Breast

Question 1

Breast Cancer

Epidemiology (2)

Answer 1

1 in 8

40,000 new cases in UK per year

Question 2

Breast Cancer 
Risk factors (6)

Answer 2

Family history
BRCA genes
Age
Past breast, ovarian, endometrial cancer
Uninterrupted oestrogen exposure: nulliparity, delay in age of 1st pregnancy, early menarche, late menopause, HRT, obesity, OCP
Not breastfeeding

Question 3

Breast Cancer

Pathology (11)

Answer 3

Adenocarcinoma
Non-invasive ductal carcinoma in situ is premalignant (asymptomatic, screening detects)
Non-invasive lobular carcinoma in situ is rare
Invasive ductal carcinoma most common (invasive means extends beyond basement membrane)
Invasive lobular carcinoma 10-15%
Medullary cancers affect the young
Colloid/mucoid cancers affect the elderly
60-70% are oestrogen receptor +ve, better prognosis (ER +ve)
Most ER +ve cancers express progesterone receptors, cancers with both respond to hormone therapy
Approx. 30% HER2 +ve = aggressive disease
Triple -ve (ER -ve, PR -ve, HER2-ve) in BRCA1 mostly

Question 4

Breast Cancer

Signs + symptoms (9)

Answer 4

Hard and fixed lump/thickening
Discharge/bleeding
Change in breast size/contour
Skin/muscle tethering
Peau d’Orange skin dimpling
Enlarged axillary/supraclavicular lymph nodes
Asymptomatic: NHS screening programme every 3 years aged 50-71
Paget’s: nipple itching, swelling, redness, ulceration, crusting, bleeding/discharge
Mets: bone pain, pleural effusion, anorexia + weight loss, neuropathic pain, headache, seizures, cord compression

Question 5

Breast Cancer

Spread (5)

Answer 5

Lymph nodes 
Liver 
Bone 
Brain 
Lungs

Question 6

Breast Cancer

Investigations (5)

Answer 6

Mammogram 
Ultrasound 
MRI 
FNA cytology 
Needle core biopsy

Question 7

Breast Cancer

Sensitivity of tests (3)

Answer 7

Clinical examination- 88%
Mammography- 93%
Ultrasound- 88%
FNA cytology- 94%

Question 8

Mammography 
Radiation dose (1)

Answer 8

1mSV

Question 9

Mammography

Signs of disease (4)

Answer 9

Dominant mass
Asymmetry
Architectural distortion
Calcifications

Question 10

Mammography 
Malignant mass (3)

Answer 10

Irregular and ill-defined
Dense
Distortion of architecture

Question 11

Mammography 
Benign mass (3)

Answer 11

Smooth
Normal density
Halo

Question 12

Breast Screening Programme (5)

Answer 12

50-70
Every 3 years 
Mammography 
Uptake 80% 
Recall for further investigations is 5-10% (additional views, clinical exam, ultrasound, FNAC)

Question 13

Ultrasound Breast

Indications (1)

Answer 13

First line in <35

Question 14

Ultrasound Breast

Solid benign mass findings (2)

Answer 14

Smooth outline

Oval shape

Question 15

Ultrasound Breast 
Malignant findings (3)

Answer 15

Irregular outline
Interrupting breast architecture
Anterior halo

Question 16

MRI Breast

Indications (4)

Answer 16

Recurrent disease
Implants
Indeterminate lesion following triple assessment (clinical examination + imaging + FNA cytology)
Screening high risk women

Question 17

Benign (3) vs Malignant (3) Breast Cytology

Answer 17

Benign: 
Low cellularity
Groups of cells (cohesion) 
Cells uniform in size 
Malignant:
High cellularity 
Loss of cohesion 
Crowded cells

Question 18

Breast FNA

Advantages (2)

Answer 18

Simple and inexpensive

Immediate results

Question 19

Breast FNA

Disadvantages (2)

Answer 19

False negatives/positives

Can’t assess invasion or grade malignancies

Question 20

Breast FNA

Complications (3)

Answer 20

Pain
Haematoma
Infection

Question 21

Breast Cancer
Staging investigations (4)

Answer 21

Bloods: FBC, U&E, creatinine, LFTs, serum calcium
CXR: baseline, lung mets
CT chest abdo: baseline, liver and lung mets
Isotope bone scan: baseline, bony mets

Question 22

Breast Cancer

Staging (9)

Answer 22

T1: 0-2cm 
T2: 1-5cm 
T3: >5cm 
T4: fixed to skin or muscle
N0: none 
N1: nodes in axilla 
N2: large or fixed nodes in the axilla 
M0: no mets 
M1: mets

Question 23

Breast Cancer

Treatment (7)

Answer 23

Breast conservation: wide local excision, followed by radiotherapy
Mastectomy
Regional control (lymph clearance): sentinel lymph node biopsy, surgical/radiotherapy axillary clearance if sentinel biopsy +ve
Hormone therapy on oestrogen receptor: tamoxifen if pre-menopause (for 5 years- stops ovaries producing oestrogen), aromatase inhibitor if post-menopausal
Chemo: adjuvant or neoadjuvant
Radio: all wide local excisions and post-mastectomy if >4 +ve axillary
Anti-Her2 immunotherapy

Question 24

Breast Cancer

Who can be a candidate for breast conservation surgery (5)

Answer 24

Tumour size <4cm 
Breast/tumour size ratio 
Suitable for radiotherapy 
Single tumours 
Patient's wish

Question 25

Breast Cancer

Complications of treatment to the axilla (4)

Answer 25

Lymphoedema
Sensory disturbance
Decreased movement at shoulder joint
Vascular damage