Breast Disease

Question 1

Clinical presenting features for breast cancer

Answer 1

Physiological swelling & tenderness (thelarche, one breast can delvelop more than the other)

Nodularity

Breast pain/ mastalgia - non-cyclical, unilateral, persistent

Palpable breast lumps

Nipple discharge including galactorrhoea (especially unilateral, blood stained)

Breast infection & inflammation usually associated with lactation

Question 2

What is benign breast disease?

Answer 2

Fibrocystic change most common benign breast disorder ✅fine needle aspiration, can get apocrine metaplasia

20-50yrs usually, hormonal aetiology (more painful before/ during period)

Smooth, mobile, regular borders, not tethered
Solid - fibroadenomas
Cystic - cysts (35-50yrs)

Both present as density on mammogram, along with invasive carcinomas

Calcification on mammogram - could be benign changes or ductal carcinoma in situ

Question 3

What are fibroadenomas?

Answer 3

Benign tumours
20-24yrs peak
Most common breast lesion

Arise in breast lobules, fibrous & epithelial tissue

Firm, non tender, highly mobile palpable lumps, smooth

Hormones involved & HRT increases incidence

Question 4

What is mammary duct ectasia ?

Answer 4

Unknown aieteiology

Dilation of major ducts filled creamy secretion with periodical inflammation

May Asymptomatic or nipple discharge (bloody, serous, creamy white or yellow), retracted nipple, acute inflammation, recurrent chronic inflammation with abscess formation

✅surgical excision of major duct, correction nipple retraction

Question 5

What is intraductal papilloma?

Answer 5

Benign growth single milk duct

Spontaneous discharge unilateral

Question 6

Infections of breast

Answer 6

Periductal Mastitis- generalised cellulitis ✅ antibiotics

Breast abscess - point tendencies, erythema, fever, related to lactation, non-lactation always abscess more frequent smokers, caused staph ✅I&D or strep (more diffuse, superficial) ✅local wound care & abx

Question 7

When to refer?

Answer 7

_>30yrs unexplained breast lump

_>50yrs any following unilateral: discharge, retraction, other changes of concern (e.g. swollen LNs)

New nipple retraction

Peak d’orange - involvement lymphatic drainage of skin (looks like orange peel)

Consider:
Skin changes suggests breast cancer

_>30yrs unexplained lump axilla

Consider Non-urgent referral:
<30yrs unexplained breast lump

Question 8

Stages of grief

Answer 8

Stability
Immobilisation 
Denial
Anger
Bargaining
Depression
Testing 
Acceptance 

Move between stages

Question 9

What does normal breast tissue look like histologically?

Answer 9

See slide 4

Question 10

What physiological changes are seen in breast tissue?

Answer 10

Prepubertal breast - few lobules

Menarche - increase number lobules, increased volume interlobular stroma

Menstrual cycle - follicular phase lobules quiescent, after ovulation cell proliferation & stromal oedema with menstruation decrease size lobules

Pregnancy - increase size/ number lobules, decrease stroma, secretory changes - cessation of lactation (atrophy lobules)

Increasing age - terminal duct lobular units decrease number/ size, interlobular stroma replaced adipose tissue

Question 11

What is the phyllodes tumour?

Answer 11

Similar stromal presentation as fibroadenomas

Usually 6th decade presentation

Question 12

What is acute mastitis?

Answer 12

Almost always during lactation

Usually staphylococcus aureus from nipple cracks & fissures

Erythematous painful breast, often Pyrexia

May produce breast abscess

✅expressing milk, antibiotics

Question 13

What is fat necrosis?

Answer 13

Inflammatory condition

Mass, skin changes or mammographic abnormality

History trauma/ surgery

Mimic carcinoma clinically and mammographically

Question 14

What stromal tumours can present in breast?

Answer 14

Fibroadenomas, phyllodes tumours, lipoma, leiomyoma, hamartoma

Mass, usually mobile, mammographic abnormality, multiple, bilateral, rubbery,
can mimic carcinoma

Localised hyperplasia

Question 15

What is gynaecomastia?

Answer 15

Enlargement makes ebreast

Often at Puberty (transient, more half boys, oestrogen peaks) and elderly (reduced testosterone)

Caused: relative decrease androgen effect or increase in oestrogen effect, klinefelter’s syndrome, cirrhosis of liver (oestrogen XS), gonadotrophin XS (functioning testicular tumour), drug related (spironolactone, chlorpromazine, marijuana, heroin, anabolic steroids)

Can mimic Male breast cancer especially unilateral

Question 16

What makes up 95% of breast cancers?

Answer 16

Adenocarcinomas

Question 17

Risk factors for breast cancer

Answer 17

Female
Uninterrupted menses
Early menarche
Late menopause
Reproductive history - never pregnant
Not Breast feeding
Obesity/ high fat diet
Western countries 
Atypical changes previous biopsy 
Previous breast cancer 
Radiation 
Hereditary (10% e.g. BRCA1/2, ovarian cancer, p53) 

exogenous oestrogens - HRT, long term OCP

Breast density higher - more ducts, harder to detect

Men:
Transgender male to female, klinefelter’s syndrome, men treated oestrogen for prostate cancer

Question 18

How do we classify breast carcinoma?

Answer 18

In situ -neoplastic population limited to ducts & lobules by basement membrane, myoepithelial cells are preserved (ductal carcinoma IS pre-cursor of invasive carcinoma, can spread, often central necrosis with calcification)

Invasive - neoplastic cells invaded beyond BM into stroma, can invade vessels & metastasize to LNs/ other sites

Ductal -

Lobule -

Question 19

What is Paget’s disease?

Answer 19

Cells can extend to nipple skin without crossing BM

Unilateral red and crusting nipple

Eczematous/ inflammatory conditions regarded suspicious & need biopsy

Question 20

How is invasive breast carcinoma a classified?

Answer 20

I Ductal c (IDC, NST), 75%, tubule slimed atypical cells, poorly differentiated, sheets pleomorphic cells, 35-50% 10yr survival
See slide 39/ 40

Invasive lobular carcinoma - 5-15%, infiltrating cells in single file, cells lack cohesion, 35-50% 10yr survival
See slide 41

Others: tubular, mucinous (older) both good prognosis

Question 21

How does breast cancer spread?

Answer 21

LNS - ipsilateral axilla normally

Distant metastases - blood vessels, often bones, lungs, liver, Brian

Invasive lobular carcinoma - spread odd sites e.g. peritoneum, GiT, ovaries, uterus

Question 22

Molecular classification of breast cancer?

Answer 22

Oestrogen positive/ negative (worse)

Her2 positive/ negative (worse)

Question 23

How does mammographic screening work?

Answer 23

47-73yrs
2view mammogram every 3yrs

Detect small impalpable Cancer & pre-invasive cancer

Asymmetric densities, parenchyma, deformities, claicfications

Further imaging, core biopsy, FnAC

Question 24

Therapeutic approaches to breast cancer

Answer 24

• mastectomy/ breast conserving surgery
• axillary surgery - depending whether there are involved nodes (sentinel node sampling or axillary dissection. Lymphatic mapping dye)
• post-op radiotherapy to chest and axilla
• chemotherapy
• hormonal treatment e.g. tamoxifen (increased risk thromboembolism/ endometrial cancer) depending on oestrogen receptor status
• herceptin depending on Her2 receptor status positive

Question 25

When do you give an ultrasound and when a mammogram?

Answer 25

Mammogram - X-ray over 35yrs, less dense breast

Question 26

What’s the Triple assessment?

Answer 26

History and clinical examination

Imaging (USS/ mammogram)

Histology (core biopsy/ fine needle aspiration)

Question 27

Which ligament suspends the breast to the chest wall?

Answer 27

Cooper’s ligament