Malignant Breast Surgery

Question 1

What is breast carcinoma in-situ?

Answer 1

• Malignancies contained within basement membrane tissue.
• Seen as pre-malignant condition typically found on imaging and rarely symptomatic at presentation

Question 2

What are types of Carcinoma In-Situ?

Answer 2

• Ductal Carcinoma In-Situ
  
  • Type of non-invasive breast malignancyv(20% of Breast cancers)
  • Malignancy of ductal tissue of breast contained within basement membrane. 20-30% develop invasive disease
• Lobular Carcinoma In-Situ
  
  • Malignancy of secretory lobules of breast contained within basement membrane.
  • Rarer than DCIS however LCIS at greater risk of developing invasive breast malignancy.
  • Usually diagnosed before menopause

Question 3

What are investigations for ductal carcinoma In-Situ?

Answer 3

• Mammography
  
  • Microcalcification on either localised or wide spread.
• Confirmed on biopsy

Question 4

How are ductal carcinoma In-Situ managed?

Answer 4

• Complete wide excision
• Widespread or multifocal DCIS
  • normally requires complete mastectomy.

Question 5

What are investigations for Lobular Carcinoma In-Situ?

Answer 5

Incidental finding during biopsy of breast

Question 6

How is a Lobular Carcinoma In-Situ managed?

Answer 6

• Low grade LCIS
  
  • Usually treated by monitoring
• Bilateral prophylactic mastectomy potentially indicted if individuals possess BRCA1 or BRCA2 genes

Question 7

What are the types of Invasive Breast Cancer?

Answer 7

• Invasive ductal Carcinoma
  
  • Most common type of carcinoma.
  • Further classified into tubular, cribiform, papillary, mucinous or medullary carcinoma showing distinct patterns of growth
• Invasive Lobular Carcinoma
  
  • More common in older women.
  • Characterised by diffuse pattern of spread that makes detection more difficult. By time of diagnosis, tumours often quite large
• Medullary carcinoma
• Colloid carcinoma

Question 8

How is Invasive Breast Cancer screened?

Answer 8

Women 50-70 years have mammogram every 3 years

• Nodal status is most important prognostic factors

Question 9

What are Risk Factors for Invasive Breast Cancer?

Answer 9

• Female sex and age: risk doubles every 10 year till menopause
• Mutation to certain genes (BRCA1 and BRCA2)
• Family history
• Previous benign disease
• Obesity
• Alcohol consumption
• Geographic variation
• Degree of exposure to unopposed oestrogen
  
  • Factors influencing this include early menarche, late menopause, nulliparous women, first pregnancy after 30 years of age and oral contraceptive or HRT use

Question 10

What are investigations for an Invasive Breast Cancer?

Answer 10

Triple assessment

• Examination
• Imaging
• Histology/cytology

Question 11

Which receptors are targeted in therapies for Invasive Breast Cancer?

Answer 11

• Oestrogen Receptor
• Progesterone Receptor
• Human epidermal growth factor receptor status

Question 12

What are differentials for Paget’s disease of Nipple?

Answer 12

• Dermatitis
• Eczema (doesn’t affect nipple whereas Paget’s Disease does)

Question 13

What is Paget’s disease of the Nipple?

Answer 13

• Rare condition presents as roughening, reddening and slight ulceration of nipple.
• Vast majority have an underlying neoplasm either in situ or invasive.
  
  • Microscopically there is involvement of epidermis by malignant ductal carcinoma cells

Question 14

What is the clinical presentation of Paget’s Disease of the Nipple?

Answer 14

• Itching or redness in nipple and/or areola with flaking and thickened skin on or around the nipple
• Area often painful and sensitive
• Flattened nipple with or without yellowish or bloody discharge

Question 15

What are investigations and management of Paget’s disease of the Nipple?

Answer 15

• Triple Assessment
  
  • Complete breast and axilla examination
  • Mammogram, ultrasound or MRI may be warranted
  • Biopsy needed to confirm diagnosis
• Management
  
  • Surgical
  • Radiotherapy

Question 16

What is Mastalgia?

Answer 16

• Refers to breast pain concern is related to breast cancer.
• Incidence of breast malignancy associated with mastalgia is low.
• Thorough assessment requires to determine cause of pain and hopeful reassure and manage their symptoms

Question 17

What are classifications of Mastalgia?

Answer 17

• Cyclical
  
  • Pain associated with menstrual cycle.
  • Caused by hormonal changes therefore most cases come in those actively menstruating or using HRT
• Non-cyclical
  
  • Caused by medication including hormonal contraceptives, anti-depressants (sertraline) or antipsychotic drugs (haloperidol)
• Extra-mammary
  
  • Chest wall pain and shoulder pain

Question 18

What are clinical featres of Mastalgia?

Answer 18

• Lumps
• Skin changes
• Fevers
• Discharge
• Association with Menstrual Cycle

Question 19

What are specific question to ask for history of Mastalgia?

Answer 19

• Drug history
• Breast-feeding
• Pregnancies
• Previous Medical history
• Family history

Question 20

What are investigations for Mastalgia?

Answer 20

• Pregnancy test
• Breast pain in isolation with no other relevant features on history or examination not an indication for imaging

Question 21

How is Mastalgia managed?

Answer 21

• Reassurance and pain control
  
  • 1st line: NSAIDs, Paracetamol
  • 2nd line treatment: Danazol, an anti-gonadotrophin agent
• Cyclical breast pain should include better fitting bra or soft-support bra during the night
• Referral to specialist may be warranted.