Breast Medicine Flashcards
What are benign breast lumps?
Non-cancerous growths or abnormalities in the breast tissue that do not invade surrounding tissues or metastasize.
What are the common types of benign breast lumps?
Fibroadenoma – Most common in young women.
Breast cysts – Fluid-filled sacs.
Fibrocystic breast changes – Lumpy, tender breasts that fluctuate with the menstrual cycle.
Intraductal papilloma – Small growth inside the milk duct.
Lipoma – Soft, fatty lump.
Phyllodes tumor – Rare, can be benign or borderline.
The most common benign breast lump in young women is ________
Fibroadenoma
What are the characteristic features of fibroadenomas?
Firm, smooth, and well-defined
Highly mobile (“breast mouse”)
Painless
Most commonly seen in young women (<30 years old)
What are the characteristic features of breast cysts?
Fluid-filled
Soft, round, or oval
Can be tender
Fluctuate with the menstrual cycle
Common in perimenopausal women
What are the characteristic features of fibrocystic breast changes?
Lumpy, nodular breasts
Cyclic breast pain and tenderness
Symptoms fluctuate with menstrual cycle
True/False
Q: Fibroadenomas are fixed and immobile.
False – Fibroadenomas are mobile and often called “breast mice.”
What features suggest a benign breast lump rather than a malignant one?
✅ Well-defined borders
✅ Mobile
✅ Soft or rubbery consistency
✅ Painful (sometimes)
🚩 Malignant lumps are often hard, irregular, fixed, and painless.
What investigations are used to assess a breast lump?
Triple assessment:
Clinical examination
Imaging (Ultrasound in young women, Mammogram in older women)
Biopsy (Fine-needle aspiration or core biopsy)
The first-line imaging for breast lumps in women under 40 is __________.
Ultrasound
What is the management of fibroadenoma?
Small and asymptomatic: Reassurance and monitoring.
Large or symptomatic (>3cm): Surgical excision may be considered.
What is the management of breast cysts?
Asymptomatic: No treatment needed.
Symptomatic (painful/enlarged): Fine-needle aspiration for drainage.
Recurrent or complex cysts: Further imaging and possible biopsy.
A 22-year-old woman presents with a smooth, mobile, painless breast lump. It is well-defined and 2cm in size. What is the likely diagnosis and management?
Likely fibroadenoma. Management: Reassurance, ultrasound, and monitoring unless symptomatic.
A 45-year-old woman presents with a soft, fluctuant, and tender lump that changes with her menstrual cycle. What is the likely diagnosis and management?
Likely breast cyst. Management: Ultrasound ± aspiration if symptomatic.
True/False
Q: Breast cysts always require surgical removal.
False – Most cysts resolve or can be managed with aspiration.
Match the breast lump to its typical feature:
Fibroadenoma
Breast cyst
Lipoma
Phyllodes tumor
A. Painless, soft, fatty lump
B. Smooth, mobile, “breast mouse”
C. Fluctuates with menstrual cycle, may be tender
D. Rare, can be benign or borderline malignant
1 → B
2 → C
3 → A
4 → D
When should a benign breast lump be referred to a breast specialist?
If suspicious features are present (hard, fixed, irregular).
If rapidly growing.
If persistent or recurrent after aspiration.
Define Mastitis
: inflammation of the breast, typically due to infection. ○ Divided into lactational and non-lactational (duct ectasia)
Define Breast Abscess
discrete collection of pus due to infection.
What is the most common causative organism of mastitis?
Staphylococcus aureus.
Causes of Lactational mastitis:
○ Combination of breastfeeding-related nipple trauma and milk stasis predisposes the breast to local infection.
Causes of Duct ectasia mastitis:
Blockage of lactiferous ducts due to squamous metaplasia leads to dilatation and inflammation. ○ Strongly associated with cigarette smoking.
Causes of Abscess
Progression of untreated infective mastitis; walled-off collection of infection forms.
Symptoms of mastitis/absesses
fever, breast pain / tenderness (often during breastfeeding)
Signs of mastitis/absesses
erythema, swelling, firmness
Duct ectasia is associated with
nipple discharge.
How is mastitis investigated/diagnosed
Mastitis is usually a clinical diagnosis based on history and examination findings.
how are absesses diagnosed
Abscesses can be diagnosed with breast ultrasound and diagnostic needle aspiration.
First line Management Lactational Mastitis
continued breastfeeding / milk expression plus simple analgesia
Second line Management Lactional Mastitis
> 24 hour duration / severe pain - add PO flucloxacillin.
First line management of non-lactational mastitis
PO flucloxacillin
First line management of breast absesses
needle aspiration and drainage plus flucloxacillin (dependent on local policy).
What is fibrocystic disease?
A condition causing multiple small breast lumps due to hormonal fluctuations.
What is the most common benign breast disease?
Fibrocystic disease
What age group is most commonly affected by fibrocystic disease?
Women aged 30–50.
Aetiology and pathophysiology of fibrocystic disease
- Normal menstrual cycle oestrogen fluctuation leads to epithelial proliferation and stromal fibrosis in the TDLUs. 2. This can lead to obstruction of ductules and terminal ducts. 3. Obstruction causes cyst formation or degeneration of the ductules. 4. Cyst rupture leads to inflammation and subsequent fibrosis.
What are the common symptoms of fibrocystic disease?
● Bilateral diffuse, symmetrical lumpiness. ● Breast pain (mastalgia) - often cyclical. ● (Sometimes) nipple discharge.
First line investigation for fibrocystic disease
breast imaging (USS or mammogram) Stratified by age and clinical suspicion:
Fibrocystic disease USS: Women <30: breast ultrasound.
Cysts / solid mass
Fibrocystic disease USS: Women >30 or highly suspicious for cancer: mammogram.
Circumscribed density
First Line Management of fibrocystic disease?
simple analgesia e.g. paracetamol, ibuprofen.
What is the most common cancer in the UK?
Breast cancer, accounting for 15% of new cancer cases annually.
How many new cases of breast cancer are diagnosed annually in the UK?
Approximately 56,000.
2 types of pre-invasive breast cancer
Ductal carcinoma in situ (DCIS) & Lobular carcinoma in situ (LCIS)
Ductal carcinoma in situ (DCIS).
● Neoplastic proliferation of epithelial cells - confined to duct without invasion through basement membrane. ● Precursor to invasive breast cancer. ● Comedo and non-comedo subtypes
Lobular carcinoma in situ (LCIS).
Neoplastic proliferation of epithelial cells, confined to TDLU.
Name some types of Invasive breast cancer
Invasive ductal carcinoma, Invasive lobular carcinoma, Medullary carcinoma, Many others - including mucinous, tubular, papillary, inflammatory etc
Which type of breast cancer is most common?
Invasive ductal carcinoma (commonest - 75%). ; Neoplastic proliferation of epithelial cells that invades through the ductal basement membrane
medullary carcinoma
More prevalent in the younger population. ● Higher grade than IDC.
Invasive carcinoma can be graded using the _________
Nottingham criteria
Which 3 components make up the Nottingham criteria
○ Gland formation ○ Nuclear atypia / pleomorphism ○ Mitosis counts (indicates rate of cellular reproduction)
A higher grade carcinoma is one that is markedly different from ___________ and is considered ________.
A higher grade carcinoma is one that is markedly different from normal breast tissue and is considered poorly differentiated.
What genetic mutation is often linked to breast cancer?
BRCA1 mutation.
What are the five steps of metastasis in breast cancer?
- Invasion through basement membrane 2. Intravasation (entry into circulation) 3. Circulation 4. Extravasation 5. Colonisation
What are the common sites of breast cancer metastasis?
bones, liver, lungs and brain.
List key risk factors for breast cancer.
- 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
What are the common symptoms of breast cancer?
breast lump
What are the common signs of breast cancer
nipple discharge, nipple retraction, skin changes e.g. peau d’orange, axillary lymphadenopathy
Metatastic features of breast cancer
weight loss, bony pain, shortness of breath.
What type of staging is used for breast cancer
TNM staging (tumour, node, metastasis) -
Stage 1A
<2cm, isolated to breast
Stage 1B
<2cm, minor axillary LN spread
Stage 2A
<2cm, spread to 1-3 ipsilateral LNs.
Stage 2B
2 - 5cm, minor axillary nodal spread or 2 - 5cm with 1-3 ipsilateral nodes or >5cm, no nodal spread
Stage 3A
4-9 ipsilateral nodes or >5cm with 1-3 ipsilateral nodes
Stage 3B
spread to skin / chest wall
Stage 3C
> 10 axillary nodes or supraclavicular spread or parasternal + axillary spread
Stage 4
distant metastatic spread to organs.
What is the NHS breast cancer screening programme?
3-yearly mammogram for women aged 50-71.
What are the “2-week wait” criteria for breast cancer referral?
○ 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 Ix for breast cancer
○ >30 or highly suspicious for cancer: mammogram ○ <30: breast ultrasound ○ Plus: ultrasound of the axilla +/- needle biopsy
Second line Ix for breast cancer
○ Fine needle aspiration and cytology ○ Plus: oestrogen / progesterone receptor testing, HER2 receptor testing
Ix : If symptoms / signs suggestive of metastasis
CT scan (CT thorax-abdomen-pelvis, CT head).
What are mammogram features of invasive carcinoma?
Pre-invasive: unifocal / widespread microcalcifications ● Invasive carcinoma: 1. Irregular spiculated mass 2. Clustered microcalcifications 3. Linear branching calcifications.
What is the first-line surgical treatment for breast cancer?
Tumour excision or mastectomy +/- breast reconstruction ○ Plus sentinel lymph node biopsy (no evidence of nodal spread) or axillary node clearance
When is radiotherapy used in breast cancer management?
After surgery, especially for invasive cancers. radiotherapy
○ Whole breast / partial-breast
○ If tumour is invasive (i.e. not DCIS, LCIS), systemic third line therapy is indicated
What systemic therapies are used for breast cancer?
: systemic therapy (guided by the PREDICT tool); oestrogen-receptor positive, HER2, chemotherapy. - systemic therapies can be neoadjuvant i.e. used to reduce tumour size before attempting surgery.
Oestrogen-receptor positive:
■ Pre-menopausal / male - tamoxifen (anti-oestrogen) ■ Post-menopausal - anastrozole / letrozole (aromatase inhibitor, prevents peripheral oestrogen synthesis) ■ Note - tamoxifen therapy can be continued long-term (5 years) before
switching to an aromatase inhibitor.
HER2 (human epidermal growth factor receptor 2) positive:
Trastuzumab (Herceptin)
Chemotherapy:
■ Including a taxane and an anthracycline ■ E.g. ACT: doxorubicin, cyclophosphamide and paclitaxel
What is ductal ectasia?
Ductal ectasia is a benign breast condition where the milk ducts become dilated and filled with fluid, leading to inflammation and potential nipple discharge.
What happens to the milk ducts in ductal ectasia?
The milk ducts widen (dilate) and become blocked with thickened secretions, leading to inflammation and fibrosis.
What are the risk factors for developing ductal ectasia?
Aging (most common in perimenopausal and postmenopausal women), smoking, and nipple inversion.
What are the typical symptoms of ductal ectasia?
Nipple discharge (thick, green, or black), breast pain or tenderness, lump near the nipple, nipple retraction, and possible redness/swelling of the breast.
True or False: Ductal ectasia always causes pain.
False. Some cases are asymptomatic.
What investigations are used to diagnose ductal ectasia?
Clinical breast examination, ultrasound, mammography, and sometimes nipple discharge cytology.
____________ is the imaging modality of choice for younger women with suspected ductal ectasia.
Ultrasound
What conditions should be considered in the differential diagnosis of ductal ectasia?
Breast cancer, mastitis, intraductal papilloma, and periductal mastitis.
Matching question:
A) Bloody nipple discharge
B) Thick greenish discharge
C) Inflammatory breast changes
D) Painful red lump near the nipple
- Ductal ectasia
- Breast cancer
- Mastitis
- Intraductal papilloma
A-4, B-1, C-3, D-2
What are the main treatment options for ductal ectasia?
Conservative management (monitoring, warm compresses, reassurance), antibiotics if secondary infection is suspected, and surgical duct excision in persistent or severe cases.
True or False: Surgery is always necessary for ductal ectasia.
False. Many cases resolve without intervention.
What are possible complications of ductal ectasia?
Secondary infection (periductal mastitis), abscess formation, nipple retraction, and misdiagnosis as malignancy.
A 50-year-old woman presents with thick green nipple discharge, mild tenderness, and a lump near her nipple. She is a smoker and perimenopausal. What is the most likely diagnosis?
Ductal ectasia
A patient with ductal ectasia is concerned about developing breast cancer. What should you tell her?
Ductal ectasia is benign and does not increase the risk of breast cancer, but any new changes should still be evaluated.
What is a fibroadenoma?
Benign tumour of the breast
What is a fibroadenoma made of?
Composed of glandular epithelium and interlobular stroma of a TDLU. Well-circumscribed, non-encapsulated.
Does a fibroadenoma infiltrate into the parenchyma of the breast ?
No
What age group is most commonly affected by fibroadenomas?
Women < 30 y/o
What causes a fibroadenoma?
Unclear - typically sex steroid-responsive (grow in pregnancy, shrink in menopause).
How does a fibroadenoma typically present?
As a solitary, mobile breast lump with a regular border.
First line investigation for fibroadenoma
breast imaging (USS or mammogram) ; Typically stratified by age and clinical suspicion
Fibroadenoma USS : Women <30: breast ultrasound.
Smooth, well-circumscribed mass with uniform hypoechogenic appearance.
Fibroadenoma USS : Women >30 or highly suspicious for cancer: mammogram.
Distinct, well-circumscribed mass.
Managment for fibroadenoma
None usually needed
What are breast implants?
Breast implants are medical prostheses used to augment, reconstruct, or alter the shape of the breast, commonly made of silicone or saline-filled shells.
What are the two main types of breast implants?
Silicone-filled and saline-filled implants.
____________ implants contain a silicone outer shell filled with sterile saltwater.
Saline implants.
What are the primary indications for breast implants?
Cosmetic breast augmentation, post-mastectomy reconstruction, congenital breast abnormalities, and asymmetry correction.
When are breast implants contraindicated?
Active breast infection, untreated breast cancer, pregnancy, or unrealistic patient expectations.
What are the common surgical approaches for breast implant placement?
Subglandular (above the muscle), submuscular (beneath the pectoralis muscle), or dual-plane placement.
Match the following implant placements with their descriptions:
A) Subglandular placement
B) Submuscular placement
C) Dual-plane placement
- Implant placed beneath the pectoralis muscle.
- Implant positioned partially under muscle and partially under glandular tissue.
- Implant positioned above the muscle and beneath breast tissue.
A-3, B-1, C-2.
What are the potential complications of breast implants?
Capsular contracture, implant rupture, infection, hematoma, rippling, breast pain, and breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL).
True or False: Breast implants need to be replaced every 10 years.
False. There is no strict timeline for replacement; it depends on complications and patient preference.
What imaging modalities are used to assess breast implants?
Ultrasound and MRI (preferred for detecting silicone implant rupture).
Routine ____________ is recommended for patients with silicone implants to check for silent rupture.
MRI
What is BIA-ALCL?
A rare type of non-Hodgkin lymphoma associated with textured breast implants.
What are the symptoms of BIA-ALCL?
Late-onset seroma (fluid collection), breast swelling, pain, or mass formation.
How is a ruptured silicone implant managed?
Surgical removal or replacement of the implant, depending on symptoms and patient preference.
True or False: Capsular contracture is treated with antibiotics alone.
False. Severe cases may require capsulectomy and implant replacement.
A 45-year-old woman with breast implants presents with swelling and a fluid collection around the implant 10 years post-surgery. What condition should be suspected?
Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL).
A patient has had breast implants for 12 years and is asymptomatic. She asks if they need to be replaced. What is the appropriate advice?
Routine replacement is not necessary unless complications arise.
What is in situ carcinoma of the breast?
In situ carcinoma refers to a non-invasive form of breast cancer where abnormal cells are confined to the ducts or lobules and have not invaded surrounding tissue.
What are the two main types of in situ carcinoma of the breast?
Ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS).
What is ductal carcinoma in situ (DCIS)?
DCIS is a non-invasive cancer where abnormal cells are found within the ductal system but have not spread beyond the basement membrane.
How is DCIS typically detected?
Through mammography, often presenting as microcalcifications.
What are the risk factors for developing DCIS?
Older age, family history of breast cancer, BRCA mutations, hormonal factors (early menarche, late menopause, HRT), and previous breast biopsies.
True or False: DCIS always presents with symptoms such as a palpable lump.
False. Many cases are asymptomatic and detected on screening mammograms
What are the treatment options for DCIS?
Breast-conserving surgery (lumpectomy) with or without radiotherapy, mastectomy for extensive disease, and endocrine therapy if hormone receptor-positive.
What is lobular carcinoma in situ (LCIS)?
LCIS is a non-invasive proliferation of abnormal cells within the lobules of the breast, which increases the risk of developing invasive carcinoma.
Is LCIS considered a precursor to invasive carcinoma?
No, LCIS is considered a marker of increased breast cancer risk rather than a direct precursor.
What are the risk factors for LCIS?
Similar to DCIS, including family history, hormonal factors, and genetic mutations.
How is LCIS usually detected?
Incidentally on breast biopsies; it is not typically visible on mammograms.
What are the management options for LCIS?
Increased surveillance (regular mammograms and clinical exams), chemoprevention (tamoxifen or raloxifene in high-risk cases), and prophylactic mastectomy in select cases.
Match the characteristics to either DCIS or LCIS:
A) Often detected via mammography
B) Found incidentally on biopsy
C) Considered a precursor to invasive cancer
D) Considered a marker of increased risk
- DCIS
- LCIS
A-1, B-2, C-1, D-2
What is the prognosis for DCIS and LCIS?
DCIS has an excellent prognosis with treatment, while LCIS indicates an increased risk of future invasive cancer rather than being a direct precursor.
What is the recommended follow-up for patients with in situ carcinoma?
Regular mammographic screening, clinical breast exams, and risk-reduction strategies based on patient history and risk factors.
A 55-year-old woman undergoes routine mammography, revealing microcalcifications. A biopsy confirms ductal carcinoma in situ. What is the next step in management?
Treatment options include breast-conserving surgery with or without radiotherapy or mastectomy for extensive disease.
A 45-year-old woman has LCIS detected incidentally on biopsy. What advice should be given regarding her breast cancer risk?
She has an increased risk of invasive breast cancer and should undergo regular surveillance, with the option of chemoprevention or prophylactic mastectomy in select cases.
What is Paget’s disease of the nipple?
A rare type of breast cancer where malignant cells affect the skin of the nipple and often indicate underlying ductal carcinoma in situ (DCIS) or invasive breast cancer.
What causes the characteristic nipple changes in Paget’s disease of the nipple?
Malignant cells migrate from underlying ductal carcinoma in situ (DCIS) or invasive breast cancer to the epidermis of the nipple.
What are the risk factors for Paget’s disease of the nipple?
Increasing age, family history of breast cancer, BRCA1/BRCA2 mutations, previous breast cancer, and estrogen exposure.
What are the key symptoms of Paget’s disease of the nipple?
Eczematous changes to the nipple (scaling, redness, crusting), itching, burning, nipple discharge, and sometimes an underlying breast lump.
True or False: Paget’s disease of the nipple always presents with an underlying palpable breast lump.
False. A lump is present in about 50% of cases, but the disease can exist without a palpable mass.
What imaging tests are used to investigate suspected Paget’s disease of the nipple?
Mammography and breast ultrasound to assess for underlying carcinoma.
What definitive test is used to diagnose Paget’s disease of the nipple?
Nipple biopsy (punch or full-thickness biopsy) to confirm malignant cells.
What are the key differential diagnoses for Paget’s disease of the nipple?
Eczema, psoriasis, nipple dermatitis, fungal infections, and contact dermatitis.
Match the following conditions with their key features:
A) Eczema
B) Paget’s disease
C) Nipple dermatitis
D) Fungal infection
- Nipple involvement only, no underlying breast mass
- Bilateral, pruritic rash affecting areola and nipple
- Often associated with allergic reactions
- Red, scaly patches with a fungal pattern
A-2, B-1, C-3, D-4
What is the first-line treatment for Paget’s disease of the nipple?
Surgical removal, typically mastectomy or breast-conserving surgery with radiation therapy.
________________ is used postoperatively if invasive cancer is present.
Adjuvant chemotherapy or hormone therapy (depending on receptor status).
What factors influence the prognosis of Paget’s disease of the nipple?
The presence of underlying invasive carcinoma, lymph node involvement, and hormone receptor status.
True or False: Paget’s disease of the nipple has a poor prognosis even if treated early.
False. Prognosis is good if no invasive carcinoma is present.
A 60-year-old woman presents with an itchy, scaly rash on her nipple that has not improved with topical steroids. What is the most appropriate next step?
Perform a nipple biopsy to rule out Paget’s disease of the nipple.
A patient is diagnosed with Paget’s disease of the nipple. What additional tests should be performed to assess for underlying carcinoma?
Mammography and breast ultrasound, followed by biopsy if suspicious areas are detected.
What is a breast papilloma?
A benign tumor that arises within the milk ducts of the breast, often leading to nipple discharge.
What are the two main types of breast papillomas?
Solitary intraductal papilloma (usually in a large duct) and multiple papillomas (typically in smaller peripheral ducts).
In which age group is intraductal papilloma most common?
Women aged 35-55 years.
What are the typical symptoms of an intraductal papilloma?
Unilateral nipple discharge (bloody or serous), breast lump (sometimes palpable), and potential breast pain or discomfort
True or False: Intraductal papillomas are always associated with pain.
False. Many cases are asymptomatic apart from nipple discharge.
What is the first-line imaging modality for investigating a suspected intraductal papilloma?
Ultrasound, especially in younger women.
________ is used to assess the presence of microcalcifications, which may indicate malignancy.
Mammography.
What additional tests can be used to diagnose intraductal papilloma?
Breast MRI (if malignancy is suspected), ductography (to visualize the ductal system), and biopsy (core needle biopsy or excisional biopsy).
What conditions should be considered in the differential diagnosis of a breast papilloma?
Breast cancer (ductal carcinoma in situ or invasive ductal carcinoma), fibrocystic breast changes, duct ectasia, and periductal mastitis.
What is the recommended management for symptomatic intraductal papillomas?
Surgical excision of the affected duct to confirm benign nature and relieve symptoms.
True or False: All intraductal papillomas require surgical removal.
False. Some cases, especially asymptomatic ones, can be monitored.
What is the risk of malignancy associated with papillomas?
Solitary papillomas have a low risk, but multiple papillomas or those with atypia have an increased risk of developing breast cancer.
What are potential complications of untreated papillomas?
Persistent nipple discharge, infection, and misdiagnosis as malignancy.
A 45-year-old woman presents with a unilateral bloody nipple discharge but no palpable lump. What is the most likely diagnosis?
Intraductal papilloma.
A patient has an intraductal papilloma detected on ultrasound. The biopsy shows atypia. What is the next step?
Surgical excision to rule out or remove any associated malignancy.
