Breast

Question 1

RF for breast cancer

Answer 1

FHx, Age, uninterrupted oestrogen exposure 
Nulliparity
1st pregnancy >30y
Early menarche
Late menopause 
HRT, COCP
Obesity
BRCA genes 
Not breastfeeding 
Past Breast Ca
1st degree premenopausal relative with breast ca

Question 2

Triple assessment

Answer 2

All lumps should undergo triple assessment
Clinical exam
Radiology- USS <35y, mammography + USS >35
Histology/cytology- FNA code biopsy, US guided core biopsy best for new lumps

Question 3

Differentials for breast pain

Answer 3

Cyclical mastalgia,
Breast cancer

Non-malignant, non-cyclical:
Angina
Gallstones
Lung disease
Thoracic outlet syndrome 
Oestrogen/HRT
Tietze’s syndrome- costochondritis + swelling of costal cartilage
Bornholm Disease

Question 4

Causes of nipple discharge

Answer 4

Duct ectasia- green/brown/red, multiple ducts, bilateral
Intraductal papilloma/adenoma/carcinoma- bloody discharge, single duct
Lactation

Question 5

Breast lump Qs

Answer 5

Previous lumps
FHx
Pain
Nipple discharge
Nipple inversion
Skin changes 
Change in size related to menstrual cycle
Number of pregnancies 
First/last/latest period
Postnatal
Breast feeding
Drugs e.g. HRY
Consider metastatic disease- weight loss,  breathlessness, back pain, abdominal mass

Question 6

Breast pain Qs

Answer 6

SOCRATES 
Bilateral/ unilateral
Rule out cardiac chest pain 
History of trauma
Masses
Related to menstrual cycle

Question 7

Nipple discharge Qs

Answer 7

Amount

Nature- colour, consistency, blood

Question 8

Management of nipple discharge

Answer 8

Diagnose cause- mammogram, USS, ductogram
Duct ectasia- smoking cessation reduces discharge from duct ectasia
Microdochectomy/total duct excision

Question 9

Breast exam general steps

Answer 9

Inspection- size and shape of any masses, overlying surface. Which quadrant, skin involvement- ulceration, dimpling, nipple inversion/discharge

Palpation of breast- confirm size and shape of any lump. Fixed/tethered to skin or underlying structures, fluctuante/compressible/hard? Tender? mobile

Palpation of lymph nodes- metastatic spread, ispilateral/bilateral, fixed

Further examination- abdomen for hepatomegaly, spine for tenderness, lungs (metastatic spread)

Question 10

Fibroadenoma

Answer 10

Benign overgrowth of collagenous mesenchyme of one breast lobule.
<30y
Firm, smooth, mobile lump
Painless
May be multiple
1/3rd regress, 1/3rd stay the same, 1/3 get bigger
Rx: observation and reassurance. If in doubt- USS +/- FNA. Surgical excision if large >3cm

no increased risk in malignancy

Question 11

Breast cysts

Answer 11

Common >35y
Benign, fluid filled rounded lump 
Not fixed to surrounding tissue
Occasionally painful 
Rx: diagnosis confirmed on aspiration

Question 12

Mastitis/breast abscesses

Answer 12

Infection of mammary duct often associated with lactation- usually s.aureus
Abscess presents as painful, hot swelling of breast segment
Rx: ABx. Open incision or percutaneous drainage of abscess

Question 13

Duct ectasia

Answer 13

Typically around menopause
Ducts became blocked and secretions stagnate
Nipple discharge (green/brown/bloody) +/- nipple retraction +/- lump
Refer for confirmation of diagnosis
Usually no Rx needed
Advise to stop smoking

Question 14

Fat necrosis

Answer 14

Fibrosis and calcification after injury to breast tissue
Scarring results in a firm lump
Refer for triple assessment
No Rx once diagnosis confirmed

Question 15

Stages of breast cancer

Answer 15

Stage 1: confined to breast, mobile
Stage 2: growth confined to breast, mobile, lymph nodes in ipsilateral axila
Stage 3: tumour fixed to muscle (but not chest wall), ipsilateral lymph nodes matted and may be fixed, skin involvement larger than tumour
Stage 4: complete fixation of tumour to chest wall, distant metastases

Question 16

Treatment of breast Ca- local disease

Answer 16

Surgery- removal of tumour by wide local excision or mastectomy +/- breast reconstruction + axillary node sampling/surgical clearance or sentinel node biopsy

Radiotherapy
Chemotherapy
Endocrine agents- aim to reduce oestrogen activity. Used in ER and PR +ve disease. Tamoxifen, aromatase inhibitors, GnRH monologues

Support
Reconstruction

Question 17

2ww referral guideline

Answer 17

Urgent referral- >30y with unexplained breast lump, >50y with symptoms or change to one nipple

Consider urgent referral if: skin changes, >30y with axillary lump

Question 18

Consider 2ww if

Answer 18

skin changes that suggest breast cancer

>30y with unexplained lump in axilla

Question 19

consider non urgent referral

Answer 19

<30 with unexplained breast lump +/- pain

Question 20

Types of breast cancer: most common

Answer 20

Invasive ductal carcinoma (most common)
Invasive lobular carcinoma
Ductal carcinoma in situ
Lobular carcinoma in situ

Question 21

indications for mastectomy

Answer 21

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

Question 22

Indications for WLE

Answer 22

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

Question 23

Causes of nipple discharge

Answer 23

Physiological
Galactorrhoea- emotional event, drugs
Hyperprolactinaemia- pituitary tumour
Mammary duct ectasia- dilatation breast ducts. thick and green
Carcinoma- blood
Intraductal papilloma- younger patients, blood stained

Question 24

Fibroadenosis

Answer 24

Middle aged women

‘Lumpy’ breasts which may be painful. Symptoms may worsen prior to menstruation

Question 25

Paget’s disease of the breast

Answer 25

Intraductal carcinoma associated with reddening and thickening of nipple/areola
May resemble eczema

Diagnosis- punch biopsy, mammography and USS of breast

Question 26

Treatment of breast cancer

Answer 26

Surgery
Radiotherapy
Hormone therapy
Biological therapy
Chemotherapy