Breast;

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

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

Answer 3

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

Question 4

How do you treat a breast cyst? [2]

Answer 4

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

Question 5

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

Answer 5

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

Question 6

Describe what a galactocele is [1]

Where/how do they usually occur? [1]

Answer 6

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 7

Where does breast cancer met. to? [4]

Answer 7

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

Question 8

How do you treat a phyllodes tumour? [1]

Answer 8

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

Question 9

Describe the difference between cyclical and non-cyclical breast pain

Answer 9

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 10

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 10

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 11

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 11

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

Question 12

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

Answer 12

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 13

When is radiotherapy offered for breast cancer? [1]

Answer 13

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 14

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 14

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 15

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 15

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 16

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

Answer 16

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 17

Which of the following is a selective oestrogen receptor downregulato

Tamoxifen
Fulvestrant
Anastrozole
Leuprorelin
Trastuzumab
Pertuzumab

Answer 17

Which of the following is a selective oestrogen receptor downregulato

Tamoxifen
Fulvestrant
Anastrozole
Leuprorelin
Trastuzumab
Pertuzumab

Question 18

most common organism causing infective mastitis is []

Answer 18

most common organism causing infective mastitis is Staphylococcus aureus

Question 19

Non-lactational breast abscesses may be caused by []

Answer 19

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 20

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

Answer 20

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 21

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 21

Patients taking these medications are at an increased risk of osteoporosis.

NB: tamoxifen causes amenorrhoea, endometrial cancer, vaginal bleeding and venous thromboembolism

Question 22

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

Answer 22

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

Question 23

Describe what causes inflammatory breast cancer [1]

Describe the presentation of inflammatory breast cancer [1]

Answer 23

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 24

How do you treat inflammatory breast cancer? [3]

Answer 24

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

Question 25

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 25

Inhibition of peripheral oestrogen synthesis

Question 26

Periductal mastitis is common in smokers and may present with recurrent infections.

Treatment is with [].

Answer 26

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

Question 27

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

Answer 27

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 28

A 74-year-old woman presents with a breast lump. On examination, it has a soft consistency. The lump is removed and sliced apart. Macroscopically there is a grey, gelatinous surface.

A. Eczema of the nipple
B. Ductal carcinoma in situ
C. Mucinous carcinoma
D. Invasive ductal carcinoma
E. Invasive lobular carcinoma

Answer 28

A 74-year-old woman presents with a breast lump. On examination, it has a soft consistency. The lump is removed and sliced apart. Macroscopically there is a grey, gelatinous surface.

A. Eczema of the nipple
B. Ductal carcinoma in situ
C. Mucinous carcinoma
D. Invasive ductal carcinoma
E. Invasive lobular carcinoma

Mucinous carcinomas comprise 2-3% of all breast cancers. They are one of the special type of carcinomas. These have a better prognosis that tumours of Non Special Type (NST) and axillary nodal disease is rare in this group.

Question 29

Comedo necrosis is a feature of high nuclear grade ductal carcinoma in situ. It is has a high risk of being associated with foci of invasion.

What causes comedo necrosis?

Ductal carcinoma in situ
Invasive ductal carcinoma
Invasive lobular carcinoma
Paget’s disease of the nipple
Lobular carcinoma in situ.

Answer 29

Comedo necrosis is a feature of high nuclear grade ductal carcinoma in situ. It is has a high risk of being associated with foci of invasion.

What causes comedo necrosis?

Ductal carcinoma in situ
Invasive ductal carcinoma
Invasive lobular carcinoma
Paget’s disease of the nipple
Lobular carcinoma in situ.

Question 30

The combination of a grade 3 tumour and axillary nodal metastasis in a young female would attract a recommendation for what therapy?

Cytotoxic chemotherapy
Radiotherapy
Endocrine therapy using letrozole
Endocrine therapy using tamoxifen

Answer 30

The combination of a grade 3 tumour and axillary nodal metastasis in a young female would attract a recommendation for what therapy?

Cytotoxic chemotherapy
Radiotherapy
Endocrine therapy using letrozole
Endocrine therapy using tamoxifen

Question 31

A 55-year-old woman presents with creamy nipple discharge. Her last mammography screening done one year ago was normal. She smokes 15 cigarettes per day. Her clinical examination was reassuring. A repeat mammogram was done and no abnormalities were detected. She is worried that it might be a tumour but not annoyed by the discharge itself. Her serum prolactin level is shown below.

Prolactin 200 mIU/L (< 600)

According to the most likely diagnosis, what is the best initial treatment?

Lumpectomy
Mastectomy
Microdochectomy
Reassurance
Total duct excision

Answer 31

Reassurance - No specific treatment is required for duct ectasia

Microdochectomy is used to treat duct ectasia (in young women) if the condition is bothering the patient. It is also used in treating intraductal papilloma.

Question 32

A patient, 32, who presents with suspected fibroadenoma.

What is the most appropriate next step for this patient? [1]

Answer 32

ultrasound of the lump.
- As the woman is under 35 years of age, an ultrasound is preferred over a mammogram.

Question 33

Ultrasound of the breast and of the right axillary lymph node show a ‘snowstorm’ sign. What is the most likely diagnosis? [1]

Answer 33

Implant rupture