Breast + Endocrine Flashcards
1
Q
What age does breast screening happen in the UK?
what do they get
A
- Between 50 and 70
- every 3 years
- can be extended from 57 to 73
- they get a mammogram in 4 standard views and in 2 views of each breast
2
Q
Identify the views in this mammograph and the outer and inner quadrants
A
- the top two images are the mediolateral oblique views the upper being on the top of the image close to the armpit
- the bottom two images are craniocaudal views and the outer being at the top of the image
3
Q
What further investigations can be done to assess calcification seen in the breast?
A
- Further Mammographic views
- True lateral: allows you to see a benign calcification that settles down → “tea cupping”
- Magnification view: extra paddle over areas of calcification to see the type of calcification and to see if it is truly ductal or benign
- Ultrasound
- looks for massive to see if there is an invasive component
- Examination
- Stereotactic biopsy → using mammography equipment for targeting
- take an X-ray of the sample as well
4
Q
What views do mammograms come in?
A
- Craniocaudal (top to bottom)
- Mediolateral oblique (up towards the armpit)
5
Q
What is the lifetime risk of developing breast cancer in women the UK?
A
If you live up to the age of 85 you have a 1 in 10 risks of getting breast cancer
6
Q
What is the risk of breast cancer in males?
A
1:200 male to female ration
usually more advanced in men
7
Q
What are the factors influencing the risk of breast cancer? of relative risk of >4.0
A
-
Age
- High risk: >50 yrs
- Low risk: <30 yrs
-
Country of birth
- High risk: North Europe
- Low risk: Asia, Africa, North Africa
-
Two first degree relatives with breast cancer at an early age?
- High risk: Yes
- Low risk: No
-
History of cancer in one breast:
- High risk: Yes
- Low risk: No
8
Q
What are the factors influencing the risk of breast cancer? of relative risk of 2.1-4.0
A
-
Nodular densities on a mammogram
- High risk: >75% of breast
- Low risk: fatty parenchyma
-
One first-degree relative with breast cancer
- High risk: Yes
- Low risk: No
-
Atypical hyperplasia confirmed on biopsy
- High risk: Yes
- Low risk: No
-
High dose radiation to chest
- High risk: Yes
- Low risk: No
-
Overiectomy before age 35
- High risk: No
- Low risk: Yes
9
Q
What are the factors influencing the risk of breast cancer? of relative risk of 1.1-2.0
A
-
Age at first full-term pregnancy
- High risk: >35 years
- Low risk: <20 years
-
Age at menarche
- High risk: <12 years
- Low risk: > 14 years
-
Age at menopause
- High risk: >55 years
- Low risk: <45 years
-
Obesity (postmenopausal)
- High risk: Obese
- Low risk: Thin/ Slim
-
Parity (postmenopausal)
- High risk: Nulliparous
- Low risk: Multiparous
-
Breastfeeding (postmenopausal)
- High risk: none
- Low risk: several years
-
Hormonal contraceptives (<45 years)
- High risk: Yes
- Low risk: No
-
HRT
- High risk: Yes
- Low risk: No
-
Socio-economic status
- High risk: High
- Low risk: Low
-
Place of residence
- High risk: Urban
- Low risk: Rural
-
Ethnicity
- High risk: Western caucasian <40yrs, African origin >40yrs
- Low risk: Asian (all)
10
Q
What is the lifetime risk of breast cancer if you have a low relative risk
A
1 in 12 to 1 in 8
12.5%
11
Q
What is the lifetime risk of breast cancer if you have a moderate relative risk?
A
1 in 8 - 1 in 4
25%
12
Q
What is the lifetime risk of breast cancer if you have a high relative risk?
A
1 in 4 to 1 in 2
50%
13
Q
What is the follow-up if breast cancer is found in one family member?
A
- Live affected relatives screened to identify a mutation in the family
- Testing offered after full genetic counselling: 2 sessions with on month term reflective period
- turn around of test results 3-6 months
14
Q
How does Hodgkins disease impact on risk of breast cancer?
A
- women treated for HD in childhood have a cumulative risk of around 15-33% by 25 years of follow up of developing breast cancer
- the risk is greater the longer the follow-up
- women created in adulthood are also at high risk; cumulative risk of 15-25% by 25 years for women treated from ages 20-29
15
Q
What is the criteria for breast screening?
A
3 yearly mammograms from 47yrs to 70yrs
2 views/double reporting
16
Q
How would you approach a patient presenting with a breast lump?
A
Triple Assessment
- History & Physical Examination
- Imaging
- Tissue diagnosis
- fine-needle aspiration (FNA)
- excisional biopsy (less common)
17
Q
How would you report/ assess a lump?
A
- Site
- Size
- Shape
- Contour
- Consistency
- Colour
- Tenderness
- Tethering
- Transillumination (testes)
18
Q
What are differentials for a breast lump?
A
- Abscess
- Fibroadenoma
- Cyst
- Localised benign lesion
- Cancer
19
Q
Describe the pathology of breast cancer
A
- The proliferation of epithelial cells
- Increased vascularity
- Loss of basement membrane
- Loss of myoepithelial cells
20
Q
What is DCIS?
A
Ductal Carcinoma in Situ
- clonal proliferation of malignant epithelial cells (black solid arrows)
- originating in the terminal duct lobular unit (black open arrow)
- without invasion of the basement membrane (black curved arrow)
21
Q
What types of breast cancer are there?
A
- Ductal Carcinoma In-situ (DCIS)
- Invasive Ductal Carcinoma
- Lobular carcinoma
22
Q
How would you describe this ultrasound of the breast and what grade would you give it?
A
- irregular ill-defined hypoechoic lesion consistent with malignancy
- U5
23
Q
What is seen in this Mammogram?
A
abnormality in the upper, outer quadrant of the left breast
M5
24
Q
What grading would you give to a patient presenting with the following and what would you refer her for (why)?
- 29 y/o female with a palpable mass on the left outer breast which is smooth, well defined and mobile
A
- graded as a P2 (benign)
- referred for an ultrasound as shes is below 40 years old
25
A female with the following history gets an ultrasound of her breast. What would the diagnosis be and any further investigations if necessary? (why)
*29 y/o female with a palpable mass on the left outer breast which is smooth, well defined and mobile*
* Well-defined hypoechoic lesion in the left outer breast → likely a fibroadenoma U3
* Would send for an ultrasound-guided biopsy as she is over 25 years old
26
A female with the following history gets a mammogram of her breast. What would the diagnosis be and any further investigations if necessary? (why)
*A 45-year-old female with bilateral lumps, previous history of cysts and a clinical examination of P2*
* Multiple well-defined opacities bilaterally consistent with cysts, M2
* Would send for an ultrasound
27
How would you describe and classify the following ultrasound of these breasts?
* Circumscribed, oval or round, anechoic masses with imperceptible wall and posterior enhancement,
* consistent with cysts, U2.
28
What are the two main types of Breast abscesses?
* Puerperal abscess: breastfeeding women
* Syberareolar inflammation → duct obstriction → milk stasis → infection
* Non-puerperal abscess
* Direct skin contamination
* Duct ectasis, stasis, obstruction and inflammation
29
What is the occurrence and meaning of people presenting with breast pain?
* Breast pain is a common and chronic symptom in women, having a prevalence of 52% in the general population
* In a study from our unit, out of 686 patients who presented with pain and had a normal examination, 3 cancers were diagnosed not related to the site of pain (the cancer detection rate therefore being lower than when screening asymptomatic population).
* Pain no longer warrants a secondary care referral if it is the only presenting symptom.
* not a sign of breast cancer
30
What is the aetiology and epidemiology of gynaecomastia?
* Non-neoplastic enlargement of male breast, secondary to ductal hyperplasia and stromal proliferation
* Hormonal, drug induced, neoplastic, idiopathic (exclude other aetiologies)
* Prevalence in general population: 32-65%
* Pubertal (peak age: 10-13 years): usually bilateral and asymmetric; 60% of young men affected to some degree; often resolves in a few months
* Senescent: Men over 60; age-related ↓ in testosterone; ↑ oestradiol from peripheral conversion in adipose tissue: Aromatization of androgens to oestrogens
31
Explain what a Nonpuerpaerla abscess is.
Its aetiology and the causative organisms
* Direct skin contamination
* Duct ectasia, stasis, obstruction (rarely from mass), and inflammation
* Squamous metaplasia of lactiferous ducts (SMOLD)
* _Recurrent mastitis, a high association with smoking_
* Causative organisms: Aerobic and anaerobic
* *S. aureus* (\> 50% MRSA), *Staphylococcus epidermidis*, *Pseudomonas aeruginosa*, *Peptostreptococcus*
* Less common: Fungal, viral, parasitic, *Mycobacterium* (including *M. tuberculosis*), cat-scratch disease
* Local and systemic treatment are necessary*
* Smoking cessation also advised*
32
Explain what a Puerpaerla abscess is.
It's aetiology and the causative organisms
What would the management be?
* Subareolar inflammation → duct obstruction → milk stasis → infection
* Infection in preexisting galactocele
* Causative organisms: *Staphylococcus aureus* most common (\> 50% MRSA = methicillin resistant)
* Continue breast emptying by breastfeeding or pumping (unless breastfeeding contraindicated by antibiotics)
* Local and systemic treatment are necessary*
* Continue breast emptying by breastfeeding or pumping (unless breastfeeding contraindicated by antibiotics)*
33
What would you see in this ultrasound of a breast?
what if any further action would you take?
* Fluid collection with thick wall and echogenic contents.
* Pus was aspirated and sent for MC&S.
34
A patient with the history below presents to your clinic would be the management in the breast clinic be?
* 29-year-old female 4 weeks postpartum with a 5-day history of breast pain and swelling.*
* On examinations she is pyrexic, tachycardia and a 'red and hard' lump is palpated in the left upper breast*
* **refer for ultrasound** → breasts would be radiosensitive since she's postpartum, and it would be very painful to put it in a mammogram machine
* **possible aspiration if a cyst is found** → gives an infective picture, would help narrow down antibiotics for her to take. Also, aspiration will help with symptoms before it becomes more solidified if they are on antibiotics
35
What is the epidemiology and aetiology of breast cysts?
* Fluid-filled mass lined by epithelium
* Most common mass in female breast
* Can occur at any age; peak prevalence: 35-50 years
* 65% of premenopausal women have cysts
* 38% of postmenopausal women not on hormone therapy (HRT) have cysts; 66% if on HRT, especially oestrogen alone
36
What would you expect to see in ultrasound and inspiration of a benign breast cyst?
* US: Circumscribed, oval or round, anechoic mass with imperceptible wall and posterior enhancement
* Mammography: Halo-sign/ appearance
* Fluid turbid yellow or green; maybe dark gray/black
* Aspiration if painful or equivocal on imaging. Routine cytology not indicated for non-bloody fluid
37
What is the aetiology and epidemiology of Fibroadenomas?
* Most common solid mass in women of all ages
* Not usually excised unless \>3cm
* Most common breast mass in women under 35 years
* Hormonally influenced growth and involution
* May grow during pregnancy
* Typically regress and calcify after menopause
* Most self-limited, involute spontaneously the following menopause
* Not ↑ risk of breast cancer
38
What is the surgical (investigatory) grading for lumps felt in the breast?
* P1 Normal
* P2 Benign (may be coarse calcification)
* P3 Uncertain/likely benign
* P4 Suspicious of malignancy
* P5 Malignant
39
What is the treatment/ management of breast cancer?
* Surgery - 80%
* Wide local excision
* Mastectomy
* Radiotherapy
* Chemotherapy
* Endocrine Therapy
40
What is considered when making the decision for the type of breast surgery?
Size of Tumour
Size of Breast
Site of Tumour
Multifocality
Patient's choice
41
What is important in treatment/ management alongside surgery?
**staging the disease**
* predicts prognosis and survival
* guides need for further treatment to improve survival (radiotherapy, chemotherapy)
* sentinel node biopsy
* reconstruction post surgery
42
What is the Nottingham Prognostic Index?
NPI = [Size (cm) x 0.2] + N + G
* this is an assessment tool used to give a general idea of how well treatment will work for a person with breast cancer and how long the person may live
* less than 3.5 is a good prognosis, \> 5 is a poor prognosis
43
What different reconstructive surgery can be done post mastectomy?
Autologous Flaps e.g
- Lat Dorsi
- TRAM: transverse rectus abdominus mycocutaneous flap
44
Give the normal anatomy of the thyroid gland
* approx. 20g
* 2 lobes joined by a thin isthmus
* the upper margin of the isthmus is just below the cricoid cartilage
* affixed to anterior and lateral aspects of trachea by loose connective tissue
* Arterial blood supply:
* Superior thyroid artery from the external carotid
* Inferior thyroid artery from the subclavians
* Venous blood supply
* Superior thyroid vein drains into the internal jugular vein
* Middle thyroid vein drains into internal jugular vein
* Inferior thyroid veins drains into the left brachiocephalic vein
* Innervation
* the laryngeal and recurrent larngeal branches of the vagus nerve pass through the thyroid
45
What structure needs to be carefully considered when doing thyroid surgery?
The recurrent laryngeal nerve as it supplies
* all muscles of larynx except the cricothyroid muscle (supplied by superior laryngeal nerve)
* the cricothyroid muscle adducts the cords
46
What does the patient need to be aware of when consenting for thyroid surgery?
* Immediate complications: Bleeding
* Early symptoms post surgery: potential voice change
* Late symptoms post surgery:
* voice change
* need for thyroxine,
* +/- calcium/ vitamin D supplements
47
What are symptoms of Thyrotoxicosis?
* nervousness
* increased sweatiness
* hypersensitivity to heat
* palpitations
* fatigue weight loss
* tachycardia
* dyspnea
* weakness
* increased appetite
* eye complaints
48
What are signs of thyrotoxicosis?
* Tachycardia
* Goiter
* Skin changes
* Tremor
* Bruit over thyroid
* Eye signs
49
What are the signs of Hypothyroidism (Myxedema)
* Weakness
* Dry, coarse skin
* lethargy
* Slow speech
* Oedema of eyelids and slightly less often the face
* Sensation of cold
* decreased sweating
* Thick tongue
* Pallor of skin
* Memory impairment
50
What are the indications to operate on the thyroid gland?
* Pressure symptoms
* difficulty with swallowing or breathing
* pain in the neck
* Cancer
* Graves' disease
* Diagnosis
* Cosmetic
51
What are predisposing factors for thyroid cancer?
* radiation to the neck in childhood
* Exposure to environmental radiation
* Chronic lymphocytic thyroiditis (lymphoma)
* Genetic (familial non-medullary thyroid carcinoma, Chromosomes 19 and 1 )
* Female (F:M = 2:1)
52
What is the pathway when a patient presents with a Goitre ?
53
Give the epidemiology of thyroid nodules
* 4-7% of adults have a thyroid nodule
* F:M = 4:1
* women more likely to be diagnosed with thyroid cancer from their 20s
* 5-10% of these are malignant
* higher risk of malignancy in men \> 60 y/o
* 10% of cold nodules are malignant
54
Explain the cytology grading of thyroid cancers
when would surgery be indicated?
* THY 1: insufficient
* THY 2: Benign (cold)
* _THY 3: indeterminant, follicular cells seen_
* _THY 4: indeterminant, probably malignant_
* _THY 5: Cancer_
_surgery would be indicated_
55
What types of surgery are offered for thyroid cancer? - in which pathologies would they be done
Hemithyroidectomy
* Toxic nodule
* diagnostic on dominant nodule
Total thyroidectomy
* cancer
* multinodular goitres
* Graves'
56
What neck/ thyroid symptoms/ presentations would indicate an urgent referral?
* Those with solitary thyroid nodules that are increasing in size
* Patients with thyroid lumps, who have family histories of thyroid cancer or who have had neck irradiation
* Thyroid lumps in patients over the age of 65
* Patients with unexplained hoarseness or voice changes associated with a goitre
* Cervical lymphadenopathy
* Stridor
57
Where do the parathyroid glands originate from embryologically?
* from the endoderm of the third and fourth pharyngeal pouches
* third → inferior parathyroid glands
* fourth → superior parathyroid glands
58
What is the function of the parathyroid glands? and what physiological response does it result in?
* detects levels of calcium in the blood
* releases PTH which acts on the Kidney's and in the Bone
* In the bone PTH
* stimulates osteoclast activity
* increase bone resorption → increased blood calcium levels
* In the kidneys PTH
* stimulates calcium reabsorption
* increases calcitriol (vit D) production
* → more Calcium and phosphate absorption
* decrease phosphate reabsorption
59
What are common causes of Hypercalaemia?
* common
* malignant disease (+/- bone mets)
* primary hyperthyroidism
60
What are less common causes of hypercalcemia?
* Thyrotoxicosis
* Vit D intoxication
* Thiazide diuretics
* increase renal tubular reabsorption calcium
* Sarcoidosis
* Familial hypocalciuric hypercalcemia
61
What are uncommon causes of hypercalcaemia?
* Lithium
* TB
* Immobilization (Pagets)
* Acromegaly
62
What are clinical features of hypercalcaemia?
**Bones**
* weakness, tiredness, lassitude
* weight loss and muscle weakness
**Stones**
* Renal calculi and nephrocalcinosis
**Abdominal Groans**
Abdominal pain
**Cardiavascular Moans**
* Cardiac arrhythmias and hypertension
* Corneal calcification
* Vascular calcification
**Psychic overtones**
* impaired concentration
* personality changes
* drowsiness, coma
63
What is the incidence of primary hyperparathyroidism?
1:1000 males
2-3:10000 females
age: 20-60 yrs
64
What is the pathological cause of primary hyperparathyroidism?
Adenoma - 80%
Hyperplasia - 20%
Carcinoma (HPRT2) - \<1%
* Associated with Multiple Endocrine Neoplasia Syndrome: MEN I
* affects, parathyroids, pancreatic islets, pituitary, adrenal cortex
* MENIIa: medullary cancer, pheochromocytoma
* MENIIb: IIa and, parathyroids, Marfinoid habitus, Neurofibromata
65
What investigations are done for suspected primary hyperparathyroidism?
* Serum Calcium
* PTH assay
* 24hr urinary analysis for calcium: hypercalciuria
* hypocalciuric in FHH
66
When would a patient be referred for surgery in hyperparathyroidism?
When
* calcium is \>0.25 -0.44mM
* 24hr urine shows calcium excretion is \> 10mmol
* Creatinine clearance reduced by 30%
* Bone density reduced by 2 SD
* Patient under 50 y/o
* Patient who cannot be followed up
67
What is used to localize the parathyroid pre-op?
a MIBI scan using
Technetium99m-Sestamibi taken up in mitochondria
68
What surgery can be done on the parathyroid?
* Standard operation: neck exploration
* excision of adenoma and confirm by frozen section
* look for other three if there is abnormal hyperplasia: total parathyroidectomy
* plus thymectomy
* Minimally invasive surgery
* laparoscopic, radioguided surgery
* under local anaesthesia
* IR
* angiographic destruction of gland
69
What measurements need to e done during parathyroid surgery?
PTH levels: pre-op, on excision, 5 mins, 10 mins after removal
a 50% drop in PTH is positive
70
What are the breast biopsy diagnosis categories?
* B1 → normal breast tissue / no lesion
* B2 → benign lesion (e.g. fibroadenoma)
* B3 → atypia, exclude something worse = excision
* B4 → atypia, likely malignant = excision
* B5a → Intraepithelial neoplasia (e.g. ductal carcinoma in-situ) = excision but no sentinel lymph node biopsy necessary
* B5b → Invasive neoplasm = excision + sentinel lymph node biopsy always necessary
71
What would you see pathologically in B1 normal/ no lesion biopsy?
* the normal organoid architecture of terminal duct lobular units and ducts and potential microcalcifications
* Luminal cuboidal layer produces the milk and the basal layer that can compress the duct and properly the milk toward the nipple
72
What would be seen in benign B2 fibroadenoma?
* stromal proliferation (not the actual functioning tissue of the breast) compressing terminal ductal lobular units and ducts
* no mitosis, no atypia or dysplasia
73
What is a rare differential of B2 fibroadenoma?
malignant Phyllodes tumours
differ from fibroadenomas as follows
larger, irregular shape, microlobulated margins, complex internal echo pattern, and hypervascularity were significant findings of phyllodes tumors.
74
What would you see in B5a ductal carcinoma in situ?
this is a non-invasive DCIS
* the proliferation of the luminal cells with abnormal mitosis
* basement membrane remains intact
* - can see calcification due to saponification in the presence of calcium from cell fragments from rapid mitosis and an acidic environment
75
What would the management for B5 lesions be?
wide local excision
* marked to orientate the pathologists
* marking allows one to assess how close to which margins the cancer was
76
What would be seen in high-grade DCIS?
Necrosis within the malignant areas still with basement membrane
higher risk of invading the basement membrane
77
What is this an image of?
Ductal adenocarcinoma
exists within the ducts however there is no clear basement membrane
78
What is the difference between ductal neoplasia and lobule neoplasia?
* ductal neoplasia retains a surface protein **E-cadherin** that lobule neoplasia does not even though they both originate from the same place
* E-cadherin sticks cells together hence…
* in lobular neoplasia, they are often multi-focal and bilateral as they can show up anywhere in the body
79
What does having an oestrogen receptor on a tumour indicate?
* anti-estrogen therapy is possible
* it is graded on how positive and negative it is, the more positive the more likely it is to respond to anti-oestrogen therapy
80
What is her2/neu?
Human epidermal growth factor receptor 2
* identifying this marker can also help guide therapy i.e use of Herceptin (trastuzumab) therapy
81
What is the rule for sentinel lymph nodes?
Sentinel lymph node biopsy is performed at the time of definitive excision (not diagnostic biopsy!)
* B1 to B5a categories do not require SNLB
* B5b category always requires SNLB
* SLNB clear - no axillary dissection
* SLNB involved by metastasis - axillary dissection
82
What does triple-negative in basal-like markers indicate?
more likely to have BRCA mutations which can be indicative of many other potential neoplasms i.e ovarian as well as breast
83
What is Ductal Ectasia?
Duct ectasia is a dilatation and shortening of the terminal breast ducts within 3cm of the nipple. It is common and the incidence increases with age. (benign)
It typically presents with nipple retraction and occasionally creamy nipple discharge . It may be confused with periductal mastitis, which presents in younger women, the vast majority of whom are smokers.
Periductal mastitis typically presents with periareolar or subareolar infections and may be recurrent.
84
What is Paget's disease of the nipple and how does it present?
Paget's disease is an eczematoid change of the nipple associated with an underlying breast malignancy and it is present in 1-2% of patients with breast cancer.
In half of these patients, it is associated with an underlying mass lesion and 90% of such patients will have an invasive carcinoma. 30% of patients without a mass lesion will still be found to have an underlying carcinoma. The remainder will have carcinoma in situ.
Paget's disease differs from eczema of the nipple in that it involves the nipple primarily and only latterly spreads to the areolar (the opposite occurs in eczema).
Diagnosis is made by punch biopsy, mammography and ultrasound of the breast.
85
How is Mastitis managed?
The first-line management of mastitis is to continue breastfeeding.
The BNF advises treating 'if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection'. The first-line antibiotic is flucloxacillin for 10-14 days, reflecting the fact that the most common organism causing infective mastitis is Staphylococcus aureus. Breastfeeding or expressing should continue during treatment.
86
What is Tamoxifen, when is it indicated and what are it's side effects?
Tamoxifen is a SERM which acts as an oestrogen receptor antagonist and partial agonist.
→ It is used in the management of oestrogen receptor-positive breast cancer.
_Adverse effects_
* menstrual disturbance: vaginal bleeding, amenorrhoea
* hot flushes - 3% of patients stop taking tamoxifen due to climacteric side-effects
* venous thromboembolism
* endometrial cancer
87
What is Anaestrole and Letrozole when are they indicated and what are their side-effects?
Anastrozole and letrozole are aromatase inhibitors that reduces peripheral oestrogen synthesis. This is important as aromatisation accounts for the majority of oestrogen production in postmenopausal women and therefore _anastrozole is used for ER +ve breast cancer in this group._
_Adverse effects_
* osteoporosis
* NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer
* hot flushes
* arthralgia, myalgia
* insomnia
88
What are the features of Fat necrosis in a breast?
More common in obese women with large breasts
May follow trivial or unnoticed trauma
Initial inflammatory response, the lesion is typical firm and round but may develop into a hard, irregular breast lump
Rare and may mimic breast cancer so further investigation is always warranted
89
What is Intraductal Papilloma?
* Intraductal papilloma is a benign tumour that grows within the lactiferous duct.
* There is usually no palpable lump but large papillomas may present with a mass.
* Usually presents in younger women and cause blood-stained nipple discharge or clear discharge with microscopic blood
* There is no increased risk of malignancy with intraductal papilloma.
90
What is a “snow storm” sign on an ultrasound?
**extracapsular breast implant rupture**
Snowstorm sign on breast ultrasound imaging represents the **presence of free silicone droplets mixed with breast tissue** giving a characteristic heterogeneous echogenic appearance with the dispersion of the ultrasound beam
91
What is used to treat breast cancer that is node +ve?
FEC-D chemotherapy
92
What risk is associated with axillary node clearance?
_arm lymphedema and functional arm impairment_
other risk of surgery including nerve and arterial damage happen at a lesser extent that can't really be measured
93
What is Fibroadenosis?
aka **fibrocystic disease, benign mammary dysplasia**
'Lumpy' breasts which may be painful.
Most common in middle-aged women, Symptoms may worsen prior to menstruation
