Breast Pain and Lumps

Question 1

Presentation of breast pain

Answer 1

• common
• truly from breast or referred
• associated with breast swelling/nodularity
• worse before menstruation and then relieved by it
• unknown cause
• exacerbated by perimenopause and exogenous hormone intake
• 2.7% breast pain have breast cancer

Question 2

Breast Pain Assessment

Answer 2

• history
• exam
• mammography
• pain charts = timing and severity
• consider = bra fitting, weight, exercise, stressing life events, breast cancer (2.7% of breast pain patients)

Question 3

Breast Pain Treatment

Answer 3

• reassurance = ‘this is common and nothing to be worried about’
• primrose oil or soya milk (phytoestrogens) in evening
• reduce fat intake
• medications = tamoxifen, danazol, zoladex, bromocriptine

Question 4

Breast Lumps Assessment

Answer 4

• history
• exam
• TRIPLE ASSESSMENT = mammography, US, cytology/histology
• one stop clinic setting

Question 5

Breast Lumps Treatment depends on?

Answer 5

• depends on lump cause

- benign or malignant

Question 6

Breast Lump Benign Cause

Answer 6

• aberrations of normal breast development and involution (ANDI)
• changes through development, cyclical change, involution
• benign disease = fibroadenoma, cysts

Question 7

Fibroadenoma

Answer 7

• stromal tissue
• proliferatory epithelium
• arises from lobular unit
• very mobile, discrete, rubbery mass
• if over 40 must differentiate from cancer
• management depends on size, age, triple assessment

Question 8

Phyllodes tumour

Answer 8

• confused with fibroadenoma
• older women
• rare <1% breast lumps
• fibroepithelial tumour
• need wide local excision

Question 9

Cysts

Answer 9

• microcyst or microcyst
• around perimenopause
• triple assessment investigation
• management = re-assure, aspirate, occasionally operate

Question 10

Sclerotic/fibrotic lesions

Answer 10

• involution of breast = fibrosis
• sclerosing adenosis
• can present with radial scar <1cm, complex sclerosing lesion >1cm (often asymptomatic)
• difficult to differentiate from malignancy

Question 11

Sclerosing adenosis

Answer 11

sclerotic lesion

• palpable mass with pain
• stromal sclerosis
• proliferative adenosis
• microcalcification and myoepithelial proliferation

Question 12

Non ANDI Breast Lumps

Answer 12

• breast infections = lactational or non
• lipoma
• fat necrosis
• Montgomery’s gland
• mondor’s disease
• gynaecomastia in men

Question 13

Montgomery’s gland

Answer 13

small periareolar glands around nipple which may develop a cyst

Question 14

Mondor’s disease

Answer 14

thrombophlebitis of superficial veins of breast

Question 15

Investigation of malignant breast lump

Answer 15

• size
• irregular edge
• fixity
• consistency
• lymph node status
• peau d’Orange
• TRIPLE assessment
• STAGING

Question 16

Triple Assessment Reporting

Answer 16

• palpation, mammogram, US, cytology, histology
  1) Normal (or cytology insufficient)
  2) Benign
  3) Indeterminate probably benign
  4) Suspicious of cancer
  5) Cancer

Question 17

Cancers causing breast lumps

Answer 17

• infiltrating ductal carcinoma
• ductal carcinoma in situ
• infiltrating lobular carcinoma
• Paget’s disease of the breast
• Lymphoma
• Sarcoma, melanoma, metastasis

Question 18

Histology of breast cancer

Answer 18

• type
• grade
• receptor status (oestrogen, progesterone, HER2)

Question 19

Management of malignant breast lump

Answer 19

• MDT = surgeons, radiologists, histopathologist, oncologist, breast specialist nurses
• point of contact
• treatment individualised

Question 20

Treatment options for breast cancer

Answer 20

SURGERY
- breast conserving
- mastectomy
- sentinel node sampling/axillary node clearance
CHEMOTHERAPY
- neo-adjuvant
- adjuvant
ENDOCRINE
- tamoxifen
- aromatase inhibitors
RADIOTHERAPY