Breast

Question 1

Differentials for nipple discharge

Answer 1

Physiological
Galactorrhoea
Hyperprolactinaemia
Mammary duct ectasia
Carcinoma
Intraductal papilloma

Question 2

Common causes of breast pain

Answer 2

Cyclical pain = hormonal changes
Non-cyclical = medication (hormonal contraceptives), infection (mastitis), pregnancy

Question 3

Management for cyclical breast pain

Answer 3

Wear supportive bra
Simple analgesia (NSAIDs)
Avoid caffeine
Apply heat to area
Hormonal Tx = danazol, tamoxifen

Question 4

Risk factors for breast cancer

Answer 4

• Lobular Carcinoma In Situ
• Late first childbirth (>35)
• Alcohol consumption
• ADH
• HRT for greater than 5 years
• COCP (returns to normal 10 yrs after stopping pill)
• Obesity (post menopausal)
• BRCA 1 and 2

Question 5

What is the screening programme for breast cancer?

Answer 5

Mammography (XR)
o MRI screening for BRCA gene carriers from age 30
o Offered every 3 years to women aged 50-70

Question 6

Presentation of breast cancer

Answer 6

• Fixed, hard, irregular non-tender lump
• Nipple discharge
• Nipple indrawing
• Nipple inversion
• Skin tethering
• Skin dimpling or oedema
• Lymphadenopathy (particularly in axilla)

Question 7

What are the different types of breast cancer?

Answer 7

• Ductal carcinoma in situ (DCIS)
• Lobular carcinoma in situ (LCIS)
• Invasive ductal carcinoma (no special type) = most common
• Invasive lobular carcinoma
• Inflammatory breast cancer
• Paget’s disease of nipple = Eczematoid change of nipple, starts at nipple and spreads to areola

Question 8

Investigations for breast cancer

Answer 8

• Mammography (older women) or USS (younger women)
• MRI scanning = Women at higher risk of developing breast cancer
• Core biopsy or fine needle aspiration
• Lymph node assessment

Question 9

What is the 2WW referral criteria for breast cancer?

Answer 9

• Unexplained breast lump if aged 30+
• Unilateral nipple changes in patients aged 50+
• Consider for unexplained lump in axilla if aged 30+
• Consider for skin changes suggestive of cancer
• Non-urgent referral for lumps if aged <30

Question 10

Surgical management options for breast cancer

Answer 10

o Breast conservation + whole breast radiotherapy = solitary lesion, peripheral, small lesion in large breast, <4cm
o Mastectomy = multifocal, central, large lesion in small breast, >4cm
o Axillary clearance

Question 11

What are the pharmacological options for breast cancer?

Answer 11

Chemotherapy
o Neoadjuvant therapy = shrink tumour before surgery
o Adjuvant therapy = after surgery to reduce recurrence

Hormone treatment given for (5-10 years) Oestrogen receptor +ve
o 1st line = tamoxifen (premenopausal women)
o Aromatase inhibitors (letrozole) for postmenopausal women

Biological therapy
o Trastuzumab (Herceptin) = targets HER2 receptor
o Pertuzumab (Perjeta) = HER2 receptor
o Neratinib (nerlynx)

Question 12

When is radiotherapy given in breast cancer?

Answer 12

o Whole breast radiotherapy recommended after a woman has had wide-local excision
o For mastectomy, RT offered for T3-T4 tumours and those with 4+ positive axillary nodes

Question 13

What follow up is given for women treated with breast cancer?

Answer 13

Surveillance mammograms yearly for 5 years

Question 14

Where does breast cancer metastase to?

Answer 14

Lungs, liver, bones, brain (2L and 2B)

Question 15

Complication of breast surgery

Answer 15

Chronic lymphoedema
Axillary web syndrome
Brachial plexus injury

Question 16

What are the side effects of radiotherapy?

Answer 16

o General fatigue
o Local skin and tissue irritation and swelling
o Fibrosis of breast tissue
o Shrinking of breast tissue
o Long term skin colour changes

Question 17

How does a fibroadenoma present?

Answer 17

• Painless, Smooth, Round, firm, mobile lump
• Well circumscribed
• Usually up to 3cm
• More common in younger women (20-40)

Question 18

Management for a fibroadenoma

Answer 18

> 3cm = surgical excision

Question 19

What is a breast cyst?

Answer 19

benign, individual fluid-filled lump

Question 20

How does a breast cyst present?

Answer 20

• Painful and fluctuate in size over menstrual cycle
• Smooth
• Well-circumscribed
• Mobile
• Possibly fluctuant

Question 21

What is Fat necrosis in the breast?

Answer 21

benign lump formed by localised degeneration and scarring of fat tissue in breast

Question 22

What can trigger fat necrosis?

Answer 22

Localised trauma
Radiotherapy
Surgery

Question 23

How does fat necrosis present?

Answer 23

• Painless, firm, irregular lump
• Fixed in local structures
• Skin dimpling or nipple inversion

Question 24

How does a lipoma present?

Answer 24

• Soft, painless, mobile lump
• Do not cause skin changes

Question 25

What are the differentials of a breast lump?

Answer 25

Breast cancer Fibroadenoma Breast cyst Fat necrosis Lipoma

Question 26

What are the risk factors for a breast abscess?

Answer 26

Smoking Damage to nipple = nipple eczema, candida infection, piercings Underlying breast disease

Question 27

What are the causes of a breast abscess/mastitis?

Answer 27

- Staph. Aureus - Streptococcus - Enterococcal - Anaerobic bacteria

Question 28

How dose a breast abscess/mastitis present?

Answer 28

- Acute onset (few days) - Swollen, fluctuant, tender lump - Nipple changes - Purulent nipple discharge - Localised pain - Warmth - Erythema - Hardening of skin or breast tissue

Question 29

What is the management of lactational mastitis

Answer 29

o Continue breastfeeding and expressing milk o Breast massage o Heat packs, warm showers o Single analgesia o Abx (flucloxacillin or erythromycin for 10-14 days) = infection suspected or symptoms not improve

Question 30

What is the management of non-lactational mastitis

Answer 30

o Analgesia o Abx (co-amoxiclav or erythromycin + metronidazole) o Treatment of underlying cause

Question 31

What is the treatment of a breast abscess?

Answer 31

o Referral to on-call surgical team o Abx o US o Drainage = needle aspiration or surgical incision and drainage o MCS of drained fluid

Question 32

Adverse affects of tamoxifen

Answer 32

menstrual disturbance: vaginal bleeding, amenorrhoea hot flushes - 3% of patients stop taking tamoxifen due to climacteric side-effects venous thromboembolism endometrial cancer

Question 33

Adverse affects of aromatase inhibitors (letrozole and anastrozole)

Answer 33

osteoporosis = NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer hot flushes arthralgia, myalgia insomnia