Breast conditions

Question 1

define breast cyst

Answer 1

benign fluid-filled cyst
*related to hormone changes

Question 2

what group is most likely to have breast cysts

Answer 2

>35 in perimenopausal women

Question 3

presenting symptoms of a breast cyst

Answer 3

breast lump (smooth)
painful
lump increases in size near menstruation

Question 4

examination findings of a breast cyst (breast exam)

Answer 4

smooth, distinct border, mobile, fluid-filled breast lump
tender + painful breast

Question 5

investigations for breast cyst

Answer 5

triple assessment (US/ mammogram (>35)=> biopsy (fine needle aspiration/ excision biopsy)

Question 6

management for breast cyst

Answer 6

no treatment needed
if large/painful => drain cyst

Question 7

define breast cancer

Types of breast cancer

Answer 7

malignancy of breast tissue

• invasive ductal carcinoma (most common)
• Ductal carcinoma in situ (DCIS)
• Locally advanced breast cancer- e.g. Inflammatory breast carcinoma (rare)- highly aggressive form
• Phyllodes tumour
• Paget’s disease of nipple
• Metastatic breast cancer

Question 8

Risk factors for breast cancer

Answer 8

• FHx- BRACA genes
• older age
• prolonged exposure to oestrogen (HRT)
• early menarche
• late menopause
• post-menopausal obesity

Question 9

presenting symptoms of breast cancer

Answer 9

• hard, irregular breast lump (typically painless)
• changes in breast shape
• nipple discharge (may be bloody)
• axillary lump
• signs of malignancy (weight loss, bone/back pain, paraneoplastic syndromes, confusion- brain metastasis)

Question 10

physical examination findings of breast cancer

Answer 10

• breast lump (firm, irregular, fixed to surrounding structures)
• peau d’orange (inflammatory cancer)
• skin tethering
• fixed to chest wall
• skin ulceration
• nipple inversion
• Paget’s

Question 11

investigations for breast cancer

Answer 11

triple assessment = clinical examination + imaging + tissue diagnosis

imaging:

• Chest/ Axillary US if <35yrs (tumour shadowing, halo sign- oedema)
• mammogram if >35yrs (can see mass, thickening, malignant calcifications)

tissue diagnosis:

• fine needle aspiration
• core biopsy (grade tumour, vascular invasion status, ER, PR and HER2 receptor status)

*HER2 (human epidermal growth factor receptor 2- cancer causing potential)

staging: (first FBC, LFT, U&E, bone profile)

• CXR
• Abdomincal (Liver) US
• CT chest/ abdo
• Bone scan

bloods:

• FBC
• U&Es
• calcium
• bone profile
• LFT
• ESR
• Tumour markers- Ca-153 (breast), CA-128 (ovarian)

Question 12

sentinel lymph node biopsy

Answer 12

radioactive tracer injected into tumour

scan identifies sentinel lymph node

biopsy of node to check spread

Question 13

Management of breast cancer

Answer 13

• early => surgery: wide lobe excision / mastectomy
• invasive => chemo/ endocrine therapy (tamoxifen, letrazole= aromatase inhibitor =>less oestrogen => early menopause)
• for post-menopausal women with invasive cancer => bisphosphonates (as aromatase inhibitors => bone thinning/ joint aches)
• radiotherapy
• If ER/PR receptor +ve => endocrine therapy (tamoxifen/ Letrazole -aromatase inhibitor)
• If HER2 receptor +ve => herceptin

Question 14

Paget’s disease of the nipple

Answer 14

eczema like hardening of skin on nipple
- due to ductal carcinoma in situ infiltrating nipple

Question 15

Locally advanced breast cancer causes

Answer 15

• invasion of skin/ chest wall muscle
• arise due to neglect, position of tumour, biologically aggressive

Question 16

Symptoms of inflammatory breast cancer

Answer 16

• breast warmth
• erythematous
• peau d’orange
• axillary lump
• oedema/ swollen breasts (dermal lymphatic invasion by carcinoma => poor lymphatic drainage)

Question 17

Management for inflammatory breast cancer

Answer 17

• neoadjuvant chemo
• followed by surgery (mastectomy)/ radiotherapy to chest wall

Question 18

Side effects of aromatase inhibitors

Answer 18

• Letrazole => joint aches, bone thinning (osteoporosis)
• Tamoxifen (hot fluses, weight gain)