Breast

Question 1

What features of a breast cancer indicate mastectomy instead of wide local excision?

Answer 1

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

Question 2

What features of a breast cancer indicate wide local incision instead of mastectomy?

Answer 2

Solitary lesion
Peripheral lesion
Small lesion in large breast
DCIS >4cm

Question 3

When is radiotherapy indicated following surgical removal of breast cancer?

Answer 3

All patients who have had a wide local excision

Patients who have had a mastectomy if T3-T4 disease or 4 or more positive axillary lymph nodes

Question 4

What adjuvant therapy can be used for women with oestrogen receptor positive breast cancer?

Answer 4

Tamoxifen

Question 5

What are 3 important side effects of Tamoxifen?

Answer 5

Increased risk of endometrial cancer
Increased risk of VTE
Menopausal symptoms

Question 6

What is commonest biological therapy used in breast cancer?
When is it indicated?
When is it contraindicated?

Answer 6

Trastuzumab (Herceptin)
Indicated in HER2 positive tumours (although it is only effective in up to a quarter of these cases)
Contraindicated in women with history of heart disorders

Question 7

What is the first step of management for a woman presenting with a new breast lump?

Answer 7

Triple Assessment

Question 8

What features of nipple discharge are indications for Triple Assessment?

Answer 8

Blood stained
Persistent
Aged >50

Question 9

Patient presents to GP with inflammation of her right breast which has not improved despite completing antibiotics course. What should the GP do now?

Answer 9

Refer to clinic for triple assessment

Question 10

What is the grading of core biopsy samples?

Answer 10

B1 - unsatisfactory sample/normal
B2 - benign
B3 - atypia, probably benign
B4 - suspicious of malignancy
B5 - malignant
B5a - carcinoma in situ
B5b - invasive carcinoma

Question 11

What are the development abnormalities of the breast?

Answer 11

• Hypoplasia (one or both breasts don’t develop)
• Juvenile hypertrophy (breasts don’t stop growing)
• Accessory breast tissue/nipples (can occur anywhere along the “milk line” from axilla to groin)

Question 12

What are the benign conditions of the breast?

Answer 12

gynaecomastia
fibrocystic change
fibroadenoma
hamartoma
scleroising lesions (scleroising adenosis and radial scar)
fat necrosis
duct ectasia
acute mastitis/abscess
Phyllodes tumour
Intraduct papilloma

Question 13

What are the causes of gynaecomastia?

Answer 13

Hormones:
- exogenous - anabolic steroids
- endogenous - endocrine disorder
Cannabis
Liver disease
Prescription drugs (e.g. spironolactone)

Question 14

When is the commonest time for fibrocystic change to occur?

Answer 14

Age 40-50/the decade before the menopause

Question 15

What often causes fibrocystic change to resolve?

Answer 15

Menopause

Question 16

What are the clinical features of fibrocystic change?

Answer 16

Lumpiness - smooth discrete lumps
Cyclical pain
sudden pain - cyst rupture
sometimes asymptomatic and picked on screening

Question 17

Gross pathology: several cysts, blue and domed containing pale fluid, lined by apocrine epithelium. What is the most likely diagnosis?

Answer 17

Fibrocystic change

Question 18

What is fibrocystic change?

Answer 18

Localised dilatation of lobular and terminal ductules (presumably due to obstruction) forming cysts. Usually thin walled, and lined by apocrine epithelium (should be lined with columnar or cuboidal epithelium - metaplasia)

Question 19

How is fibrocystic change managed?

Answer 19

Exclude malignancy
Reassure
Excise if necessary (e.g. due to pain)

Question 20

What benign breast condition is a circumscribed lesion composed of cell types normal to the breast but present in an abnormal proportion or distribution (formed from a disordered collection of lobules, stroma, and fat)?

Answer 20

Hamartoma

Question 21

In which groups of women are fibroadenomas typically seen?

Answer 21

Young women

African women

Question 22

30 year-old female patient presents with a new breast lump. O/E it is rubbery, sooth and mobile. She has no other symptoms. What is the most likely diagnosis? What is your initial management?

Answer 22

• Fibroadenoma

- Triple Assessment

Question 23

What is a fibroadenoma?

Answer 23

Localised hyperplasia
Biphasic tumour: epithelium and stroma
grey-white, rubbery, circumscribed lesion

Question 24

What are sclerosing adenosine and radial scar?

Answer 24

benign, disorderly proliferation of acini and stroma
Sclerosing adenosis: proliferation of the terminal duct lobular unit
Radial scar (complex sclerosing lesion): dense fibroelastic core (with central puckering), radiating stellate connective tissue fibrosis containing distorted ductules

Question 25

What are 2 causes of fat necrosis?

Answer 25

Local trauma | Warfarin therapy

Question 26

What is the process of fat necrosis?

Answer 26

Damage and disruption of adipocytes Initial necrosis is accompanied by haemorrhage and followed by acute inflammatory reaction (infiltration by foamy macrophages) Subsequent fibrosis and scarring and calcification Can result in a firm lump, retraction of the nipple, or fixation of the skin (all of these also occur in cancer)

Question 27

What condition is characterised by progressive dilatation of large or intermediate ducts, with surrounding chronic predicate inflammation and fibrosis?

Answer 27

Duct Ectasia

Question 28

What are the clinical features of Duct ectasia?

Answer 28

- affects sub-areolar ducts - pain - acute episodic inflammatory changes - bloody +/or purulent discharge (contains foamy macrophages which are in the ducts) - fistula formation - nipple retraction and distortion - associated with smoking - "bag of worms" on palpation

Question 29

What is the management of duct ectasia?

Answer 29

Treat acute infections Smoking cessation excise ducts exclude malignancy

Question 30

What are the 2 main causes of mastitis or abscess?

Answer 30

Breast feeding | Duct ectasia

Question 31

What are the organisms associated with mastitis due to breastfeeding?

Answer 31

``` Staph aureus (most common cause - from baby's mouth) - can treat with flucloxacillin Strep pyogenes (acute pyogenic mastitis via abrasion of the nipple) ```

Question 32

65 year-old female presents with right breast lump. Pathology report says it is a benign biphasic tumour with cellular stromal overgrowth, and compressed "leaf-like" clefts of epithelium. What is the most likely diagnosis?

Answer 32

Phyllodes tumour

Question 33

40 year-old female presents with unilateral bloody nipple discharge. Investigation shows that there are papillary fronds containing fibrovascular core and covered by myoepithelium and epithelium in the sub-areolar ducts. Epithelium is benign. What is the most likely diagnosis?

Answer 33

Intraduct papilloma

Question 34

80 year-old female presents with a breast lump. She had breast cancer 15 years ago which was treated with wide local excision and adjuvant radiotherapy. What is the likely diagnosis?

Answer 34

Radiation-induced angiosarcoma

Question 35

Where does breast carcinoma arise from?

Answer 35

Glandular epithelium of terminal duct lobular unit