Breast

Question 1

What is the triple assessment?

Answer 1

Hospital-based assessment clinic that allows for the early and rapid detection of breast cancer
1) History and examination
2) Imaging – mammography & ultrasound (more useful in women <35 years and in men)
3) Histology – biopsy is required of any suspicious mass or lesion

Question 2

What is galactorrhoea?

Answer 2

Defined as copious, bilateral, multi-ductal, milky discharge, not associated with pregnancy or lactation
Occurs almost exclusively in females and most commonly in adults

Question 3

List causes of galactorrhoea

Answer 3

Hyperprolactinaemia – idiopathic, pituitary adenoma, drug-induced, neurological, hypothyroidism, renal failure/liver failure, damage to the pituitary stalk
Normoprolactinaemic – less common & typically idiopathic

Question 4

List investigations for galactorrhoea

Answer 4

Essential to exclude pregnancy in all females within the reproductive age range
Should have serum prolactin levels checked, TFTs, LFTs + U&Es
Pituitary tumour is suspected – MRI head with contrast

Question 5

Describe the management for galactorrhoea

Answer 5

Identifying and treating the underlying cause
Confirmed pituitary tumours – dopamine agonist therapy & referred to neurosurgery for potential trans-sphenoidal surgery

Question 6

List types of benign breast tumours

Answer 6

Fibroadenoma
Adenoma
Papilloma
Lipoma
Phyllodes tumours

Question 7

Describe a fibroadenoma

Answer 7

Most common benign growth in the breast & usually occurs in women of a reproductive age
Proliferations of stromal and epithelial tissue of the duct lobules
Examination – highly mobile lesions that are well-defined and rubbery, multiple & bilateral
Very low malignant potential & can be left in situ with routine follow up appointments

Question 8

Describe an adenoma

Answer 8

Ductal adenoma is a benign glandular tumour, typically occurring in the older female population
Lesions are nodular & can easily mimic malignancy -> most cases will undergo escalation for triple assessment

Question 9

Describe a papilloma

Answer 9

Intraductal papillomas are benign breast lesions that occur in females in 40-50 years (typically in subareolar region)
Symptoms: bloody/clear nipple discharge, mass
Usually require biopsy and same cases may be excised to ensure no atypical cells/neoplasia are present

Question 10

Describe a lipoma

Answer 10

Soft and mobile benign adipose tumour
Low malignant potential – usually only removed if they are enlarging or causing aesthetic issues

Question 11

Describe Phyllodes tumours

Answer 11

Rare fibroepithelial tumours
Commonly larger, occur in an older age group & comprised of both epithelial and stromal tissue
1/3 have malignant potential & 10% will recur after excision -> should be widely excised

Question 12

What is gynaecomastia?

Answer 12

Condition by which males develop breast tissue due to an imbalanced ratio of oestrogen and androgen activity
Usually benign disease but breast cancer can develop in about 1% of cases

Question 13

Describe the pathophysiology of gynaecomastia

Answer 13

Physiological gynaecomastia – adolescence (delayed testosterone surge relative to oestrogen), older population (decreasing testosterone levels)
Pathological gynaecomastia:
1) Lack of testosterone
2) Increased oestrogen levels
3) Medication
4) Idiopathic

Question 14

What is mastitis?

Answer 14

Inflammation of the breast tissue
Most common cause is from infection (staph aureus), but occasionally be granulomatous

Question 15

Describe the classification of mastitis

Answer 15

1) Lactational mastitis – presents during the first 3 months of breastfeeding/during weaning
a. Cracked nipples & milk stasis
b. More common with first child
2) Non-lactational mastitis – especially in women with other conditions such as duct ectasia
a. Tobacco smoking is important risk factor -> damage to sub-areolar duct walls & predisposing to bacterial infection

Question 16

Describe the management of mastitis

Answer 16

Systemic abx therapy and simple analgesics
Lactational mastitis – continued milk drainage/feeding is recommended

Question 17

What is a breast abscess and its management?

Answer 17

Collection of pus within the breast lined with granulation tissue, most commonly developing from acute mastitis
Confirmed via an ultrasound scan
Initial phase – often fully reversible with prompt empirical abx and US-guided needle therapeutic aspiration
Important complication of drainage – mammary duct fistula

Question 18

Describe breast cysts

Answer 18

Epithelial lined fluid-filled cavities
Usually in the perimenopausal age group
Present singularly or with multiple lumps & appear as distinct smooth masses

Question 19

Describe investigations and management of breast cysts

Answer 19

Can be identified by their typical halo shape on mammography & definitively diagnosed using USS
Aspiration – cancer may be excluded if the fluid is free of blood/lump disappears
Management – self-resolving
2% of patients with cysts have carcinoma at presentation & patients with cysts have 2-3 times greater risk of developing breast cancer in the future

Question 20

Describe mammary duct ectasia

Answer 20

Dilation and shortening of the major lactiferous ducts
Common presentation in peri-menopausal women
Presents with coloured nipple discharge, palpable mass or nipple retraction

Question 21

Describe investigations and management of mammary duct ectasia

Answer 21

Identified by mammography by dilated calcified ducts without any other features of malignancy
Biopsy – multiple plasma cells on histology
Managed conservatively

Question 22

What is fat necrosis?

Answer 22

Common condition caused by an acute inflammatory response in the breast -> ischaemic necrosis of fat lobules
Often referred to as traumatic fat necrosis due to its association with trauma
Usually asymptomatic or presenting as a lump

Question 23

Describe investigations and management of fat necrosis

Answer 23

May be suggested by positive traumatic history and/or hyperechoic mass on USS
Core biopsy is often taken to categorically rule out malignancy
Self-limiting & only requires analgesia and reassurance

Question 24

Describe a ductal carcinoma in situ

Answer 24

Most common type of non-invasive breast malignancy
Malignancy of the ductal tissue of the breast that is contained within the basement membrane
Often detected during screening – suspicious microcalcifications, subsequently confirmed on biopsy
Any should be treated with surgical excision

Question 25

Describe a lobular carcinoma in situ

Answer 25

Non-invasive lesion of secretory lobules of the breast that is contained within the basement membrane
Usually diagnosed as an incidental finding during biopsy of the breast
Management depends on the grade:
- Low grade: treated by monitoring rather that excision
- Bilateral prophylactic mastectomy can be potentially indicated if individuals possess the BRCA1/BRCA2 genes

Question 26

List different types of invasive breast cancers

Answer 26

Invasive ductal carcinoma
Invasive lobular carcinoma
Others – medullary carcinoma, invasive micropapillary carcinoma or metaplastic carcinoma

Question 27

List risk factors for invasive breast cancer

Answer 27

Female
Increasing age
Family history of breast cancer
Exposure to unopposed oestrogen – early menarche, late menopause, nulliparity & long term HRT
Previous benign breast disease
Obesity
Alcohol & smoking

Question 28

List clinical features of invasive breast cancer

Answer 28

Symptomatically/asymptomatically via screening
Breast or axillary lump
Asymmetry
Swelling
Abnormal nipple discharge
Nipple retraction
Skin changes
Mastalgia

Question 29

Describe the investigations and management for invasive breast cancer

Answer 29

Gold standard for diagnosis is triple assessment
Management determined by a MDT
Treatment options include surgery, radiotherapy, chemotherapy, hormonal therapy and/or antibody therapy

Question 30

What is Paget’s disease on the nipple?

Answer 30

Persistent roughening, scaling, ulcerating or eczematous change to the nipple
Vast majority of Paget’s will also have an underlying neoplasm

Question 31

Describe the clinical presentation of Paget’s disease of the nipple

Answer 31

Itching or redness in the nipple and/or areola
Flaking and thickened skin on/around the nipple
Area often painful and sensitive

Question 32

Describe the investigations and management for Paget’s disease of the nipple

Answer 32

Biopsy needed to confirm diagnosis
First line management is operative – nipple and areola will need to be removed
In cases associated with underlying malignancy, radiotherapy may also be necessary