Breast disorders 2

Question 1

Fibroadenoma?

Answer 1

Common in women under the age of 30 years
Often described as ‘breast mice’ due as they are discrete, non-tender, highly mobile lumps

<30 breast ultrasound
>30 breast mammogram

No treatment

Question 2

Fibrocystic disease?

Answer 2

Multiple small breast lumps
Middle aged women 30-50
Bilateral diffuse, symmetrical lumpiness- breast pain often cyclical

<30 Ultrasound
>30 or suspicious for cancer- mammogram

Management simple analgesia

Question 3

Mastitis?

Answer 3

Mastitis: inflammation of the breast, typically due to infection.
○ Divided into lactational and non-lactational (duct ectasia)

Lactational mastitis:
○ Combination of breastfeeding-related nipple trauma and milk stasis predisposes
the breast to local infection.
● Duct ectasia mastitis:
○ Blockage of lactiferous ducts due to squamous metaplasia leads to dilatation
and inflammation.
○ Strongly associated with cigarette smoking

Lactational Mastitis:
○ First Line: continued breastfeeding / milk expression plus simple analgesia
○ Second Line: >24 hour duration / severe pain - add PO flucloxacillin.

Non-lactational Mastitis:
○ First Line: PO flucloxacillin

Fever, pain, breast tenderness, erythema, swelling, (duct ectasia- nipple discharge)

Question 4

Abscess?

Answer 4

Breast abscess: discrete collection of pus due to infection

Abscess:
○ Progression of untreated infective mastitis; walled-off collection of infection forms

Breast Abscess:
○ First Line: needle aspiration and drainage plus flucloxacillin (dependent on local
policy)

Question 5

Breast cancer prognostic index?

Answer 5

Nottingham criteria

Question 6

Breast cancer RFs?

Answer 6

1. Increasing age
2. Female sex (100:1 F:M incidence)
3. Family history
4. Inherited genetic mutations e.g. BRCA1
5. Endogenous oestrogen exposure:
   a. Early menarche
   b. Nulliparity / absence of breastfeeding
   c. Late menopause
6. Exogenous oestrogen and progestin exposure:
   a. Systemic hormonal HRT
   b. Systemic hormonal contraception

Question 7

Breast cancer presentation?

Answer 7

Symptoms include: breast lump
● Signs include: nipple discharge, nipple retraction, skin changes e.g. peau d’orange,
axillary lymphadenopathy.
● Metastatic features include: weight loss, bony pain, shortness of breath

Question 8

Breast cancer screening?

Answer 8

50-71 every 3 years

Question 9

Breast cancer investigations?

Answer 9

Investigations:
● 2 week wait criteria:
○ Unexplained breast lump in a woman aged >30.
○ Unexplained axillary lump in a woman aged >30.
○ Unilateral nipple changes in a woman aged >50.
○ Skin changes suggestive of breast cancer, any age.
● First Line: breast imaging
○ >30 or highly suspicious for cancer: mammogram
○ <30: breast ultrasound
○ Plus: ultrasound of the axilla +/- needle biopsy
● Second Line: biopsy
○ Fine needle aspiration and cytology
○ Plus: oestrogen / progesterone receptor testing, HER2 receptor testing.
● If symptoms / signs suggestive of metastasis:
○ CT scan (CT thorax-abdomen-pelvis, CT head).

Question 10

Breast cancer management?

Answer 10

First line- surgery- tumour excision or mastectomy with sentinel lymph node biopsy
Plus: radiotherapy

Adjuvent systemic therapy guided by the PREDICT tool:

Oestrogen receptor positive: Pre menopausal: tamoxifen
Post menopausal: anastrozole/letrozole (aromatase inhibitor)

HER2- Trastuzumab (Herceptin)

Chemotherapy- taxane and anthraycline