Breast

Question 1

What are fibroadenomas, what are the types and what is their progression and management?

Answer 1

Benign breast lump that form from the lobules of the breast.

Most common breast lump in 18-25 year olds

Can be:

• Juvenile (kids)
• Common
• Giant (>4cm)

Most stay the same, 30% regress and 10% grow

A giat one may warrant a biopsy

Question 2

Breast cysts, presentation?

Answer 2

Most frequently perimenopausal females

Soft, fluctuant swellings

On imaging they will usually show a ‘halo appearance’ on mammograph

Question 3

Management of a breast cyst?

Answer 3

If symptomatic:

- Aspiration, will dissappear.

Question 4

Presentation of duct ectasia?

Answer 4

Cheese like nipple discharge (green)

Retraction of nipple

No treatment needed, unless troublesome discharge

Younger will have microdochectomy
Older will have duct excision

Question 5

Breast cancer can be three different types according to what?

Answer 5

Her positive

ER and HER Neg

ER and HER negative

Question 6

What drugs do you use to treat ER positive breast cancer?

Answer 6

Tamoxifen
- Selective oestrogen receptor modulators

Anastrazole and letrozole

• Aromatase inhibitors
• Used in post menopausal as most oestrogen is produced through aromatase when post-menopausal.

Question 7

What is sclerosing adenosis, how does it present?

Answer 7

Disorder of involution, causes distortion of distal lobular unit.

Breast lump or breast pain

Mammographic changes may mimic carcinoma

Question 8

Breast epithelial hyperplasia Presentation, cause and management?

Answer 8

Varying presentation

• May be generalised lumpiness
• May have a discrete lump

Increased cellularity of terminal lobular unit,

Atypical features and a FH of BC means you need to closely monitor or resect as high risk of malignancy

Question 9

How does fat necrosis present, management?

Answer 9

About 40% have a history of trauma, physical features similar to carcinoma

Need imagine and core biopsy

Question 10

What is ductal papilloma presentation, management?

Answer 10

Nipple discharge, may have a mass if large, normally single duct in origin.

Microdochectomy

Question 11

Types of Breast cancer?

Answer 11

1. Invasive ductal carcinoma is most common (no special type).
   - Causes pagets disease

Others are special type:

2. Invasive lobular carcinoma

Then In situ:

3. Ductal carcinoma in situ (can become invasive ductal).
4. Lobular Carcinoma in Situ (isn’t really Breast cancer, doesn’t invade).

Others are also special type and quite rare, e.g. medullary breast cancer).

Question 12

Management of breast cancer?

Answer 12

Surgery (majority)
Wide local excision or mastectomy.

Mastectomy

• Multifocal tumour
• Central tumour
• Large lesion in small breasts
• DCIS > 4
• Pt choice

Wide local excision

• Solitary lesion
• Peripheral
• Smaller lesion in large breasts
• DCIS <4cm
• Patient choice

Radiotherapy

• After wide local excision
• If 4 or more positive nodes
• T3/4 tumours

`Hormonal (ER+)

• Tamoxifen in pre and peri menipausal
• Aromatase inhibitors in Post menopausal

Biological (HER+)
- Herceptin

Chemo

• Sometimes to downstage disease
• Post surgery if axillary node disease

Question 13

What system can you use for prognosis in breast cancer, what is it made up of?

Answer 13

Nottingham prognostic index

Tumour size x 0.2 PLUS the lymph node score:

• 1 is no lymph nodes
• 2 is 1-3
• 3 is >3

2-2.4 infers 94% survival
>5.4 is 50% survival

Question 14

When should you refer for breast cancer?

Answer 14

2ww

• Aged 30 and over and have an unexplained breast lump with or without pain or
• Aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern.

Consider 2ww

• Skin changes
• Aged > 30 with axillary lump

Question 15

Breast cancer risk factors?

Answer 15

BRCA1, BRCA2 genes - 40% lifetime risk of breast/ovarian cancer

1st degree relative premenopausal relative with breast cancer (e.g. mother)

nulliparity, 1st pregnancy > 30 yrs (twice risk of women having 1st child < 25 yrs)

early menarche, late menopause (menarche not unopposed oestrogen)

combined hormone replacement therapy (relative risk increase * 1.023/year of use), combined oral contraceptive use

past breast cancer

not breastfeeding

ionising radiation

p53 gene mutations

obesity

previous surgery for benign disease (?more follow-up, scar hides lump)

Question 16

Breast cancer screening programme details?

Answer 16

47-73 years mammogram every 3 years.

Question 17

What is cyclical mastalgia?

Answer 17

Common cause in younger females, cyclical with menstrual cycle.

Question 18

Causes of bloody nipple discharge?

Answer 18

Carcinoma

Duct papilloma

Question 19

Features of breast abscess? Management?

Answer 19

Lactational mastitis is common

Infection is usually with Staphylococcus aureus
On examination there is usually a tender fluctuant mass

Management:
1. Treatment is with antibiotics and ultrasound guided aspiration

2. Overlying skin necrosis is an indication for surgical debridement, which may be complicated by the development of a subsequent mammary duct fistula.

Question 20

How to tell apart pagets and nipple eczema?

Answer 20

Pagets involves nipple primarily then spreads to areola

Eczema is from areola inwards

Question 21

First line management for mastitis, if no systemic signs?

Answer 21

COntinue breast feeding