Breast

Question 1

What adjuvant therapy is used in oestrogen receptor (ER) positive breast cancer?

Answer 1

Pre- or peri-menopausal: tamoxifen (selective oestrogen receptor modulator - SERM)

Post-menopausal: Anastrazole (aromatase inhibitor)

Question 2

When is herceptin used in breast cancer?

Answer 2

It is a monoclonal antibody (biological therapy) that is used for patients who have HER2+ breast cancer

Question 3

What are the indications for a mastectomy vs wide local excision?

Answer 3

Mastectomy:
* Multifocal tumour
* Central tumour
* Large lesion in small breast
* DCIS > 4cm

Wide local excision:
* Solitary lesion
* Peripheral tumour
* Small lesion in large breast
* DCIS < 4cm

Question 4

What are the indications for radiotherapy post-breast surgery?

Answer 4

Wide local excision: all women (reduces risk of recurrence by 2/3)

Mastectomy: T3-T4 tumours or if four or more positive axillary nodes

Question 5

When do you offer abx in mastitis?

Answer 5

• if systemically unwell
• if nipple fissure present
• if symptoms do not improve after 12-24 hours of effective milk removal
• if culture indicates infection

Question 6

What is the definitive management of a breast abscess?

Answer 6

Incision and drainage

Question 7

What is the 2WW referral criteria for breast cancer?

Answer 7

Refer if:
* aged 30 and over and have an unexplained breast lump with or without pain or
* aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern

Consider referring if:
* with skin changes that suggest breast cancer or
aged 30 and over with an unexplained lump in the axilla

Question 8

What level of referral should you do in people aged under 30 with an unexplained breast lump with or without pain?

Answer 8

Non-urgent

Question 9

What is the common presentation of periductal mastitis?

Answer 9

Smokers and may present with recurrent infections. May present with features of inflammation, abscess or mammary duct fistula

Occurs at a younger age than duct ectasia

Treatment is with co-amoxiclav

Question 10

What are adverse effects of Selective oEstrogen Receptor Modulators (SERM)?

Answer 10

• menstrual disturbance: vaginal bleeding, amenorrhoea
• hot flushes - 3% of patients stop taking tamoxifen due to climacteric side-effects
• venous thromboembolism
• endometrial cancer

Question 11

What are adverse effects of aromatase inhibitors?

Answer 11

• osteoporosis - NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer
• hot flushes
• arthralgia, myalgia
• insomnia

Question 12

What is the typical appearance of inflammatory breast cancer?

Answer 12

• Progressive, erythema and oedema of the breast
• Absence signs of infection such as fever, discharge or elevated WCC and CRP
• Elevated CA 15-3

Question 13

What abx is offered in mastitis?

Answer 13

Oral flucloxacillin for 10-14 days

As the most common organism causing infective mastitis is Staphylococcus aureus

Question 14

What does the NHS Breast Screening Programme consist of?

Answer 14

Women between the ages 50-70 years are offered a mammogram every 3 years

Question 15

What is the most common type of breast cancer?

Answer 15

Invasive ductal carcinoma (no special type)

Accounts for 70-80% of all breast cancers

Question 16

What is the difference between invasive ductal carcinoma and invasive lobular carcinoma?

Answer 16

Invasive ductal carcinoma: originates in the cells that line the milk ducts of the breast and then invades the surrounding tissue (calcification is seen on mammogram)

Invasive lobular carcinoma: begins in the lobules (the glands that produce milk) and can spread to other areas of the body

Question 17

What are the features of duct ectasia?

Answer 17

• Patients usually present with nipple discharge, which may be from single or multiple ducts (usually present age >50 years)
• The discharge is often thick and green
• Normal during breast involution that occurs during the menopausal period

Question 18

What are features of an intraductal papilloma?

Answer 18

• Growth of papilloma in a single duct
• Usually presents with clear or blood stained discharge originating from a single duct
• No increase in risk of malignancy

Question 19

What are the features of fibroadenomas?

Answer 19

• Develop from a whole lobule
• Mobile, firm, smooth breast lump - a ‘breast mouse’
• 12% of all breast masses
• Over a 2 year period up to 30% will get smaller
• No increase in risk of malignancy
• If >3cm surgical excision is usual

Question 20

What is the mechanism of Selective oEstrogen Receptor Modulators (SERM)?

Answer 20

Complete or partial antagonism of the oestrogen receptor

Examples:
* Complete - raloxifene
* Partial - tamoxifen

Question 21

What is the management of cyclical mastalgia?

Answer 21

• Supportive bra
• Standard oral or topical analgesia
• Flaxseed oil and evening primrose oil sometimes used but not NICE-licensed
• If conservative measures do not improve within 3 months, refer

Question 22

What is a side effect of axillary node clearance?

Answer 22

Arm lymphedema and functional arm impairment

Question 23

What should you ask if a patient is presenting with dry skin around the nipple?

Answer 23

If they have any other dry skin around the body - will most likely be eczema as opposed to Paget’s disease

Question 24

Risk factors for breast cancer

Answer 24

Female sex
AGE AGE AGE
High BMI
Dense Breasts
Alcohol
Previous breast cancer + radiation exposure
Urban living
Nulliparous, not breast feeding
Family history
Early menarch and late menopause

Question 25

What is the age limit for breast USS and mammogram?

Answer 25

USS <40 - due to breast tissue being denser and harder to analyse on mammgram

Mammogram > 40

Question 26

In patients with breast cancer with clinically palpable lymphadenopathy, what is the primary surgery of option?

Answer 26

Axillary node clearance