Breast

Question 1

What is meant by mammary duct ectasia? [1]

How does this present? [3]

Answer 1

Dilatation in breast ducts
- There is inflammation in the ducts, leading to intermittent discharge from the nipple.
-. As the ducts shorten and dilate a degree of symmetrical slit like retraction occurs.

Presentation:
* Thick, green discharge
* Nipple retraction or inversion
* Tenderness or pain
**

Ectasia means dilation

Question 2

Which population does mammary duct ectasia typically present in? [1]

What is another major risk factor? [1]

Answer 2

Perimenopausal women

Smoking is significant RF

Question 3

How does mammary duct ectasia present on mammogram? [1]

Answer 3

Microcalcifications are a key finding to remember on a mammogram, although they are not specific to mammary duct ectasia.

Question 4

How do you treat mammary duct ectasia? [1]

Answer 4

Mammary duct ectasia may resolve without any treatment. It is not associated with an increased risk of cancer.

Management depends on the individual patient:

Reassurance after excluding cancer may be all that is required
Symptomatic management of mastalgia (supportive bra and warm compresses)
Antibiotics if infection is suspected or present
Surgical excision of the affected duct (microdochectomy) may be required in problematic cases

Question 5

Triple assessment of a breast lump is standard practice to exclude or diagnose cancer. This involves: [3]

Clinical features that may suggest breast cancer are: [4]

Answer 5

Clinical assessment (history and examination)
Imaging (ultrasound or mammography)
Histology (fine needle aspiration or core biopsy)

? cancer
* Lumps that are hard, irregular, painless or fixed in place
* Lumps may be tethered to the skin or the chest wall
* Nipple retraction
* Skin dimpling or oedema (peau d’orange)

Question 6

The NICE guidelines (updated January 2021) recommend a two week wait referral for suspected breast cancer for [2]

Answer 6

• An unexplained breast lump in patients aged 30 or above
• Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes)

NB:
The NICE guidelines recommend also considering a two week wait referral for:

An unexplained lump in the axilla in patients aged 30 or above
Skin changes suggestive of breast cancer

Question 7

Describe what is meant by firbocystic breast changes [2]

Answer 7

The connective tissues (stroma), ducts and lobules of the breast respond to the female sex hormones (oestrogen and progesterone), becoming fibrous (irregular and hard) and cystic (fluid-filled).

These changes fluctuate with the menstrual cycle.

Question 8

Fibroadenoma - how / when do you treat? [1]

Answer 8

If >3cm surgical excision is usual, Phyllodes tumours should be widely excised (mastectomy if the lesion is large)

Question 9

Management of fibrocystic breast changes is to exclude cancer and manage symptoms. Options to manage cyclical breast pain (mastalgia) include: [4]

Answer 9

• Wearing a supportive bra
• Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen
• Avoiding caffeine is commonly recommended
• Applying heat to the area
• Hormonal treatments (e.g., danazol and tamoxifen) under specialist guidance

Question 10

The most common cause of breast lumps is? [1]

Answer 10

Breast cysts

Question 11

How do breast cysts present on examination? [4]

Answer 11

Smooth, discreet lump
Mobile
Possibly fluctuant

Question 12

How do you treat a breast cyst? [2]

Answer 12

• Cysts should be aspirated
• Those which are blood stained or persistently refill should be biopsied or excised

Question 13

What is fat necrosis? [1]
What is fat necrosis caused by? [1]

Answer 13

Fat necrosis causes a benign lump formed by localised degeneration and scarring of fat tissue in the breast. It may be associated with an oil cyst, containing liquid fat

Fat necrosis is commonly triggered by localised trauma, radiotherapy or surgery, with an inflammatory reaction resulting in fibrosis and necrosis (death) of the fat tissue. It does not increase the risk of breast cancer.

Question 14

On examination, fat necrosis can be:
[5]

Answer 14

On examination, fat necrosis can be:

• Painless
• Firm
• Irregular
• Fixed in local structures
• There may be skin dimpling or nipple inversion

Question 15

How do you investigate ?fat necrosis of breast [1]

Answer 15

Imaging and core biopsy
- Ultrasound or mammogram can show a similar appearance to breast cancer. Histology (by fine needle aspiration or core biopsy) may be required to confirm the diagnosis and exclude breast cancer.

Question 16

[] occur in women that are lactating (producing breast milk), often after stopping breastfeeding

Answer 16

Galactoceles occur in women that are lactating (producing breast milk), often after stopping breastfeeding

Question 17

Describe what a galactocele is [1]

Where/how do they usually occur? [1]

Answer 17

They are breast milk filled cysts that occur when the lactiferous duct is blocked, preventing the gland from draining milk

They present with a firm, mobile, painless lump, usually beneath the areola.

Question 18

Where does breast cancer met. to? [4]

Answer 18

Metastasis – 2B2L = brain, bones, lung, liver

Question 19

Describe what is meant by a phyllodes tumour [1]

Answer 19

Phyllodes tumours are rare tumours of the connective tissue (stroma) of the breast, occurring most often between ages 40 and 50.

They are large and fast-growing. They can be benign (~50%), borderline (~25%) or malignant (~25%).

Malignant phyllodes tumours can metastasise.

Question 20

How do you treat a phyllodes tumour? [1]

Answer 20

Treatment involves surgical removal of the tumour and the surrounding tissue (“wide excision”). They can reoccur after removal

Question 21

.

Answer 21

.

Question 22

Describe the difference between cyclical and non-cyclical breast pain

Answer 22

Cyclical breast pain:
- is more common and is related to hormonal fluctuations during the menstrual cycle.
- The pain typically occurs during the two weeks BEFORE menstruation (the luteal phase) and settles during the menstrual period.
- There may be other symptoms of premenstrual syndrome, such as low mood, bloating, fatigue or headaches.

Non-Cyclical Breast Pain:
- Non-cyclical breast pain is more common in women aged 40 – 50 years
- It is more likely to be localised than cyclical breast pain. Often no cause is found. However, it may be caused by: Medications (e.g., hormonal contraceptive medications); Infection (e.g., mastitis); Pregnancy

Question 23

Diagnosis:
A [] can help diagnose cyclical breast pain.

The three main things to exclude when someone presents with breast pain are:

Answer 23

Diagnosis
A breast pain diary can help diagnose cyclical breast pain.

The three main things to exclude when someone presents with breast pain are:
* Cancer (perform a thorough history and examination)
* Infection (mastitis)
* Pregnancy (perform a pregnancy test)

Question 24

Describe what is meant by an intraductal papilloma [1]

Answer 24

• An intraductal papilloma is a warty lesion that grows within one of the ducts in the breast.
• It is the result of the proliferation of epithelial cells.
• The typical presentation is with clear or blood-stained nipple discharge.

Question 25

Describe the presentation of an intraductal papilloma [4]

Answer 25

Intraductal papillomas are often **asymptomatic**. They may be picked up incidentally on mammograms or ultrasound. They may present with: * **Nipple discharge** (clear or blood-stained) * **Tenderness or pain** * **A palpable lump**

Question 26

Describe how you investigate an intraductal papilloma [2]

Answer 26

**Patients require triple assessment with**: * Clinical assessment (history and examination) * Imaging (ultrasound, mammography and MRI) * Histology (usually by core biopsy or vacuum-assisted biopsy) **Microdochectomy** - Ductography may also be used. This involves **injecting contrast into the abnormal duct and performing mammograms to visualise that duct**. The papilloma will be seen as an area that does not fill with contrast (a “filling defect”).

Question 27

Which is the most common type of breast cancer Invasive ductal carcinoma. Invasive lobular carcinoma Ductal carcinoma-in-situ (DCIS) Lobular carcinoma-in-situ (LCIS)

Answer 27

Which is the most common type of breast cancer **Invasive ductal carcinoma.** - This is the most common type of breast cancer. To complicate matters further this has recently been renamed **'No Special Type (NST)'**. In contrast, lobular carcinoma and other rarer types of breast cancer are classified as 'Special Type' Invasive lobular carcinoma Ductal carcinoma-in-situ (DCIS) Lobular carcinoma-in-situ (LCIS)

Question 28

Describe what is meant by Paget's disease of the nipple [1]

Answer 28

**Paget's disease of the nipple is an eczematoid change of the nipple associated with an underlying breast malignancy and it is present in 1-2% of patients with breast cancer** - In **half of these patients**, it is associated with an **underlying mass lesion** and **90% of such patients will have an invasive carcinoma**. - **30% of patients without a mass lesion** will still be found to have an **underlying carcinoma**. **The remainder will have carcinoma in situ.**

Question 29

Describe the features of breast cancer [5]

Answer 29

* Breast lump: typically painless. Classically described as fixed, hard * Breast skin changes * Bloody nipple discharge * Inverted nipple * Axillary mass * Skin dimpling or oedema (peau d’orange)

Question 30

Describe the different types of surgery [2] for breast cancer and why they might be given to patients, Give the reasons you would choose one / other [4]

Answer 30

Women either have a **wide-local excision** or a **mastectomy**: - Around **two-thirds of tumours** can be **removed with a wide-local excision.**

Question 31

Chemoprevention of breast cancer can occur with which drugs for: premenopausal [1] and post-menopausal [1] What is the one pathological state that is a CI for post-menopausal women? [1]

Answer 31

**Chemoprevention** may be offered for women at high risk, with: * **Tamoxifen** if premenopausal * **Anastrozole** if postmenopausal (except with severe osteoporosis)

Question 32

Which surgeries can be provided for high risk breast cancer patients [2]]

Answer 32

**Risk-reducing bilateral mastectomy or bilateral oophorectomy** (removing the ovaries) is an option for women at high risk. - This is suitable for only a small number of women and requires significant counselling and weighing up risks and benefits.

Question 33

When is radiotherapy offered for breast cancer? [1]

Answer 33

1. Whole breast radiotherapy is recommended after a woman has had **a wide-local excision** as this may reduce the risk of recurrence by around two-thirds. 2. For women who've had a **mastectomy** radiotherapy is offered for **T3-T4 tumours** and for those with **four or more positive axillary node**

Question 34

Which are the three breast cancer receptors? [3]

Answer 34

* **Oestrogen receptors** (ER) * **Progesterone receptors** (PR) * **Human epidermal growth factor** (HER2) **Triple-negative breast cancer is where the breast cancer cells do not express any of these three receptors**. This carries a worse prognosis, as it limits the treatment options for targeting the cancer.

Question 35

Gene Expression Profiling Gene expression profiling involves assessing which genes are present within the breast cancer on a histology sample. This helps predict the probability that the breast cancer will reoccur as a distal metastasis (away from the original cancer site) within 10 years. The NICE guidelines (2018) [DG34] recommend this for which breast cancers? [1]

Answer 35

Gene Expression Profiling Gene expression profiling involves assessing which genes are present within the breast cancer on a histology sample. This helps predict the probability that the breast cancer will reoccur as a distal metastasis (away from the original cancer site) within 10 years. The NICE guidelines (2018) [DG34] recommend this for women with early breast cancers that are **ER positive but HER2 and lymph node negative**. It helps guide whether to give additional chemotherapy.

Question 36

TOM TIP: What do you need to remember about a patient with breast cancer who has had axillary clearance (if they were re-emitted) [1]

Answer 36

TOM TIP: It is important to remember that you should **avoid taking blood or putting a cannula in the arm on the side of previous breast cancer removal surgery.** This is because there is a higher risk of **complications** and **infection** due to the impaired lymphatic drainage on that side.

Question 37

What are the two first line treatments for oestrogen receptor positive breast cancers? [2]

Answer 37

**Tamoxifen** for premenopausal women **Aromatase inhibitors** for postmenopausal women (e.g., **letrozole, anastrozole or exemestane**)

Question 38

Which of the following is an aromatase inihibitor Tamoxifen Fulvestrant Anastrozole Leuprorelin Trastuzumab Pertuzumab

Answer 38

Which of the following is an aromatase inihibitor Tamoxifen Fulvestrant **Anastrozole** Leuprorelin Trastuzumab Pertuzumab

Question 39

Which of the following is a selective oestrogen receptor modulator (SERM) Tamoxifen Fulvestrant Anastrozole Leuprorelin Trastuzumab Pertuzumab

Answer 39

Which of the following is a selective oestrogen receptor modulator (SERM) **Tamoxifen** Fulvestrant Anastrozole Leuprorelin Trastuzumab Pertuzumab

Question 40

Which of the following is a selective oestrogen receptor downregulato Tamoxifen Fulvestrant Anastrozole Leuprorelin Trastuzumab Pertuzumab

Answer 40

Which of the following is a selective oestrogen receptor downregulato Tamoxifen **Fulvestrant** Anastrozole Leuprorelin Trastuzumab Pertuzumab

Question 41

Which of the following targets the HER2 receptor [2] Tamoxifen Fulvestrant Anastrozole Leuprorelin Trastuzumab Pertuzumab

Answer 41

Which of the following targets the HER2 receptor Tamoxifen Fulvestrant Anastrozole Leuprorelin **Trastuzumab** **Pertuzumab**

Question 42

Name three HER2 receptor drugs [3]

Answer 42

**Trastuzumab** (Herceptin) is a monoclonal antibody that targets the HER2 receptor. It may be used in patients with HER2 positive breast cancer. **Notably, it can affect heart function; therefore, initial and close monitoring of heart function is required.** **Pertuzumab** (Perjeta) is another monoclonal antibody that targets the HER2 receptor. It may be used in patients with HER2 positive breast cancer. This is used in combination with trastuzumab (Herceptin). **Neratinib** (Nerlynx) is a tyrosine kinase inhibitor, reducing the growth of breast cancers. It may be used in patients with HER2 positive breast cancer.

Question 43

Tamoxifen increases the risk of which cancer? [1] Why? [1] / Describe the MoA

Answer 43

**increase the risk of endometrial cancer:** - It **blocks oestrogen receptors in breast tissue**, and **stimulates oestrogen receptors in the uterus and bones**. This means it helps prevent osteoporosis, but it does increase the risk of endometrial cancer.

Question 44

Name three aromatase inhibitors [3] Describe their MoA [1]

Answer 44

**Letrozole, anastrozole or exemestane** Aromatase inhibitors work by **blocking the creation of oestrogen in fat tissue.**

Question 45

*It can be caused by bacterial infection, blocked milk ducts, or a combination of both. breast pain, swelling, redness, and warmth, as well as fever and flu-like symptoms in severe cases.* refers to which breast pathology?

Answer 45

**Mastitis**

Question 46

most common organism causing infective mastitis is **[]**

Answer 46

most common organism causing infective mastitis is **Staphylococcus aureus**

Question 47

What is the treatment plan for mastitis?

Answer 47

the first-line management of mastitis is to **continue breastfeeding.** simple measures * **analgesia** * **warm compresses** the first-line antibiotic is **oral flucloxacillin for 10-14 day**

Question 48

What is a complication of infectious mastitis [1]

Answer 48

**Breast abscesses** - The infective organism is most commonly **Staphylococcus aureus** , and up to 50-60% of such cases have been reported to involve methicillin-resistant Staphylococcus aureus (MRSA)

Question 49

Non-lactational breast abscesses may be caused by **[]**

Answer 49

Non-lactational breast abscesses may be caused by **duct ectasia,** which is a thickening and widening of the mild duct generally seen in women aged 45-55, and that can cause mastitis and subsequent infection.

Question 50

Describe the treatment regime for breast abscesses [3]

Answer 50

Question 51

3Describe how you treat Paget's disease of the nipple [4]

Answer 51

**Surgery**: The mainstay of treatment for Paget's disease of the nipple is surgical. There are two primary surgical options: * **Breast-Conserving Surgery (BCS):** It involves the excision of the nipple-areola complex and a margin of healthy tissue. **Typically followed by radiation therapy** or * **Mastectomy**: recommended when an invasive or in situ carcinoma in the breast parenchyma is present, separate from the nipple-areola complex, or in the case of multifocal disease. **Systemic Therapy** - Patients with ER-positive tumours should be offered adjuvant hormonal therapy. HER2-positive tumours may benefit from targeted therapy with trastuzumab.

Question 52

Prior to breast surgery for cancer, what do you investigate for as it determines management?

Answer 52

**presence/absence of axillary lymphadenopathy determines management**: women with **no palpable axillary lymphadenopathy** at presentation: - should have a **pre-operative axillary ultrasound** before their **primary surgery** - if **negative** then they should have a **sentinel node biopsy to assess the nodal burden** in patients **with breast cancer who present with clinically palpable lymphadenopathy**: - **axillary node clearance is indicated at primary surgery** -

Question 53

Anastrozole is an aromatase inhibitor used for the treatment of oestrogen receptor-positive breast cancer in postmenopausal women Name a significant risk of using this drug [1]

Answer 53

Patients taking these medications are at an increased risk of **osteoporosis**. ## Footnote NB: tamoxifen causes amenorrhoea, endometrial cancer, vaginal bleeding and venous thromboembolism

Question 54

In the UK, all women are offered breast cancer screening with mammography every **[]** years between the ages of 50 and 70 years.

Answer 54

In the UK, all women are offered breast cancer screening with mammography **every 3 years** between the ages of 50 and 70 years.

Question 55

*An obese woman presents with an irregular lump on the lateral aspect of her right breast associated with skin tethering. Biopsy excludes a malignant cause.* Suggest? [1]

Answer 55

**Fat necrosis** (the trauma can occur unnoticed)

Question 56

*A 41-year-old woman presents with a two-month history of an irregular fixed lump in her left breast.* Suggests? [1]

Answer 56

The combination of a persistent lump spanning at least one menstrual cycle and the irregularity point to a diagnosis of **cancer**.

Question 57

A 56-year-old woman has recently been diagnosed with breast cancer. She attends an appointment with her consultant to discuss the potential treatment options. She has a solitary lesion in the upper outer quadrant of her right breast which is 2.5cm in diameter. Her cancer is staged as T2 N1 M0. What management option is this patient most likely to be offered? * Neoadjuvant FEC chemotherapy followed by a right-sided mastectomy * Neoadjuvant FEC chemotherapy followed by a wide local excision * Neoadjuvant FEC-D chemotherapy followed by a wide local excision and whole breast radiotherapy * Right-sided mastectomy followed by FEC-D chemotherapy * Right-sided mastectomy followed by whole breast radiotherapy

Answer 57

* Neoadjuvant FEC chemotherapy followed by a wide local excision * **Neoadjuvant FEC-D chemotherapy followed by a wide local excision and whole breast radiotherapy** * Right-sided mastectomy followed by FEC-D chemotherapy * Right-sided mastectomy followed by whole breast radiotherapy

Question 58

What four factors determine if a breast cancer surgery is a mastectomy? [4]

Answer 58

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

Question 59

What four factors determine if a breast cancer surgery is a wide local excision? [4]

Answer 59

DCIS < 4cm Peripheral tumour Solitary lesion Small lesion in large breast

Question 60

Describe what causes inflammatory breast cancer [1] Describe the presentation of inflammatory breast cancer [1]

Answer 60

**IBC** is a rare but rapidly progressive form of breast cancer caused by **obstruction of lymph drainage causing erythema and oedema** **progressive** **erythema** and **oedema of the breast** in the **absence** **signs** of **infection** such as **fever, discharge or elevated WCC and CRP)** and an **elevated CA 15-3.**

Question 61

How do you treat inflammatory breast cancer? [3]

Answer 61

neo-adjuvant chemotherapy first-line, followed by total mastectomy +/- radiotherapy.

Question 62

A 58-year-old undergoes a triple assessment after finding a lump in the right upper lateral quadrant of her breast. Her last menstrual period was 8 years ago, she has never used any hormonal contraceptives or hormone replacement therapy and has no other past medical history. A biopsy shows the presence of ductal carcinoma in situ that is progesterone receptor-negative, HER2-negative, and oestrogen receptor-positive. She is offered a lumpectomy with adjuvant radiotherapy and endocrine therapy. What is the mechanism of action of the most likely drug she will be given? Complete oestrogen receptor antagonism GnRH receptor agonism GnRH receptor antagonism Inhibition of peripheral oestrogen synthesis Partial oestrogen receptor antagonism tamoxifen

Answer 62

**Inhibition of peripheral oestrogen synthesis**

Question 63

Tamoxifen works by which MoA? [1] Complete oestrogen receptor antagonism GnRH receptor agonism GnRH receptor antagonism Inhibition of peripheral oestrogen synthesis Partial oestrogen receptor antagonism

Answer 63

Tamoxifen works by which MoA? [1] Complete oestrogen receptor antagonism GnRH receptor agonism GnRH receptor antagonism Inhibition of peripheral oestrogen synthesis **Partial oestrogen receptor antagonism**

Question 64

**Periductal mastitis** is common in smokers and may present with recurrent infections. Treatment is with **[]**.

Answer 64

Periductal mastitis is common in smokers and may present with recurrent infections. **Treatment is with co-amoxiclav**

Question 65

*A 20-year-old lady presents with a mobile lump in the upper outer aspect of her right breast. On examination she has a firm mobile mass in the upper outer quadrant of her right breast.*

Answer 65

**Fibroadenoma**

Question 66

Which of the following is associated with a halo sign on mammography Breast cyst Duct ectasia Atypical ductal hyperplasia Fibroadenoma95

Answer 66

Which of the following is associated with a halo sign on mammography **Breast cyst** Duct ectasia Atypical ductal hyperplasia Fibroadenoma

Question 67

**[]** is recommended after a woman has had a **wide-local excision** as this may reduce the risk of recurrence by around two-thirds

Answer 67

**Whole breast radiotherapy** is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence by around two-thirds

Question 68

Which drug do you use for **perimenopausal women?** Anastrozole Enoxaparin Goserelin Tamoxifen Trastuzumab

Answer 68

Which drug do you use for **perimenopausal women?** Anastrozole Enoxaparin Goserelin **Tamoxifen** Trastuzumab