Breast surgery: malignancy, duct ectasia and pagets

Question 1

What is triple assessment?

Answer 1

One stop shop for 2 ww.
Involves:
History and examination
Imaging 
Histology- core needle biopsy as fine needle is cytology only and core needle can differentiate between invasive and in situ carcinoma.

Question 2

How do we classify breast carcinoma?

Answer 2

In situ or invasive. Ductal or lobular

Question 3

What is an in situ carcinoma?

Answer 3

Neoplastic population of cells limited
to ducts and lobules by basement
membrane (BM), myoepithelial cells
are preserved. Does NOT invade into vessels and
therefore cannot metastasise or kill
the patient.

Question 4

A patient comes in with a breast mass. On examination, you notice peau d’orange. What does this mean? What type of breast cancer is it more likely to be?

Answer 4

Means lymphatic drainage of the skin of breast is involved. More likely to be an invasive breast cancer as invades LN.

Question 5

What is duct ectasia

Answer 5

Shortening and dilation of major lactiferous duct

Question 6

How does mammary duct ectasia present?

Answer 6

Green/yellow discharge from nipple–> blood stained triple assessment
Palpable mass
nipple retraction

Question 7

What would you find on mammography in mammary duct ectasia?

Answer 7

calcified and dilated ducts without malignant change

Question 8

What would you see on biopsy of mammary duct ectasia?

Answer 8

Plasma cells

Question 9

How do you treat mammary duct ectasia?

Answer 9

Conservatively usually however if there is unremitting nipple discharge, duct excision can take place

Question 10

What is the history you would expect for a patient with fat necrosis

Answer 10

trauma or radiotherapy/ surgery

The presentation of fat necrosis can vary, but typically includes:
- A firm or hard, irregular lump in the breast
- Overlying skin may show signs of inflammation, such as redness and warmth, or bruising

Question 11

What factors determine prognosis in breast cancer?

Answer 11

1) Whether the malignant tumor is in situ or invasive.
2) 2) The tumor stage - Tumor size, Lymph Node involvement, Distal Metastasis.
3) 3) Grade of the tumor.
4) 4) Histology of the tumor.
5) 5) Gene expression profile.

Question 12

Define invasive breast cancer

Answer 12

Neoplastic cells invade beyond the BM into the stroma. They can invade vessels and metastasise to LN and other sites.

Question 13

How does invasive breast cancer present?

Answer 13

Mass or abnormality on mammogram. Gradual breast enlargement. PMH or FHx of breast cancer

Question 14

What would you find on examination of breast with invasive breast cancer?

Answer 14

Lump - hard, painless, irregular margins, fixed to the skin or chest wall. Skin dimpling, Peau d’orange, discharge that is bloody or unilateral. Nipple retraction.

Question 15

What does Peau d’orange show?

Answer 15

Involvment of lymphatic drainage of the skin.

Question 16

How can invasive breast cancer be classified?

Answer 16

Ductal or lobular. Ductal is more common

Question 17

A woman attends your clinic with a breast lump. What differentials are possible?

Answer 17

• Fibroadenoma,
• fibrocystic breast,
• fat necrosis,
• intraductal papilloma,
• breast abscess,
• Phyllodes tumour (a tumour that grows in stroma of breast).
• Radial scar,
• atypical ductal hyperplasia,
• atypical lobular hyperplasia.

Question 18

Name two risk factors for breast cancer

Answer 18

• Age
• obesity
• gene mutations - BRCA1, BRCA2.
• Early menarche or late menopause (as longer exposure to hormones).
• PMH of breast cancer or breast disease.
• FHx of breast or ovarian cancer.
• Previous treatment using radiation.
• Exogenous oestrogen use - long term OCP or HRT.

Question 19

What is the difference between a ductal carcinoma and lobular carcinoma of the breast (both non-invasive)?

Answer 19

Ductal - limited to the ducts by the basement membrane. Lobular - limited to the lobules by the basement membrane.

Question 20

How does non-invasive ductal carcinoma in situ present (DCIS)?

Answer 20

No Sx apart from lump present, and bloody nipple discharge.

Question 21

How are DCIS or LCIS detected?

Answer 21

Through screening

Question 22

How does LCIS present?

Answer 22

Rarely presents as a palpable mass. Found incidentally.

Question 23

Define Paget’s disease

Answer 23

A disease of the nipple associated with breast cancer. 97% have an underlying neoplasm.

Question 24

How does Paget’s disease present?

Answer 24

Rough, red and ulcerated nipple. Itching of the nipple or areola. Flaking and thickened skin around nipple. Pt may mention bloody or yellow discharge.

Question 25

What would be seen on examination of a pt with Paget’s disease?

Answer 25

Painful and sensitive nipple. Flattened nipple.

Question 26

A woman (60yrs) with a PMH of breast cancer has a mastectomy. She is then started on an aromatase inhibitor. What is the main complication of these drugs in post menopausal women?

Answer 26

Increases risk of osteoporosis.

Question 27

What is the link between fibrocystic changes and breast cancer?

Answer 27

increases likelihood of breast cancer by 2-3x.

Question 28

features of pagets disease of the nipple?

Answer 28

Weepy crusty lesion on the nipple with the areola spared until later

Question 29

Nice guidelines about unexplained breast lump?

Answer 29

Women aged >30 with an unexplained breast lump using 2WW

Question 30

malignancy associated with blood stained discharge?

Answer 30

Papilloma

Passbook says most duct papillomas unlikely to be malignant ?

Question 31

What is a complication associated with axillary node clearance?

Answer 31

arm lymphedema and functional arm impairment