Breast

Question 1

What are the most common causes of breast lumps in the following age brackets:
- 20-30s
- 30-40s
- 60-70s?

Answer 1

• 20-30s → fibroadenomas, abscesses
• 30s-40s → cysts
• 60-70s → breast cancer

Question 2

What are fibroadenomas? How do they present & how are they managed?

Answer 2

= common benign tumours of stromal/epithelial breast duct tissue.

• More common in women aged 20-40yrs as they are responsive to oestrogen & progesterone.

Presentation:

• Painless, smooth, round lump
• Well circumcised, rubbery, firm
• Mobile under the skin → breast mice
• Usually up to 3cm in diameter
• Often occur in multiples

Diagnosis & Management:

• USS + FNA to confirm
• Surgical excision if >3cm

Question 3

How do breast cysts present (& what is the key difference between this & fibroadenoma), and how are they managed?

Answer 3

• Occur most commonly between ages 30 and 50 → more so in the perimenopausal period.

Presentation:

• Smooth, well-circumcised lumps
• Soft or firm
• Mobile
• May appear rapidly
• Painful → cyclical with periods
• May fluctuate in size over the menstrual cycle.

Diagnosis & Management:

• Ultrasound - shows as a smooth, black filled cyst.
• Mammogram & aspiration → can also help relieve pain. Clear fluid is reassuring.
• Any solid areas remaining after cyst aspiration should be biopsied to exclude intracystic papillary carcinoma.

Diagnosis & Management:

• Ultrasound - shows as a smooth, black filled cyst.
• Mammogram & aspiration → can also help relieve pain. Clear fluid is reassuring.
• Any solid areas remaining after cyst aspiration should be biopsied to exclude intracystic papillary carcinoma.

Question 4

What is duct ectasia & how does it present?

Answer 4

• Ducts can shorten & dilate perimenopausally → inflammation in the ducts leads to intermittent discharge from the nipple.
• Common in smokers
• Symptoms
  
  • Thick or watery discharge, green or bloodstained.
  • Tenderness or pain
  • Slit-like nipple retraction
  • Breast lump, which may produce nipple discharge when pressure applied
• Management → triple assessment, supportive care, reassurance, antibiotics if infection suspected

Question 5

What is an intraductal papilloma & how does it present?

Answer 5

• = a warty lesion that grows within one of the breast ducts, caused by benign epithelial proliferation usually in the ducts near nipples.
• Presentation:
  
  • Common cause of clear or bloody nipple discharge.
  • Tenderness or pain
  • May be a palpable lump → excision is advised to exclude any malignancy.
• Investigations → triple assessment, ductography (filling defect)

Question 6

What are the two types of mastitis? For both, what are the causes & management?

Answer 6

• Lactational mastitis → usually in early weeks postpartum
  
  • Due to poor latch, nipple trauma, milk stasis
  • S.Aureus most common
  • Patients feel very unwell with fever & flu-like illness
  • Management
    
    • Supportive → analgesia, continue breast feeding
    • Treated early with antibiotics → flucloxacillin
    • If an abscess forms it should be drained promptly through aspiration
• Non-lactational → periductal mastitis
  
  • Most commonly seen in smokers.
  • S.Aureus, enterococci, and anaerobic bacteria most common
  • Repeated infection +/- abscess formation at the edge of the areola → fistula formation.
  • Co-amoxiclav is usually first-line.

Question 7

What are the risk factors of breast cancer?

Answer 7

• Increased oestrogen exposure →Early menarche, late menopause, HRT, obesity, nulliparity, obesity
• COCP → small increased risk, but this returns to normal 10 years after stopping the pill
• Age
• Female gender
• Family history (first degree relative)
• BRCA1/2 mutations
• Not having breastfed
• Lifestyle → excessive alcohol & fat intake

Question 8

How is breast cancer managed surgically?

Answer 8

Surgery
- least necessary op
- If clear margin, small in large breast, solitary, peripheral, then WIDE LOCAL EXCISION
-If large in small breast, multiple, central, then MASTECTOMY
- If no palpable lymphadenopathy - PRE-OP USS, if this is -ve then SENTINEL NODE BIOPSY
- if palpable lymphadenopathy - AXILLARY NODE CLEARANCE

Question 9

What are the hormonal therapy options for breast cancer?

Answer 9

• Tamoxifen → for premenopausal women with ER+ cancer
  
  • Side effects → increased risk of endometrial cancer, VTE, and menopausal symptoms
• Aromatase inhibitors → postmenopausal women with ER+ cancer, eg letrozole, anastrozole

Question 10

What biological therapy can be given to HER2 positive breast cancer?

Answer 10

Herceptin/trastuzumab