Breast Surgery

Question 1

Breast anatomy

Answer 1

The breasts sit in front of the chest wall, which contains the ribs and pectoral muscles. Most of the breast is adipose (fatty) tissue. The areola surrounds the nipple. Behind the nipple are the ducts, which lead into the lobules, where breast milk is produced. Milk is secreted through the ducts and out of openings on the nipple.

Question 2

Breast cancer and clinical features

Answer 2

The most significant differential of a breast lump is breast cancer.

Triple assessment of a breast lump is standard practice to exclude or diagnose cancer. This involves:

Clinical assessment (history and examination)
Imaging (ultrasound or mammography)
Histology (fine needle aspiration or core biopsy)

Clinical features that may suggest breast cancer are:

Lumps that are hard, irregular, painless or fixed in place
Lumps may be tethered to the skin or the chest wall
Nipple retraction
Skin dimpling or oedema (peau d’orange)

The NICE guidelines (updated January 2021) recommend a two week wait referral for suspected breast cancer for:

An unexplained breast lump in patients aged 30 or above
Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes)

The NICE guidelines recommend also considering a two week wait referral for:

An unexplained lump in the axilla in patients aged 30 or above
Skin changes suggestive of breast cancer

The NICE guidelines suggest considering non-urgent referral for unexplained breast lumps in patients under 30 years.

Question 3

Fibroadenoma

Answer 3

Fibroadenomas are common benign tumours of stromal/epithelial breast duct tissue. They are typically small and mobile within the breast tissue. They are sometimes called a “breast mouse”, as they move around within the breast tissue.

They are more common in younger women, aged between 20 and 40 years. They respond to the female hormones (oestrogen and progesterone), which is why they are more common in younger women and often regress after menopause.

On examination, fibroadenomas are:

Painless
Smooth
Round
Well circumscribed (well-defined borders)
Firm
Mobile (moves freely under the skin and above the chest wall)
Usually up to 3cm diameter

Fibroadenomas are not cancerous and are not usually associated with an increased risk of developing breast cancer. Complex fibroadenomas and a positive family history of breast cancer may indicate a higher risk.

Question 4

Fibrocystic breast changes

Answer 4

Fibrocystic breast changes were previously called fibrocystic breast disease. However, fibrocystic breast changes, and generalised lumpiness to the breast, is considered a variation of normal and not a disease. The connective tissues (stroma), ducts and lobules of the breast respond to the female sex hormones (oestrogen and progesterone), becoming fibrous (irregular and hard) and cystic (fluid-filled). These changes fluctuate with the menstrual cycle.

It is a benign (non-cancerous) condition, although it can vary in severity and significantly affect the patient’s quality of life if severe. 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.

Symptoms can affect different areas of the breast, or both breasts, with:

Lumpiness
Breast pain or tenderness (mastalgia)
Fluctuation of breast size

Question 5

Managing fibrocystic breast changes

Answer 5

Management of fibrocystic breast changes is to exclude cancer and manage symptoms. Options to manage cyclical breast pain (mastalgia) include:

Wearing a supportive bra
Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen
Avoiding caffeine is commonly recommended
Applying heat to the area
Hormonal treatments (e.g., danazol and tamoxifen) under specialist guidance

Question 6

Breast cysts

Answer 6

Breast cysts are benign, individual, fluid-filled lumps. They are the most common cause of breast lumps and occur most often between ages 30 and 50, more so in the perimenopausal period. They can be painful and may fluctuate in size over the menstrual cycle.

On examination, breast cysts are:

Smooth
Well-circumscribed
Mobile
Possibly fluctuant

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 7

Fat necrosis of the breast

Answer 7

Fat necrosis causes a benign lump formed by localised degeneration and scarring of fat tissue in the breast. It may be associated with an oil cyst, containing liquid fat. Fat necrosis is commonly triggered by localised trauma, radiotherapy or surgery, with an inflammatory reaction resulting in fibrosis and necrosis (death) of the fat tissue. It does not increase the risk of breast cancer.

On examination, fat necrosis can be:

Painless
Firm
Irregular
Fixed in local structures
There may be skin dimpling or nipple inversion

Ultrasound or mammogram can show a similar appearance to breast cancer. Histology (by fine needle aspiration or core biopsy) may be required to confirm the diagnosis and exclude breast cancer.

After excluding breast cancer, fat necrosis is usually treated conservatively. It may resolve spontaneously with time. Surgical excision may be used if required for symptoms.

Question 8

Lipoma

Answer 8

Lipomas are benign tumours of fat (adipose) tissue. They can occur almost anywhere on the body where there is adipose tissue, including the breasts.

On examination, lipomas are typically:

Soft
Painless
Mobile
Do not cause skin changes

They are typically treated conservatively with reassurance. Alternatively, they can be surgically removed.

Question 9

Galactocele

Answer 9

Galactoceles occur in women that are lactating (producing breast milk), often after stopping breastfeeding. They are breast milk filled cysts that occur when the lactiferous duct is blocked, preventing the gland from draining milk. They present with a firm, mobile, painless lump, usually beneath the areola. They are benign and usually resolve without any treatment. It is possible to drain them with a needle. Rarely, they can become infected and require antibiotics.

Question 10

Phyllodes tumour

Answer 10

Phyllodes tumours are rare tumours of the connective tissue (stroma) of the breast, occurring most often between ages 40 and 50. They are large and fast-growing. They can be benign (~50%), borderline (~25%) or malignant (~25%). Malignant phyllodes tumours can metastasise.

Treatment involves surgical removal of the tumour and the surrounding tissue (“wide excision”). They can reoccur after removal.

Chemotherapy may be used in malignant or metastatic tumours.

Question 11

Breast pain

Answer 11

Breast pain (mastalgia) is common. It can be:

Cyclical – occurring at specific times of the menstrual cycle
Non-cyclical – unrelated to the menstrual cycle

Pain is not typically considered a symptom of breast cancer. After a proper assessment and without other features of breast cancer (e.g., a lump or skin changes), patients with mastalgia can generally be reassured.

Question 12

Cyclical breast pain

Answer 12

Cyclical breast pain is more common and is related to hormonal fluctuations during the menstrual cycle. The pain typically occurs during the two weeks before menstruation (the luteal phase) and settles during the menstrual period. There may be other symptoms of premenstrual syndrome, such as low mood, bloating, fatigue or headaches.

Symptoms are typically:

Bilateral and generalised
Heaviness
Aching

Question 13

Non-cyclical breast pain

Answer 13

Non-cyclical breast pain is more common in women aged 40 – 50 years. It is more likely to be localised than cyclical breast pain. Often no cause is found. However, it may be caused by:

Medications (e.g., hormonal contraceptive medications)
Infection (e.g., mastitis)
Pregnancy

The pain may not originate in the breast but instead come from:

The chest wall (e.g., costochondritis)
The skin (e.g., shingles or post-herpetic neuralgia)

Question 14

Diagnosing cyclical breast pain

Answer 14

A breast pain diary can help diagnose cyclical breast pain.

The three main things to exclude when someone presents with breast pain are:

Cancer (perform a thorough history and examination)
Infection (mastitis)
Pregnancy (perform a pregnancy test)

Question 15

Managing cyclical breast pain

Answer 15

Wearing a supportive bra
Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (oral or topical)
Avoiding caffeine is commonly recommended
Applying heat to the area
Hormonal treatments (e.g., danazol and tamoxifen) under specialist guidance

Question 16

Gynaecomastia

Answer 16

Gynaecomastia refers to the enlargement of the glandular breast tissue in males. Male breast enlargement is relatively common, particularly in adolescents and older men (aged over 50 years). It may also be present in newborns due to circulating maternal hormones, resolving as the maternal hormones are cleared.

Question 17

Causes of gynaecomastia

Answer 17

Gynaecomastia is generally caused by a hormonal imbalance between oestrogen and androgens (e.g., testosterone), with higher oestrogen and lower androgen levels. Raised oestrogen stimulates breast development, whilst androgens have an inhibitory effect on breast development.

Prolactin is a hormone that also stimulates glandular breast tissue development (as well as breast milk production). Therefore, raised prolactin (hyperprolactinaemia) can cause gynaecomastia. It is worth remembering that dopamine has an inhibitory effect on prolactin. Dopamine antagonists (e.g., antipsychotic medications) block dopamine production, which can allow prolactin levels to rise and cause gynaecomastia and galactorrhea (breast milk production).

Gynaecomastia is idiopathic in many cases, meaning no cause is found.

Gynaecomastia may be physiological in adolescents, where there can be proportionally higher oestrogen levels around puberty. This resolves after a few years, as the hormone levels balance.

Gynaecomastia can be caused by conditions that increase oestrogen:

Obesity (aromatase is an enzyme found in adipose tissue that converts androgens to oestrogen)
Testicular cancer (oestrogen secretion from a Leydig cell tumour)
Liver cirrhosis and liver failure
Hyperthyroidism
Human chorionic gonadotrophin (hCG) secreting tumour, notably small cell lung cancer

TOM TIP: It is worth remembering the link between gynaecomastia and Leydig cell testicular tumours. About 2% of patients presenting with gynaecomastia have a testicular tumour. An examination question might describe a patient presenting with gynaecomastia and ask what additional examination should be performed. The answer will be a testicular examination. Also, examine for signs of liver failure and hyperthyroidism.

Gynaecomastia can be caused by conditions that reduce testosterone:

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

There is a long list of medications and drugs that can cause gynaecomastia:

Anabolic steroids (raise oestrogen levels)
Antipsychotics (increase prolactin levels)
Digoxin (stimulates oestrogen receptors)
Spironolactone (inhibits testosterone production and blocks testosterone receptors)
Gonadotrophin-releasing hormone (GnRH) agonists (e.g., goserelin used to treat prostate cancer)
Opiates (e.g., illicit heroin use)
Marijuana
Alcohol

TOM TIP: It is worth remembering spironolactone as a cause for gynaecomastia, as this seems to come up in exams. It is also worth remembering to ask about anabolic steroid use, as this is the most common cause I have seen in young men in clinical practice. A large proportion cases of gynaecomastia will be idiopathic.

Question 18

Assessing gynaecomastia

Answer 18

It is important to distinguish between gynaecomastia and breast enlargement due to obesity (pseudogynaecomastia). On palpation, there will be firm tissue behind the areolas in gynaecomastia, representing growth of the gland and duct tissue. This is different to simple adipose (fat) tissue, which is soft and more evenly distributed.

The next step is to try and establish the cause.

The key points to cover in the history are:

Age of onset, duration and change over time
Associated sexual dysfunction (indicating low testosterone)
Any palpable breast lumps or skin changes (exclude breast cancer)
Associated symptoms that may indicate the cause (e.g., testicular lumps or symptoms of hyperthyroidism)
Prescription medication (e.g., antipsychotics, spironolactone or GnRH agonists)
Use of anabolic steroids, illicit drugs or alcohol

The key points to cover in the examination are:

True gynaecomastia versus simple adipose tissue
Unilateral or bilateral
Any palpable lumps, skin changes or lymphadenopathy (exclude breast cancer)
Body mass index (BMI)
Testicular examination (e.g., lumps, atrophy or absence)
Signs of testosterone deficiency (e.g., reduced body and pubic hair)
Signs of liver disease (e.g., jaundice, hepatomegaly, spider naevi and ascites)
Signs of hyperthyroidism (e.g., sweating, tachycardia and weight loss)

Question 19

Investigating gynaecomastia

Answer 19

Investigations will be determined by history and examination findings. Simple gynaecomastia in an otherwise healthy adolescent may be managed with watchful waiting. Unexplained rapid-onset gynaecomastia in a 30 year old male with no apparent cause may require in-depth investigations.

Blood tests:

Renal profile (U&Es)
Liver function tests (LFTs)
Thyroid function tests (TFTs)
Testosterone
Sex hormone-binding globulin (SHBG)
Oestrogen
Prolactin (hyperprolactinaemia)
Luteinising hormone (LH) and follicle-stimulating hormone (FSH)
Alpha-fetoprotein and beta-hCG (testicular cancer)
Genetic karyotyping (if Klinefelter’s syndrome is suspected)

Imaging:

Breast ultrasound (may help assess the extent of gynaecomastia)
Mammogram (if cancer is suspected)
Biopsy (if cancer is suspected)
Testicular ultrasound (if cancer is suspected)
Chest x-ray (if lung cancer is suspected)

Question 20

Managing gynaecomastia

Answer 20

Management depends on the underlying cause. Gynaecomastia almost always resolves with time in adolescents. Stopping a causative drug (e.g., anabolic steroids or spironolactone) will usually resolve the symptoms. Patients may be referred to the specialist breast clinic where the cause is unclear or cancer is suspected.

Treatment options in problematic cases (e.g., pain or psychological distress) include:

Tamoxifen (a selective oestrogen receptor modulator that reduces the effect of oestrogen on the breast tissue)
Surgery

Question 21

Galactorrhea

Answer 21

Galactorrhea refers to breast milk production not associated with pregnancy or breastfeeding. Breast milk is produced in response to the hormone prolactin.

Prolactin is produced in the anterior pituitary gland. It is also produced in other organs, such as the breast and prostate. Prolactin also regulates aspects of immune function and metabolism.

Dopamine blocks the secretion of prolactin. Therefore, dopamine antagonists (i.e., antipsychotic medications) can result in raised prolactin and galactorrhea. Dopamine agonists (e.g., bromocriptine or cabergoline) can be used to suppress prolactin secretion.

Pregnancy and Breastfeeding

Milk production may start in small amounts during the second or third trimester of pregnancy, and leaking can occur during that time. Oestrogen and progesterone inhibit the secretion of prolactin. In pregnancy, higher levels of oestrogen and progesterone inhibit breast milk production.

Oxytocin stimulates breast milk excretion. Full milk production starts shortly after birth in response to oxytocin release and a rapid drop in oestrogen and progesterone.

Breast milk production will taper off and stop once breastfeeding stops.

Question 22

Hyperprolactinaemia

Answer 22

Galactorrhoea is usually associated with a raised prolactin level (hyperprolactinaemia).

There is a long list of causes of hyperprolactinaemia, but the key causes to remember are:

Idiopathic (no cause can be found)
Prolactinomas (hormone-secreting pituitary tumours)
Endocrine disorders, particularly hypothyroidism and polycystic ovarian syndrome
Medications, particularly dopamine antagonists (i.e., antipsychotic medications)

Prolactin suppresses gonadotropin-releasing hormone (GnRH) by the hypothalamus, leading to reduced LH and FSH release. Therefore, hyperprolactinaemia can also present with:

Menstrual irregularities, particularly amenorrhoea (absent periods)
Reduced libido (low sex drive)
Erectile dysfunction (in men)
Gynaecomastia (in men)

Question 23

Prolactinomas

Answer 23

Prolactinomas are tumours of the pituitary gland that secrete excessive prolactin. This may be associated with multiple endocrine neoplasia (MEN) type 1, an autosomal dominant genetic condition.

Prolactinomas can be:

Microprolactinomas – smaller than 10 mm
Macroprolactinomas – larger than 10 mm

Macroadenomas can have adverse effects relating to their size:

Headaches
Bitemporal hemianopia (loss of the outer visual fields in both eyes)

The optic chiasm sits just above the pituitary gland. The optic chiasm is the point where the optic nerves coming from the eyes cross over to different sides of the head. Only the nerves fibres containing the signal from the outer visual fields cross over, whereas the fibres from the inner visual fields continue on the same side. A pituitary tumour of sufficient size will start to press on the optic chiasm, where the nerves cross, leading to a visual field defect, with loss of vision in the outer visual fields in both eyes (the inner visual fields are spared). This is called bitemporal hemianopia.

TOM TIP: It is worth properly understanding and remembering bitemporal hemianopia, as it is commonly tested in exams. If you find it a bit confusing, there is a Zero to Finals YouTube video explaining it in detail. Remember to examine the visual fields in any patient with symptoms that may be related to a pituitary tumour.

Question 24

Non-milk discharge

Answer 24

Other conditions can cause nipple discharge that is not breast milk:

Mammary duct ectasia
Duct papilloma
Pus from a breast abscess

Question 25

Investigating galactorrhea

Answer 25

A pregnancy test is essential in women with childbearing potential presenting with breast milk production.

Blood tests include:

Serum prolactin
Renal profile (U&Es)
Liver function tests (LFTs)
Thyroid function tests (TFTs)

An MRI scan is the investigation of choice for diagnosing pituitary tumours.

Question 26

Managing galactorrhea

Answer 26

Management is targeted at the underlying cause.

Dopamine agonists (e.g., bromocriptine or cabergoline) can be used to treat the symptoms of hyperprolactinaemia. They block prolactin secretion and improve symptoms.

Trans-sphenoidal surgical removal of the pituitary tumour is the definitive treatment of hyperprolactinaemia secondary to a prolactinoma. The pituitary gland and tumour are accessed and removed through the nose and sphenoid bone.

Question 27

Mammary duct ectasia

Answer 27

Mammary duct ectasia is a benign condition where there is dilation of the large ducts in the breasts. Ectasia means dilation. There is inflammation in the ducts, leading to intermittent discharge from the nipple. The discharge may be white, grey or green.

Mammary duct ectasia occurs most frequently in perimenopausal women. Smoking is a significant risk factor.

Question 28

Presentation of mammary duct ectasia

Answer 28

Mammary duct ectasia may present with:

Nipple discharge
Tenderness or pain
Nipple retraction or inversion
A breast lump (pressure on the lump may produce nipple discharge)

It may be picked up incidentally on a mammogram, leading to further assessment and investigations.

Question 29

Diagnosing mammary duct ectasia

Answer 29

The initial priority is to exclude breast cancer, as they can present in similar ways. This involves triple assessment with:

Clinical assessment (history and examination)
Imaging (ultrasound, mammography and MRI)
Histology (fine needle aspiration or core biopsy)

Microcalcifications are a key finding to remember on a mammogram, although they are not specific to mammary duct ectasia.

Other investigations that may be performed:

Ductography – contrast is injected into an abnormal duct, and mammograms are performed to visualise the duct
Nipple discharge cytology – examining the cells in a sample of the nipple discharge
Ductoscopy – inserting a tiny endoscope (camera) into the duct

Question 30

Managing mammary duct ectasia

Answer 30

Mammary duct ectasia may resolve without any treatment. It is not associated with an increased risk of cancer.

Management depends on the individual patient:

Reassurance after excluding cancer may be all that is required
Symptomatic management of mastalgia (supportive bra and warm compresses)
Antibiotics if infection is suspected or present
Surgical excision of the affected duct (microdochectomy) may be required in problematic cases

Question 31

Intraductal papilloma

Answer 31

An intraductal papilloma is a warty lesion that grows within one of the ducts in the breast. It is the result of the proliferation of epithelial cells. The typical presentation is with clear or blood-stained nipple discharge.

Intraductal papillomas are benign tumours; however, they can be associated with atypical hyperplasia or breast cancer.

Question 32

Presentation of intraductal papilloma

Answer 32

Intraductal papillomas can occur at any age, but most often occur between 35-55 years.

Intraductal papillomas are often asymptomatic. They may be picked up incidentally on mammograms or ultrasound.

They may present with:

Nipple discharge (clear or blood-stained)
Tenderness or pain
A palpable lump

Question 33

Diagnosing intraductal papilloma

Answer 33

Patients require triple assessment with:

Clinical assessment (history and examination)
Imaging (ultrasound, mammography and MRI)
Histology (usually by core biopsy or vacuum-assisted biopsy)

Ductography may also be used. This involves injecting contrast into the abnormal duct and performing mammograms to visualise that duct. The papilloma will be seen as an area that does not fill with contrast (a “filling defect”).

Question 34

Managing intraductal papilloma

Answer 34

Intraductal papillomas require complete surgical excision. After removal, the tissue is examined for atypical hyperplasia or cancer that may not have been picked up on the biopsy.

Question 35

Lactational mastitis

Answer 35

Mastitis refers to inflammation of breast tissue and is a common complication of breastfeeding. It can occur with or without associated infection.

Mastitis can be caused by an obstruction in the ducts and accumulation of milk. Regularly expressing breast milk can help prevent this from occurring.

Mastitis can also be caused by infection. Bacteria can enter at the nipple and back-track into the ducts, causing infection and inflammation. The most common bacterial cause is Staphylococcus aureus.

Question 36

Presentation of mastitis

Answer 36

Mastitis presents with:

Breast pain and tenderness (unilateral)
Erythema in a focal area of breast tissue
Local warmth and inflammation
Nipple discharge
Fever

Question 37

Managing mastitis

Answer 37

Where mastitis is caused by blockage of the ducts, management is conservative, with continued breastfeeding, expressing milk and breast massage. Heat packs, warm showers and simple analgesia can help symptoms.

When conservative management is not effective, or infection is suspected (e.g., they have a fever), antibiotics should be started. Flucloxacillin is the first line, or erythromycin when allergic to penicillin. A sample of milk can be sent to the lab for culture and sensitivities. Fluconazole may be used for suspected candidal infections.

Women should be encouraged to continue breastfeeding, even when an infection is suspected. It will not harm the baby and will help to clear the mastitis by encouraging flow. Where breastfeeding is difficult, or there is milk left after feeding, they can express milk to empty the breast.

A breast abscess is a rare complication if mastitis is not adequately treated. This may need surgical incision and drainage.

Question 38

Candida of the nipple

Answer 38

Candidal infection of the nipple can occur, often after a course of antibiotics. This can lead to recurrent mastitis, as it causes cracked skin on the nipple that creates an entrance for infection. It is associated with oral thrush and candidal nappy rash in the infant.

Candida infection of the nipple may present with:

Sore nipples bilaterally, particularly after feeding
Nipple tenderness and itching
Cracked, flaky or shiny areola
Symptoms in the baby, such as white patches in the mouth and on the tongue, or candidal nappy rash

Both the mother and baby need treatment, or it will reoccur. Treatment is with:

Topical miconazole 2% to the nipple, after each breastfeed
Treatment for the baby (e.g., oral miconazole gel or nystatin)

Question 39

Breast abscess

Answer 39

A breast abscess is a collection of pus within an area of the breast, usually caused by a bacterial infection. This may be a:

Lactational abscess (associated with breastfeeding)
Non-lactational abscess (unrelated to breastfeeding)

Pus is a thick fluid produced by inflammation. It contains dead white blood cells of the immune system and other waste from the fight against the infection. When pus becomes trapped in a specific area and cannot drain, an abscess will form and gradually increase in size.

Mastitis refers to inflammation of breast tissue. Often this is related to breastfeeding (lactational mastitis), although it can be caused by infection. Bacteria can enter at the nipple and back-track into the ducts, causing infection and inflammation. Mastitis caused by infection may precede the development of an abscess.

Smoking is a key risk factor for infective mastitis and breast abscesses. Damage to the nipple (e.g., nipple eczema, candidal infection or piercings) provides bacteria entry. Underlying breast disease (e.g., cancer) can affect the drainage of the breast, predisposing to infection.

Question 40

Causes of breast abscess

Answer 40

The most common causative bacteria are:

Staphylococcus aureus (the most common)
Streptococcal species
Enterococcal species
Anaerobic bacteria (such as Bacteroides species and anaerobic streptococci)

TOM TIP: It is worth becoming familiar with the effective antibiotics against different classes of bacteria. Staph aureus, streptococcal and enterococcal bacteria are gram positive, meaning that penicillins are likely to be effective. Flucloxacillin, in particular, is used against staph aureus skin infections (this association is worth remembering). However, anaerobic bacteria can also cause breast abscesses, and simple penicillins (e.g., amoxicillin or flucloxacillin) do not cover anaerobic bacteria. Co-amoxiclav (amoxicillin plus clavulanic acid) covers anaerobes. Metronidazole gives excellent anaerobic cover (also worth remembering), so it can also be added to the mix.

Question 41

Presentation of breast abscess

Answer 41

The presentation of mastitis or breast abscesses is usually acute, meaning the onset is within a few days.

Mastitis with infection in the breast tissue presents with breast changes of:

Nipple changes
Purulent nipple discharge (pus from the nipple)
Localised pain
Tenderness
Warmth
Erythema (redness)
Hardening of the skin or breast tissue
Swelling

The key feature that suggests a breast abscess is a swollen, fluctuant, tender lump within the breast. Fluctuance refers to being able to move fluid around within the lump using pressure during palpation. Where there is infection without an abscess, there can still be hardness of the tissue, forming a lump, but it will not be fluctuant as it is not filled with fluid.

There may be generalised symptoms of infection, such as:

Muscle aches
Fatigue
Fever
Signs of sepsis (e.g., tachycardia, raised respiratory rate and confusion)

Question 42

Managing breast abscess

Answer 42

The diagnosis of mastitis or a breast abscess can usually be made clinically, with a history and examination.

The NICE clinical knowledge summaries (last updated January 2021) recommend different management for mastitis depending on whether it is lactational or non-lactational.

Lactational mastitis caused by blockage of the ducts is managed conservatively, with continued breastfeeding, expressing milk and breast massage. Heat packs, warm showers and simple analgesia can help symptoms. Antibiotics (flucloxacillin or erythromycin/clarithromycin where there is penicillin allergy) are required where infection is suspected or symptoms do not improve.

Management of non-lactational mastitis involves:

Analgesia
Antibiotics
Treatment for the underlying cause (e.g., eczema or candidal infection)

Antibiotics for non-lactational mastitis need to be broad-spectrum. The NICE clinical knowledge summaries (last updated January 2021) recommend either:

Co-amoxiclav
Erythromycin/clarithromycin (macrolides) plus metronidazole (to cover anaerobes)

Management of a breast abscess requires:

Referral to the on-call surgical team in the hospital for management
Antibiotics
Ultrasound (confirm the diagnosis and exclude other pathology)
Drainage (needle aspiration or surgical incision and drainage)
Microscopy, culture and sensitivities of the drained fluid

Women who are breastfeeding are advised to continue breastfeeding when they have mastitis or breast abscesses. They should regularly express breast milk if feeding is too painful, then resume feeding when possible. This is not harmful to the baby and is important in helping resolve the mastitis or abscess.

Question 43

Breast cancer and risk factors

Answer 43

Breast cancer is the most common form of cancer in the UK. It mostly affects women and is rare in men (about 1% of UK cases). Around 1 in 8 women will develop breast cancer in their lifetime.

Risk Factors

Female (99% of breast cancers)
Increased oestrogen exposure (earlier onset of periods and later menopause)
More dense breast tissue (more glandular tissue)
Obesity
Smoking
Family history (first-degree relatives)

The combined contraceptive pill gives a small increase in the risk of breast cancer, but the risk returns to normal ten years after stopping the pill.

Hormone replacement therapy (HRT) increases the risk of breast cancer, particularly combined HRT (containing both oestrogen and progesterone).

Question 44

Genetics and breast cancer

Answer 44

BRCA refers to the BReast CAncer gene. The BRCA genes are tumour suppressor genes. Mutations in these genes lead to an increased risk of breast cancer (as well as ovarian and other cancers).

The BRCA1 gene is on chromosome 17. In patients with a faulty gene:

Around 70% will develop breast cancer by aged 80
Around 50% will develop ovarian cancer
Also increased risk of bowel and prostate cancer

The BRCA2 gene is on chromosome 13. In patients with a faulty gene:

Around 60% will develop breast cancer by aged 80
Around 20% will develop ovarian cancer

There are other rarer genetic abnormalities associated with breast cancer (e.g., TP53 and PTEN genes).

Question 45

Ductal Carcinoma In Situ

Answer 45

Pre-cancerous or cancerous epithelial cells of the breast ducts
Localised to a single area
Often picked up by mammogram screening
Potential to spread locally over years
Potential to become an invasive breast cancer (around 30%)
Good prognosis if full excised and adjuvant treatment is used

Question 46

Lobular Carcinoma In Situ

Answer 46

A pre-cancerous condition occurring typically in pre-menopausal women
Usually asymptomatic and undetectable on a mammogram
Usually diagnosed incidentally on a breast biopsy
Represents an increased risk of invasive breast cancer in the future (around 30%)
Often managed with close monitoring (e.g., 6 monthly examination and yearly mammograms)

Question 47

Invasive Ductal Carcinoma - NST

Answer 47

NST means no special/specific type, where it is not more specifically classified (e.g., medullary or mucinous)
Also known as invasive breast carcinoma of no special/specific type (NST)
Originate in cells from the breast ducts
80% of invasive breast cancers fall into this category
Can be seen on mammograms

Question 48

Invasive Lobular Carcinomas (ILC)

Answer 48

Around 10% of invasive breast cancers
Originate in cells from the breast lobules
Not always visible on mammograms

Question 49

Inflammatory Breast Cancer

Answer 49

1-3% of breast cancers
Presents similarly to a breast abscess or mastitis
Swollen, warm, tender breast with pitting skin (peau d’orange)
Does not respond to antibiotics
Worse prognosis than other breast cancers

Question 50

Paget’s Disease of the Nipple

Answer 50

Looks like eczema of the nipple/areolar
Erythematous, scaly rash
Indicates breast cancer involving the nipple
May represent DCIS or invasive breast cancer
Requires biopsy, staging and treatment, as with any other invasive breast cancer

Question 51

Rarer Types of Breast Cancer

Answer 51

Medullary breast cancer
Mucinous breast cancer
Tubular breast cancer
Multiple others

Question 52

Breast Cancer Screening

Answer 52

The NHS breast cancer screening program offers a mammogram every 3 years to women aged 50 – 70 years.

Screening aims to detect breast cancer early, which improves outcomes. Roughly 1 in 100 women are diagnosed with breast cancer after going for a mammogram.

There are some potential downsides to screening:

Anxiety and stress
Exposure to radiation, with a very small risk of causing breast cancer
Missing cancer, leading to false reassurance
Unnecessary further tests or treatment where findings would not have otherwise caused harm

Generally, the benefits far outweigh the downsides and breast cancer screening is recommended.

Question 53

High-risk patients for breast cancer

Answer 53

There are different recommendations for screening patients with a higher risk due to a family history of breast cancer. These are in the NICE guidelines (2013, updated 2019).

There are specific criteria for a referral from primary care for patients that may be at higher risk due to their family history. For example:

A first-degree relative with breast cancer under 40 years
A first-degree male relative with breast cancer
A first-degree relative with bilateral breast cancer, first diagnosed under 50 years
Two first-degree relatives with breast cancer

Depending on their risk factors, they may be seen in a secondary care breast clinic or a specialist genetic clinic.

Patients require genetic counselling and pre-test counselling before performing genetic tests. This is to discuss the benefits and drawbacks of genetic testing, such as the implications for family members and offspring.

Annual mammogram screening is offered to women with increased risk, between specific age ranges, depending on their level of risk (potentially starting from aged 30, if high risk).

Chemoprevention may be offered for women at high risk, with:

Tamoxifen if premenopausal
Anastrozole if postmenopausal (except with severe osteoporosis)

Risk-reducing bilateral mastectomy or bilateral oophorectomy (removing the ovaries) is an option for women at high risk. This is suitable for only a small number of women and requires significant counselling and weighing up risks and benefits.

Question 54

Presentation of breast cancer

Answer 54

Clinical features that may suggest breast cancer are:

Lumps that are hard, irregular, painless or fixed in place
Lumps may be tethered to the skin or the chest wall
Nipple retraction
Skin dimpling or oedema (peau d’orange)
Lymphadenopathy, particularly in the axilla

Question 55

Referral criteria for breast cancer

Answer 55

The NICE guidelines (updated January 2021) recommend a two week wait referral for suspected breast cancer for:

An unexplained breast lump in patients aged 30 or above
Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes)

The NICE guidelines recommend also considering a two week wait referral for:

An unexplained lump in the axilla in patients aged 30 or above
Skin changes suggestive of breast cancer

The NICE guidelines suggest considering non-urgent referral for unexplained breast lumps in patients under 30 years.

Question 56

Triple diagnostic assessment in breast cancer

Answer 56

Once a patient has been referred for specialist services under a two week wait referral for suspected cancer, they should initially receive a triple diagnostic assessment comprising of:

Clinical assessment (history and examination)
Imaging (ultrasound or mammography)
Biopsy (fine needle aspiration or core biopsy)

Question 57

Imaging breast cancer

Answer 57

Younger women generally have more dense breasts with more glandular tissue.

Ultrasound scans are typically used to assess lumps in younger women (e.g., under 30 years). They are helpful in distinguishing solid lumps (e.g., fibroadenoma or cancer) from cystic (fluid-filled) lumps.

Mammograms are generally more effective in older women. They can pick up calcifications missed by ultrasound.

MRI scans may be used:

For screening in women at higher risk of developing breast cancer (e.g., strong family history)
To further assess the size and features of a tumour

Question 58

Lymph node assessment and breast cancer

Answer 58

Women diagnosed with breast cancer require an assessment to see if cancer has spread to the lymph nodes. All women are offered an ultrasound of the axilla (armpit) and ultrasound-guided biopsy of any abnormal nodes.

A sentinel lymph node biopsy may be used during breast cancer surgery where the initial ultrasound does not show any abnormal nodes.

Sentinel Lymph Node Biopsy

Sentinel node biopsy is performed during breast surgery for cancer. An isotope contrast and a blue dye are injected into the tumour area. The contrast and dye travel through the lymphatics to the first lymph node (the sentinel node). The first node in the drainage of the tumour area shows up blue and on the isotope scanner. A biopsy can be performed on this node, and if cancer cells are found, the lymph nodes can be removed.

Question 59

Breast cancer receptors

Answer 59

Breast cancer cells may have receptors that can be targeted with breast cancer treatments. These receptors are tested for on samples of the tumour and help guide treatment. There are three types of receptors:

Oestrogen receptors (ER)
Progesterone receptors (PR)
Human epidermal growth factor (HER2)

Triple-negative breast cancer is where the breast cancer cells do not express any of these three receptors. This carries a worse prognosis, as it limits the treatment options for targeting the cancer.

Question 60

Gene expression profiling and breast cancer

Answer 60

Gene expression profiling involves assessing which genes are present within the breast cancer on a histology sample. This helps predict the probability that the breast cancer will reoccur as a distal metastasis (away from the original cancer site) within 10 years.

The NICE guidelines (2018) [DG34] recommend this for women with early breast cancers that are ER positive but HER2 and lymph node negative. It helps guide whether to give additional chemotherapy.

Question 61

Breast cancer metastasis

Answer 61

You can remember the notable locations that breast cancer metastasis occur using 2 Ls and 2 Bs:

L – Lungs
L – Liver
B – Bones
B – Brain

TOM TIP: Breast cancer can spread to any region of the body. In patients with a metastatic tumour, regardless of where it is, the primary could be breast cancer. This is worth remembering, as you may be asked “where might this metastasis have originated” in an exam or OSCE scenario. If the patient is female, answering “breast cancer” will be a good answer. The other cancer that can spread practically anywhere, and may be less obvious, is melanoma (a type of skin cancer).

Question 62

Staging breast cancer

Answer 62

The first step in staging is with triple assessment (clinical assessment, imaging and biopsy). Additional investigations may be required to stage the breast cancer:

Lymph node assessment and biopsy
MRI of the breast and axilla
Liver ultrasound for liver metastasis
CT of the thorax, abdomen and pelvis for lung, abdominal or pelvic metastasis
Isotope bone scan for bony metastasis

The TNM system is used to stage breast cancer. This grades the tumour (T), nodes (N) and metastasis (M).

Question 63

Surgery for breast cancer

Answer 63

Tumour Removal

The objective is to remove the cancer tissue along with a clear margin of normal breast tissue. The options are:

Breast-conserving surgery (e.g., wide local excision), usually coupled with radiotherapy
Mastectomy (removal of the whole breast), potentially with immediate or delayed breast reconstruction

Axillary Clearance

Removal of the axillary lymph nodes is offered to patients where cancer cells are found in the nodes. Usually, the majority or all lymph nodes are removed from the axilla. This increases the risk of chronic lymphoedema in that arm.

Question 64

Chronic lymphoedema and breast cancer

Answer 64

Lymphoedema is a chronic condition caused by impaired lymphatic drainage of an area. Lymphoedema can occur in an entire arm after breast cancer surgery on that side, with removal of the axillary lymph nodes in the armpit.

The lymphatic system is responsible for draining excess fluid from the tissues. The tissues in areas affected by an impaired lymphatic system become swollen with excess, protein-rich fluid (lymphoedema).

The lymphatic system also plays an important role in the immune system. Areas of lymphoedema are prone to infection.

There are specialist lymphoedema services that can help manage patients. Non-surgical treatment options include:

Massage techniques to manually drain the lymphatic system (manual lymphatic drainage)
Compression bandages
Specific lymphoedema exercises to improve lymph drainage
Weight loss if overweight
Good skin care

TOM TIP: It is important to remember that you should avoid taking blood or putting a cannula in the arm on the side of previous breast cancer removal surgery. This is because there is a higher risk of complications and infection due to the impaired lymphatic drainage on that side.

Question 65

Radiotherapy and breast cancer

Answer 65

Radiotherapy is usually used in patients with breast-conserving surgery to reduce the risk of recurrence. High-dose radiation is delivered from multiple angles to concentrate radiation on a targeted area. Patients will have a course of radiotherapy after surgery, for example, with a session of radiotherapy every day for 3 weeks.

Common radiotherapy side effects include:

General fatigue from the radiation
Local skin and tissue irritation and swelling
Fibrosis of breast tissue
Shrinking of breast tissue
Long term skin colour changes (usually darker)

Question 66

Chemotherapy and breast cancer

Answer 66

Oncologists will guide chemotherapy. Chemotherapy is used in one of three scenarios:

Neoadjuvant therapy – intended to shrink the tumour before surgery
Adjuvant chemotherapy – given after surgery to reduce recurrence
Treatment of metastatic or recurrent breast cancer

Question 67

Hormone treatment and breast cancer

Answer 67

Patients with oestrogen-receptor positive breast cancer are given treatment that disrupts the oestrogen stimulating the breast cancer.

There are two main first-line options for this:

Tamoxifen for premenopausal women
Aromatase inhibitors for postmenopausal women (e.g., letrozole, anastrozole or exemestane)

Tamoxifen is a selective oestrogen receptor modulator (SERM). It either blocks or stimulates oestrogen receptors, depending on the site of action. It blocks oestrogen receptors in breast tissue, and stimulates oestrogen receptors in the uterus and bones. This means it helps prevent osteoporosis, but it does increase the risk of endometrial cancer.

Aromatase is an enzyme found in fat (adipose) tissue that converts androgens to oestrogen. After menopause, the action of aromatase in fat tissue is the primary source of oestrogen. Aromatase inhibitors work by blocking the creation of oestrogen in fat tissue.

Tamoxifen or an aromatase inhibitor are given for 5 – 10 years to women with oestrogen-receptor positive breast cancer.

TOM TIP: It is worth committing tamoxifen and aromatase inhibitors (e.g., letrozole) to memory, their relationship to menopausal status and their basic mechanism of action. These are good facts for examiners to test you on.

Other options for women with oestrogen-receptor positive breast cancer, used in different circumstances, are:

Fulvestrant (selective oestrogen receptor downregulator)
GnRH agonists (e.g., goserelin or leuprorelin)
Ovarian surgery

Question 68

Targeted treatments for breast cancer

Answer 68

Trastuzumab (Herceptin) is a monoclonal antibody that targets the HER2 receptor. It may be used in patients with HER2 positive breast cancer. Notably, it can affect heart function; therefore, initial and close monitoring of heart function is required.

Pertuzumab (Perjeta) is another monoclonal antibody that targets the HER2 receptor. It may be used in patients with HER2 positive breast cancer. This is used in combination with trastuzumab (Herceptin).

Neratinib (Nerlynx) is a tyrosine kinase inhibitor, reducing the growth of breast cancers. It may be used in patients with HER2 positive breast cancer.

Question 69

Follow-up post-breast cancer

Answer 69

The NICE guidelines (2018) recommend all patients treated for breast cancer have surveillance mammograms yearly for 5 years (longer if they are not yet old enough for the regular breast screening programme).

Patients treated for breast cancer are given an individual written care plan, including details on:

Designated contacts and details
Adjuvant treatment review dates
Surveillance dates
Advice on identifying recurrence
Support service details

Question 70

Reconstructive breast surgery

Answer 70

Reconstructive surgery is offered to all patients having a mastectomy. There are two options:

Immediate reconstruction, done at the time of the mastectomy
Delayed reconstruction, which can be delayed for months or years after the initial mastectomy

There are several different methods for reconstructing the breasts. The most suitable will depend on individual factors and preferences.

After breast-conserving surgery, reconstruction may not be required. The standard options, if needed, are:

Partial reconstruction (using a flap or fat tissue to fill the gap)
Reduction and reshaping (removing tissue and reshaping both breasts to match)

After mastectomy, the options for reconstructing the breast(s) include:

Breast implants (inserting a synthetic implant)
Flap reconstruction (using tissue from another part of the body to reconstruct the breast)

Implants

Inserting an implant is a relatively simple procedure (compared with a flap) with minimal scarring. It gives an acceptable appearance but can feel less natural (e.g., cold, less mobile and static size and shape). There can also be long-term problems, such as hardening, leakage and shape change.

Latissimus Dorsi Flap

The breast can be reconstructed using a portion of the latissimus dorsi and the associated skin and fat tissue. The tissue is tunnelled under the skin to the breast area.

“Pedicled” refers to keeping the original blood supply and moving the tissue under the skin to a new location.

“Free flap” refers to cutting the tissue away completely and transplanting it to a new location.

Transverse Rectus Abdominis Flap (TRAM Flap)

The breast can be reconstructed using a portion of the rectus abdominis, blood supply and skin. This can be either as a pedicled flap (tunnelled under the skin) or a free flap (transplanted). It poses a risk of developing an abdominal hernia due to the weakened abdominal wall.

Deep Inferior Epigastric Perforator Flap (DIEP Flap)

The breast can be reconstructed using skin and subcutaneous fat from the abdomen (no muscle) as a free flap. The deep inferior epigastric artery, with the associated fat, skin and veins, is transplanted from the abdomen to the breast. The vessels are attached to branches of the internal mammary artery and vein. This is a complex procedure involving microsurgery. There is less risk of an abdominal wall hernia than with a TRAM flap, as the abdominal wall muscles are left intact.