Breast Lump

Question 1

The genetic predisposition to breast cancer
continues to be delineated with the strong
predisposition from mutations in the genes ______ and _____

Answer 1

BRCA1

and BRCA2

Question 2

The commonest lumps are those associated with

______

Answer 2

mammary dysplasia (32%)

Question 3

_______ is also a common cause of

cysts, especially in the premenopause phase

Answer 3

Fibrocystic disease

Question 4

Over________ of isolated breast lumps prove to be
benign but clinical identification of a malignant tumour
can only definitely be made following aspiration
biopsy or histological examination of the tumour

Answer 4

75%

Question 5

What is the triple test for breast masses?

Answer 5

1 Clinical breast examination
2 Imaging—mammography and/or ultrasound ± MRI
3 Fine-needle aspiration cytology ± core biopsy

Question 6

Breast cancer is the most common cancer in
females. The risk of developing breast cancer
before age 85 in Australian women is ______

Answer 6

1 in 8

Question 7

The average age of diagnosis of breast CA is ____

Answer 7

60.7 years

Question 8

About _____ of all new cancers in women are

breast neoplasms.

Answer 8

25%

Question 9

Ddx for different types of dc

— intraduct papilloma (commonest)
— intraduct carcinoma
— fibrocystic disease

Answer 9

Bloodstained

Question 10

What is the discharge?

— fibrocystic disease
— mammary duct ectasia

Answer 10

Green–grey

Question 11

What is the dc?
— fibrocystic disease
— intraduct carcinoma (serous)
— breast abscess (pus)

Answer 11

Yellow:

Question 12

What is the dc?

— lactation cysts
— lactation
— hyperprolactinaemia
— drugs (e.g. antipsychotic, cocaine)

Answer 12

Milky white (galactorrhoea):

Question 13

Causes of periareolar inflammation

Answer 13

Causes may be

inverted nipple or mammary duct ectasia.

Question 14

It starts as an eczematous-looking, dry
scabbing red rash of the nipple and then proceeds to
ulceration of the nipple and areola

Answer 14

Paget disease of the nippl

Question 15

Time of examination for breast lumps: ideally,__________

Answer 15

4 days after the end

of the period

Question 16

Red flag pointers for breast lumps

Answer 16

• Hard and irregular lump
• Skin dimpling and puckering
• Skin oedema (‘peau d’orange’)
• Nipple discharge
• Nipple distortion
• Nipple eczema
• Postmenopausal women

Question 17

What are the draining lymphatic nodes of the breast

Answer 17

The draining lymphatic nodes are in the axillae,

supraclavicular fossae and internal mammary chain

Question 18

Most cancers occur in the ________

Answer 18

upper outer quadrant

Question 19

Lumps that are usually benign and require no

immediate action are

Answer 19

tiny (<4 mm) nodules in
subcutaneous tissue (usually in the areolar margin);
elongated ridges, usually bilateral and in the lower
aspects of the breasts; and rounded soft nodules
(usually <6 mm) around the areolar margi

Question 20

A hard mass is suspicious of malignancy but

cancer can be soft because of______

Answer 20

fat entrapment

Question 21

The _________ which is usually found in

the heavier breast, is often nodular and firm to hard.

Answer 21

inframammary ridge,

Question 22

Positive signs of malignancy on Xray mammography include an _________

Answer 22

irregular infiltrating mass with focal spotty microcalcification.

Question 23

Xray Mammo for screening

• established benefit for women _______
• possible benefit for women in their ______
• follow-up in those with breast cancer, as 6%
develop in the opposite breast
• localisation of the lesion for fine-needle aspiration

Answer 23

over 50 years

40s

Question 24

This is mainly used to elucidate an area of breast
density and is the best method of defining benign
breast disease, especially with cystic changes.

Answer 24

Breast ultrasound

Question 25

When is breast UTZ usually useful

Answer 25

It is | generally most useful in women less than 35 years old

Question 26

Indications for breast UTZ ``` • pregnant and lactating breast • differentiating between ____ and ___ • palpable masses at _______ • for more accurate localisation of lump during fine-needle aspiration ```

Answer 26

fluid-filled cysts and solid mass periphery of breast tissue (not screened by mammography)

Question 27

* <35 years: _____ * 35–50 years: __________ • >50 years: bilateral mammography ± bilateral ultrasound

Answer 27

bilateral ultrasound; bilateral mammography if ultrasound suspicious bilateral mammography + bilateral ultrasound

Question 28

Ddx: Very young women—12 to 25 years

Answer 28

Inflamed cysts or ducts, usually close to areola Fibroadenomata, often giant Hormonal thickening, not uncommon Malignancy rare

Question 29

Investigations for 12-25 years old presenting with mass

Answer 29

* mammography contraindicated | * ultrasound helpful

Question 30

Young women—26 to 35 years DDx

Answer 30

Classic fibroadenomata Fibrocystic disease with or without discharge Cysts uncommon Malignancy uncommon

Question 31

Investigations for 26-35 years old presenting with mass

Answer 31

* mammography: breasts often very dense | * ultrasound often diagnostic

Question 32

Women—36 to 50 years (premenopausal) ddx

Answer 32

``` Cysts Fibrocystic disease, discharges, duct papillomas Malignancy common Fibroadenomata occur but cannot assume Inflammatory processes not uncommon ```

Question 33

Investigations for 36-50: 1 2

Answer 33

* mammography useful | * targeted ultrasound useful

Question 34

Women—over 50 years (postmenopausal) ddx

Answer 34

Any new discrete mass—malignant until proven otherwise Any new thickening—regard with suspicion Inflammatory lesions—probably duct ectasia (follow to resolution) Cysts unlikely

Question 35

over 50, post menopausal dxtics

Answer 35

* mammography usually diagnostic (first line) | * ultrasound may be useful

Question 36

Ddx Women—over 50 years, on hormones

Answer 36

Any new mass—regard with suspicion Cysts may occur—usually asymptomatic Hormonal change not uncommon

Question 37

Dxtics Women—over 50 years, on hormones

Answer 37

• mammography usually diagnostic but breast may become more dense • ultrasound may be useful if above normal or unhelpful and lump suspicious

Question 38

Oestrogen receptors are uncommon in normal breasts but are found in _____ of breast cancers, although the incidence varies with age

Answer 38

two-thirds

Question 39

If the lump is cystic—_____; if solid—perform a _______ and then manage according to outcomes. If it is suspicious, an_______ is the preferred option

Answer 39

aspirate fine-needle biopsy excisional biopsy

Question 40

Indications for biopsy or excision | of lump

Answer 40

• The cyst fluid is bloodstained. • The lump does not disappear completely with aspiration. • The swelling recurs within 1 month

Question 41

Ninety per cent of breast cancers are _________, the remainder being lobular carcinoma, papillary carcinomas, medullary carcinomas and colloid or mucoid carcinomas.

Answer 41

invasive ductal carcinomas

Question 42

RF for breast CA

Answer 42

(>40 years), Caucasian race, pre-existing benign breast lumps, alcohol >1–2 SDs/day, HRT >5 years, personal history of breast cancer, family history in a first-degree relative (raises risk about threefold), nulliparity, late menopause (after 53), obesity, childless until after 30 years of age, early menarche, ionising radiation exposure.

Question 43

Up to ______ of cases are familial, with most being | autosomal dominant

Answer 43

5%

Question 44

The majority of patients with breast cancer | present with a lump ______

Answer 44

(76%).

Question 45

________ is a non-invasive abnormal proliferation of milk duct epithelial cells within the ductal–lobular system and is a precursor lesion for invasive breast cancer

Answer 45

DCIS

Question 46

Tumour excision followed by whole breast irradiation was the most preferred local therapy for most women with _______

Answer 46

stage I or II cancer

Question 47

T or F Total mastectomy and breast-conservation surgery had an equivalent effect on survival

Answer 47

T

Question 48

________is preferred for a large tumour, multifocal disease, previous irradiation and extensive tumour on mammography

Answer 48

Total mastectomy

Question 49

Recommendations for radiotherapy after | mastectomy are

Answer 49

— tumours >4 cm in diameter — axillary node involvement of >3 nodes — the presence of positive or close tumour margins

Question 50

________ following tumour excision is one of several techniques for partial breast irradiation

Answer 50

Intraoperative radiotherapy

Question 51

Cytotoxic chemotherapy has an important place in management, especially in young healthy women who are ____ and ______

Answer 51

E receptor negative and have | visceral spread

Question 52

Newer regimens containing _________ have largely replaced the traditional CMF (cyclophosphamide, methotrexate and fluorouracil) regimen

Answer 52

anthracyclines (e.g. epirubicin) and a taxane (e.g. docetaxel)

Question 53

Adjuvant hormonal therapy by the anti-oestrogen agent _______ (o) daily if E receptor + ve, which is a specific modulating agent, is widely used and is most suitable in postmenopausal women

Answer 53

tamoxifen 20 mg

Question 54

________ (for hormone receptor + ve cancer in postmenopausal women): anastrozole, letrozole, exemestane

Answer 54

aromatase inhibitors

Question 55

________: recommended for women with bony metastases since evidence indicates reversal of bone density loss and cancer recurrence

Answer 55

bisphosphonates

Question 56

fibroadenosis, chronic mastitis, mammary | dysplasia, cystic hyperplasia

Answer 56

Fibrocystic disease

Question 57

FCC •Most common in women between_____ • _______-related (between menarche and menopause)

Answer 57

30 and 50 years Hormone

Question 58

FCC Consider mammography if ______

Answer 58

diffuse lumpiness is | present in patient >40 years

Question 59

Common in women aged 40–50 years (perimenopausal) • Rare under 30 years • Associated with mammary dysplasia

Answer 59

Breast cyst

Question 60

Dx of breast cyst

Answer 60

* Mammography * Ultrasound (investigation of choice) * Cytology of aspirate

Question 61

Mx of breast cyst

Answer 61

• Drainage with a fine needle | Surgery is rarely required

Question 62

Localised nodularity ``` Usually: • in upper_____ of breast • a physiological change to breast • managed with _______ • investigate with imaging in older women if asymmetric or perceived change ```

Answer 62

outer quadrant clinical surveillance

Question 63

These milk-containing cysts arise during pregnancy and present postpartum with similar signs to perimenopausal cysts. • They vary from 1–5 cm in diameter

Answer 63

Lactation cysts (galactoceles

Question 64

Lactation cysts (galactoceles) aspirate

Answer 64

• Treat by aspiration: fluid may be clear or milky.

Question 65

• A discrete, asymptomatic lump • Usually in 20s (range: second to sixth decade, commonly 15–35 years) • Firm, smooth and mobile (the ‘breast mouse’)

Answer 65

Fibroadenoma

Question 66

Location of Fibroadenoma

Answer 66

• Usually in upper outer quadrant

Question 67

True about Fibroadenoma They double in size about every_______

Answer 67

12 months

Question 68

Fibroadenoma ____ and ________ is recommended plus mammography in older women

Answer 68

Ultrasound and fine-needle aspiration or core biopsy | with cytology

Question 69

When to do excision biopsy for suspicious fibroad

Answer 69

Excision biopsy if large (>3–4 cm), continues to enlarge, suspicious biopsy or woman >40 years

Question 70

These are giant fibroadenoma-like tumours that are usually benign but 25% are malignant and metastasise. They are completely excised with a rim of normal breast tissue

Answer 70

Phyllodes tumour

Question 71

_______s usually the end result of a large bruise or trauma that may be subtle, such as protracted breastfeeding

Answer 71

Fat necrosis

Question 72

T or F | The full triple test is required in fat necrosis

Answer 72

t

Question 73

These are benign hyperplastic lesions within large mammary ducts and are not premalignant (nor usually palpable).

Answer 73

Duct papillomas

Question 74

Duct papillomas should be______

Answer 74

excised

Question 75

Synonyms: plasma cell mastitis, periductal mastitis

Answer 75

Mammary duct ectasia

Question 76

In this benign condition a whole breast quadrant may be indurated and tender. The larger breast ducts are dilated.

Answer 76

Mammary duct ectasia

Question 77

Mammary duct ectasia: The lump is usually located near the _____

Answer 77

margin of the areola and is a firm or hard, tender, poorly | defined swellin

Question 78

It should be noted that mammography may be of limited value in the presence of prostheses, especially if a________

Answer 78

fibrous capsule exists | around the prosthesis.

Question 79

This is a long-term complication of surgery plus irradiation for breast cancer treatment when there is a failure of the lymphatic system to adequately drain extracellular fluid

Answer 79

Lymphoedema of arm

Question 80

What to exclude in lymphedema of arm

Answer 80

Exclude obstruction of the | deep venous system by Doppler ultrasound

Question 81

Cause of Neonatal enlargement of breasts

Answer 81

This is due to transplacental passage of lactogenic hormones. The swelling usually lasts 7–10 days if left alone

Question 82

The usual presentation is the development of one | breast in girls commonly 7–9 years of age but sometimes younger

Answer 82

Premature hyperplasia

Question 83

Screening mammography should be encouraged for | women between ______ and ____

Answer 83

50 and 70 years, and performed at | least every 2 years

Question 84

Sp of mammography

Answer 84

90%

Question 85

regular BSE is | recommended for all women_____

Answer 85

35 years and over

Question 86

_______ commonly occur in women in their late teens and 20s, ________ between 35 years and the menopause, and ______is the most common cause of a lump in women over 50 years

Answer 86

Fibroadenomas benign breast cysts cancer

Question 87

Never assume a palpable mass is a _____ | in any woman over 30 years of age

Answer 87

fibroadenoma

Question 88

Gentle palpation is required. Squeezing breast tissue between finger and thumb tends to produce _____

Answer 88

‘pseudolumps

Question 89

_____ and _____ can be | clinically indistinguishable from breast cancer

Answer 89

Mammary duct ectasia and fat necrosis

Question 90

Nine out of 10 women who get breast cancer do | not have a _______

Answer 90

strong family history

Question 91

T or F The oral contraceptive pill has been generally shown not to alter the risk of breast cancer.

Answer 91

T

Question 92

Never assume a lesion is a ________—prove it with | ultrasound or successful aspiration

Answer 92

cyst

Question 93

T or F Mammography can not detect breast cancers which are too small to feel.

Answer 93

F it can detect

Question 94

T or F Mammography is not a diagnostic tool.

Answer 94

T

Question 95

Recommended mammography screening for | women:

Answer 95

50–69 years and those aged 40–49 who | request it.