Breast Mass/Cancer

Question 1

Ddx

Answer 1

Fibroadenoma
Fibrocystic changes
Fat necrosis
Intraductal papilloma
Breast abscess
Atypical ductal/lobular hyperplasia
DCIS
Invasive breast cancer

Question 2

Percentage of women presenting with breast mass that are malignant

Answer 2

10%

Question 3

What is triple assessment?

Answer 3

History and physical examination
Imaging (USS <40, Mammogram)
Biopsy - Incisional for diagnosis and core biopsy for hormonal staging. FNA cytology and core biopsy

Question 4

Most common cause of breast mass

Answer 4

Fibroadenoma

• 15-25 (reproductive age)
• Mobile, rubbery, well defines
• Glandular, fatty tissue develops from lobules
• If <25 years clinical exam; >25 triple assessment
• May compress adjacent ducts to become slit like structures
• On scan has popcorn calcification
• 2x risk of developing cance

Question 5

Indication to remove fibroadenoma

Answer 5

- Patient prefers 
>4cm 
Growing fast 
Distorting breast contour 
Questionable histology/cytology

Question 6

Bloody nipple discharge: typical type of lesion

Answer 6

Intraductal papilloma

Question 7

When are breast abscesses more common and why?

Answer 7

Breastfeeding, first 3 months or weaning.
Incorrect/poor attachment causing irritation to the nipple or weaning (increase milk in boob –>milk stasis obstruction)
Usually staph aureus or granulomatous.

Question 8

Cause of dimpling in breast cancer

Answer 8

Malignant infiltration of fibrous contraction of coopers ligaments

Question 9

Lymphatic drainage of breast

Answer 9

Axillary, parasternal and posterior intercostal

Question 10

Benign neoplastic proliferations

Answer 10

Fibroadenoma
Atypical ductal/lobular sclerosing adenosis
Ductal papilloma

Question 11

Fine Needle biopsy pros and cons

Answer 11

Pros: Cytology, simple and quick, nil preparation, results available quickly, no need to stay in hospital, no scarring
cons: may not collect enough material for definite diagnosis

Question 12

Core biopsy pros and cons

Answer 12

Recommended sample.
- Pros: Can distinguish between invastic and insitu, histology, shower receptors, takes <30 minutes, no special preparation, removes more material than FNB (definite diagnosis), don’t need to stay in hospital
Cons: takes longer than FNB, bruising and pain, anesthetic needed, can cause scar

Question 13

Risk Factors for breast cancer

Answer 13

Family hx 
ALONE: 
Age (older) 
Late menopause 
Obesity and low social class
Nulliparity 
Early menstration

Question 14

What are the screening suggestions?

Who is at increased risk/can start earlier?

Answer 14

Every two years from age 50.

Increased risk if two 1st or 2nd degree relatives on the same side of family dianogsed with breast cancer and/or ovarian cancer + one of following:

• Male
• Bilateral
• Breast and Ovarian
• 3rd relative diagnosed on same side
• Jewish ancestor

Question 15

Suggested follow up on breast cancer

Answer 15

To check for reoccurance/new cancer, treatment toxicities, psychosocial support, Fmx & genetic testing

• 1-2 years post: meet every 3 months
• 3-4 years post: every 6 months
• 5+: 12 monthly

Mammogram + USS follow up:
1-2 years post: 6-12 months
3-4 years: 12 months
5+: annually

Question 16

Types of Breast cancer

Answer 16

Invasive Ductal carcinoma

Invasive lubule carcinoma

Question 17

Symptoms of breast cancer

Answer 17

Painless bump/nodule
Tethered, asymmetrical, p’au de orange, pucking of skin, axial LN, Swelling, Paget changes, nipple retraction, nipple discharge (bloody, unilateral)

Question 18

Post-Triple assessment treatment

Answer 18

1. Grading (histology)
2. Genetic testing (if Fmx)
3. Staging (TNM)
4. CT abdo/pelvis/chest/brain & PET scan
5. Senile Lymph node
6. FBC
7. Echo (baseline for chemo)
8. Portacath for chemo
9. Multi-disciplinary team meeting
10. Tattoo/clip tumour
11. Tx options (surgery - masectomy, WLE + RT, + Chemo)

Question 19

What is Nottingham index?

Answer 19

Prognostic index:

(Size cm + 0.2) + Grade + nodal status

Question 20

Hormonal Treatment

Answer 20

ER +: Tamoxifin (pre-menopausal, block ER), Aromitase inhibitor (Post-menopausal, inhibit conversion . of androgen to oestrogen, bind ER) .
SE: menopausal symptoms (loss of sexual drive, vaginal dryness, hot flushes, night sweats)

HER2: Hepcidin (monoclonal AB that . targets human epidermal growth factor receptor
SE: cardiotoxicity

Question 21

Paget’s Disease of Nipple

Answer 21

• Rare
• Rough/red/ulceration of nipple
• 97% have underlying neoplasm
• Malignant cells travel from ducts to nipple OR cells from nipple become malignant
• Itching, redness, flaking, thick skin, painful, flattened nipple, blood/yellow discharge
• Surgical removal of nipple and areolar

Question 22

Duct Ectasia: What, aetiology, symptoms, Ix, Tx

Answer 22

Dilation and shortening of lactiferous ducts, (dilation is normal with ageing) –> results in blockage/clogging with sticky substance or inflammation.
A: involution (normal change from glandular to fatty tissue), smoking and nipple inversion
S: green/yellow discharge, palpable mass, tender, red, retraction
Ix: Mammogram, U/S, biospy
Tx: infection: metronidazole: chronic - major duct excision: abscess - drainage.

Question 23

Fat necrosis

Answer 23

Caused by trauma, recent surgery, radiation, warfarin or . infection
- Inflammatory process –> ischaemic necrosis of fat lobules
Asymptomatic, presents as lump.
Self-limiting, analgesia and reassurance.

Question 24

Papilloma: what, presentation, Tx

Answer 24

Polyps of epithelium lines lactiferous ducts. Benign breast lesion. 40-50 years.
Bloody or clear nipple discharge +/- mass.
Triple assessment as appears similar to ductal carcinoma on imaging.
Tx: surgical excision

Question 25

Mastalgia

Answer 25

Breast pain
(rare with breast cancer - must exclude)
3 types: Cyclical, non-cyclical and extra-mammary
1) Most common, pre-menopausal, with periods, pain . in axillary and medial aspect of arm. AE: Coffee, increased fat, fluid retention
2) Medications (OCP, haliperidol, sertraline). Unilateral and chronic, well localised
3) pain in chest wall or shoulder

Ix: if in isolation no investigations required
Mx: investigate underlying cause, reassurance and analgesia