Breast

Question 1

Breast exam: Why raise arms above head?

Answer 1

Strains ligaments of Astley Cooper and may bring to light a previously unnoticed skin dimple or inverison caused by an underlying breast cancer

Question 2

How to check if a breast lump is tethered?

Answer 2

Ask pt to place hands on hip and push inwards - will tense pec major - if lump fixed to that, mobility when you move it will decrease.

Question 3

Breast Cancer: Risk Factors

Answer 3

1) FH:
- 1st vs 2nd degree relative
- Uni vs bilateral
- Usually AD with variable penetrance
- BRCA1 (Chr17) - 2% Askenazi Jews, commoner with FH breast/ovarian cancer
- BRCA2 (Chr13)

2) Oestrogen exposure
- Late menarche, early menopause, young pregnancy, parity = lower risk
nb. Pregnancy >35 increased risk
- OCP
- HRT - taken beyond age of 55 = small risk, typically 3-5 extra cancers per 1000 women over 5 years (stops after)
- -> Oestrogen only HRT = smallest risk, Combined is largest

3) Previous Breast disease

4) Other:
- Obesity: Peripheral androgenisation of oestrigens
- High socioeconomic, sat fats, alcohol

Question 4

Breast MDT team?

Answer 4

Consultant breast surgeon
Consultant oncologist
Breast care nurse/ CNS
Radiologist
Histopathologist
Cytologist
MDT coordinator.
\+- Plastics, genetics, palliative care

Question 5

Triple assessment?

Answer 5

History + Examination

Mammography (>40) / US (if under 40)

Question 6

Painful vs Painless breast lumps?

Answer 6

Painless:

• cancers (painless + Unremitting growth)
• Cysts/fibroadenomas can also be painless

Painful:
Lumpy breast tissue (fibrocystic disease)
- Periductal mastitis
- Benign cystic disease
- Fibroadenomas

Question 7

FNA?

Answer 7

• 10ml synringe + green needle inserted into lump
• Cyst will disappear as soon as aspirated
• Contents of needle expressed onto slide, smeard with another slide, air dried or fixed + sent to pathologist for H&E stain + interpretation

Cytology score from C1- C5 
C1 - Insufficient material
C2 - Benign
C3 - Atypical cells, probably benign
C4 - Suspicious of malignancy
C5 - Malignant

Question 8

Mammography - Breast views?

Breast cancer Px?

Which cancer is classically missed

Answer 8

Craniocaudal + oblique

Breast cancer - classically a white asymmetrical spiculated lesion containing microcalcification

DICS may just be a cluster of microcalcification

Lobular carcinoma (about 10% of all breast cancers) classically missed –> MRI more sensitive.

Question 9

Core biopsy?

Answer 9

Performed in FNA score is C1-C3/ radiology/clinical examination suspicious of breast cancer
–> Can then be sent for histology and can differentiate between invasive and In situ cancer.

Question 10

Breast Cancer stage General Mx

Answer 10

Stage I/II - Surgical resection

Stage III/IV - Avoid surgery unless to gain local control eg. fungating/ painful tumour

Question 11

Conservation surgery for breast?

Answer 11

WLE + limited axillary surgery + radiotherapy

- For small primary tumours (

Question 12

When would single masectomy be advised?

Answer 12

• Tumour >4cm
• Large tumour in small breast
• Won’t achieve good cosmetic result
• Nipple involvement
• Multifocal disease
• -> NB. all women must be counselled about reconstructive options
• Radiotherapy not necessary unless tumour close to chest wall or greater than >5cm. Radiotherapy compromises the subsequent quality of any reconstruction

Question 13

Surgical Mx of impalpable cancer?

Answer 13

Stereotactic localisation under mammographic control

• Needle placed into area of microcalcification
• Pt has area of breast containing needle + margin excised
• Excised specimen X-rayed to ensure entire area of calcification removed

Question 14

Single best predictor of survival from breast cancer?

Answer 14

Involvement of axillary lymph nodes

- No. of local nodes containing tumour reflects possibility of wide spread (micro)mets

Question 15

Axillary Tx in Breast cancer?

Axillary clearance levels?

Answer 15

1) US guided FNA pre-op to sort out node-positive pts who need axillary node dissection
- -> If scan/FNA clear -> SNB
- If histology from SNB +ve - Second operation to clear rest from axilla

Axillary clearance: Removing nodes up to first axillary vein (level I)

• Medial border of pec minor (level 2)
• Border of first rib (level 3)

Question 16

SNB procedure

Answer 16

1) Preoperative injection of radioisotope + blue dye into skin of breast
2) During surgery, combined use of radioisotope _ colour to track sentinal node(s). If histology +ve, second operation to clear rest from axilla

Question 17

Axillary node clearance risks?

Answer 17

The more extensive the node removal, the greater the risk of dmg to the sensory nerves of the axilla (intercostobrachial nerves)
- Lymphoedema of breast, hand, forearm and/or arm

Question 18

Difference between in situ/ invasive breast cancer

Answer 18

In situ - has not breached the basement membrane of the duct and is a risk for the development of invasive disease

–> Surgery can eliminate the risk

Question 19

Untreated DCIS risk rate?

What is the other type of carcinoma ins itu

Answer 19

20-30% of pts with untreated DCIS will progress to invasive breast cancer within 10 years

• Lobular carcinoma in situ
• Rarer and tends to be multi-focal

Question 20

Most common type of invasive breast cancer? Other types?

Answer 20

80% are NOS (not otherwise specified)
Other types are named based on morphology:
- Lobular
- Tubular
- Medullary
- Mucinous
- Papillary

–> Special types tend to have a better prognosis than NOS

Question 21

What is Paget’s disease of the nipple?

Answer 21

Unilateral, red, eczematous lesion of the nipple and area that may ulcerate and bleed.

• Histology shows infiltrating malignant cells
• Usually an underlying invasive/DCIS breast cancer

Tx: usually masectomy

Question 22

Grading of breast cancer. Name & Components?

Other prognostic factors?

Answer 22

Bloom-Richardson method:

• Number of mitoses
• Tubule formation
• Degree off nuclear polymorphism
• -> total score assigned to appearance of tumour microscopically.

Grade influences prognosis:

• Grade I : good prognosis
• Grade II: intermediate
• Grade III: Poor

Other factors: max tumour diameter, no. of lymph nodes (most important)

Question 23

Adjuvant vs neoadjuvant?

Answer 23

Neoadjuvant - before surgery, to shrink size of tumour

Adjuvant - after therapy, to reduce risk of recurrence and death (by 20%) due to micrometastases.

Question 24

Adjuvant chemotherapy options

Answer 24

• Combination chemotherapy, particularly regimes containing anthracyclines are more effective than single0agent chemo. 6 cycles of cytotoxic chemo once a month is norm

Question 25

Endo therapy in breast cancer?

Answer 25

- Adjuvant endo therapy not used if primary does not contain ER - Optimal duration for endo tx is 5 yrs Oestrogen-receptor antagonists (tamoxifen) in premenopausal women Aromatase inhibitors (Arimidex) in postmenopausal women nb. Ovarian ablation by chemical/oophorectomy also effective reduces the risk of recurrence and death from breast cancer in premenopausal but rarely used

Question 26

Monoclonal therapy in breast cancer?

Answer 26

Herception - target HER2/neu oncoprotein

Question 27

Tx of advanced (Stage III/IV/recurrent breast cancer)

Answer 27

1) Bone scan, CT scan of lungs/liver, FBC 2) Biopsy/histology to find out ER status - -> Stage III with no evidence of mets can be treated with neoadjuvant therapy + surgical resection, followed by adjuvant chemo and radiotherapy Local recurrence of previous WLE --> Masectomy if no mets Mets: Tx generally palliative - No sx - ?don't treat - Bone mets/pain --> bisphosphonates + radiotherapy

Question 28

Breast cancer: routes of spread

Answer 28

1) Direct extension - muscle/chest wall, resulting in fixity, to skin (ulceration which may bleed/get infected) 2) Lymphatics (Oedema of overlying skin becomes pitted by adherence of sweat ducts and hair follicles - Peau d'orange + lymphoedema of arm) 3) Haematologically: Bones, lungs, liver 4) Transcoelomic spread - pleural seeding leading to malignant pleural effusion

Question 29

DCIS Mx

Answer 29

Impalpable? WLE under stereotactic guidance - Margins not clear? - Re-excision IF grade II/III - Radiotherapy IF extensive DCIS involving large areas of breast, >40mm or multifocal: - Mastectomy +- reconstruction

Question 30

Breast screening programme?

Answer 30

Women aged 47-73 invited every 3yrs for mammograms - 60 cancers per 10 000 attendees picked up - Mammography required highly trained radiologists and detects around 93% of breast cancers

Question 31

Breast reconstruction types?

Answer 31

- Becker prosthesis placed under Pec Major (Simplest) - Autologous tissue flaps (lat dorsi/rectus) can be combined with implants to increase breast volume - useful where skin replacement needed - nipple reconstructed in subsequent operation. Aim of reconstruction is to create symmetry so augmentation or reduction of opposite breast may be necessary

Question 32

Lumpy breast tissue cause?

Answer 32

Benign fibrocystic breast disease - Oestrogen/progesterone during luteal phase --> Epithelial proliferation & increased vascularity - lumpy tender breast tissue Benign cystic disease of breast - PC 5/10 years before menopause when terminal ducts undergo apoptosis and leave an isolated TLAU which continues to produce fluid

Question 33

Fibroadenoma of breast? Tx

Answer 33

Benign discrete lumps in breast - Overgrowth of collagenous mesenchyme which surrounds each terminal lobuloalveolar unit (TLAU) and usually presents before the age of 30. Tx: Conservatively, or excised as day case Occasionally grow to great size (Giant fibroadenoma)

Question 34

Mastalgia

Answer 34

Either: 1) Cyclical, occurring in the week prior to menses - Common, lasts 4-5/7 - Evening primrose oil may help, if taken for ATLEAST 2/12 2) Unrelated to menstrual cycle - pain down breast and nipple associated with pain in axilla and radiation down arm - Associated with back pain in 15% Nb: Tietze's - costochondritis may present similarly --> Classic sign = pain on pressing costal cartilage - NSAID

Question 35

Mastitis - Epidemiology - Types - organism - Mx

Answer 35

- Commonly affects women of childbearing age Lactational infection: - During breast feed - PC: pain + swelling + tenderness - Usually S.aureus Tx. Fluclox - Treat abscesses with repeated aspiration + Abx so women can continue to breastfeed. If abscess persist - breastfeeding should be stopped by switching baby to bottle + surgical I+D Non-lactational aka. periductal mastitis: - Periareolar region - Complications commoner in smokers - Major ducts under areola become dilated (duct ectasia) - May be interstitial lymphocytic infiltrate - Major Complication: Rupture of one or more ducts --> Rupture through skin : mammillary fistula Mx: Difficult. Excision of whole major duct system

Question 36

Nipple discharge

Answer 36

- Physiological discharge common: ranges from white-green-black - Other non-malignant cause = duct papilloma - -> blood stained d/c from single duct DDx: - underlying carcinoma - if sinister causes ruled out, tx is duct excision (hatfield's procedure) 'if you imagine your nipple is a clockface, how many hours is it coming out from' - Is it spontaenous or on squeezing

Question 37

Breast screening

Answer 37

- All women aged 47-70 - 2 views every 3 years - Double reporting - Recall to screening unit for further views or additional imaging

Question 38

How does paget's differ from nipple eczema?

Answer 38

It involves the nipple primarily and only latterly spreads to the areolar (the opposite occurs in eczema). Diagnosis is made by punch biopsy, mammography and ultrasound of the breast.

Question 39

Fibroadenomas?

Answer 39

Under the age of 25 years the breast is usually classified as undergoing development. Lobular units are being formed and a dense stroma is formed within the breast tissue. This may result in the development of fibroadenomas. As a group fibroadenomas account for 13% of all palpable breast lesions. However, in women aged 18-25 they constitute up to 60% of all palpable breast lesions. The are classified as juvenile, common and giant. The former occur in early adolescence and the latter are characterised by a size greater than 4cm. In young females with small fibroadenomas (less than 3cm on imaging) a policy of watchful waiting without biopsy may be adopted. A size of greater than 4cm attracts a recommendation for core biopsy to exclude a phyllodes tumour. The natural history of fibroadenomas is that 10% will increase in size, 30% regress and the remainder stay the same. This does not apply during pregnancy and lactation when they may increase in size substantially and subsequently sequester milk. Some women may wish to have their fibroadenomas excised, they can usually be shelled out through a circumareolar incision. Smaller lesions may be removed using a mammotome.

Question 40

Mondor's disease?

Answer 40

A rare condition which involves thrombophlebitis of the superficial veins of the breast and anterior chest wall. It sometimes occurs in the arm or penis. In axilla, this condition is known as axillary web syndrome