Breast Conditions Benign and Malignant

Question 1

how are results graded fro FNA

Answer 1

• C1 - Unsatisfactory
• C2 - Benign
• C3 - Atypia, probably benign
• C4 - Suspicious of malignancy
• C5 - Malignant

Question 2

how are findings graded for core needle biopsies?

Answer 2

• B1 - Unsatisfactory / normal
• B2 - Benign
• B3 - Atypia, probably benign
• B4 - Suspicious of malignancy
• B5 - Malignant

–B5a - carcinoma in situ

–B5b - invasive carcinoma

Question 3

what are the risk factos for breast cancer?

Answer 3

• HRT (combined: extra 19 cancers per 1000 oestrogen alone– 5 extra cancers per 1000 )
• Alcohol (>14 units per week)
• Weight
• Post Radiotherapy treatment for Hodgkin’s disease
• Previous breast cancer
• Family history of breast cancer
• Genetic: BRCA1 and BRCA2
• Early menarche and late menopause
• Late or no pregnancy

Question 4

how does breast cancer present?

Answer 4

• Asymptomatic: Breast Screening (50-70 yrs)
• Symptomatic: Outpatient Clinic

Lump (36%)

Mastalgia (persistent unilateral pain) (17.5%)

Nipple discharge (blood-stained) (5%)

Nipple changes (Paget’s disease, retraction) (3%)

Change in the size or shape of the breast (1%)

Lymphoedema (Swelling of the arm)

Dimpling of the breast skin

Question 5

how are breast problems investigated?

Answer 5

Triple Assessment:

History/ Examination

Imaging Mammography <40 years/ Ultrasound >40 years

Pathology: Cytology(FNA)/ histopathology (core biopsy)

Question 6

what extra information can obtain from a core biopsy as opposed to FNA

Answer 6

invasive

ER, PR, HER2 status

Question 7

what is the most common type of breast cancer?

Answer 7

80% Ductal Carcinoma

10% Lobular Carcinoma

Question 8

how are tumours graded?

Answer 8

•Degrees of glandular formation, nuclear pleomorphism & frequency of mitosis

(each scored from 1-3)

Grade I: Score 3-5

GradeII: 6 and 7

Grade III: 8 and 9

Question 9

what staging investigations are performed for breast cancer?

Answer 9

• Blood tests: FBC, UE’s, LFTs, Ca 2+/PO2-
• CXR
• AUSS - if indicated
• Bone scan (Nuclear Medicine)- if indicated

Question 10

describe the TNM Classification

Answer 10

Question 11

Radiotherapy is offered to all wide local excision patients as adjuvant therapy.

How long will a course of radiotherapy last for?

Answer 11

•40 Gy –50 Gy over 3 weeks or 5 weeks

Question 12

what is the treatment of Vertebral Fractures/ Collapse

+/-Spinal Cord Compression?

Answer 12

Urgent radiotherapy

Surgical decompression

Steroids (Oedema)

Question 13

List all the Benign Breat Diseases

Answer 13

ANDIs (aberration of normal development and involution)

• Fibroadenoma
• Breast Cyst
• Duct Papilloma

Hormonale Changes

• Mastalgia
• Nipple Discharge
• Gynaecomastia

Infective Changes

• Abscess
• Periductal Mastitis
• Fat Necrosis

Question 14

How is a fibrodenoma investigated and when is a fibroadenoma excised?

Answer 14

• If proven on US and FNA cytology do not require excision
• Excision- if unable to obtain pathological diagnosis, increasing in size, deforming.

Question 15

how is a breast cyst treated

Answer 15

• Aspirate after USS/mammography
• Residual lump – investigate as lump

Question 16

how does a duct papilloma present?

What is the treatment?

Answer 16

• Can cause bloodstained nipple discharge
• Excision by Microdochectomy (Single Duct Excision) or Total Duct Excision
• Minimal malignant potential

Question 17

what is a risk facor for periductal mastitis?

How is it treated?

Answer 17

• Common in female smokers
• Antibiotics
• Aspiration
• Incision and drainage
• Investigation of ALL persisting lesions

Question 18

how would you treat a breast abcess

Answer 18

• Encourage continued breast feeding
• Cytology/ bacteriology
• Flucloxacillin +/- aspiration
• Co-amoxicillin
• Persistent abscess – aspiration/incision & drainage
• Persistent – investigation for underlying pathology

Question 19

what drugs can help with gynaecomastia?

Answer 19

•Danazol or Tamoxifen can provide symptomatic improvement

Question 20

what percentage of bloody nipple discharge is malignant?

Answer 20

•5-10% of patients with a bloodstained discharge will have an underlying malignancy

Question 21

what are the differences between cyclical and non-cyclical Mastalgia?

Answer 21

CYCLICAL

• Premenopausal
• Average age 34
• Heightened awareness, discomfort, fullness, heaviness
• Classically – outer half of each breast
• Can be unilateral

NON-CYCICAL

• Older women
• Average age 43
• Pain can arise from chest wall, breast or outside breast
• Continuous/Random
• Burning/Drawing

Question 22

when is imaging necessary with mastalgia

Answer 22

when it is unilateral

Question 23

Mild/Moderate Symptoms of mastalgia treatment

Answer 23

Mild/Moderate Symptoms

• Reassurance
• Well fitting bra
• ?Topical NSAIDS

Question 24

what drug treatments are used to relieve severe mastalgia

Answer 24

Question 25

which tumours commonly metastisize to the breast?

Answer 25

•Carcinoma

–Bronchial

–Ovarian serous carcinoma

–Clear cell carcinoma of kidney

• Malignant melanoma
• Soft tissue tumours

–Leiomysarcoma

Question 26

what’s the pathology of Paget’s?

Answer 26

• High grade DCIS extending along ducts to reach the epidermis of the nipple
• Still in situ carcinoma (ie non-invasive)

Question 27

define invasive carcinoma

Answer 27

• Malignant epithelial cells which have breached the BM
• Infiltration of normal tissues
• Risk of metastasis and death

Question 28

which condition can mimc carcinoma and become calcified?

Answer 28

Radial scar / Complex sclerosing lesion

Question 29

which condition can present with

–Affects sub-areolar ducts

–Pain

–Acute episodic inflammatory changes

–Bloody and/or purulent D/C

–Fistulation

–Nipple retraction and distortion

what is the management?

Answer 29

Duct Ectasia

–Treat acute infections

–Exclude malignancy

–Stop smoking

–Excise ducts