breast disease- malignant & benign

Question 1

list the 7 in situ breast malignancies

Answer 1

Carcinoma in situ, NOS*
Comedocarcinoma, noninfiltrating
Cribriform carcinoma in situ
Intraductal carcinoma and lobular carcinoma in situ
Intraductal carcinoma, noninfiltrating, NOS
Lobular carcinoma in situ, NOS
Noninfiltrating intraductal papillary adenocarcinoma
Paget’s disease and intraductal carcinoma of breast
Paget’s disease, mammary

Question 2

list the 15 invasive breast malignancies

Answer 2

Adenoid cystic carcinoma
 Carcinoma, NOS
 Carcinoma undifferentiated, NOS
 Carcinosarcoma, NOS
 Cribriform carcinoma, NOS
 Infiltrating duct carcinoma, NOS
 Inflammatory carcinoma
 Lobular carcinoma, NOS
 Medullary carcinoma, NOS
 Mucinous adenocarcinoma
 Paget's disease and infiltrating duct carcinoma of breast
 Phyllodes tumor, malignant
 Secretory carcinoma of breast
 Squamous cell carcinoma, NOS
 Tubular adenocarcinoma

Question 3

list the risk factors for breast cancer?

Answer 3

being female
growing older- age
gene mutations
atypical ductal or lobular hyperplasia 
lobular carcinoma in situ
atypical epithelial hyperplasia 

\+birth of first child after 30
high alcohol consumption
early menarche
fam hx breast cancer
prev breast cancer
nulliparity
postmenopausal obesity

Question 4

state the 6 most common symptoms of breast cancer on presentation

Answer 4

dimpled or depressed skin
visible lump
nipple changes (inversion)
bloody discharge
texture change- peau d'orange
colour change

Question 5

ductal carcinoma

• typical findings
• diagnosis

Answer 5

-stellate solid mass
pleomorphic casting microcalcifications

-US useful if breasts mammographically dense
definitively via image guided core needle biopsy

Question 6

ductal carcinoma in situ

• findings
• dx

Answer 6

• most commonly non palpable, seen at screening as malignant calcifications
• vacuum assisted core biopsy

Question 7

Invasive lobular carcinoma

• findings
• histology?

Answer 7

• not normally palpable or apparent on imaging

- indian file pattern

Question 8

list the treatment options in breast cancer? (7)

Answer 8

breast conserving surgery
modified radical mastectomy
\+breast reconstruction
radiation therapy
adjuvant system therapy (chemotherapy/hormonal therapy/targeted therapies)

Question 9

breast conserving surgery

• what is it?
• consists of?

Answer 9

-wide local excision +/- oncoplastic surgery

after surgery radiation therapy is performed(5 days a week for 3-6 wks)

Question 10

Modified radical mastectomy

-what is it?

Answer 10

-removes the entire breast, including overlying skin and axillary lymph nodes
modification= preservation of pec major

Question 11

Radiation therapy

-indications

Answer 11

-involvement of more than 3 nodes, + tumour margins or tumours >5cm

Question 12

Adjuvant systemic therapy

-what is it?

Answer 12

-basically polychemotherapy, chemical ooperectomy

Question 13

most commonly used hormonal therapy?

Answer 13

Tamoxifen

in ER+ cancer

Question 14

targeted therapies

• over expression of what can be targeted?
• name of drug for ^?
• other examples of therapies

Answer 14

• HER-2 over expression
• Herceptin (Trastuzumab) it is a recombinant humanised monoclonal antibody (RHMA)

-bevacizumab (RHMA against vascular endothelial growth factor, for mets
lapatinib (inhibits epidermal growth factor receptor and human epidermal growth factor receptor 2)

Question 15

Fibroadenoma

• define
• on examination?
• risk of cancer?
• Dx
• differential Dx

Answer 15

-benign neoplasm of the breast

-rubbery/firm,
mobile,
smooth with distinct borders,
nontender

• tend to decrease in size after the menopause, very small
• US guided core biopsy
• Phyllodes tumour but these tend to be larger and occur in older women, this will require wide local excision

Question 16

Mastalgia

• what is it?
• normal patter?
• management

Answer 16

• breast pain
• generally cyclic and during the immediate premenstrual phase of the cycle, generally bilateral
• if non cyclical then likely localised, unilateral and persistent

-mammogram for an over 35 yr old
reassure that it is physiologic
advise a well fitting bra might help
possibility of tamoxifen and topical NSAIDS helping

Question 17

Cyst

• on examination?
• treatment?

Answer 17

-usually during late reproductive yrs
palpable
clearly defined
soft 
mobile and
smooth
tender before menstruation

-can be diagnosed and treated via FNA

Question 18

Papilloma

• what is it?
• signs of intracystic carcinoma, action?

Answer 18

-a benign intracystic papillary proliferation
might be assoc with bloody cyst fluid

-rare, fluid grossly bloody or residual mass after aspiration
US guided core biopsy

Question 19

Nipple discharge

• difference between physiologic and pathologic?
• causes
• investigations?

Answer 19

• physiologic: clear, yellow and watery elicited from most women of reproductive age
  pathologic: bloody discharge form a single duct

-intraductal papilloma
think malignancy if assoc palpable mass
paget’s disease (perceived as discharge)

-If pathologic
mammography, US, surgical excision

Question 20

Mastitis

• what is it?
• causes?
• presentation?
• treatment?

Answer 20

-inflammation or infection of the breast

-puerperal mastitis, normally causes by staph aureus
non-puerperal, causes by S. aureus, Peptostreptococcus magnus and/or Bacteroides fragilis

-fever, erythema, induration, tenderness, swelling

-puerperal: flucloxicilin 500mg Oral every 6 hrs
continue breast feeding
re-examin every 3 days
non-puerperal: Augmentin 625mg orally every 8 hrs for 7 days

Question 21

breast abscess

• presentation?
• dx?
• treatment
• complication of chronic abscess?

Answer 21

• flocculaent-bulginh mass usually located in the central area of the mastitis
• US will verify a fluid filled pus centre

-aspiration with an 18 gauge needle with LA, side aspirate to microbiology
if not effective then open surgical drainage under GA

-pariareolar fistula
if unresponsive think malignancy

Question 22

adenolipoma

• what is it?
• presentation?

Answer 22

• benign neoplasm formed from adipose and glandular tissue

- smooth palpable mass

Question 23

ductal hyperplasia

-what is it?

Answer 23

-benign histologic process but if atypical might be assoc with DCIS

Question 24

Fat necrosis

-diagnosis?

Answer 24

-distinct mammographic pattern and secondary to trauma

Question 25

galactocele

-what is it?

Answer 25

-palpable milk filled cyst, assoc with preg/lactation and can be diagnosed via FNA

Question 26

What is Mandor’s disease?

Answer 26

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.