Breast Cancer

Question 1

How does a fibroadenoma present?

Answer 1

Commonest under 35 years
‘Breast mice’: discrete, non tender, highly mobile

If >3cm, surgical excision

Question 2

What is fibroadenosis?

Answer 2

Also called fibrocystic disease or benign mammary dysplasia

Lumpy painful breasts in middle aged women, most commonly before menstruation

Question 3

What is mammary duct ectasia and how does it present?

Answer 3

Dilatation of the large breast ducts causing the walls to fall in on themselves, blocking the ducts.
Presents with a tender lump around the areola and green nipple discharge

Question 4

What is the triple assessment for breast cancer?

Answer 4

Examination
Imaging (USS and mammography)
FNA

Question 5

What are the NICE guidelines on the investigations of breast cancer?

Answer 5

Following triple assessment;

MRI should be used if there is high tissue density on mammography, when planning breast conserving surgery, or if there is discrepancy between clinical assessment and mammography

All women with cancer should have an USS of the axilla.
If the USS is positive = lymph node biopsy. If the USS is negative = sentinel node biopsy

Question 6

What are the indications for mastectomy?

Answer 6

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

Question 7

What are the indications for wide local excision?

Answer 7

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

Question 8

When is radiotherapy offered to women?

Answer 8

Offered to
All women who have had wide local excision (reduces risk of recurrence)
Women who have had mastectomy with T3/T4 cancer/4+ axillary nodes

Question 9

What are the three important outcomes following breast surgery?

Answer 9

Psychological morbidity
Local recurrence
Mortality

Question 10

Where does bone typically metastasise too?

Answer 10

Breast
Bronchus
Thyroid
Kidney
Prostate

Question 11

What is the guidance on giving chemotherapy to breast cancer patients depending on whether they have positive or negative lymph nodes?

Answer 11

Node positive = chemotherapy recommended

Node negative = 21 gene test. If you are high risk = chemotherapy. Low risk = no chemotherapy.

Question 12

What additional treatments can be offered to ER positive pre-menopausal and post-menopausal women?

Answer 12

Pre-menopausal: tamoxifen

Post-menopausal: aromatase inhibitor (anastrozole) and bisphosphonates

Question 13

What are the side effects of tamoxifen?

Answer 13

Increased risk of endometrial cancer, VTE and menopausal symptoms

Question 14

When is Herceptin (trastuzumab) used?

Answer 14

25% of women with breast cancer over express human epidermal growth factor type 2 (HER2) on the surface of tumour cells.
Herceptin blocks the binding of oestrogen to this cell therefore blocking cell growth/division.

CI in women who have heart disorders as it can cause CCF and cardiomyopathy

Question 15

What artery is involved in breast reconstruction?

Answer 15

Deep inferior epigastric artery

Question 16

How do you identify the sentinel node?

Answer 16

The sentinel node is the first node which drains an area of tissue
Injection of vital blue dyes plus technetium labelled colloids allow identification

If positive = axillary lymph node clearance or axillary radiotherapy

Question 17

How does tamoxifen work?

Answer 17

SERM (selective oestrogen receptor modulator) with mixed agonist and antagonist properties.
Blocks breast receptors (therefore causes hot flushes, dryness etc but stimulates bones and endometrium).

Question 18

How does anastrozole work?

Answer 18

Selective aromatase inhibitor

Blocks conversion of androgen to oestrogen in peripheral tissue only so only use in post-menopausal women

Question 19

When should you refer people using 2WW if you suspect breast cancer?

Answer 19

> 30 with any unexplained lump

>50 with either retraction, discharge or other changes of concern in one nipple only

Question 20

What are the risk factors for breast cancer?

Answer 20

Nulliparity
BRCA1/BRCA2
early menarche/late menopause 
COCP
not breast feeding

Question 21

What is the management of breast cysts?

Answer 21

Cysts should be aspirated

Those which are bloodstained or persistently refill should be biopsied/excised

Question 22

What is the management of fat necrosis?

Answer 22

Imaging and core biopsy

Question 23

How does periductal mastitis present and what is it’s management?

Answer 23

Patients are at a younger age than in duct ectasia
Inflammation, abscess, mammary duct fistula
Associated with smoking

Treat with ABx, abscess will require drainage

Question 24

Where does breast cancer metastasise too?

Answer 24

Lungs
Liver
Bones
Brain

Question 25

What drug do you use to treat galactorrhoea?

Answer 25

Bromocriptine

Question 26

What medications can cause galactorrhoea?

Answer 26

Beta blockers
Spironolactone
Digoxin
Methyldopa
SSRIs
Antipsychotics and dopamine antagonists

Question 27

What are the different forms of breast conserving surgery?

Answer 27

Lumpectomy

Wide local excision

Question 28

Name three possible complications from radiotherapy

Answer 28

Fibrosis of breast tissue
Local skin irritation
Long term skin colour changes

Question 29

Name three types of breast reconstructive surgery

Answer 29

DIEP flap (tissue from abdomen used and deep inferior epigastric artery)
Transverse rectus abdominus flap (TRAM flap)
Latissimus dorsi flap