Breast

Question 1

fibroadenoma?

Answer 1

‘Breast mice’
Benign non-tender firm mobile lump
No malignancy risk
If >3cm, excise

Question 2

breast cyst?

Answer 2

Smooth discrete lump, may be fluctuant, may be painful (cyclical)
Small increased breast ca risk
Aspirate - biopsy if blood / persistently refilling
Can excise

Question 3

sclerosing adenosis?

Answer 3

breast lump, pain
biopsy, excision not mandatory

Question 4

epithelial hyperplasia?

Answer 4

generalised lumpiness / discrete lump
If atypical sx / FHx - malignancy risk
Leave, or excise if ca risk

Question 5

fat necrosis?

Answer 5

40% traumatic cause, mimics carcinoma
Image, core biopsy

Question 6

duct papilloma?

Answer 6

Growth of papilloma in single duct
Nipple discharge - clear / blood stained
No malignancy risk
Microdochectomy to tx

Question 7

duct ectasia?

Answer 7

Dilatation + shortening of terminal breast duct - blocks with stagnant secretions
Px - nipple discharge, thick/green, nipple retraction
Mx - stop smoking, microdochectomy / total duct excision

Question 8

periductal mastitis?

Answer 8

Younger pt than ectasia, strong association with smoking
Inflammation, abscess, mammary duct fistula
Mx - abx, drain abscess

Question 9

breast abscess?

Answer 9

lactational mastitis common, usually S aureus
Tender, fluctuant mass on examination, fever
Abx, US-guided aspiration
Surgical debridement for skin necrosis

Question 10

TB of breast?

Answer 10

rare, chronic breast / axillary sinus in 50%
Dx by biopsy culture / histology

Question 11

breast cancer RFx?

Answer 11

• Female
• Increased oestrogen exposure - earlier period onset, later menopause
• Dense breast - more glandular tissue
• Obesity
• Smoking
• FHx 1st degree relative
• cOCP (risk returns to normal 10yrs after stopping)
• HRT - especially combined HRT

Genetics
- BRCA 1 - breast, ovarian, bowel, prostate risk
- BRCA 2 - breast, ovarian risk
- TP53, PTEN

Question 12

types of breast cancer?

Answer 12

Ductal carcinoma in situ (DCIS)
Cancerous epithelial cells of breast ducts, one area, picked up on screening, potential to spread

Lobular carcinoma in situ (LCIS)
Pre-cancerous, in pre-menopause, asym, found incidentally on biopsy, increased risk invasive ca, monitor

Invasive ductal carcinoma NST (no specific type)
Not classified, originate from cells in breast ducts, see on mammogram, 80% of invasive

Invasive lobular carcinoma (ILC)
Originate from cells in breast lobules, 10% of invasive

Inflammatory breast ca
Cancer cells block lymph drainage, swollen, warm, tender, peau d’orange (pitting skin), no abx response

Question 13

what is pagets?

Answer 13

Paget’s
Erythematous, scaly rash, breast ca involving nipple, 90% have invasive ca

Question 14

breast cancer receptors?

Answer 14

Oestrogen receptor (ER)
Progesterone receptor (PR)
Human epidermal growth factor (HER2)

Triple negative breast cancer - none of these receptors, worse prognosis

Question 15

where does breast cancer metastasise to?

Answer 15

lung, liver, bone, brain

Question 16

breast cancer screening programme?

Answer 16

Mammogram every 3yrs to women 50-70yo

Question 17

what factors make someone a high risk breast cancer patients?

Answer 17

Eg, 1st degree relative:
With breast cancer <40yo
Male with breast cancer
Bl breast cancer, first diagnosed <50yo
2x 1st degree relative with breast cancer

Question 18

management of high risk breast cancer patients?

Answer 18

Genetic testing maybe
Annual mammogram
Chemoprevention
- Tamoxifen (premenopause - antioestrogen)
- Anastrozole (post-menopause, except if severe osteoporosis)

Surgery - bl mastectomy / oophorectomy

Question 19

breast cancer presentation?

Answer 19

Lump - hard, irregular, painless, fixed in place
May be tethered to skin / chest wall
Nipple retraction, discharge (blood-stained)
Skin dimpling / oedema (peau d’orange)
Lymphadenopathy (axilla)

Question 20

breast lump referral criteria?

Answer 20

2ww - unexplained breast lump >30yo / unilateral nipple discharge >50yo

Consider 2ww - unexplained axilla lump >30yo / skin changes

Consider non-urgent referral - unexplained breast lump +/- pain

Question 21

breast cancer investigations/

Answer 21

• history + exam
• USS / mammography
• Biopsy - fine needle / core

USS - younger women, look at lumps

Mammogram - older, see calcifications

MRI - screening, further tumour assessment

Lymph nodes - US axilla / US-guided biopsy / sentinel node biopsy (in surgery)

TNM staging

Nottingham prognostic index to indicate survival

Question 22

breast cancer management?

Answer 22

Surgery
- Wide local excision - <4cm, solitary peripheral mass
- Mastectomy - >4cm, multifocal, central mass
- Reconstruction
- Lymph node clearance

Radio / chemo

Hormone Tx
- Tamoxifen - does increase endometrial cancer risk
- Anastrozole / letrozole
- Fulvestrant - selective oestrogen receptor down-regulator
- GnRH agonist - goserelin
- Ovarian surgery

HER2 - herceptin (trastuzumab) - MAb targeting HER2 - can affect heart function
Also perjeta, nerlynx

Yearly mammograms for 5yrs