Breast conditions

Question 1

Name some risk factors associated with breast cancer

Answer 1

Female, ageing, gene mutations, atypical ductal or lobular hyperplasia, lobular carcinoma in situ, atypical epithelial hyperplasia, birth of 1st child >30, consumption of alcohol >once a day, early menarche, late menopause, family history of breast cancer, previous breast cancer, nulliparity, postmenopausal obesity

Question 2

What are the most common breast cancer presentation symptoms?

Answer 2

Dimpled or depressed skin, visible lump, nipple change excluding inversion, bloody discharge, texture change, colour change

Question 3

What is the most common histologic type of breast cancer?

Answer 3

Ductal carcinoma is the most common histologic type of BC, accounting for as many as 80% of breast malignancies

Question 4

What investigation is used to find a definitive diagnosis for a ductal carcinoma of the breast?

Answer 4

Image-guided tissue core-needle biopsy

Question 5

How do most women with ductal carcinoma present?

Answer 5

Patient usually notices a lump and presents to her physician

Question 6

What are the pros and cons of ultrasound as an investigation for BC?

Answer 6

Helpful in defining a malignant solid mass, particularly in a young woman or a women with mammographically dense breasts. It is not effective in evaluating calcifications as they are often not perceived on US

Question 7

Ductal carcinoma in situ (DCIS) is most commonly non-palpable and perceived on screening mammography as malignant calcifications (pleomorphic and of the casting type). How would the definitive diagnosis then be reached?

Answer 7

Stereotactic vacuum-assisted core biopsy

Question 8

Invasive lobular carcinoma is often not apparent either by palpation or imaging, until the cancer is at an advanced stage. What is thought to be a tumour marker for invasive carcinoma and thus would aid prognosis?

Answer 8

Lobular carcinoma in situ is thought to be a tumour marker with associated increased risk of eventual invasive carcinoma that is usually of the ductal type

Question 9

What is breast conserving surgery?

Answer 9

It is the preferred treatment for BC. Can have the form of a wide local excision with or without an oncoplastic procedure to shape the breast

Question 10

What is an essential component of breast conserving surgery?

Answer 10

Radiation therapy - usually performed in an oncologic radiation therapy centre in daily fractions (5 days per week) for 3-6 weeks

Question 11

What is a modified radical mastectomy?

Answer 11

Modified mastectomy is removal of the entire breast including the overlying skin and the axillary lymph nodes. The major modification is the preservation of the pec major muscle, which facilitates improved wound healing and potentially allows reconstruction

Question 12

What is the main difference between non-skin sparing mastectomy and skin sparing mastectomy?

Answer 12

Immediate or delayed breast reconstruction following conventional non-skin sparing mastectomy (NSSM) often results in prominent scars on the new breast and a paddle of skin that is of a different color and texture. Skin-sparing mastectomy (SSM) preserves most of the overlying skin during an immediate breast reconstruction (IBR) thus leading to a superior aesthetic outcome

Question 13

Name some of the ways breast reconstruction is achieved and factors that influence the choice of reconstruction method

Answer 13

Breast reconstruction can be achieved using a breast prosthesis, the latissimus dorsi (LD) myocutaneous flap (usually plus a breast prosthesis) deep inferior epigastric perforator (DIEP) free flap, transverse rectus abdominis myocutaneous (TRAM) flap, or superior/inferior gluteal artery perforator (S-GAP or I-GAP) free flaps. The choice of the reconstruction method depends upon the patient’s body habitus, co-morbidity, smoking history, size and shape of her breasts, her preference and the surgeon’s experience.

Question 14

What are indications for post-mastectomy radiation therapy?

Answer 14

More than 3 nodes involved, positive surgical margins and/or tumours larger than 5cm

Question 15

What is the most commonly used hormonal therapy in breast cancer treatment?

Answer 15

Tamoxifen

Question 16

HER-2 overexpression is implicated in the pathogenesis of breast cancer and represents a key marker and determinant of patient outcome. Name a therapy which targets HER-2

Answer 16

Herceptin (trastuzamab) is a recombinant humanised monoclonal antibody which targets HER-2

Question 17

Name a humanised monoclonal antibody that works against vascular endothelial growth factor and as a result is used first-line for metastatic breast cancer

Answer 17

Bevacizumab

Question 18

What is lapatinib?

Answer 18

Lapatinib is a dual inhibitor of epidermal growth factor receptor (EGFR) and human epidermal growth factor receptor 2 (HER-2) tyrosine kinases. It is indicated for use in combination with capecitabine for the treatment of patients with advanced breast cancer or metastatic breast cancer (MBC) whose tumors overexpress HER-2 (ErbB2) and who have received previous treatment that included an anthracycline, a taxane, and herceptin.

Question 19

What is the most common benign neoplasm of the breast?

Answer 19

Fibroadenoma

Question 20

How does a woman with a fibroadenoma normally present?

Answer 20

Normally present with a palpable mass in the early reproductive years of a woman’s life but can present at almost any age

Question 21

How is a diagnosis of fibroadenoma normally confirmed?

Answer 21

Ultrasound core biopsy

Question 22

On examination, how would a fibroadenoma feel?

Answer 22

A fibroadenoma is typically rubbery to firm, mobile, smooth with distinct borders, and is usually non-tender

Question 23

How are fibroadenomas normally treated?

Answer 23

When definitely diagnosed, fibroadenomas need not be removed, because they tend to remain unchanged or decrease in size approaching the menopause and usually become non-palpable after the menopause. However, some women prefer to have such breast lumps excised. This can be performed electively in the form of open lumpectomy or percutaneous vacuum-assisted core biopsy as an outpatient procedure under local anesthesia.

Question 24

What tumour resembles fibroadenoma in clinical presentation and cytology?

Answer 24

The uncommon phyllodes tumors resemble fibroadenomas in clinical presentation and cytology but are often larger (3–6 cm) and tend to occur in older women (35–45 years old) and tend to increase in size.

Question 25

How should a Phyllodes tumour be managed?

Answer 25

The diagnosis requires histologic verification. Phyllodes tumors can be histologically benign, indeterminate, or malignant. The tumor should be excised with wide (1-cm), clear, surgical margins and carefully followed up. Metastasis is rare

Question 26

What is cyclic mastalgia?

Answer 26

Pain in the breast during periods. Cyclic variant is usually diffuse and most intense during the intermediate premenstrual phase of the cycle. Cyclic mastalgia is usually bilateral but can be unilateral. Non-cyclic mastalgia is usually localised, often persistent and less responsive to treatment than cyclic mastalgia. Mastalgia is rarely associated with malignancy unless there is a palpable breast mass

Question 27

On examination, what does a breast cyst feel like?

Answer 27

A cyst is typically palpable, clearly defined, soft, mobile and smooth. Can be tender, especially before menstruation

Question 28

What is an effective way of diagnosing and treating a cyst?

Answer 28

FNA is an effective method - as much fluid as possible should be aspirated from the cyst. Only grossly bloodly fluid needs to be sent for cytologic evaluation. After FNA, the area of the cyst must be palpated to be certain there is no residual mass

Question 29

What is a papilloma?

Answer 29

A benign intracystic papillary proliferation called a papilloma can occur within a cyst and is often associated with bloody cyst fluid

Question 30

What should be suspected when the cyst fluid is grossly bloody or there is a residual mass after aspiration?

Answer 30

Intracystic carcinoma should be clinically suspected. Ultrasound-guided biopsy of any intra-cystic lesion or irregular cystic wall is recommended for histological diagnosis

Question 31

Describe physiologic nipple dicharge

Answer 31

Usually clear, yellow and watery and can be elicited from the nipples of most women of reproductive age. Bloody nipple discharge, especially from a single duct is pathologic and should be evaluated

Question 32

What is the most common cause of spontaneous nipple discharge?

Answer 32

Intraductal papilloma or papillomas (these are benign lesions)

Question 33

How should pathological nipple discharge be investigated?

Answer 33

Mammography, ultrasound and surgical excision of the discharging ducts - must be excised and histologically evaluated so as not to miss the rare intraductal carcinoma

Question 34

How does Paget’s disease affect the nipple?

Answer 34

Can present as an erythematous weeping lesion on the surface of the nipple and the areola, although it usually presents as a dry, scaly, eczematous lesion. The patient may perceive this as nipple discharge. The diagnosis is made by histologic tissue biopsy. There is often an underling palpable mass or a radiological abnormality

Question 35

What are the clinical signs of mastitis?

Answer 35

Fever, erythema, induration, tenderness and swelling

Question 36

How should puerperal (pregnancy or lactation related) mastitis be managed?

Answer 36

A full course of antibiotics effective for staph aureus should be administered as soon as clinical signs of mastitis begin. The patient should be examined every 3 days to be certain the infection is responding to therapy and that there is no evidence of abscess formation. Breast feeding should be continued and/or the infected breast can be pumped until the mastitis clears

Question 37

How does a breast abscess usually present?

Answer 37

Presents as a flocculent sometimes bulging mass usually located in the central area of the mastitis. Focused ultrasound can verify a fluid-filled (pus) centre

Question 38

How is a breast abscess managed?

Answer 38

Aspiration with a number 18-gauge needle using local anesthesia is diagnostic and can be therapeutic if all the pus is aspirated. The aspirate is sent for mocrobiological analysis. The aspiration may have to be repeated every 3 days, particularly if there is more than 10 milliliters of pus initially aspirated. If the repeated aspirations are not effective in clearing the abscess, then open surgical dependent drainage under general anesthesia is required. Antibiotics should be continued until all evidence of inflammation (cellulitis) has cleared

Question 39

What should be considered if the mastitis is unresponsive to antibiotic therapy?

Answer 39

Inflammatory carcinoma should be considered particularly if the mastitis seems to spread over the entire breast

Question 40

What is ductal hyperplasia?

Answer 40

Ductal hyperplasia is a benign histologic process, but when the hyperplasia is atypical it is associated with an increased risk of carcinoma and thought potentially to be the beginning of transformation to ductal carcinoma in situ and eventually invasive ductal carcinoma

Question 41

What does fat necrosis mimic?

Answer 41

Fat necrosis can mimic cancer by examination but has a distinct mammographic appearance and is often secondary to breast trauma. Fat necrosis usually subsides spontaneously but may leave a residual mammographic lesion

Question 42

What is a galactocele?

Answer 42

A galactocele is a palpable milk-filled cyst most commonly associated with pregnancy or lactation. FNA can diagnose and drain a galactocele.

Question 43

What is Mondor’s disease?

Answer 43

Mondor’s disease is phlebitis and subsequent clot formation in the superficial (skin) veins of the breast. Typically, Mondor’s disease presents as a firm, vertical, cord-like structure usually associated with a history of trauma to the breast; for example, surgery. The lesion usually resolves spontaneously in 8–12 weeks