Breast

Question 1

Anatomy of the breasts:
- Function + structure
- Location vertically and horizontally
- Vasculature
- Lymph nodes
- Nerves
- What’s in a triple assessment

Answer 1

• modified apocrine sweat g
• 2–> 6th costal cart, lat edge sternum –> mid axil line
• internal and ext mammary arts
• axillary, parasternal, intercostal
• intercostal, supraclavicular
• exam/history, imaging, biopsy

Question 2

Galactorrhea:
- Causes (5)

Mastalgia:
- Cyclical vs non causes (5)

Answer 2

• hyperprolactinoma, ssris/spironolactone/antipsychotics, liver disease, hypothyroid, lactation
• cyclical: menstruation, fibrocystic disease
• non: contraception, antidepressants, antipsychotics

Question 3

Breast carcinoma:
- Name 2 types

Invasive:
- Risk factors
- Symptoms (5)
- Investigations
- Screening
- Management

Answer 3

• DCIS (microcalcifications seen) most common, LCIS
• risk factors: BRCA1/2, age, smoking, alcohol, benign disease, obesity, early menarche/HRT/ nulliparous, fem
• symptoms: irreg/hard lump, nipple retraction, peau d’orange, mastalgia, discharge
• ix: triple assess, check er/her/pr expression, sentinel lymph node biopsy, mammography, pre op axillary uss
• screening: 50-70 every 3 years mammography,
• mx:
  ER+ (tamoxifen if pre menop, anatrazole if post), HER+ (trastuzumab Herceptin)
  Tamoxifen (ER selective antagonism): VTE, hot flushes, vaginal bleeding, endometrial ca
  Anastrozole (aromatase inhibitors reduce peripheral oestrogen synthesis): osteoporosis (need DEXA before), hot flushes, arthralgia, myalgia, insomnia

If WLE give radiotherapy after, if mastectomy radiotherapy if t3/4
If DCIS <4cm, peripheral, small, solitary lesion - WLE
If multifocal tumour, central, large lesion, DCIS >4cm - mastectomy
If clinically palp lymphadenopathy need axillary node clearance is primary surgery
Nottingham prognostic infex indicates survival based on tumour size, lymph node, grade

Question 4

Pagets Disease of nipple:
- Definition
- Symptoms
- ix

Answer 4

• definition: ulceration of nipple where 97% have underlying neoplasm where ductal carcinoma migrates to epidermis
• symptoms: red, rough, dry, flaky, itchy
• ix: punch biopsy, mammogram, uss

Question 5

Fibroadenoma:
- Definition
- Symptoms
- Management

Answer 5

• definition: Benign proliferation of epithelial and stromal tissue in duct lobules
• symptoms: smooth rubbery mobile mouse like
• mx: excise if >3cm, no inc risk of malignancy

Question 6

Adenoma:
- Definition
- Management

Answer 6

• definition: benign glandular tumour in older
• mx: triple assess as looks similar to cancer

Question 7

Lipoma:
- Definition
- Symptoms

Answer 7

• adipose tissue
• smooth soft mobile

Question 8

Intraductal papilloma:
- Definition
- Symptoms
- Management

Answer 8

• definition: - Growth inside milk ducts
• symptoms - in younger pts, bloody discharge, no palp lump
• mx - can form into multi ductal papilloma (atypical duct hyperplasia) which inc risk cancer so microdochectomy

Question 9

Phyllodes tumour:
- Definition
- Management

Answer 9

• epithelial and stomach tumour, 40-50s, similar to fibroadenoma
• remove as 1/3 malignant potential

Question 10

Mastitis:
- Definition
- Causes
- Symptoms
- Management
- Complications

Answer 10

• definition: inflammation of breast tissue
• causes: staph aures - common in lactating or smokers
• symptoms: red hot painful swollen, unilateral, fever
• mx: continue breast feeding, if no improvement after 12-24 hours flucoloxacillin 10-14 days, analgesia/warm compresses
• complications: abscess (tender, fluctuant mass) - aspiration, drain), mamm duct fistula

Question 11

Mammary duct ectasia:
- Definition
- Risk factors
- Symptoms
- Investigations
- Management

Answer 11

• definition - shortening and dilatation of lactiferous ducts causing inflammation
• risk factors - smoking, peri menop
• Symptoms: - post menopausal, green yellow or creamy discharge, nipple retraction, bilateral, peri-areolar lump
• ix: - mammography and dilated ca ducts so mimics cancer
• mx - reassurance, if v troublesome then microdochectomy or duct excision if older

Question 12

Fat necrosis:
- Definition
- Risk factors
- Symptoms
- Investigations

Answer 12

• definition - inflammation causing necrosis of fat lobules and fibrosis
• risk factors - surgery, radiological intervention
• symptoms - lump, discharge, skin dimpling, pain, nipple inversion
• ix - uss (hyper echoic mass meaning calcif) so core biopsy
  -complications: fibroadenosis which are painful lumpy breasts, worse with menstruation

Question 13

Breast cyst:
- Definition
- Symptoms
- Investigations
- Management
- Complications

Answer 13

• definition: fluid filled cavity
• symptoms: smooth tender fluctuates during cycle lump
• ix: uss, mama (halo appearance), cytology
• mx: self resolves or aspirate
• fibrocystic disease (oest/prog cause tissues to fibrose causing cyclical pain)

Question 14

Breast cancer referral 2ww

Answer 14

> 30 with unexplained lump including axilla
50 with any nipple changes
Skin changes suggestive

Routine referral if: <30 + unexplained lump