Breast

Question 1

what are the benign lumps of the breast

Answer 1

fibroadenosis/fibrocystic change
fibroadenoma
cysts
fat necrosis
phylloides tumour

Question 2

what is the most common cause of breast lumps

Answer 2

fibroadenosis/fibrocystic change

Question 3

what causes fibroadenosis

Answer 3

it is a combination of localised fibrosis, inflammatory changes and hormone driven cyclical pain

Question 4

how does fibroadenosis present

Answer 4

classically between menarche and menopause with lumpy breasts and cyclical pain/swelling

Question 5

what is the treatment for fibroadenosis

Answer 5

reassurance
anti-inflammatorys
topical evening primrose oil
hormone manipulation

Question 6

what is a fibroadenoma

Answer 6

benign overgrowth of one lobule of the breast

Question 7

what age range does fibroadenoma most commonly present in

Answer 7

25-35

Question 8

what is the presentation of a fibroadenoma

Answer 8

rubbery firm mobile breast lump with little or no pain

Question 9

how does a fibroadenoma progress

Answer 9

1/3 regress, 1/3 stay the same, 1/3 get bigger

Question 10

what size does a fibroadenoma have to be to consider removal

Answer 10

> 4cm + symptomatic

Question 11

what is a breast cyst

Answer 11

Cavities lined by flattened epithelium derived from ductal unit filled with watery fluid

Question 12

how should breast cysts be treated

Answer 12

drained under USS, and if the fluid is suspicious (blood stained) send for cytology

Question 13

what causes fat necrosis of the breast

Answer 13

recent trauma mostly

Question 14

how does a fat necrosis present

Answer 14

firm lump in breast

may be some redness/bruising

Question 15

what is a phylloides tumour

Answer 15

Rapidly growing benign tumour of the stroma

Smooth, hard lumps

Question 16

whats the lifetime risk of breast cancer in women

Answer 16

12.5%

Question 17

what are most breast cancers

Answer 17

90% invasive ductal adenocarcinoma
5% invasive lobular carcinoma
5% lobular/ductal in situ

Question 18

how does the oestrogen receptor status of breast cancer relate to prognosis

Answer 18

OR positive = better prognosis

Question 19

how does HER2 receptor status of breast cancer relate to prognosis

Answer 19

HER2 = worse prognosis

Question 20

what are the pathological consequences of breast cancer

Answer 20

Paget’s Disease of the nipple
Spread of intraductal carcinoma in the breast
leading to eczematous changes around the nipple
any eczematous rash on the breast should be investigated (biopsied)

Local spread
Into overlying skin causing nipple retraction/tethering
Into the pectoral muscles which may cause deep fixation of the tumour

Lymphatic spread
Can prevent lymphatic drainage
Gives the peau d’lorange appearance
Nodes in the axilla are also often involved

Vascular spread
Distal dissemination is most commonly to the bone
Signs of this are pathological fractures and hypercalcaemia
Other sites are the ovaries (krukenberg tumour) and lung

Question 21

what are common metastases sites for breast cancer

Answer 21

lung, bone, ovary, liver

Question 22

what are the risk factors for breast cancer

Answer 22

Genetic - 25%
Personal history
Family History
BRCA status

Family - 75% - mostly due to oestrogen exposure 
early menarche
late menopause
nulliparity
not breast feeding
HRT
obesity
smoking

Question 23

what is the best way to assess a breast lump

Answer 23

triple therapy

clinical exam
imaging - USS if <35, mammography + USS if >35
FNAC/core biopsy

Question 24

why is mammography not done on women <35

Answer 24

breast tissue is too dense

Question 25

what are the signs of breast cancer on mammography

Answer 25

spiculated lesion with microcalcifications

Question 26

if metastases are expected what should be done

Answer 26

liver USS
Bone scan
CXR

Question 27

how is nodal assessment performed in confirmed breast cancer

Answer 27

Dye is injected around the tumour bulk to identify the first 1-2 nodes of drainage which are removed and analysed histologically

If negative it can be assumed there is no nodal involvement

If positive full axillary clearance is required

20% risk of lymphaedema

Question 28

what are the surgical options for breast cancer

Answer 28

wide local excision - breast conserving

simple mastectomy

breast reconstruction

Question 29

in what situations is a mastectomy preferred over a wide local excision

Answer 29

Tumour is large

Breasts are small

Tumour is central

Late presentation + complications

Question 30

apart from surgery, what adjuvent disease is available for breast cancer

Answer 30

invasive disease = adjuvant radiotherapy

nodal disease or high grade tumour = chemo

ER/HER2 positive = 5 years hormonal therapy

Question 31

what hormonal therapy is preferred in women with oestrogen positive breast cancer , peri/premenopausal and postmenopausal

Answer 31

tamoxifen = pre/peri

aromatase inhibitors (letrazole, aromasin,exemestrone) = post menopausal

Question 32

what hormonal therapy is used in HER2 positive breast cancer

Answer 32

Herceptin + chemo

Question 33

what score is used to measure prognosis of breast cancer + how is it scored

Answer 33

nottingham prognostic index

NPI = tumour size (cm) * 0.2 + histological grade + nodal status

Question 34

how does the nottingham prognostic index affect 10 year survival rates with surgery alone

Answer 34

NPI <2.4 = 95%

2. 4-3.4 = 85%
3. 4-4.4 = 70%
4. 4-5.4 = 50%

> 5.4 = 20%

Question 35

what can cause a milky discharge from the nipple

Answer 35

pregnancy or hyperprolactinaemia

Question 36

what causes green discharge from the nipple

Answer 36

ductal ectasia or a fibroadenotic cyst

Question 37

what causes red discharge from the nipple

Answer 37

usually blood, which indicates breast cancer

RED FLAG

Question 38

what is the antibiotic treatment for periductal mastitis

Answer 38

flucoxacillin

Question 39

what causes brown discharge from the nipple

Answer 39

mammary ductal ectasia , fibrocystic disease