Breast

Question 1

3 tissue types in breast

Answer 1

fat, fibrous tissue, glandular tissue

Question 2

Breast lobules are divided into segments by ___

Answer 2

suspensory ligaments of Astley Cooper

dimpling of skin in advanced breast CA due to malignant infiltration & contraction of Cooper’s ligament

Question 3

Structure of the breast duct

Answer 3

1) Opening at nipple
2) Lactiferous sinus
3) Major duct
4) Terminal duct lobular unit
5) Stroma (surrounds lobular units)

Question 4

Major lymphatic drainage of breast

Answer 4

75% - axillary nodes (anterior, posterior, lateral, medial, apical) that drain into supraclavicular & jugular nodes

20% drain into internal mammary nodes

Question 5

Division of axillary lymph nodes

Answer 5

Divided by pectoralis minor

Level I: lateral to PM
Level II: behind PM
Level III: medial to PM

Question 6

More likely pathological characteristics of nipple discharge

Answer 6

1) unilateral
2) bloody
3) uni-ductal
4) spontaneous (no need press)
5) persistent (>2x/week)

Question 7

Characteristics of paget’s disease

Answer 7

unilateral
distinct edges
no itching, no vesicles
nipple destroyed
underlying lump present

Question 8

Characteristics of nipple eczema

Answer 8

bilateral
indistinct edges
itching, vesicles
nipple not destroyed
no underlying lump

Question 9

Differentials for nipple discharge causes can be classified by

Answer 9

discharge colour

Question 10

Ddx blood discharge

Answer 10

intraductal papilloma
mammary ductal CA (DCIS or invasive)
fibrocystic change

Question 11

Ddx clear (serous) or straw-coloured discharge

Answer 11

ductal papilloma/CA
mammary ductal ectasia (benign condition - ducts dilated + inflamed + fibrosed)

Question 12

Ddx purulent, foul smelling discharge

Answer 12

1) lactational mastitis
- usually staph aureus
2) breast abscess

Question 13

Ddx white, milky discharge

Answer 13

1) drug related galactorrhea - dopamine antagonists (usually inhibit prolactin), estrogenic effect

2) spontaneous galactorrhea - prolactinoma

3) lactation

Question 14

Triple assessment in breast CA

Answer 14

History + clinical exam
Imaging (mammogram/US)
Histopathological

Question 15

Risk factors for breast CA

Answer 15

1) Personal malignancy Hx
2) Family Hx - 1st deg relative with cancer, BRCA carrier
3) Previous chest wall irradiation
4) Estrogen exposure - menarche, menopause, OC, hormone replacement therapy, nulliparity, late first live birth
5) Pre-malignant breast conditions: atypical ductal/lobular hyperplasia

Question 16

BRCA1 tumours tend to be ___, ___, ___

BRCA2 tumours tend to be ___, ___

Answer 16

hormone receptor negative (triple -ve), high grade, poorly differentiated

hormone receptor positive, well-differentiated

Question 17

Premenopausal women in early reproductive period (<25), breast lumps are usually ___

Answer 17

fibroadenoma

Question 18

Ddx for benign breast neoplasms

Answer 18

1) Atypical: atypical lobular/ductal hyperplasia
2) Typical: intraductal papilloma
3) Non-proliferative epithelial alterations: cysts, apocrine metaplasia
4) others: Phyllodes tumour, lipoma

breast infection

Question 19

Ddx of malignant breast neoplasms

Answer 19

Carcinoma in situ: DCIS, LCIS
Invasive CA: ductal/lobular, inflammatory, other subtypes

Question 20

Fibroadenoma arise from ___. Presents as a ____. Commonly occurs in those under ___.

Answer 20

terminal duct lobular units

well-circumscribed, mobile lump with rubbery consistency

30

Question 21

Phyllodes tumour is a ___ tumour. Can be ___, spreads via ___. Local recurrence ___, distant metastasis is ___.

Answer 21

fibroepithelial
benign, borderline, malignant
blood
common, rare

Question 22

Fibrocystic breast change occurs in women aged ___. Presents with ___. Patients should be re-examined on ____.

Answer 22

20-55
premenstrual breast pain or lump

day 10 of menstrual cycle (hormonal influence is lowest, lump should diminish in size)

Question 23

Two views of mammography

Answer 23

cranio-caudal (CC)
mediolateral oblique (MLO)

Question 24

On mammogram, breast pointing to the right means its the ___ breast

Answer 24

left

Question 25

MLO view allows you to see ___, capture ___

Answer 25

axillary tail enlarged lymph nodes

Question 26

Recommendation for mammogram

Answer 26

1x yearly 40-49yrs old 1x every 2 years 50-69 yrs old

Question 27

For breast biopsy, ___ is preferred over ___ as it is able to view ___

Answer 27

core biopsy FNAC tissue architecture/invasion

Question 28

Biggest risk factors for breast cancer

Answer 28

Genes: BRCA, TP53 mutation (56-87% higher risk) Oral contraceptives (24%) Previous breast disease (atypical hyperplasia) - 20% Family history

Question 29

DCIS pathophysiology. How many tumours usually?

Answer 29

proliferation of malignant ductal cells from terminal duct lobular unit, confined by basement membrane with preserved myoepithelial layer usually unicentric *positive for E cadherin

Question 30

Lobular intraepithelial neoplasia pathophysiology How many tumours usually?

Answer 30

LIN combines LCIS and atypical lobular hyperplasia. Arises from terminal duct lobular unit. Not pre-malignant lesion, but marker of increased risk for cancer. usually multicentric, bilateral *negative for e-cadherin

Question 31

What is invasive carcinoma of no special type

Answer 31

Unclear origin of tumour. Not ductal nor lobular

Question 32

Invasive lobular carcinoma tends to metastasise to

Answer 32

GIT, gynae organs, peritoneum

Question 33

Inflammatory breast CA presentation

Answer 33

rapid swelling, +/- skin changes, nipple retraction, erythematous swollen breast w/o palpable mass

Question 34

Triple negative breast cancer means ___, has a ___ prognosis

Answer 34

ER, PR, HER2 negative poor prognosis - lack of treatment target

Question 35

Stage 4 breast tumour occurs when tumour has ___

Answer 35

invaded chest wall, skin inflammatory breast CA is stage 4

Question 36

Breast-conserving surgery MUST be accompanied with ___

Answer 36

post-operative radiotherapy

Question 37

Current recommendation for mastectomy

Answer 37

Simple mastectomy + sentinal lymph node biopsy KIV axillary clearance *if SLNB positive, then axillary clearance performed

Question 38

Autologous breast reconstruction uses muscle from ___ or ___

Answer 38

latissimus dorsi rectus abdominis

Question 39

What is a sentinal lymph node?

Answer 39

First draining lymph node. If negative then other lymph nodes unlikely to have tumour cells

Question 40

Neoadjuvant chemo increases possibility of ___, reduces ___ to improve ___

Answer 40

breast conserving surgery tumour size, improve cosmesis

Question 41

Treatment drugs for ER/PR positive cancer

Answer 41

pre-menopausal: tamoxifen post-menopausal: aromatase inhibitors

Question 42

Treatment for HER2 positive cancers

Answer 42

Herceptin (trastuzumab)

Question 43

Paget's disease is associated with ___

Answer 43

underlying DCIS/invasive carcinoma

Question 44

Unlike eczema, paget's disease ___

Answer 44

destroys the nipple usually unilateral

Question 45

Causes of gynaecomastia

Answer 45

DOPING N Others drugs - oestrogens, spironolactone, tricyclic antidepressants, cannabis organ failure - liver, kidney, testicle, hyperthyroid physiological idiopathic nutrition - malnutrition hypoGonadism Neoplasm - carcinoma, prolactinoma