Clinical presentations

Question 1

What are the causes of benign breast lumps?

Answer 1

Fibroadenosis/fibrocysitc change
Fibroadenoma
Cysts
Fat necrosis (trauma to the breast)
Phylloides tumor (rapidly growing benign tumours of the storm, smooth hard lumps)

Question 2

What is fibroadenosis/fibrocystic change in breasts?

Answer 2

Most common cause fo breast lumps
Combination of localised fibrosis, inflammation, cyst formation and hormone driven breast pain
Present exclusively between menarche and the menopause with lumpy breasts and cyclical pain/swelling
Treatment involves reassurance, anti-inflammatories, topical evening primrose oil or hormone manipulation (COC)

Question 3

What is fibroadenoma in the breast?

Answer 3

A benign overgrowth of one lobule of the breast, usually solitary
Most frequent in women 25-35
Usually painless or cause very localised pain
Highly mobile, firm and smooth lumps that evade palpation (breast mice)
1/3 regress, 1/3 stay the same, 1/3 get bigger
Generally don’t require treatment, removal may be indicated if >4cm

Question 4

What are cysts in the breast?

Answer 4

Can be associated with fibrocystic change or occur alone
They are cavities lined by flattened epithelium derived from the ductal unit, filled with watery fluid
They classically present in perimenopausal women as round symmetrical lumps, occasionally with pain
They should be drained with USS guidance and if fluid is suspicious (blood stained) it should be sent for cytology

Question 5

What are the pathological consequences of carcinoma of the breast?

Answer 5

Paget's disease of the nipple (spread of intra-ductal carcinoma of the breast, leading to eczematous changes around the nipple)
Local spread (into overlying skin to produce tethering of the skin/nipple retraction and into pectoral muscles)
Lymphatic spread (can prevent lymphatic drainage, give peau d'orange)
Vascular spread (distal dissemination to the bone (fractures and hypercalcaemia) other sites int h lung and ovary (krukenberg tumour)

Question 6

What are the risk factors for carcinoma of the breast?

Answer 6

Genetic factors (PH,FH,BRCA) 25% of risk
Early menarche/menopause
Nulliparity (or late age of first child)
Not breast feeding 
HRT
Obesity 
Smoking

Question 7

How is a breast lump diagnosed?

Answer 7

Triple assessment:
Clinical examination
Breast imaging (have USS and mammogram if >35)
Cytology (FNAC if cystic, core biopsy if solid)

Question 8

What clinical features increase the likelihood of response to endocrine treatment for metastatic disease?

Answer 8

Oestrogen or progesterone receptor positive
Long interval (more than 2 years) from initial surgery to time of relapse

Question 9

What endocrine therapy is used for premenopausal patients?

Answer 9

Suppression of ovarian function by means of oophorectomy, radiation-induced ovarian ablation- Goserelin
Anti-oestrogen- tamoxifen
Progesterone

Question 10

What endocrine therapy is used for postmenopausal patients?

Answer 10

Tamoxifen
Progesterone
Aromatase inhibitors- anastrozole

Question 11

What are poor prognostic features for breast cancer?

Answer 11

Young age 
Pre-menopausal
Tumour size
High tumour grade
Oestrogen and progesterone receptor negative 
Positive nodes

Question 12

What’s the local treatment for early breast cancer?

Answer 12

Surgery with wide local excision and breast conservation or mastectomy with or without reconstruction
Radiotherapy is given to the conserved breast after wide local excision to reduce local recurrence

Question 13

What adjuvant systemic treatment is used for early breast cancer?

Answer 13

Tamoxifen adjuvant therapy immediately following surgery for oestrogen and/or progesterone receptor positive disease

Question 14

What are the normal breast changes in women?

Answer 14

Puberty- oestrogen promotes development of mammary ducts and distribution of fatty tissue, progesterone induces alveolar growth
Menstrual cycle- after ovulation breasts become tender and swollen
Pregnancy- high levels of placental oestrogen, progesterone and prolactin promote mammary growth
Postnatal- sharp decline in progesterone and oestrogen permits prolactin to stimulate the alveoli and milk is produced. Suckling stimulates secretion of prolactin and releases oxytocin which stimulates myoepithelial cells to contract
Menopause- breasts become softer and more homogenous, decrease in size, atrophy of secretory portions, atrophy of the ducts

Question 15

What is mastitis?

Answer 15

Painful inflammatory condition of the breast, commonly associated with breast-feeding
Tenderness
Swelling and erythema, wedge-shaped distribution
Fever
Malaise
Rapid onset
usually unilateral