Breast

Question 1

BREAST: Identify and describe the major types of breast lump (fibroadenoma, fibroadenosis, cyst, carcinoma).

Answer 1

Question 2

BREAST: Classification of the main types of carcinoma of the breast

Answer 2

• In situ vs invasive
• Adenocarcinoma (duct or lobules) vs other cell types

Question 3

BREAST: Describe the aetiology, morphology and pathological consequences of carcinoma of the breast.

Answer 3

Aetiology:

• Incidence increases with age
• FHx, with genetic abnormality (BRCA1/2)

Morphology:

• Most commonly invasive adenocarcinomas, of which 90% are ductal and 5% are lobular
• May be oestrogen receptor positive or negative, with ER positive carrying a better prognosis
• HER-2 and progesterone receptors may also be therapeutic targets. HER2 positive indicates a poorer prognosis

Pathological consequences:

• Paget’s disease of the nipple: Eczematous changes around the nipple
• Local spread: Can lead to tethering and nipple retraction
• Lymphatic spread
• Vascular spread: Bone, lung and ovary (Krunkenburg tumour)

Question 4

BREAST: List the risk factors for carcinoma of the breast

Answer 4

Genetic factors:

• FHx

Environmental factors:

IN GENERAL *increased oestrogen exposure*

• Early menarche/late menopause
• Nulliparity
• Not breast feeding
• HRT
• Obesity
• Smoking

Question 5

BREAST: Describe the investigations required for a breast lump

Answer 5

TRIPLE ASSESSMENT

1. Clinical examination
2. Histology/cytology
   
   • FNA (cystic lump) or core biopsy (solid lump, also best for new breast lumps)
3. Mammography and US (or just US if < 35 years old - as breast tissue is too dense for mammography)

Question 6

BREAST: Describe the principles of management of fibroadenoma, cyst, nipple discharge and breast pain.

Answer 6

• Breast cyst → Radiolucent ‘halo sign’ seen on US
• Duct ectasia sees a slit-like retraction occur, as the ducts shorten
• Causes of nipple discharge
  
  • Green/yellow discharge → duct ectasia
  • Bloody/serous discharge → intraductal papilloma
  • Bilateral nipple discharge → prolactinoma

Question 7

BREAST: Describe the clinical staging of breast carcinoma

Answer 7

TNM

Tumour: T1 < 2cm, T2 2-5cm, T3 > 5cm, T4 sees the mass fixed to the chest and peau d’orange

Nodes: N0 = no nodes, N1 = mobile ipsilateral nodes, N2 = fixed nodes

Metastasis: M0 = no distant metastases, M1 = distant metastases