Breast Disease

Question 1

What are the 4 different methods used to perform a biopsy?

Answer 1

U/S-guided, stereotactic (take mammogram at 2 slightly different angles, see shadow, use software program to figure out where it is) or MRI-guided FNAC

FNAB

VAC

Question 2

FNAC

Answer 2

Fine needle aspiration cytology

Question 3

Limitation of FNAC

Answer 3

Cannot differentiate between invasive cancer and DCIS

Question 4

Limitation of FNAC

Where is it used?

Answer 4

Cannot differentiate between invasive cancer and DCIS

Used in setting of known cancer of the breast to determine if lymph nodes affected

Question 5

VAC

Answer 5

Bigger core biopsy; uses vacuum to suck tissue into larger needle

Can remove 3-4mm lesions completely

Question 6

What causes peau d’orange?

Answer 6

Obstructed lymphatics

Question 7

Triple test

Answer 7

Examination

Mammogram + U/S

Pathology

Question 8

23 year old woman who commenced the OCP 6/12 ago presents with 3/12 Hx of L breast lump which is slightly tender; it does not vary with menstrual cycle

What does this Hx suggest?

Answer 8

No fluctuation with menstrual cycle so not likely to be hormonal change

Fibroadenoma is most common in young women

Question 9

How does a fibroadenoma present clinically?

Answer 9

Mobile (“breast mouse”)

Smooth and well defined

Firm but not rock hard

May be slightly lobulated

Can be very large and can grow rapidly

Question 11

Describe the natural Hx of a fibroadenoma

Answer 11

1/3 get smaller, most stay the same (they do all their growing in the patient’s 20s), small percentage get bigger

Question 12

What is this U/S appearance consistent with?

Answer 12

Fibroadenoma

Question 13

Benita, 38 year old woman, presents with a 3/12 Hx of breast tenderness with presence of a mass

Further r/v suggests that the pain fluctuates and is worst immediately prior to her period when the lump she describes is quite obvious; with onset of menses the pain and nodularity settles

Dx?

Answer 13

Probably fibrocystic disease or natural variation in breast tissue density with hormonal changes

Due to effect of oestrogen and progesterone on breast glandular tissue and lining of intramammary ducts (more common in women in 30s and 40s)

Question 14

Benita, 38 year old woman, presents with a 3/12 Hx of breast tenderness with presence of a mass

Further r/v suggests that the pain fluctuates and is worst immediately prior to her period when the lump she describes is quite obvious; with onset of menses the pain and nodularity settles

Ix?

Question 15

Benita, 38 year old woman, presents with a 3/12 Hx of breast tenderness with presence of a mass

Further r/v suggests that the pain fluctuates and is worst immediately prior to her period when the lump she describes is quite obvious; with onset of menses the pain and nodularity settles

Mx?

Answer 15

OCP may help

Evening primerose oil is effective in 60-70% (believed to change fluid retention; also prescribed for PMS and pelvic pain)

Consider denisol (but beware AEs e.g. hirsutism, which may not disappear on ceasing Rx)

FU in 3-4 months then discharge

NB Sometimes resolves spontaneously following child-birth

Question 16

Connie, 43, presents with a very short Hx of sudden onset of a breast lump in the R breast; she examines her breasts regularly and was devastated to find this new lump developed over a matter of days

Had noticed some mild tenderness in this area prior to the development of the lump

DDx?

Answer 16

Benign breast disease: hormonal mastopathy, cystic disease of the breast (fibrocystic disease is the histological descriptor), mammary dysplasia, aberrations of normal development and involution

Cyst may be complicated (e.g. bleeding); this would account for the sudden onset

Need to rule out underlying DCIS

Question 17

Connie, 43, presents with a very short Hx of sudden onset of a breast lump in the R breast; she examines her breasts regularly and was devastated to find this new lump developed over a matter of days

Had noticed some mild tenderness in this area prior to the development of the lump

U/S performed; interpret the findings

When would this require referral to breast clinic?

Answer 17

Simple cyst: black in the middle, well-defined, hyper-reflective posteriorly, circular

Would only require referral to breast clinic if palpable lump, complex or complicated cyst

Question 18

Deanne, 49, presents with 2/12 Hx of nipple discharge from the L breast only

What features of the presentation are important in evaluating the cause of the nipple discharge?

Answer 18

Bilateral or unilateral: if related to hormonal change (e.g. lactation), would expect from both breasts

Does it come from multiple openings in the nipple (there are 15-20) or just from one spot: if it comes from many, this suggests the discharge is physiological

Question 19

Deanne, 49, presents with 2/12 Hx of nipple discharge from the L breast only

What are some common causes of nipple discharge?

Answer 19

Hormonal (e.g. pituitary tumour)

Cancer (relatively uncommon)

Infection (mastitis; not common, usually comes from around the areola)

Papillary lesions, e.g. warty growth (usually within large duct systems, often singular but may be multiple, with multiple having a greater association with cancer risk), papilloma (most common cause of bloody discharge)

Cyst draining into duct system (usually clear not bloody discharge)

Question 20

Deanne, 49, presents with 2/12 Hx of nipple discharge from the L breast only

Ix?

Answer 20

Mammogram

Focussed U/S of nipple

Question 21

Deanne, 49, presents with 2/12 Hx of nipple discharge from the L breast only

Mx?

Answer 21

Biopsy (usually excisional)

Question 22

What is the main cause of a serous nipple discharge? What are some less common causes?

Answer 22

Hyperplastic lesions (papillary lesions including hyperplasia, papilloma, carcinoma-in-situ and invasive ductal carcinoma)

Less common: duct ectasis

Question 23

What is the main cause of a bloody nipple discharge? What are some less common causes?

Answer 23

Hyperplastic lesions (papillary lesions including hyperplasia, papilloma, carcinoma-in-situ, invasive ductal carcinoma)

Less common: duct ectasia, pregnancy

Question 24

What is the main cause of a watery nipple discharge? What are some less common causes?

Answer 24

Hyperplastic lesions (papillary lesions including hyperplasia, papilloma, carcinoma-in-situ and invasive ductal carcinoma)

Less common: duct ectasia

Question 25

What is duct ectasia?

Answer 25

Widening of the duct

Moderate ectasia is considered ANDI (aberrations in the normal development and involution of the breast)

Question 26

What is the main cause of a coloured opalescent nipple discharge? What are some less common causes?

Answer 26

Duct ectasia

Less common: cyst

Question 27

What is the main cause of discharge of milk from the nipple? What are some less common causes?

Answer 27

Physiological

Less common: galactorrhoea of endocrine origin

Question 28

List 4 features of missed cancers

Answer 28

Young age (under 40)

Multiple visits with the patient complaining of a similar problem

A palpable abnormality which is disregarded because a mammogram is reported as normal (need the triple test!)

Multiple clinicians reviewing the patient without appropriate communication

Question 29

Jenny, 57, has recently udergone her third round screening mammogram and a suspicious lesion in her L breast was identified; she has been recalled to undergo further assessment in 3 days

BreastScreen ring 3 days later to tell you that an image-guided biopsy has confirmed the Dx of a 9mm grade 1 cancer in the L central breast

When should the patient commence treatment?

Answer 29

Most women in Vic receive definitive treatment 3-4 weeks following biopsy

Question 30

45 year old woman presents with short vague Hx of mass in L breast; physical exam reveals a discrete slightly tender regular mass in this area

She has never had a mammogram; a mammogram is order but shows only a small cyst in the area of concern confirmed by an U/S

However, in the contralateral R breast a 5cm area of pleomorphic microcalcification is noted

DDx?

Answer 30

Cancer or DCIS (more likely invasive if there is a mass effect)

Question 31

What does macrocalcification suggest?

Answer 31

“Popcorn” in old fibroadenomas

Question 32

45 year old woman presents with short vague Hx of mass in L breast; physical exam reveals a discrete slightly tender regular mass in this area

She has never had a mammogram; a mammogram is order but shows only a small cyst in the area of concern confirmed by an U/S

However, in the contralateral R breast a 5cm area of pleomorphic microcalcification is noted

Likely Dx? How would you confirm this Dx? What are the Mx principles?

Answer 32

Likely Dx: DCIS

Confirm with stereotactic biopsy

Mx: same as invasive cancer, but no need for sentinel node excision (if there is very extensive or high-grade necrosis, do sentinal node because of the small chance of micro-invasion) - remove area, give some radiotherapy to remaining breast

Question 33

Marilyn, 63, presents with 2/12 Hx of vague mass in L breast; recently she noted that the overlying skin has become a little indraw when she raised her hand above her head

What does this suggest?

Answer 33

Tethering suggests local infiltration (atttachment to skin and pectoral muscle)

Question 34

Marilyn, 63, presents with 2/12 Hx of vague mass in L breast; recently she noted that the overlying skin has become a little indraw when she raised her hand above her head

U/S performed; interpret the findings

Next steps?

Answer 34

Irregular, tall vertically with some posterior shadowing - this is consistent with a cancer

Perform an U/S guided biopsy to confirm, and then refer to breast surgeon for wide local excision and sentinel node biopsy

Question 35

How is tumour and sentinel node identified for surgery?

Answer 35

Hookwire is inserted to identify location of tumour

Sentinel node is located via LN scintigraphy (injection of a radioisotope attached to colloid around the areolar complex, which then gets caught up in the lymphatics and drains to the LNs)

Some surgeons inject peri-tumoural but this is more likely to identify the intra-mammary sentinel node (don’t really care about this) and carries increased risks (e.g. of pneumothorax)

Once the dye has been injected, the sentinel LN will look blue macroscopically AND a gamma probe with Geiger counter will also be used to help located the “hot” node

Question 36

Marilyn, 63, presents with 2/12 Hx of vague mass in L breast; recently she noted that the overlying skin has become a little indraw when she raised her hand above her head

Final pathology is of a 21mm high grade cancer completely resected, ER and PR negative HER 2 non-amplified with involvement of 3/3 sentinel LNs

Is further surgery indicated?

Answer 36

Yes; perform an axillary dissection to remove rest of LNs as a second procedure (used to do it at the time of surgery, but now considered unnecessary due to current adjuvent treatments)

Question 37

Marilyn, 63, presents with 2/12 Hx of vague mass in L breast; recently she noted that the overlying skin has become a little indraw when she raised her hand above her head

Final pathology is of a 21mm high grade cancer completely resected, ER and PR negative HER 2 non-amplified with involvement of 3/3 sentinel LNs

After axillary dissection: further 1/16 nodes were positive (so 4/19)

How many LNs are in the axilla in the average woman?

Answer 37

15 (can be more, can be less)