

skin tethering, dimpling

palpable LN in axilla

Question 24

what are RF for breast cancer

Answer 24

genetics (BRCA genes, p53 mutation)
FH: 1st degree relative pre-menopausal breast cancer
oestrogen exposure (nulliparity, 1st preg >30yo, early menarche, late menopause, COCP, combined HRT)
past breast cancer
not breastfeeding
radiation
obesity

Question 25

what are protective factors for BC

Answer 25

multiparity breastfeeding oral contraceptives (controversial)

Question 26

how does breast cancer present externally on the nipple

Answer 26

Paget's disease of the nipple - eczematous change - pruritic

Question 27

what screening is done for breast cancer

Answer 27

50-71 years old every 3 years mammogram

Question 28

when do you do urgent 2ww referral for bc

Answer 28

\>30, unexplained breast lump with / without pain \>50 if single nipple discharge or retraction

Question 29

what assessment do you do for BC

Answer 29

triple assessment - hx and exam - imaging (USS\<40, mammography \>40) - pathology (FNA, core biopsy)

Question 30

what other info does histology tell you about breast cancer?

Answer 30

Receptor status - Oestrogen receptor - Progesterone receptor - HER2 receptor

Question 31

what are the two most common types of breast cancer

Answer 31

Invassive ductal carcinoma (most common) invasive lobular carcinoma (second most common)

Question 32

What additional Ix do you need to do for breast cancer patients? what does this mean for future ix

Answer 32

USS axilla if normal - sentinel node biopsy if abnormal - axillary node clearance of ALL LYMPH NODES

Question 33

what further investigation is needed in woman \<40 with breast cancer after she's had triple test, US etc

Answer 33

CALL BACK for mammography and MRI

Question 34

what lymph system do breast cancers drain to

Answer 34

75%: lateral axillary nodes 25%: parasternal nodes or opposite breast

Question 35

How do you manage BC surgically

Answer 35

MASTECTOMY vs WIDE LOCAL EXCISION overall, this should be up to patient choice Mastectomy: - muttifocal / central tumour - large lesion in small breast ! WLE: - solitary, peripheral tumour - small lesion in large breast!

Question 36

What othher therapies are available for breast cancer tx

Answer 36

Radiotherapy Hormone therapy Chemo

Question 37

When is radiotherapy recommended

Answer 37

after WLE after mastectomy in \>4xm, +ve LN

Question 38

when can you do hormone therapy in breast cancer

Answer 38

ONLY if ESTROGEN receptor +ve

Question 39

wat is prognostic index for chemo

Answer 39

nottinghham prognostic inded

Question 40

When MUST you refer for 2ww pathway

Answer 40

\>30 with unexplained breast lump \>50 with nipple discharge, retraction or other changes (think PAGET'S)

Question 41

When can you give Hormone therapy in beast cancer=

Answer 41

If ER +ve ONLY

Question 42

What hormone therapies can you give depending on age

Answer 42

Pre/perimenopausal: tamoxifen (SERM) post-menopausal: anastrozole/letrozole (aromatase inhibiitiors)

Question 43

side effects of tamoxifen

Answer 43

amenorrhoea endometrial cancer PV bleed VTE

Question 44

side effects of anastrozle /letrozole and why

Answer 44

OSTEOPOROSIS because they are aromatase inhibitorrs, so they reduce oestrogen synthesis, causing osteoporosis

Question 45

when can you give BIOLOGICAL therapy

Answer 45

if HER2 positive

Question 46

when do you give chemotherapy for breast cancer

Answer 46

if LN involved of Triple neg / HER2+ve

Question 47

why can you give NEOadjuvant chemo (i.e. before surgery)

Answer 47

to shrink tumour size before surgery /(this may allow to do WLE rather than mastectomy)

Question 48

which condition causes blood stained discharge without a palpable mass?

Answer 48

intraductal papilloma! it is essentially just some local epithelal proliferation

Question 49

cx of axillary node clearance

Answer 49

lymphoedema functional arm impairment

Question 50

what is inflammatory breast cancer

Answer 50

type of IDC (Invasive Ductal Carcinoma) cancerous cells block the lymph drainage, causing an inflamed appearance of the breast

Question 51

what does inflammatory breast cancer look like

Answer 51

SWOLLEN AND RED BREAST but inflammatory markers are normal