Breast

Question 1

Discuss the investigation and management of nipple discharge

Answer 1

• nipple discharge is usually unilateral, where galactorrhea is bilateral milky discharge (require prolactin level)
  Red Flags
• unilateral, spontaneous, bloody or guaiac positive discharge
• palpable mass
• age >40, male sex
  Mammography
• assess for anatomy and mass
  Management
• benign can just follow with possible excision of terminal duct if affecting quality of life
• pathological then get surgical excision of duct

Question 2

List the causes of nipple discharge

Answer 2

Benign
- intra-ductal papilloma (most common)
- mammary duct ectasia
Malignancy
- intra-ductal or invasive ductal carcinoma 
Infection
- abscess
- mastitis

Question 3

List the causes of breast pain

Answer 3

Cyclical
- bilateral intense soreness few days before menses due to hormonal changes
Non-Cyclical Intra-Mammary causes
- structural with large breast or cyst present
- trauma
- infection
- inflammatory: ductal ectasia
- hormone replacement
- malignancy

Question 4

Discuss the investigation and management of breast pain

Answer 4

Investigations:
- benign history and physical then no investigations
- patient <30 with no risk factors, then ultrasound
- patient >30 then mammogram
Symptomatic Treatment
- lifestyle modification (sports bra, restrict coffee and chocolate)
- warm or cold compress
- analgesic
- danazol if severe

Question 5

Discuss the presentation and management of mastitis

Answer 5

Pathophysiology
- infection of breast tissue through bacterial entry through duct
- staph aureus, enterococcus, anaerobic strep
Presentation
- unilateral localized pain
- nipple discharge
- sub-areolar mass
- nipple inversion
- erythematous and fluctuant skin
Investigation
- ultrasound
Management
- hot/cold compress
- lactational mastitis then Keflex
- non-lactational mastitis but may require more broad coverage with amox-clav

Question 6

List the differential for a breast mass

Answer 6

Benign (younger pre-menopausal women)
- structural: cyst, fibrocystic breast disease
- infection
- benign tumour: lipoma, lactational adenoma
- pre-malignant tumour proliferative without atypia: ductal hyperplasia, intra-ductal papilloma, fibroadenoma, sclerosing adenosis
- pre-malignant atypical hyperplasia: atypical ductal hyperplasia, atypical lobular hyperplasia
Malignant
- lobular carcinoma or invasive lobular
- ductal carcinoma or invasive ductal
- phyllodes

Question 7

Differentiate between a benign and malignant breast lesion

Answer 7

Benign
- Small <2cm
- superficial
- smooth
- round
- rubbery
- mobile with well defined border
Malignant
- large >2cm
- hard
- irregular
- non-mobile
- fixed to skin or chest wall with non-defined borders

• all get mammogram and biopsy to rule out breast cancer

Question 8

List the screening guidelines and follow up for breast cancer

Answer 8

Mammogram:

• asymptomatic women 40-49 done at discretion of physician
• asymptomatic women 50-74 then screen every 1-2 years (yearly if recommended by radiologist, history of breast cancer, or strong family history of breast or ovarian cancer)
• asymptomatic >74 every 1-2 years if in good health

BIRADS

• BIRADS 0 require further follow up imaging
• BIRADS 1-2 require no further follow up
• BIRADS 3 require follow up in 6 months
• BIRADS 4 and 5 require biopsy
• BIRADS 6 is biopsy confirmed
• any follow up from mammogram is mammogram with increased views, ultrasound or MRI

Question 9

List the risk factors for breast cancer

Answer 9

• female gender
• older age
• personal history of breast cancer
• increased density on mammogram
• radiation to chest wall
• family history of breast or ovarian cancer
• early menarche (<12)
• late menopause (>55)
• long term hormone replacement
• nulliparity or first birth after age 30
• no breast feeding
• alcohol
• obesity
• physical inactivity

Question 10

List the differences between the non-invasive epithelial cancers

Answer 10

Ductal Carcinoma in situ
- involves the ducts
- go on to affect ipsilateral breast
- unicentric
Lobular Carcinoma in situ
- involves the lobules
- both breasts are at risk
- multicentric

Question 11

Discuss the presentation of breast cancer

Answer 11

• 50% in upper outer quadrant and 20% around areola
• asymptomatic and detected by screening
• nipple discharge
• change in breast skin color or texture
• skin dimpling or inversion
• Paget disease: eczema of areola, burning sensation, nipple inversion
• Inflammatory breast cancer: peau d’orange (thickening, erythema, edema and warmth due to obstruction of lymphatic channels)

Question 12

Discuss the management of breast cancer

Answer 12

Hormone receptivity
- estrogen and progesterone receptor positive have best prognosis as are responsive to hormone therapy
- use tamoxifen for pre-menopausal (selective estrogen modulator) or anastrozole (aromatase inhibitor) for post-menopausal
- her2 new overexpression treated with herceptin
Surgery:
- Lumpectomy with adjuvant radiotherapy (stage 1) and adjuvant radio and chemotherapy (stage 2)
- Mastectomy with radio and chemotherapy for stage 3 (possibly neo-adjuvant chemotherapy if not initially operable)
- sentinel lymph node biopsy with possible dissection if positive
Chemotherapy
- neoadjuvant chemotherapy to improve surgical success
- topoisomerase 2 inhibitors: doxorubicin
- microtubule inhibitor: docetaxel
- platinum: cisplastic
- alkylating agent: cyclophosphamide
- antimetabolite: 5FU