Breast Disease

Question 1

Breast cancer screening

Answer 1

In England all women aged 50-70 are invited to have screening every 3 years
Mammogram

Question 2

What are fibroadenomas?

Answer 2

Fibroadenomas are benign tumours of fibrous and epithelial tissue which arise from lobules.

Question 3

Clinical features of fibroadenoma

Answer 3

young age of presentation
firm, non-tender mass
rounded with smooth edges
highly mobile
normally don’t grow beyond 3cm

Question 4

Management of fibroadenoma

Answer 4

can be managed with surgical excision but many will also regress after menopause if conservatively managed

Question 5

Investigations for fibroadenoma

Answer 5

although benign, triple assessment done to rule out sinister pathology

Question 6

Ductal Carcinoma features

Answer 6

Most common form of breast tumour (75%)

Abnormal proliferation of ductal cells

The ductal cells lose their acinar structure and their nuclei become abnormally large

If the basement membrane is not breached then it is considered ductal carcinoma in situ (DCIS)

Question 7

Lobular Carcinoma features

Answer 7

~15% of breast cancers
More likely to be bilateral and multi-centric

Abnormal proliferation of lobular cells, arranged in single rows.
–> Cells often small, bland and uniform

Frequently impalpable or not appreciable as a discrete lump

Question 8

Medullary Carcinoma features

Answer 8

More common in younger patients and those with BRCA1 mutations

Composed of solid sheets of anaplastic cells with large pleomorphic nuclei, prominent nucleoli and frequent mitoses

Often significant lymphocytic infiltration surrounding the tumour

Often better prognosis than ductal tumours

Question 9

Phyllodes Tumour features

Answer 9

Rare (<1%)

Composed of epithelial and stromal tissue which grows in a ‘leaf-like’ pattern

Also called cystosarcoma phyllodes

Most are benign (75%) and 25% malignant

Question 10

Which gene abnormality is most related to familial breast cancer?

Answer 10

BRAC1 and 2

Question 11

What is Paget’s disease of the nipple?

Answer 11

A rare condition of the nipple which is associated with underlying cancer

Question 12

Clinical features of Paget’s disease of the nipple

Answer 12

Eczema-like rash on the skin of the nipple and areola: may be itchy, red, crusty and inflamed.
Nipple discharge which may be bloody.
Burning sensation. increased sensitivity or pain.
Nipple changes such as nipple retraction or inversion.
Some cases: palpable breast lump.

Question 13

What is puerperal mastitis?

Answer 13

Inflammation of the breast, associated with lactation in postpartum women

Question 14

Clinical features of puerperal mastitis

Answer 14

Painful, tender, red and hot breast
Systemic symptoms: fever, rigors, myalgia, fatigue, nausea and headache
Normally unilateral and typically presents 1wk postpartum

In some cases there may be development of a breast abscess which presents as fluctuant, tender mass with overlying erythema

Question 15

What is cyclical mastalgia?

Answer 15

Cyclical mastalgia is breast tenderness that comes and goes with the monthly menstrual cycle.

May be associated with fibrocystic changes to the breast presenting as breast ‘lumpiness’ or duct ectasia.

Question 16

Epidemiology of fat necrosis of the breast

Answer 16

More common in obese people
Usually following trauma to the breast

Question 17

Clinical features of fat necrosis

Answer 17

Can vary from a firm, round lump to a hard, irregular lump.
Overlying skin inflammation/bruising
Usually found following trauma to the breast

Question 18

Complications of breast surgery

Answer 18

Anaesthetic
–> Stroke, venous thromboembolism, myocardial infarction

Surgical
–> Pain, bleeding, infection, seroma, displeasure with cosmetic outcome

Axillary node clearance related injury
–> lymphoedema, damage to brachial plexus, axillary artery/vein injury

Question 19

Risk factors for breast cancer

Answer 19

Increased hormone exposure
–> early menarche or late menopause, nulliparity or late first pregnancy, oral contraceptive or HRT

BRCA1/2 mutations

Advancing age
Caucasian ethnicity
Obesity & lack of physical activity
Alcohol and tobacco use
Hx of breast cancer
Previous radiotherapy treatment

Question 20

Indications for urgent referral to breast assessment clinic

Answer 20

Urgent cancer referral pathway (2 week wait) for breast cancer if:
- They are >=30 w/ an unexplained breast mass (regardless of pain or not)
- They are >= 50 presenting w/ nipple discharge, retraction or other concerning symptom
- Consider referral if there are skin changes suggestive of breast cancer or if the patient is 30 years or older w/ an unexplained mass in the axilla

Question 21

Management of oestrogen (ER) positive tumours

Answer 21

Premenopausal: Tamoxifen (oestrogen receptor antagonist)

Postmenopausal: Anastrozole (aromatase inhibitor)

Question 22

Management of HER2 positive tumours

Answer 22

Trastuzumab (Herceptin) which is a monoclonal antibody against the extracellular domain of the HER2 receptor

Question 23

Components of triple assessment of breast cancer

Answer 23

1. Clinical examination: of the breast and surrounding lymph nodes
2. Radiological examination: most commonly mammogram but can involve breast US and MRI
3. Biopsy: typically a core needle biopsy or fine needle aspirate (FNA)

Question 24

Side effects of tamoxifen

Answer 24

Hot flushes
Nausea
Vaginal bleeding and discharge
Weight gain
^ risk of DVT/PE
^ risk of endometrial cancer (weak agonist on endometrial tissue)

Question 25

Side effects of anastrozole/letrozole

Answer 25

Hypo-oestrogenism (hot flushes, fatigue, osteoporosis)

Question 26

Trastuzumab (Herceptin) side effects

Answer 26

Cardiac dysfunction: inc. heart failure
Teratogenicity

Question 27

What is a lactational breast abscess?

Answer 27

Infectious mastitis may lead to an accumulation of pus in an area of the breast, leading to the development of a lactational breast abscess

Question 28

Most common cause of lactational breast abscess

Answer 28

Most common causative agent is Staphylococcus aureus (enters via a crack in the nipple skin or through a milk duct)

Question 29

Clinical features of lactational breast abscess

Answer 29

Fever or rigors
Malaise
Pain and erythema over an area of the breast
May be a fluctuant mass present, but it is not always palpable
Hx of recent or current mastitis

Question 30

Management of lactational breast abscess

Answer 30

Incision and drainage or needle aspiration (with or without diagnostic US)
Oral or IV Abx according to local protocol

Question 31

Mechanism of action of tamoxifen

Answer 31

Oestrogen receptor antagonist

Question 32

Epidemiology of Fibrocystic disease of the breast

Answer 32

Most common benign breast disease
Occurs most commonly in 20-50 year old age group

Question 33

Cause of fibrocystic disease of the breast

Answer 33

Caused by the cumulative effect of cyclical hormones such as oestrogen and progesterone which leads to chronic changes in the breast inc. multiple small cysts and proliferative changes

Question 34

Clinical features of fibrocystic disease of the breast

Answer 34

Bilateral ‘lumpy’ breast - most commonly upper outer quadrant
Breast pain
Symptoms which worsen with the menstrual cycle - normally peaking 1 week before menstruation

Question 35

Management of fibrocystic disease of the breast

Answer 35

Treatment is supportive
–> recommending a soft but well-fitting bra, alongside analgesia
Most cases will resolve after menopause

Question 36

First-line treatment of mastitis

Answer 36

Flucloxacillin

Question 37

What is a radial scar?
How does it show up on a mammogram?

Answer 37

A benign breast condition which can mimic a breast carcinoma. It describes idiopathic sclerosing hyperplasia of the breast ducts.

Typically asymptomatic and picked up incidentally.

Mammogram shows a star or rosette-shaped lesion with a translucent centre

Question 38

What is mastitis?

Answer 38

Inflammation of the breast, with or without infection

Question 39

Management of mastitis

Answer 39

Analgesia
Reassure lactating women that they can continue to breastfeed
Advise on methods to facilitate milk removal e.g. manual expression
Consider a course of oral Abx according to local protocol
If condition does not improve, may require IV Abx or surgical management, particularly if a breast abscess develops

Question 40

What is mammary-duct ectasia

Answer 40

Mammary-duct ectasia describes the dilation and thickening of the lactiferous ducts of the breast
–> resulting in the blockage of the ducts and a consequence of accumulation of fluid

Question 41

Presentation of mammary-duct ectasia

Answer 41

Present with thick, sticky green or yellow nipple discharge with nipple inversion.

Typically perimenopausal patients

Question 42

What is intraductal papilloma?

Answer 42

A benign breast lesion that grows within the mammary ducts of the breast.

Question 43

Presentation of intraductal papilloma

Answer 43

Typically present with blood-tinged nipple discharge without any skin changes or palpable lumps.

Question 44

Epidemiology of malignant phyllodes tumour

Answer 44

commonly in women in their 40s/50s

Question 45

Clinical features of phyllodes tumours

Answer 45

A smooth, hard, palpable breast mass
Quick growing
Rarely metastasise