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1
Q

common sites of metastasis for breast cancer

A

bone
lung
liver
brain

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2
Q

presentation of breast cancer

A
  • lunp: hard, painless, craggy, associated tethering, poorly circumscribed
  • nipple discharge, inversion
  • skin change
  • distant metastases
  • screening
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3
Q

risk factors for breast cancer

A
  • other cancers: ovarian
  • FHx breast, ovarian hx
  • uninterrupted oestrogen exposure (nulliparity, late pregnancy, early menarche/late menopause, HRT/OCP_
  • age
  • obesity
  • high alcohol
  • gender
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4
Q

examination in breast cancer

A
  • CHAPERONE
  • 45 degrees and exposed to waist
  • inspection + manoeuvres to accentuate
  • palpation of breast and axilla (lymph nodes)
  • if discharge, get pt to squeeze their nipple to assess colour, consistency and blood
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5
Q

4 S’s, C’s, 4 T’s and AMPLE mnemonics of lump description

A

site, size, shape, surface
colour, contour, consistency, coffin pulse
tethering, tender, temperature, trans-illumination
auscultation, mobility, pulsatile, lymph nodes, edge

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6
Q

investigations for suspected breast cancer

A

bloods - FBC, CRP, U&E, LFT, bone profile (high calcium)
imaging - mammogram +/- US
special tests - biopsy

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7
Q

triple assessment of a breast lump

A
  • clinical examination
  • imaging: <35 = US, >35 = mammogram
  • core biopsy or fine-needle aspiration (cytology/histology)
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8
Q

what is important from cytology/histology of breast cancer in terms of approaching tx

A
  • oestrogen receptor/progesterone receptor expression

- human epidermal growth factor 2 receptors (HER2)

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9
Q

3 types of breast cancer

A
  1. ductal (invasive): 70%
    - medullary = younger
    - mucinous = older
  2. lobular: 15%
    - more likely to be oestrogen receptor positive
    - likely bilateral or multiple sites
  3. nipple: Paget’s disease
    - may be associated with ductal carcinoma
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10
Q

staging systems used for breast cancer

A
  • TNM

- stage 1-4

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11
Q

number staging in breast cancer

A
  1. confined to breast, mobile
  2. ” with lymph nodes on ipsilateral side
  3. fixed to muscle but not chest wall, ipsilateral nodes matted, skin involvement
  4. complete fixation to chest wall and distant metastases
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12
Q

imaging used to stage breast cancer

A

CT chest, abdo, pelvis

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13
Q

mx of breast cancer: local/regional vs systemic

A 
local/regional
- surgery
- radiotherapy
systemic:
- chemotherapy
- hormonal therapy
- monoclonal antibody tx
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14
Q

surgery options for breast cancer

A
  • wide local excision (breast conserving tx)

- mastectomy (+ breast construction if required)

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15
Q

indications for mastectomy

A
  • patient preference
  • multicentricity (2+ cancers widely spaced apart)
  • previous lumpectomy or radiation therapy to breast/chest
  • pregnancy (can’t have radiotherapy)
  • large lump (high tumour:breast ratio)
  • genetics: BRCA positive
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16
Q

complications of radiotherapy

A
  • skin changes
  • nausea
  • pneumonitis, pericarditis
  • rib fractures
  • lymphoedema
  • brachial plexopathy
  • secondary cancer (angiosarcoma)
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17
Q

when are hormone therapies used in breast cancer

A

when oestrogen-receptor for progesterone-receptor positive

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18
Q

3 classes of hormone therapy in breast cancer

A
  1. tamoxifen
    - oestrogen-receptor blocker (used in ER or PR positive cancers)
  2. aromatase inhibitors (anastrozole)
    - used in post-menopausal women
  3. zoladex (anti-gonadotrophin)
    - used in pre-menopausal women
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19
Q

side effects of tamoxifen

A
  • increased risk of DVT

- increased risk of endometrial cancer

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20
Q

side effects of anastrozole

A

osteoporosis

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21
Q

side effects of all hormone therapies used in breast cancer

A

induce a menopausal state

  • hot flushes
  • weight gain
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22
Q

which monoclonal antibody tx is used in breast cancer and when

A 
if HER2 (human epidermal growth factor 2 receptor) positive
Herceptin (trastuzumab)
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23
Q

side effect of trastuzumab used in breast cancer

A

congestive cardiac failure

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24
Q

when to suspect familial cause of breast ca

A
  • breast ca <50yrs (2+ first degree relatives++)
  • male breast ca
  • bilateral breast cancer
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25
Q

differentials for breast lump

A
  • fibroadenoma
  • fibrocystic change (fibroadenosis)
  • breast cysts
  • breast abscess
  • fat necrosis
  • lipoma
  • phyllodes tumour
  • breast cancer
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26
Q

2ww referral criteria

A
  • discrete lump with fixation that enlarges +/- concerns e.g. FHx
  • women >30yo with persistent breast or axillary lump or focal lumpiness after menstrual period
  • previous breast cancer with new suspicious sx
  • skin/nipple changes suggestive of cancer
  • unilateral bloody nipple discharge
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27
Q

definition of fibroadenoma

A

benign tumor of stromal/epithelial breast duct tissue

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28
Q

characteristics of fibroadenoma

A
  • smooth, well circumscribed, firm, mobile lump
  • usually up to 3cm
  • common in younger patients (<40yo), hormone dependent and regress after menopause
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29
Q

timing of fibrocystic breast disease

A

women of menstruating age - sx often occur prior to menstruating and resolve afterwards

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30
Q

sx of fibrocystic breast disease

A
  • bilateral breast lumpiness
  • bilateral breast pain/tenderness
  • fluctuation of breast size
  • around menstruation: often occur <10 days before and resolve after
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31
Q

tx of fibrocystic breast disease

A

supportive clothing
NSAIDs
weight loss
hormonal contraception may exacerbate (consider stopping)

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32
Q

epidemiology of breast cysts

A

age 30-60

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33
Q

characteristics of breast cyst

A

smooth, well circumscribed, mobile, possibly fluctuant lump

fluctuate in size over menstrual cycle

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34
Q

tx of breast cysts

A

conservative tx

needle aspiration or local excision

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35
Q

definition of breast abscess

A

acute (usually bacterial) infection of the breast tissue

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36
Q

presentation of breast abscess

A

fever
pus discharge from nipple
local erythema, tenderness and heat

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37
Q

tx of breast abscess

A

abx

may require surgical incision and drainage

38
Q

definition of fat necrosis

A

lump formed by local degeneration or scarring of fat tissue

inflammatory reaction resulting in fibrosis and eventually necrosis

39
Q

causes of fat necrosis

A

local trauma

breast surgery

40
Q

characteristics of fat necrosis

A

firm, irregular, fixed lump

may cause skin dimpling or nipple inversion

41
Q

tx of fat necrosis

A

benign and may resolve spontaneously

tx conservatively or with surgical excision

42
Q

radiological appearance of fat necrosis

A

similar to breast cancer

43
Q

definition of lipoma

A

benign collection of fat

44
Q

characteristics of lipoma

A

soft, painless and mobile lump up to 20cm in size

45
Q

tx of lipoma

A

tx conservatively

may require surgical excision

46
Q

definition of phyllodes tumor

A

large, fast growing, periductal stromal cell neoplasm

can be benign (50%), borderline (25%) or malignant (25%)

47
Q

epidemiology of phyllodes tumour

A

most common between age 40-50

48
Q

tx of phyllodes tumour

A

local excision

49
Q

differentials for nipple discharge

A
  • breast cancer
  • mammary duct ectasia
  • intraductal papilloma
  • breast abscess
50
Q

presentation of mammary duct ectasia

A
  • nipple discharge, often blood stained
  • mastalgia (non-cyclical)
  • nipple inversion or retraction
  • may have palpable subareolar mass
51
Q

tx of mammary duct ectasia

A

conservative tx and often settles spontaneously

surgical excision if persistent

52
Q

definition of mammary duct ectasia

A

milk duct in breast widens and walls thicken

leads to blockage of duct and fluid build-up

53
Q

main risk factor for mammary duct ectasia

A

smoking

54
Q

definition of intraductal papilloma

A

small (2-3mm) wart-like lesion within breast duct

can obstruct duct causing cysts or twist -> necrosis

55
Q

presentation of intraductal papilloma

A
  • usually present around post-menopausal period

- serous or bloody nipple discharge

56
Q

ix for intraductal papilloma

A

breast ductography

57
Q

prognosis of intraductal papilloma

A

benign but can represent or increase risk of cancer

58
Q

tx of intraductal papilloma

A

surgical excision and vigilant breast screening

59
Q

which hormone causes galactorrhoea

A

prolactin

60
Q

where is prolactin produced

A

anterior pituitary

breast and prostate cells

61
Q

definition of prolactinoma

A

tumour of the pituitary gland causing excess prolactin secretion

62
Q

presentation of prolactinoma

A 
gynaecomastia
sexual dysfunction
amenorrhoea
infertility
bitemporal hemianopia
galactorrhoea
63
Q

tx of galactorrhoea

A

bromocriptine (dopamine agonist blocks prolactin)

64
Q

drug causes of galactorrhoea

A 
contraceptives
SSRIs
antipsychotics, domperidone and metoclopramide (dopamine antagonists)
methyldopa
beta blockers
digoxin
spironolactone
65
Q

endocrine causes of galactorrhoea

A

hypothyroidism
acromegaly
cushings
PCOS

66
Q

risk factors for breast cancer

A 
female
oestrogen exposure
alcohol
obesity
FHx in first-degree relative
67
Q

which chromosomes host the BRCA 1 and 2 genes

A 
BRCA1 = 17
BRCA2 = 13
68
Q

BRCA faulty genes and risk of developing breast (and ovarian) cancer

A 
BRCA1 = 60-80% develop breast cancer, 40% develop ovarian cancer
BRCA2 = 40% develop breast cancer, 15% develop ovarian cancer
69
Q

4 most common sites of breast cancer metastasis

A

lungs
liver
brain
bones

70
Q

definition of ductal carcinoma in situ

A

pre-cancerous or cancerous epithelial cells of breast ducts, localised to single area

71
Q

prognosis of ductal carcinoma in situ

A

around 30% become invasive breast cancer

good prognosis if fully excised with adjuvant tx

72
Q

definition of lobular carcinoma in situ

A

pre-cancerous condition occurring typically in pre-menopausal women

73
Q

presentation of lobular carcinoma in situ

A

asymptomatic and undetectable on mammogram

often picked up incidentally on biopsy

74
Q

mx of lobular carcinoma in situ

A

close monitoring - 6 monthly examination and yearly mammogram

75
Q

most common invasive breast cancer

A

invasive ductal carcinoma (80%)

76
Q

presentation of inflammatory breast cancer

A

presents similarly to breast abscess or mastitis

swollen, warm, tender breast with pitting skin (peau d’orange)

77
Q

prognosis of inflammatory breast cancer

A

worse than other breast cancers

78
Q

definition of paget’s disease of the nipple

A

erythematous, scaly, eczema-like rash of the nipple/areolar indicating breast cancer involving the nipple - may represent ductal carcinoma in situ or invasive breast cancer

79
Q

who is offered breast cancer screening

A

women aged 50-70

screening every 3 years

80
Q

what is the breast triple assessment

A

clinical assessment/examination
breast imaging (US or mammogram)
biopsy (FNA or core)

81
Q

when is US used instead of mammogram

A

younger women have denser breasts with more glands therefore US is more useful than mammogram in women <30yo
mammogram more effectively picks up calcifications (older women)

82
Q

typical history for fibroadenoma

A

mobile, firm breast lump

83
Q

typical history for breast cyst

A

smooth, discrete lump which may be fluctuant

‘halo’ sign

84
Q

typical history for fat necrosis

A

after trauma, hard mass which may increase in size initially

85
Q

typical history for duct papilloma

A

blood stained nipple discharge

86
Q

typical history for duct ectasia

A

green/brown nipple discharge may be in an older lady

tender lump around areolar

87
Q

what is the percentage chance that a) sibling and b) children of a BRCA1 carrier have the gene

A

both is 50%

88
Q

typical history for periductal mastitis

A

smoker presenting with recurrent breast infections

89
Q

tx of periductal mastitis

A

co-amoxiclav

90
Q

when is wide local excision preferred over mastectomy

A

if discrete tumour of <4cm

91
Q

when is surgical excision indicated in fibroadenoma

A

if >3cm

92
Q

hormone therapies used for breast cancer in pre and peri menopausal women vs post menopausal women

A 
pre/peri = tamoxifen
post = anastrozole (aromatase inhibitors)

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