Breast surgery and endocrine disease

Question 1

A worried 23-year-old woman, who started taking the combined contraceptive pill 3 months ago, presents with a 1-day history of discovering a painless lump in the right breast. The patient states that the lump was not there a month ago. On examination, a slightly mobile, discrete, well-defined, non-tender, firm 1 cm
diameter lump is found. There is no lymphadenopathy. The most likely diagnosis
here is:
A. Breast cyst
B. Lipoma
C. Fibroadenoma
D. Sebaceous cyst
E. Carcinoma of the breast

Answer 1

C. Fibroadenoma

Fibroadenomas (C) classically present in females below the age of 35, they are infrequent in women aged 35-40. They are described as painless, often highly mobile, rubbery to firm, non-fluctuant and discrete. They are colloquiallyrefered to as ‘breast mice’.

Breast cysts (A) occur with greater frequency after 35, they are painful, often fluctuant, and are usually discrete, tense and mobile.

Breast carcinoma (E) is rare under 35, and typicaly presents with a solitary, painless, ill-defined lump of varying size which may also have skin tethering.

Lipomas (B) are very common and are soft, fluctuant, irregular lumps.

Sebaceous cysts (D) are round, soft lumps attached to teh skin and have a central punctum.

Question 2

A 36-year-old nulliparous woman attends your clinic with a 7-day history of left breast pain after being involved in a car accident. On examining her breast, you notice a hard, irregular 3 cm, immobile, tender lump. You also notice some skin tethering and overlying bruising in the region of the lump. The most likely diagnosis is:
A. Breast carcinoma
B. Breast cyst
C. Fat necrosis
D. Breast abscess
E. Fibroadenosis

Answer 2

C. Fat necrosis

Although irregularity of the lump combined with skin tethering may be alarming for the possibility of breast carcinoma (A), the history here of trauma and the overlying skin tenderness and bruising make fat necrosis (C) more likely.

For the same reasons the other options here are also less likely given this history.

Question 3

A 33-year-old, non-smoking, breastfeeding woman is 10 days postpartum. She has a 4-day history of a slight crack on the surface of her left nipple. She presents with a 2-day history of severe continuous pain in the left breast which has prevented her from sleeping. On examination, you find the outer quadrants of the left breast to be red, warm and tender with a hard 3 cm lump at the edge of the left nipple.
The most likely diagnosis is:
A. Acute mastitis
B. Breast cyst
C. Fat necrosis
D. Breast abscess
E. Periductal mastitis

Answer 3

D. Breast abscess

Infection of the breast from skin commensuals during lactation, usually staphylococci, results in pus formation leading to segmental breast inflammation and a lactational breast abcess (D). This process is usually as a result of cracks in the nipple due to breast feeding.

This process results in cellulitis and can lead to breast tissue necrosis if not treated promptly.

The hard painful lump, and continous pain is more strongly suggestive of a breast abcess over acute mastitis (A)

With no history of trauma a fat necrosis (C) is unlikely here.

Periductal mastitis (E) is possible but classically presents in non-lactating women of reproductive age and is associated with smoking.

Question 4

A 65-year-old nulliparous woman presents to your clinic with a lump in her left breast, which was discovered 7 months ago. On examination you find a hard, illdefined, non-tender, 3.5 cm lump behind the left nipple. The patient has also had bloody, non-purulent discharge from the left nipple for over 3 months. The most likely diagnosis here is:
A. Mammary duct ectasia
B. Breast carcinoma
C. Duct papilloma
D. Periductal mastitis
E. Acute mastitis

Answer 4

B. Breast carcinoma

The patient being in her sixth decade combined with a nulliparous history are risk factors for breast carcinoma (B), the blood stained discharge and a single hard ill-defined, non-tender lump make this the most likely diagnosis.

A milky or dirty-green discharge would be suggestive of mammary duct ectasia (A) which is common in post-menopausal women and is often bilateral.

With acute and periductal mastitis (D)(E) there would be expected to be mastalgia.

Duct papilloma (C) is a typical cause of blood stained discharge,but the prescence of a discrete lump makes it less likely than carcinoma, although in reality they are note acurately differentiated on clinical examination alone.

Question 5

A 43-year-old woman presents to your clinic with a 2-month history of localized dull pain in the right breast. The pain intensifies just before her period. On examination, you find a discrete 2.5 cm mobile, tense, tender, fluctuant lump in the lower inner quadrant of the right breast. The most likely diagnosis here is:
A. Fibroadenosis
B. Periductal mastitis
C. Breast cyst
D. Fat necrosis
E. Fibroadenoma

Answer 5

C. Breast cyst

Breast cysts (C) typically occur in women over 40 and up to the menopause. It is thought that they occur due to hormonal imbalences around the time of menopause.

The pre-menstruation tenderness is not always a feature, they present as a mobile and fluctuant lump suggestive of a fluid filled cyst.

Fibroadenomas (E), known as breast mice, are infrequent after the age of 35-40, and given that the lump is fluctuant it is more suggestive of a fluid filled cyst.

With no history of trauma to the area a fat necrosis is less likely (D).

Periductal mastitis (B) is commonly seen in non-lactating women in thier 30’s (with an association with smoking) with pain often developing in the areolar area.

Question 6

A 47-year-old perimenopausal woman presents with a 3-week history of green discharge from the right nipple. On examination, the right nipple is non-tender, has a ‘slit-like’ appearance and is retracted. The most likely diagnosis is:
A. Galactorrhoea
B. Duct papilloma
C. Breast carcinoma
D. Mammary duct ectasia
E. Periductal mastitis

Answer 6

D. Mammary duct ectasia

Mammary duct ectasia (D) is common in the decade around menopause, the discharge can vary from milky, brown, or a dirty green colour. The discharge can occur bilaterally and is occasionally associated with cyclical mastalgia.

Nipple retraction is often a feature of breast carcinoma (C), however the description of being ‘slit-like’ is typical of mammary duct ectasia.

Galactorrhoea (A) is unlikely here as the discharge is unilateral and is not actually milky.

A duct papilloma (B) would typically present with bloody discharge.

Periductal mastitis (E) does not usually present with nipple discharge and is more commonly seen in women in thier thirties.

Question 7

A 31-year-old woman presents after having noticed multiple lumps in both breasts which become very painful before the onset of her menses. On examination, you find bilateral diffuse lumpy areas in the upper outer quadrants of both breasts with some areas of tenderness. There is no lymphadenopathy. The most likely diagnosis
is:
A. Breast cysts
B. Fibroadenosis
C. Fibroadenoma
D. Breast carcinoma
E. Fat necrosis

Answer 7

B. Fibroadenosis

Fibroadenosis (B) is more often seen in women between 25 and 40, there may be multiple or single lumps and may be detected in one or both breasts. These lumps can become extremely tender prior to menstruation. Although fibroadenomas (C) are a good answer, but would usually present in women in thier early to late 20’s as a mobile discreet rubbery lump.

Breast carcinoma (D) is unlikey because of the age of the patient and the cyclical nature of the symptoms.

There is no history of local trauma so fat necrosis (E) is unlikely

Breast cysts (A) are also possible but unlikely given the age of the patient and thier non-fluctuant nature.

Question 8

A 67-year-old woman, with a 25-year smoking history, on hormone replacement therapy, presents to clinic expressing concerns regarding a recent increase in size of her right breast. On examination, you find a non-tender, mobile, nodular 3 cm mass in the left breast. The right breast is significantly larger than the left and has a ‘teardrop’ appearance. The most likely diagnosis here is:
A. Paget’s disease of the nipple
B. Inflammatory breast carcinoma
C. Breast abscess
D. Malignant phyllodes tumour
E. Fibroadenoma

Answer 8

D. Malignant phyllodes tumour

This is most likely to be a malignant phyllodes tumour (D), these rare tumours account for around 0.5% of all breast tumours. The warning signs here are the recent size increase and the non-tender mobile lump that gives rise to the charecteristic ‘tear-drop’ shape. Phyllodes tumours share many histological and clinical features with fibroadenomas (E) but they are generally found in an older age group to the early to late 20’s.

Inflammatory breast carcinoma (B) is associated with pain, which differentiates it from other forms of breast malignancy, breast erythema, peau d’orange and skin ridging with or without a palpable mass.

Paget’s disease of the nipple (A) presents with unilateral, non-itchy, irregular eczematous skin changes of the nipple. It is not to be confused with eczema of the nipple which is usualy bilateral with puritis and can spare the nipple.

Breast abcess (C) is unlikely here.

Question 9

A worried 59-year-old city worker arrives at your clinic with a 1-month history of having noticed a non-itchy, persistent, burning rash in the region of her right breast. On examination you find the right nipple and the skin overlying the areola to be red and eczematous. Axillary lymphadenopathy is present. The most likely cause is:
A. Breast abscess
B. Malignant phyllodes tumour
C. Paget’s disease of the nipple
D. Basal cell carcinoma
E. Mastitis

Answer 9

C. Paget’s disease of the nipple

Paget’s disease of the nipple (C) is the most likely answer here, the non-itchy eczematoid changes in the overlying skin and the lymphadenopathy is highly suggestive of malignancy. Paget’s disease of the nipple almost always occurs on a background of intraductal or invasive carcinoma.

BCC (D) would be seen as raised pearly pink papules that later become ulcerated.

as seen in the last question, a malignant phyllodes tumour (B) would present with a palpable mass and an increase in size of the breast, often in a ‘teardrop’ shape.

Mastitis (E) and breast abcess (A) are also unlikel due to the specific presentation

Question 10

A 21-year-old nulliparous woman presents to your clinic with a 1-month history of bilateral breast pain. The pain, which is dull and achy in nature, is poorly localized and widespread across both breasts. The pain gradually increases in severity and is worse just before her menses. The pain usually starts to get better once her menses start. On examination, both breasts are tender. There are no
lumps, skin changes or obvious swellings. The most likely diagnosis here is:
A. Non-cyclical mastalgia
B. Tietze’s syndrome
C. Cyclical mastalgia
D. Acute bacterial mastitis
E. Traumatic fat necrosis

Answer 10

C. Cyclical mastalgia

A presentation of bilateral breast pain that intensifies just before menses, and then is relieved after the start of menses is almost certainly cyclical mastalgia (C). This is believed to be a response by breast tissue to hormonal changes, but this is unclear.

Non-cyclical mastalgia (A) would not have an observed link with the menstrual cycle.

Tietze’s (B) is chondritis of the costal cartilages and would present with charecteristic tenderness over the 2nd, 3rd or 4th costochondral junctions.

Acute bacterial mastitis (D) would not normally affect both breasts and is certainly not associated with the menstrual cycle.

Traumatic fat necrosis (E) is not a good answer as there is no history of trauma.

Question 11

A 25-year-old woman presents to your clinic after discovering, for the first time, two lumps in the inner lower quadrant of her left breast. On examination you find these lumps to be 2 cm in size, solid, discrete, mobile and non-tender. The right breast is normal and there is no lymphadenopathy. The most appropriate course of
management is:
A. Request a mammogram
B. Reassure the patient and discharge her
C. Request an ultrasound of the left breast
D. Request fine needle aspiration
E. Request a core biopsy

Answer 11

C. Request an ultrasound of the left breast

All breast lumps are ‘triple assessed’ which entails clnical examination, ultrasound imaging (for under 35yo) or mammograms (older than 35), followed by fine needle aspiration cytology and/or core biopsy for cytological and histological assessment respectively.

As this woman is under 35 the discovery of two new breast lumps indicates that an ultrasound (C) is the next investigation indicated after the clinical examination.

Mammography (A) would be the best choice if the patient was over 35.

Reassurance and discharge (B) is definitely the wrong approach

(D) and (E) would only take place after imaging.

Question 12

A 25-year-old woman is diagnosed with fat necrosis of the left breast following a traumatic injury 14 days earlier. She has slight bruising of the lower outer quadrant of the left breast with moderate tenderness. What would be the most appropriate course of management?
A. Reassurance and discharge
B. Follow-up appointment in 3 months
C. Wide local excision
D. Left mastectomy
E. Follow-up appointment in 6 months

Answer 12

A. Reassurance and discharge

In most cases traumatic fat necrosis does not warrent any treatment (A), sometimes there can remain a hard irregular lump after the initial injury resolves and this can be confused with carcinoma. If there was a hard lump then an ultrasound and core biopsy would be indicated, but that is not the case here.

All the other options here are not appropriate.

Question 13

A 38-year-old woman, and mother of two healthy children, is diagnosed with a fluid-filled cyst after mammography. The woman does not have any significant family history of carcinoma and the cyst is located in the outer-lower quadrant of the right breast. What would be the most appropriate course of action?
A. Wide local excision
B. Follow-up appointment in 3 months
C. Fine needle aspiration
D. Reassure and discharge
E. Core biopsy

Answer 13

C. Fine needle aspiration

Once a breast cyst has been diagnosed imaging the next stage of the triple assessement is to perform a fine needle aspiration (C) or core biopsy depending on the nature of the lump (E). Given that this is fluid filled the correct answer is FNA (C)

Progressing to excision (A) at this stage is premature

Reassurance (D) and follow up appointment (B) would not be appropriate without first performing a FNA.

Question 14

A 30-year-old woman who is 12 days postpartum and breastfeeding is diagnosed with acute mastitis of the left breast. Four days earlier, she discovered a painful crack in the region of the left nipple and noticed that the surrounding skin was tender, warm and red in colour. The patient is not allergic to penicillin and you decide to prescribe a course of antibiotics. What would be the most appropriate antibiotic for treating this condition?
A. Erythromycin
B. Amoxicillin
C. Ciprofloxacin
D. Flucloxacillin
E. Cephalexin

Answer 14

D. Flucloxacillin

For lactational acute mastitis flucloxacillin (D) is the antibiotic of choice. This case is typical where a crack in the nipple allows invasion by Staph.aureus (most commonly). Flucloxacillin is a penicillinase-resistant antibiotic that is very effective against S.aureus infections. Breastfeeding or milk expression is encouraged and has ben shown to speed recovery.

Amoxicillin (B), a penicilin, and ciprofloxacin (C), a quinolone are widely ineffective against S.aureus due to resistance.

Erythromycin (A), a macrolide, would be the choice for patients allergic to penicillins as it is not as effective.

Cephalexin (E), a cephalosporin, can be used but it’s spectrum of activity is less broad so is not considered a first line treatment for a breast abcess.

Question 15

After a triple assessment, a 28-year-old woman is diagnosed with a fibroadenoma of the left breast. The patient has a significant family history of breast carcinoma. The non-tender lump is situated in the inner lower quadrant of the left breast. The lump is approximately 1.5 cm x 1.5 cm. What is the most appropriate course of management?
A. Excision of the lump
B. Reassure and follow-up after 3 months
C. Discharge
D. Fine needle aspiration
E. Perform triple assessment in 6 weeks

Answer 15

A. Excision of the lump

After the diagnosis of fibroadenoma, small lesions (less than 2.5cm) do not require excision. In most cases, reassurance and discharge is the required order of business, however this patients significant family history of breast carcinoma, it is essential and reassuring for her to offer to excise teh lump. So this makes answer (A) the most appropriate answer here.

Question 16

A 45-year-old perimenopausal woman is diagnosed with mammary duct ectasia of the right breast after having had small and infrequent amounts of milky green discharge from the right nipple for over 2 months. The patient has no significant family history and mammography findings are normal. What is the most appropriate course of management?
A. Reassure and discharge
B. Surgical resection of the duct system of the right breast (Hadfield’s
operation)
C. Commence antibiotic therapy
D. Perform mammography of the right breast in 3 months
E. Mastectomy of the right breast

Answer 16

A. Reassure and discharge

Providing that investigations are normal, then mammary duct ectasia does not warrant treatment (A). Excision (B) is only performed if the discharge is frequent and excessive.

Antibiotic treatment (C) will not provide any curative effect

Mammography after 3 months (D) will be unlikey to have any bearing on management.

Mastectomy (E) is not a recommended treatment modality.

Question 17

A 48-year-old perimenopausal woman presents with a 2-month history of a painful lump in her right breast. On examination you find a 2.5 cm tense, fluctuant, mobile lump in the outer lower quadrant of the right breast. The most appropriate course of action is:
A. Computed tomography scan
B. Mammography
C. Fine needle aspiration
D. Core biopsy
E. Mammography and core biopsy

Answer 17

B. Mammography

After any clinical examination of a breat lump the next stage is to perform imaging of the lump. For a patient under 35 the modality is ultrasound, and for a patient over 35 (such as this one) the modality is mammography (B).

CT scanning (A) is not part of the triple assessment.

FNA (C) and Core biopsy (D) are not considered until a radiological assessment has been conducted.

The decision about performing an FNA or core biopsy should be made after imaging the lump, so for this reason requesting a combination mammography and core biopsy (E).

Question 18

A 60-year-old woman was found to have one focal area of microcalcification (approximately 35 mm in diameter) in the left breast. An ultrasound-guided biopsy of this area was taken for histological assessment, which revealed low-grade ductal carcinoma in situ. In light of this, what would be the most appropriate treatment modality for this patient?
A. Mastectomy
B. Mastectomy + postoperative radiotherapy
C. Wide local excision + postoperative radiotherapy
D. Mastectomy + axillary staging and clearance + postoperative
radiotherapy
E. Wide local excision + axillary staging and clearance + postoperative
radiotherapy

Answer 18

C. Wide local excision + postoperative radiotherapy

Although mastectomy +/- postoperative radiotherapy (A)(B) are accepted treatments for ductal carcinoma in situ, if there is the case of a small (less than 40mm diameter) lesions that are of a non-aggresive type then wide local excision with post-operative radiotherapy (C) is offered. This has advantages because it preserves the breast tissue as much as possible which has greater aestetic/psychological results.

Mastectomy + postoperative radiotherapy is offered when DCIS is found in multiple areas of the breast

Question 19

A 25-year-old woman is diagnosed with cyclical mastalgia. She presents to your outpatient clinic asking for the most effective treatment, with the least side effects, to relieve her breast pain. Which one of the following are you most likely to
prescribe?
A. Danazol
B. Bromocriptine
C. Tamoxifen
D. Gamma-linoleic acid
E. Topical non-steroidal anti-inflammatory gels

Answer 19

D. Gamma-linoleic acid

Gamma-Linoleic acid (D) is also known as evening primrose oil and is the mainstay of treatment for cyclical mastalgia and has been shown to be effecive at high doses.

Topical NSAIDs (E) have also proved beneficial, and have a low side effect profile.

Hormonal therapies (A)(B)(C) have all been shown to be effective but have many unwanted side effects.

Question 20

A 46-year-old man is diagnosed with invasive ductal carcinoma of the right breast after having discovered a lump 3 months before. The patient is found to have stage 2 breast cancer and the tumour is an aggressive type. The most appropriate treatment option for this patient is?
A. Cytotoxic chemotherapy
B. Mastectomy + axillary clearance + postoperative radiotherapy +
systemic chemotherapy
C. Wide local excision
D. Mastectomy + postoperative radiotherapy
E. Palliative care programme

Answer 20

B. Mastectomy + axillary clearance + postoperative radiotherapy + systemic chemotherapy

Treatment options for male breast cancer are similar to those for female breast cancer, the most common type in males and females being invasive ductal carcinoma.

Patients who have stage 1 or 2 are more suitable for surgery whereas surgery is to be avoided in patients that have locally advanced cancer (stage 3) or metastatic disease (stage 4). Stage 3 or 4 ductal carcinoma is treated with chemotherapy.

In this particular case the patient has stage 2 disease and so is suitable for surgery. The best prognosis is conferred by option (B), the addition of systemic chemotherapy is an improvement in prognosis over radiotherapy alone.

Any wide local incision would be insufficient for an invasive malignancy.

Question 21

A 34-year-old premenopausal woman presents to your clinic with a lump in her right breast. On examination you find a 2.5 cm fluctuant, mobile, tender lump in the inner lower quadrant of the right breast. The ultrasound report suggests a fluidfilled
cyst. The most appropriate course of action is:
A. Breast magnetic resonance imaging
B. Fine needle aspiration
C. Core biopsy
D. Reassure and discharge
E. Mammography

Answer 21

B. Fine needle aspiration

The patient has been clinically assessed and radiologically imaged, meaning that either a core biopsy (C) or fine needle aspiration (B) is the next step. Given that the imaging has shown the lump to be cystic then FNA for cytology is the best option.

Breast MRI (A) is used for multi-focal or bilateral disease, as well as patients who have cosmeti implants due to greater risk of breast cancer.

The remaining answers are incorrect asexplained in previous questions.

Question 22

In which one of the following scenarios is the complication of lymphoedema of the arm more likely to occur after resection of a breast tumour and axillary clearance?
A. Mastectomy + axillary clearance + postoperative radiotherapy to the
chest wall
B. Mastectomy + axillary clearance + systemic chemotherapy
C. Mastectomy + axillary clearance + postoperative radiotherapy to the
axilla
D. Mastectomy + axillary clearance
E. Mastectomy + postoperative radiotherapy

Answer 22

C. Mastectomy + axillary clearance + postoperative radiotherapy to the
axilla

This combination of treatment is most likely to lead to lymphoedema, as such it is not routinely offered.

Question 23

A 28-year-old woman, who was hospitalized 2 months ago following a head injury, attends the outpatient clinic with a 6-week history of polyuria and polydipsia and no other symptoms. Her blood pressure is 117/83 mmHg and her heart rate is 68 beats/min. From the list below select the most appropriate management option.
A. Carbimazole
B. Desmopressin
C. Spironolactone
D. Thyroxine
E. Octreotide

Answer 23

B. Desmopressin

Given that this woman’s symptoms are isolated to polyuria and polydipsia, and this occurred following a head injury it makes craniogenic diabetes insipidus a likely cause of her symptoms. In the craniogenic form there is insufficient ADH sucretion from the posterior pituitary gland, desmopressin (B) is a synthetic analoge of ADH.

Of the other drugs here; Carbimazole (A) is given to patients with hyperthyroidism.

Spironolactone (C) in endocrine medicine is given to patient’s with Conn’s syndrome

Thyroxine (D) is for hypothyroidism

Octreotide (E) is a somatostatin analogue given to patients with acromegaly or carcinoid syndrome.

Question 24

During a ward round, you are asked by your surgical registrar about the
management of a phaeochromocytoma. Select from the list below the most
appropriate management plan for a phaeochromocytoma:
A. Surgical resection, followed by b blockade, followed by a blockade
B. Lifelong b and a blockade
C. Surgical resection
D. b blockade, followed by a blockade, followed by surgical resection
E. a blockade, followed by b blockade followed by surgical resection

Answer 24

E. a blockade, followed by b blockade followed by surgical resection

The definitive management of a phaeochromocytoma is surgical excision but there needs to be a catecholamine blockade first. This blocade must be started with an alpha blockade (usually with phenoxybenzamine 7-10 days before surgery) and then a beta blockade when there has been sufficient effect. If this is not done correctly the unoppossed alpha receptor activation can precipitate a hypertensive crisis.

‘always a before b’

Question 25

A 58-year-old postmenopausal woman has been seen in clinic following a
discovery of a 3 cm, non-tender, irregular, firm lump in the upper outer quadrant of the left breast. Mammography and ultrasound imaging respectively reveal that the lump has areas of calcification and is a solid mass. The most appropriate course of action is:
A. Repeat mammography and ultrasound scans in 6 months
B. Reassure and discharge
C. Repeat mammography and ultrasound scans in 3 months
D. Fine needle aspiration
E. Core biopsy

Answer 25

E. Core biopsy

Always triple assess lumps, in this case the first two stages have been carried out and so it calls for a fine needle aspiration (D) or core biopsy (E). The description is of a solid lump and so a core biopsy is indicated.