Breast lump differentials

Question 1

What is the most common cause of breast masses

Answer 1

Fibroadenoma

Question 2

Normal changes to the breasts during pregnancy and breast-feeding

Answer 2

Tenderness, discomfort or pain

Increase in size

Areolar and nipple changes(darkening of colour, enlargement of nipples, enlargement of the montgomery glands on the areola)

Leaking of colostrum or milk

Question 3

Normal changes to the breasts during pregnancy and breast-feeding

Answer 3

Tenderness, discomfort or pain

Increase in size

Areolar and nipple changes(darkening of colour, enlargement of nipples, enlargement of the montgomery glands on the areola)

Leaking of colostrum or milk

Question 4

What are fibroadenomas

Answer 4

Arise in breast lobules and are composed of fibrous and epithelial tissue

Hormones seem to be involved in aetiology, and HRT increases incidence

Question 5

Fibroadenomas features

Answer 5

Firm, non-tender, highly mobile palpable lumps

Question 6

What are complex and multiple fibroadenomas associated with

Answer 6

Increase in risk of breast cancer

Question 7

First line imaging investigation for breast lump

Answer 7

Ultrasound before age 40

Mammogram above 40

Question 8

What are phyllodes tumours

Answer 8

Rare growths of breast that can have benign or malignant characteristics which present as a rapidly growing, painless breast mass

Question 9

Which factors are associated with an increased risk of local recurrence for phyllodes tumours

Answer 9

Increased cellularity
Atypia
Mitoses
Positive margins

Question 10

What is a fibrocystic breast

Answer 10

Spectrum of patholoigcal changes to include epithelial hyperplasia, apocrine metaplasia, and cystic dilation and fibrosis

Question 11

Which population are commonly affected by benign breast cysts

Answer 11

Premenopausal and perimenopausal women

Question 12

Features of breast cysts

Answer 12

Characteristically mobile and have distinct borders on exam

Sometimes tender and can fluctuate with the menstrual cycle

Question 13

What does breast fat necrosis occur secondary to

Answer 13

Injury of the breast

Source may be iatrogenic(e.g. breast biopsy, breast reduction or augmentation) or traumatic(seat belt injury)

Question 14

How do breast fat necrosis lesions present

Answer 14

Hard, fixed masses and demonstrate acoustic shadowing on ultrasound - characteristics suspicious for malignancy that mandate biopsy

Question 15

What are breast papillomas

Answer 15

Typically benign, but they can be associated with histological findings of atypia, papillary ductal carcinoma in situ(DCIS) or invasive papillary cancer

Question 16

Presentation of breast papilloma

Answer 16

Blood nipple discharge

Detected as a mass within the breast

Question 17

Who does breast abscesses typically occur in

Answer 17

Women who are breastfeeding

Thought to result from ruptured sub-areolar ducts that leak into the periductal space

Question 18

Genes implicated in breast cancer

Answer 18

BRCA-1 and BRCA-2 mutations are more common in women with a family history of: breast cancer before age 50 years, bilateral breast cancer, breast and ovarian cancer in the same relative, male breast cancer

Ashkenazi jewish ancestry

Question 19

What should a family history include with regards to eliciting risk of breast cancer

Answer 19

any family members with cancer 
primary cancer site 
whether affected relative had multiple primary cancers 
age of diagnosis 
age at death and sex

Question 20

Characteristic features of breast examination indicative of malignancy

Answer 20

Irregular fixed masses 
Skin thickening(peau d'orange) 
Nipple changes 
Enlarged axillae and regional lymph nodes 
Variation in breast size 
Dimpling or retraction of skin 
Nipple inversion

Question 21

What is nipple inversion or excoriation associated with

Answer 21

Paget’s disease of the breast

Question 22

When should a person with a breast lump be referred for an urgent assessment by a breast specialist

Answer 22

Women > 30 years with an unexplained breast lump should be referred for an urgent(within 2 weeks) assessment by a breast specialist

Unilateral nipple changes in patients aged above 50

Question 23

Why should aspirated cyst fluid not be sent for cytology

Answer 23

With the exception of bloody cystic fluid, malignant cells are generally not identified

Question 24

What may mastitis be associated with

Answer 24

Lactation

Question 25

Management of mastitis associated with lactation

Answer 25

Warm compresses and analgesia such as ibuprofen/paracetamol Encourage to continue breast feeding Penicillianse-resistant antibiotic such as flucloxacillin Incision and drainage in the event of an abscess Swabs should be sent for culture

Question 26

What are spontaneous peripheral abscesses in non-lactating women associated with

Answer 26

Diabetes and immune compromise | Smoking and nipple rings can predispose to non-lactational mastitis

Question 27

Features of cyclical mastalgia

Answer 27

Tenderness and nodularity of the breasts in the premenstrual phase Rapidly resolves as menstruation starts

Question 28

Management of fibrocysts

Answer 28

``` Analgesia Good well-fitting bra Avoid caffeine Applying heat to the area Hormonal treatments(tamoxifen) under specialist guidance ```

Question 29

Management of intraductal papilloma

Answer 29

Triple assessment with examination, imaging and biopsy in a specialist breast clinic

Question 30

What is duct ectasia

Answer 30

Dilatation and shortening of the terminal breast ducts within 3 cm of the nipple

Question 31

How does duct ectasia present

Answer 31

Nipple retraction and occasionally creamy nipple discharge

Question 32

Management of duct ectasia

Answer 32

Patients with troublesome discharge may be treated by microdochectomy(if young) or total duct excision(if older)

Question 33

In which population are fibroadenomas more common in

Answer 33

Younger women aged between 20 to 40 years

Question 34

When do fibrocystic breast changes tend to occur

Answer 34

It is common in women of menstruating age. Symptoms often occur prior to menstruating (within 10 days) and resolve once menstruation begins. Symptoms usually improve or resolve after menopause.

Question 35

Features of breast cysts

Answer 35

Smooth Well-circumscribed Mobile Possibly fluctuant

Question 36

Management of breast cysts

Answer 36

Breasts cysts require further assessment to exclude cancer, with imaging and potentially aspiration or excision. Aspiration can resolve symptoms in patients with pain. Having a breast cyst may slightly increase the risk of breast cancer.

Question 37

What is tamoxifen

Answer 37

Selective oEstrogen Receptor Modulator (SERM) which acts as an oestrogen receptor antagonist and partial agonist. It is used in the management of oestrogen receptor positive breast cancer

Question 38

Adverse effects of tamoxifen

Answer 38

menstrual disturbance: vaginal bleeding, amenorrhoea hot flushes - 3% of patients stop taking tamoxifen due to climacteric side-effects venous thromboembolism endometrial cancer

Question 39

What causes gynaecomastia

Answer 39

hormonal imbalance between oestrogen and androgens (e.g., testosterone), with higher oestrogen and lower androgen levels Also raised prolactin Idiopathic Physiological(adolescents)

Question 40

Which conditions can increase oestrogen levels in males to cause gynaecomastia

Answer 40

Obesity (aromatase is an enzyme found in adipose tissue that converts androgens to oestrogen) Liver cirrhosis and liver failure Hyperthyroidism

Question 41

Tumours associated with gynaecomastia

Answer 41

Testicular cancer (oestrogen secretion from a Leydig cell tumour) Human chorionic gonadotrophin (hCG) secreting tumour, notably small cell lung cancer

Question 42

Medications which can cause gynaecomastia

Answer 42

``` Anabolic steroids Antipsychotics Digoxin Spironolactone marijuana opioids ```

Question 43

Which conditions reduce testosterone to cause gynaecomastia

Answer 43

Testosterone deficiency in older age Hypothalamus or pituitary conditions that reduce LH and FSH levels (e.g., tumours, radiotherapy or surgery) Klinefelter syndrome (XXY ) Orchitis (inflammation of the testicles, e.g., infection with mumps) Testicular damage

Question 44

Mx of gynaecomastia

Answer 44

Resolves with time in adolescents Stop causative drug Tamoxifen Surgery

Question 45

Most common type of breast cancer

Answer 45

DCIS

Question 46

Mx of DCIS

Answer 46

Complete wide excision Widespread or multifocal DCIS requires complete mastectomy

Question 47

Surgical options for breast cancer

Answer 47

Breast conserving - wide local excision Mastectomy Axillary surgery - Sentinel node biopsy, axillary node clearance

Question 48

Complications of axillary node clearance

Answer 48

paraesthesia, seroma formation, and lymphedema in the upper limb

Question 49

Risk factors for breast cancer

Answer 49

``` Female Age BRCA1 and 2 Family history Exposure to unopposed oestrogen early menarche ```

Question 50

How can paget's disease be differentiated from eczema

Answer 50

Paget's always affects the nipple and only involves the areola as a secondary event Eczema nearly always involves the areola and spares the nipple

Question 51

Mx of Paget's disease of breast

Answer 51

Surgical | Radiotherapy if malignancy associated

Question 52

Criteria for primary breast cancer prognosis

Answer 52

Nottingham prognostic index