Day 6 Breast Flashcards
Fibroadenosis
(fibrocystic disease, benign mammary dysplasia)
(2)
Most common in middle-aged women
‘Lumpy’ breasts which may be painful. Symptoms may worsen prior to menstruation
A 45-year-old office-clerk had come in to see her GP regarding a rash around the right nipple area. She complains that the areola region is itchy and sore. Further questioning also reveals that the rash has been there for 6 weeks and has not improved with E45 cream. She has a history of eczema that is well controlled with E45 only. She also reported that the rash started on the nipple and spreads outwards to the areola On examination the rash looks erythematous and crusty, it does not extend beyond the nipple-areola complex.
What further steps should be taken?
What is the diagnosis?
The key to this question is in the history, the rash started on the nipple and spreads outwards involving the areola.
Even if she has a history of eczema, this needs urgent attention by a breast consultant to rule out Paget’s disease.
Fibroadenoma (2)
- Common in women under the age of 30 years
- Often described as ‘breast mice’ due as they are discrete, non-tender, highly mobile lumps
A 38-year-old lady who smokes heavily presents with recurrent episodes of infection in the right breast. On examination, she has an indurated area at the lateral aspect of the nipple areolar complex. Imaging shows no mass lesions. What is the most likely diagnosis?
Periductal mastitis is common in smokers and may present with recurrent infections. Treatment is with co-amoxiclav.
A 52-year-old lady presents to her general practitioner.
She is concerned about a lump which she has noticed on her left breast associated with a green nipple discharge.
On examination, she has a tender lump on her left breast next to her areola. It is not discoloured or hot to touch.
What is the diagnosis?
Duct ectasia: non-malignant breast disease with thick green nipple discharge, occurring with breast involution
Typically occurring around menopause as the breasts undergo involution. Duct ectasia reflects a shortening and widening of the terminal breast ducts around the nipple.
Breast cancer (2)
- Characteristically a hard, irregular lump. There may be associated nipple inversion or skin tethering
- Paget’s disease of the breast - intraductal carcinoma associated with a reddening and thickening (may resemble eczematous changes) of the nipple/areola
A 52-year-old lady presents with an episode of nipple discharge. It is usually clear in nature.
On examination the discharge is seen to originate from a single duct and although it appears clear, when the discharge is tested with a labstix it is shown to contain blood.
Imaging and examination shows no obvious mass lesion.
The correct answer is: Intraductal papilloma
Intraductal papilloma usually cause single duct discharge. The fluid is often clear, although it may be blood stained.
If the fluid is tested with a labstix (little point in routine practice) then it will usually contain small amounts of blood. A microdocechtomy may be performed.
Breast abscess (2)
- More common in lactating women
- Red, hot tender swelling
A 55-year-old women presents with nipple discharge. On examination she has a slit like retraction of the nipple in the centre of this area is a small amount of cheese like material. No discrete mass lesion is palpable in the underlying breast.
The correct answer is: Duct ectasia
Duct ectasia is a common alteration in the breast that occurs with ageing. As the ducts shorten and dilate a degree of symmetrical slit like retraction occurs. A small amount of cheese like discharge may occur.
Mammary duct ectasia (4)
- Dilatation breast ducts.
- Most common in menopausal women
- Discharge typically thick and green in colour
- Most common in smokers
A 49-year-old woman presents with a tender lump around the areola associated with a green nipple discharge.
Mammary duct ectasia
- Dilatation breast ducts.
- Most common in menopausal women
- Discharge typically thick and green in colour
- Most common in smokers
A 44-year-old woman is diagnosed with breast cancer. She has no past medical history of note, is pre-menopausal and has no family history of breast or ovarian cancer.
Staging suggests early disease and she has a wide-local excision followed by whole-breast radiotherapy.
Pathology results show that the tumour is oestrogen receptor positive, HER2 negative.
Which adjuvant treatments is she most likely to be offered?
Tamoxifen is used as the women is pre-menopausal.
There is ongoing debate about whether therapy should be for 5 years or longer.
A 64-year-old obese female presents with a breast lump. She was hit on the breast by a cricket ball when playing with her grandson.
Fat necrosis
An obese, post menopausal woman, with a history of trauma points towards fat necrosis. Trauma causes inflammation of fat cells, leading to formation of a lump. Mammography will be needed to differentiate it from breast disease
An 88-year-old lady presents with a large mass in the upper inner quadrant of her right breast. Investigations confirm an oestrogen receptor positive, invasive ductal carcinoma. She has declined operative treatment.
The correct answer is: Endocrine therapy using letrozole
Elderly patients may be managed using endocrine therapy alone. Eventually most will escape hormonal control. In post menopausal women oestrogens are produced by the peripheral aromatization of androgens and aromatase inhibitors are therefore the most popular agent in this age group.
A 74-year-old woman presents with a breast lump. On examination, it has a soft consistency.
The lump is removed and sliced apart. Macroscopically there is a grey, gelatinous surface.
Mucinous carcinoma
Mucinous carcinomas comprise 2-3% of all breast cancers.
They are one of the special type of carcinomas. These have a better prognosis that tumours of Non Special Type (NST) and axillary nodal disease is rare in this group.
Duct papilloma (3)
- Local areas of epithelial proliferation in large mammary ducts
- Hyperplastic lesions rather than malignant or premalignant
- May present with blood stained discharge
You are working in general practice. An 87-year-old lady complains that her right nipple is exquisitely itchy. On examination, you note that the nipple is erythematous and there is some blood-stained discharge on the inside of her bra.
What is the most appropriate management?
What is the diagnosis
Imaging and biopsy
Paget’s disease of nipple
A 65-year-old lady presents with a lesion affecting her right breast.
On examination she has a weeping, crusting lesion overlying the right nipple, the areolar region is not involved.
There is no palpable mass lesion in the breast, there is a palpable axillary lymph node.
What is the most likely diagnosis?
A weeping, crusty lesion such as this is most likely to represent Pagets disease of the nipple (especially since the areolar region is spared). Although no mass lesion is palpable, a proportion of patients will still have an underlying invasive malignancy (hence the lymphadenopathy).
Discuss (5)Improve
What is a triple assessment?
triple assessment, as the name indicates, includes three modalities, physical examination, imaging (mammography and/or ultrasound), and biopsy (FNAC and core biopsy).
A 41-year-old woman presents with a two-month history of an irregular fixed lump in her left breast.
What is the diagnosis?
Breast cancer
The combination of a persistent lump spanning at least one menstrual cycle and the irregularity point to a diagnosis of cancer.
A 53-year-old woman presents with a bloody nipple discharge. On mammography there is calcification behind the nipple areolar complex. A core biopsy shows background benign change, but cells that show comedo necrosis which have not breached the basement membrane.
Ductal carcinoma in situ
Comedo necrosis is a feature of high nuclear grade ductal carcinoma in situ. It is has a high risk of being associated with foci of invasion.
A 64-year-old woman attends oncology clinic following a diagnosis of oestrogen receptor (ER) positive breast cancer. Her consultant decides to commence treatment with anastrozole, an aromatase inhibitor.
Of the following, which is a potential complication associated with this treatment?
Osteoporosis
Aromatase inhibitors (AIs) such as anastrozole and letrozole reduce peripheral oestrogen synthesis. This accounts for the majority of oestrogen synthesis in post-menopausal women, and therefore aromatase inhibitors are used in this group.
A 60-year-old woman diagnosed with a primary breast carcinoma is deciding whether or not to consent to have an axillary node clearance.
Which complication should the patient be made aware of, specifically relating to this procedure?
Axillary node clearance is associated with arm lymphedema and functional arm impairment
A 21-year-old female notices a bloody discharge from the nipple. She is otherwise well. On examination there are no discrete lesions to feel and mammography shows dense breast tissue but no mass lesion.
Intraductal papilloma
Intraductal papillomata are the commonest cause of blood stained nipple discharge in younger women. There is seldom any palpable mass. An ultrasound is required and possibly a galactogram.
A 72-year-old woman complains of ‘eczema’ on her left nipple. On examination the areola is erythematous and thickened.
Paget’s disease of the breast
A 68-year-old woman is assessed in the breast clinic after having an abnormal mammogram. Clinical exam of the breast reveals a small fixed lump in the right breast. What is the most common type of breast cancer?
Invasive ductal carcinoma (no special type) is the most common type of breast cancer
A 32-year-old woman presents with a tender breast lump. She has a 2 month old child. Clinically there is a tender, fluctuant mass of the breast.
The correct answer is: Breast abscess
This lady is likely to be breast feeding and is at risk of mastitis. This may lead to an abscess if not treated. Staphylococcus aureus is usually the causative organism.
A 48-year-old lady presents with discomfort in the right breast. On examination she has a discrete soft fluctuant area in the upper outer quadrant of her right breast. A mammogram is performed and a ‘halo sign’ is seen by the radiologist.
The correct answer is: Breast cyst
Lesions such as breast cysts compress the underlying fat and produce a radiolucent area (halo sign). If symptomatic these cysts should be aspirated.
A 20-year-old lady presents with a mobile lump in the upper outer aspect of her right breast. On examination she has a firm mobile mass in the upper outer quadrant of her right breast.
The correct answer is: Fibroadenoma
Fibroadenomas account for 60% of discrete breast lesions in the 18-25 year age group. They are mobile lesions. Core biopsy should be performed in lesions measuring more than 4cm in diameter.
A 48-year-old woman presents to her GP after finding a suspicious lump in her left breast. After referral to a breast surgeon, she is found to have a 1.5cm HER2+ carcinoma. On clinical examination she has no palpable axillary lymph nodes, but her pre-operative axillary ultrasound shows several suspicious looking nodes.
What next step should be taken to manage the patient’s axilla?
In women with breast cancer and no palpable lymphadenopathy, if a pre-operative axillary ultrasound is positive then they should have a sentinel node biopsy to assess the nodal burden
An obese woman presents with an irregular lump on the lateral aspect of her right breast associated with skin tethering. Biopsy excludes a malignant cause.
Fat necrosis
A 35-year-old woman complains of ‘lumpy’ breasts. Her symptoms are worse in the premenstrual period.
Fibroadenosis
A 26-year-old woman has noticed a discrete, non-tender lump which is highly mobile on examination.
The correct answer is: Fibroadenoma
A 66-year-old woman was recently diagnosed with breast cancer. After undergoing a mastectomy, her oncologist has started her on anastrozole to reduce the risk of recurrence.
She has a history of depression and hypothyroidism, for which she takes fluoxetine and levothyroxine respectively.
What complication is she most likely to experience with her breast cancer treatment?
Aromatase inhibitors (e.g. anastrozole) may cause osteoporosis
A 23-year-old lady has presented to her GP with a lump on her right breast. She does not have a family history of breast cancer.
On examination, there is a smooth, rubbery, mobile mass measuring 3.5cm in diameter and with clearly defined edges.
She has had an ultrasound of her breasts which reports that there is a single round solid mass of 3.5cm diameter, which is well circumscribed and lobulated.
What is the diagnosis?
What would her treatment be?
Breast fibroadenoma: surgical excision is usual if >3cm
A 53-year-old lady presents with a creamy nipple discharge. On examination she has discharge originating from multiple ducts and associated nipple inversion.
The correct answer is: Duct ectasia
Duct ectasia is common during the period of breast involution that occurs during the menopausal period. As the ducts shorten they may contain insipiated material. The discharge will often discharge from several ducts.
A 44-year-old female presents to the GP with change of the skin surrounding her nipple. She believes it has become thicker and redder over the last 2 months. She has no past medical history of note.
The correct answer is: Paget’s disease of the breast
This is a typical presentation of Paget’s disease of the breast associated with reddening and thickening of the nipple/ areola. It may resemble eczema.
A 57-year-old woman has breast cancer and, among her other treatments, she is being given trastuzumab.
Which of the following is a reason for treating breast cancer with trastuzumab?
HER2 +ve women can be given herceptin (trastuzumab)
What is the heritability of the BRCA1 gene?
Both children and her sister have a 50% chance of inheriting the gene
Autosomal dominant
A 29-year-old female presents with a lump in her left breast. She is very worried as it appeared suddenly over a month ago describes it as being located below the nipple. As well as this she has noted there is mild tenderness to the lump. She is not aware of any triggers or trauma. On examination, a well-defined, 2cm mobile mass is felt in the left breast. There is no skin discolouration or discharge.
What is the most likely diagnosis?
Fibroadenoma
A 55-year-old lady has undergone a wide local excision and sentinel lymph node biopsy for breast cancer. The histology report shows a completely excised 1.3cm grade 1 invasive ductal carcinoma. The sentinel node contained no evidence of metastatic disease. The tumour is oestrogen receptor negative.
Radiotherapy
Radiotherapy is routine following breast conserving surgery. Without irradiation the local recurrence rates are approximately 40%.
A 30-year-old breastfeeding mother presents to GP with a 3-day history of a left inflamed nipple. There is mild tenderness around the nipple but she is continuing to breastfeed. She is afebrile and vital signs are within normal range.
What do you tell her?
First-line management of mastitis is to continue breastfeeding
A 40-year-old female presents to the GP with unusual discharge from her breast. She has no children and is not breastfeeding but is complaining of blood stained discharge from her nipple.
The correct answer is: Duct papilloma
A breast or duct papilloma is a local area of epithelial proliferation in large mammary ducts and may present with blood stained discharge.
A 18-year-old female notices a non tender mobile breast lump. Clinically there is a smooth lump which is not tethered to the skin.
The correct answer is: Fibroadenoma
Also called a breast ‘mouse’ due to its mobility. It is a benign condition arising from the breast lobule. May enlarge in pregnancy.
Ultrasound of the breast and of the right axillary lymph node show a ‘snowstorm’ sign. What is the most likely diagnosis?
The ‘snowstorm’ sign on ultrasound of axillary lymph nodes indicates extracapsular breast implant rupture.
A 28-year-old woman gave birth two weeks ago.
Today, she has presented to the general practitioner with two days of right breast pain and a tender area that feels firm, warm and swollen, and looks erythematous.
She had reduced milk output.
What is the most likely diagnosis?
What is the most appropriate management?
The patient is suffering from lactational mastitis
First-line management of mastitis is to continue breastfeeding
Flucloxacillin is prescribed for 10-14 days if the patient is systemically unwell
What is Paget’s disease of the nipple?
It can present with skin changes suggestive of eczematous skin changes, but is associated with breast malignancy.
Paget’s disease is an eczematoid change of the nipple associated with an underlying breast malignancy and it is present in 1-2% of patients with breast cancer.
A 38-year-old lady has undergone a mastectomy and axillary node clearance for invasive ductal carcinoma. The histology report shows a completely excised 3.5cm lesion which is grade 3. Two of the axillary lymph nodes contain metastatic disease. The tumour is oestrogen receptor negative.
The correct answer is: Cytotoxic chemotherapy62%
The combination of a grade 3 tumour and axillary nodal metastasis in a young female would attract a recommendation for chemotherapy. Some may also add herceptin (if they are HER 2 positive).
A 74-year-old woman presents with an erythematous rash originating in the nipple. It is spreading to the surrounding areolar area and the associated normal tissue.
Paget’s disease of the nipple
Paget’s is associated with DCIS or invasive carcinoma.Unlike eczema of the nipple which predominantly affects the areolar region, Pagets will usually affect the nipple first and then spread to the areolar area. Diagnosis is made by punch biopsy
A 60-year-old woman, who experienced premature menopause, has been diagnosed with breast cancer that is ER +ve. Which of the following is an appropriate treatment for this woman due to her tumour being ER +ve?
Tamoxifen is used in ER +ve women who are pre- or perimenopausal, aromatase inhibitors are used in those who are post-menopausal
NHS Breast Screening Programme (2)
women aged 47-73 years
Women are offered a mammogram every 3 years
A 71-year-old woman with no co-morbidities presents with a T2 HER2+ breast carcinoma.
On clinical examination she has palpable axillary lymph nodes, and an ultrasound-guided needle biopsy confirms nodal metastasis.
On discussion with the surgeon, the patient decides emphatically that she does not want any surgery to the axilla.
What non-surgical option is available to manage the patient’s axillary metastases?
In patients with breast cancer who present with clinically palpable lymphadenopathy, axillary node clearance is indicated at primary surgery
A 48-year-old female attends for an appointment with her GP as she has been experiencing some green-brown coloured nipple discharge.
She is otherwise well and denies any other changes to her breasts.
She has had 3 children which she has breastfed and isn’t on any hormonal contraception.
What is the most common cause of brown-green nipple discharge?
Brown-green nipple discharge is most commonly associated with duct ectasia.
A 34-year-old female presents with a 1-month history of a breast lump. She first noticed it after she tripped and fell over. It was initially firm. On examination, there is a hard irregular lump.
The correct answer is: Fat necrosis
Fat necrosis is typical in obese women with large breasts and may follow trivial or unnoticed trauma. It is typically firm initially and may develop into a hard and irregular lump.
A 60-year-old woman with a T4N0M0 primary triple-negative breast carcinoma is seen in a pre-operative breast oncology clinic, where the oncologist suggests that a course of neo-adjuvant chemotherapy (NACT) would be beneficial.
What should the patient be aware of when considering whether to undergo NACT?
A key reason for considering neo-adjuvant chemotherapy in breast cancer is to try to downsize the tumour before surgery and allow breast conserving surgery rather than mastectomy
Fat necrosis (4)
- More common in obese women with large breasts
- May follow trivial or unnoticed trauma
- Initial inflammatory response, the lesion is typical firm and round but may develop into a hard, irregular breast lump
- Rare and may mimic breast cancer so further investigation is always warranted
