Obs + Gynae - Breast

Question 1

Name 5 risk factors for breast cancer

Answer 1

• Previous Hx
• Age
• Family history
• Genetic factors (BRCA1 - chromosome 17, BRCA2 - chromosome 13 and TP53 mutations carry very high risk)
• Nulliparity (or first child after age 30)
• Not having breast-fed (breast-feeding is protective)
• Early menarche/late menopause
• Radiation to chest
• Obesity and the consumption of alcohol
• HRT
• Combined oral contraception

Question 2

What chromosome is BRCA1 on?

Answer 2

chromosome 17

Question 3

What chromosome is BRCA2 on?

Answer 3

chromosome 13

Question 4

Name 3 staging investigations for breast cancer

Answer 4

• ER/Epidermal growth factor/progesterone receptor (PR) status
• Blood tests (LFTs)
• CXR (CT if metastases)
• Bone scintigraphy
• Positron Emission Tomography (PET)

Question 5

Name a diagnostic investigation for breast cancer

Answer 5

Core needle/open/excision/incisional biopsy, Fine needle aspiration

Question 6

What do T, N and M mean in context of breast cancer staging?

Answer 6

T = primary tumour, N = regional lymph nodes, M = (presence of metastases)

Question 7

Name the 4 principal treatment modalities for breast cancer?

Answer 7

Surgery, Chemotherapy, Radiotherapy, Hormonal therapy

Question 8

How do aromatase inhibitors work?

Answer 8

They block conversion of androgens to oestrogen in peripheral tissues.
(Anastrozole and letrozole are non-steroidal aromatase inhibitors. Exemestane is a steroidal aromatase inhibitor)
(Aromatase inhibitors are prescribed as initial adjuvant therapy in postmenopausal women with oestrogen-receptor-positive tumours)

Question 9

Name the most commonly used ER blocker drug used for ER positive tumours

Answer 9

Tamoxifen

Question 10

Name the most commonly used monoclonal antibody used for HER2 positive tumours

Answer 10

Trastuzumab

Question 11

How often is breast cancer screening and for what age?

Answer 11

The NHS breast cancer screening program offers a mammogram every 3 years to women aged 50 – 70 years

Question 12

NICE guidelines (Jan 21) recommend a two week wait referral for suspected breast cancer for what symptoms?

Answer 12

An unexplained breast lump in patients aged 30 or above
Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes)

(also consider for lump in axilla or skin changes suggestive of breast ca)

Question 13

Triple diagnostic assessment for breast cancer?

Answer 13

• Clinical assessment (history and examination)
• Imaging (ultrasound or mammography)
• Biopsy (fine needle aspiration or core biopsy)

Question 14

Which scan is more useful in younger and which more useful in older women?

Answer 14

• Ultrasound scans are typically used to assess lumps in younger women (e.g., under 30 years). They are helpful in distinguishing solid lumps (e.g., fibroadenoma or cancer) from cystic (fluid-filled) lumps.
• Mammograms are generally more effective in older women. They can pick up calcifications missed by ultrasound.
• MRI scans may be used:
  For screening in women at higher risk of developing breast cancer (e.g., strong family history)
  To further assess the size and features of a tumour

Question 15

2 Ls and 2 Bs of breast cancer metastasis

Answer 15

L – Lungs
L – Liver
B – Bones
B – Brain

Question 16

First-line hormone treatment for premenopausal vs postmenopausal women with oestrogen-receptor positive tumours?
(+ how long is it given?)

Answer 16

• Tamoxifen for premenopausal women
• Aromatase inhibitors for postmenopausal women (e.g., letrozole, anastrozole or exemestane)
  (+ for 5 – 10 years)

Question 17

Tamoxifen increases risk of which cancer?

Answer 17

Endometrial cancer

Question 18

What is a breast mouse?

Answer 18

Fibroadenoma

Question 19

Fibroadenoma features

Answer 19

• Painless
• Smooth
• Round
• Well circumscribed (well-defined borders)
• Firm
• Mobile (moves freely under the skin and above the chest wall)
• Usually up to 3cm diameter

Question 20

When are fibrocystic breast changes most likely to occur?

Answer 20

Symptoms often occur prior to menstruating (within 10 days) and resolve once menstruation begins. Symptoms usually improve or resolve after menopause.

Question 21

Management of Fibrocystic breast changes

Answer 21

• Wearing a supportive bra
• Non-steroidal anti-inflammatory drugs (NSAIDs) (ibuprofen)
• Avoiding caffeine is commonly recommended
• Applying heat to the area
• Hormonal treatments (e.g., danazol and tamoxifen) under specialist guidance

Question 22

Fat necrosis features in breast

Answer 22

• Painless
• Firm
• Irregular
• Fixed in local structures
• There may be skin dimpling or nipple inversion

(It may resolve spontaneously with time. Surgical excision may be used if required for symptoms)

Question 23

What does a breast cyst feel like?

+ what age most commonly?

Answer 23

• Smooth
• Well-circumscribed
• Mobile
• Possibly fluctuant

(+ most often between ages 30 and 50, more so in the perimenopausal period. They can be painful and may fluctuate in size over the menstrual cycle)

Question 24

What duct is blocked in a Galactocele?

Answer 24

Lactiferous duct

Question 25

Phyllodes tumour management

Answer 25

Treatment involves surgical removal of the tumour and the surrounding tissue (“wide excision”). They can reoccur after removal.

Chemotherapy may be used in malignant or metastatic tumours.

Question 26

The most common causative organism of breast abscess?

Answer 26

Staph aureus

also: Streptococcal species
Enterococcal species
Anaerobic bacteria (such as Bacteroides species and anaerobic streptococci)

(Penicillins (Flucloxacillin) are effective against gram + (S aureus, Strep, Enterococcal)
(Co-amoxiclav covers anaerobes)
( Metronidazole gives excellent anaerobic cover so can also be added to the mix)

Question 27

Mastitis with infection in the breast tissue presents with what breast changes?

Answer 27

• Nipple changes
• Purulent nipple discharge (pus from the nipple)
• Localised pain
• Tenderness
• Warmth
• Erythema (redness)
• Hardening of the skin or breast tissue
• Swelling

Question 28

Management of lactational vs non-lactational mastitis

Answer 28

Lactational mastitis (caused by blockage of lactiferous ducts)

• managed conservatively
• continue breastfeeding / expressing milk
• breast massage
• Heat packs, warm showers and simple analgesia
• Antibiotics (flucloxacillin or erythromycin/clarithromycin where there is penicillin allergy) are required where infection is suspected or symptoms do not improve.

Non-lactational mastitis

• Analgesia
• Antibiotics (broad spectrum - Co-amoxiclav or Erythromycin + metronidazole)
• Treatment for the underlying cause (e.g., eczema or candidal infection)

Question 29

Breast Abscess management

Answer 29

• Referral to the surgical team
• Antibiotics
• Ultrasound (confirm the diagnosis and exclude other pathology)
• Drainage (needle aspiration or surgical incision and drainage)
• Microscopy, culture and sensitivities of the drained fluid

(Women who are breastfeeding are advised to continue breastfeeding when they have mastitis or breast abscesses. They should regularly express breast milk if feeding is too painful, then resume feeding when possible. This is not harmful to the baby and is important in helping resolve the mastitis or abscess)

Question 30

What are women told about breastfeeding if they present with a breast abscess or mastitis?

Answer 30

Women who are breastfeeding are advised to continue breastfeeding when they have mastitis or breast abscesses. They should regularly express breast milk if feeding is too painful, then resume feeding when possible. This is not harmful to the baby and is important in helping resolve the mastitis or abscess.