Breast

Question 1

In the assessment of breast lumps, what is the acronym and what factors are in each domain?

Answer 1

She Cuts The Fish

S: size, site, skin, single
C: Colour, consistency, contour, compressibility
T: Trans-illuminable, tenderness, temperature
F: fixation (tethering), fluctuance

Question 2

What is a fibroadenoma?

What demographic of women does it occur in?

Answer 2

• Benign neoplasm of a lobule- arising from stroma (fibre) and glandular (adenoma) epithelium
• young women of child-bearing age, 20s-30s. Most common type of benign breast lump

Question 3

What is the first line investigation for all benign breast lumps?

What is second line investigation for Fibroadenoma/ breast cyst?

Answer 3

USS <40> mammography

• Fibroadenoma: fine needle aspiration
• Breast cyst: fine needle aspiration

Question 4

What is the SCTF for fibroadenoma?

Answer 4

S: single, 1-5cm
C: well demarcated, firm consistency, smooth
T: painless
F: mobile, “breast mouse”

Question 5

What is the SCTF for fibrocystic/ fibroadenosis?

Answer 5

S: Single or multiple “lumpy”, unilateral or bilateral
C: well demarcated, clear nipple discharge sometimes
T: usually painless/ sometimes painful, transilluminable
F: Fluctuant, mobile

Question 6

What is the SCTF for duct ectasia?

Answer 6

S: sub-areolar mass, nipple inversion
C: Firm, thick yellow-green discharge
T: Tender
F: Fixed

Question 7

When does breast fat necrosis usually occur?

How does it present?

Answer 7

• Secondary to trauma

- Painful, irregular hard lump with overlying bruising/ redness of skin

Question 8

What is intraductal papilloma?
What demographic of women?
How does it present?

Answer 8

• Benign neoplasm growing within ducts
• Peri-post menopausal women
• Subareolar mass (usually small), bloody or clear discharge

Question 9

Give the aetiology of mastitis. What can it lead to if untreated?

Give 2 at risk women of mastitis.
Which organism is the most common cause?

Answer 9

• breast inflammation caused by milk stasis/ over production
• if untreated can rarely lead to abscess

Breast-feeding, smoker >30

Staphylococcus aureus- can enter through cracked skin, e.g. nipple

Question 10

What is the SCTF of mastitis?

Answer 10

S: general swelling, inflamed skin, nipple may be cracked
C: redness, firm
T: tender and uncomfortable, warm to touch
F: Flu like symptoms: fever, aches, chills, generally unwell

Non-lactational presents with history of previous infections, less pronounced systemic upset.

Question 11

Give 3 management steps of mastitis

Answer 11

• If lactational, encourage breastfeeding
• analgesia
• Antibiotics sometimes required

Question 12

Give 4 steps in management of breast abscess following mastitis.

Answer 12

• IV or oral Abx
• US guided FNA
• FBC+ blood cultures if systemic infection
• Surgical incision + drainage

Question 13

Give 2 complications of breast abscess

Answer 13

• Mammary fistula
• Rarely overlying skin may undergo necrosis

Untreated may discharge onto skin surface. Non-lactational breast abscesses tend to re-occur

Question 14

Breast cancer is the most common cancer in the UK. 1 in 7 females. What is the most common type of breast cancer?

Answer 14

-Invasive ductal carcinoma

Question 15

What is the difference between staging and grading?

Answer 15

• Staging- analyses the spread: TNM staging

- Grading: analyses the differentiation: Nottingham grading system .

Question 16

Give 1 non-invasive and 3 invasive breast cancers

Answer 16

non invasive: DCIS

Invasive: Infiltrative ductal carcinoma, infiltrative lobular carcinoma, Paget’s disease of the breast.

Question 17

Give 8 risk factors for developing breast cancer.

Answer 17

• Oestrogen exposure:- early menarche, late menopause, HRT/OCP
• Nulliparity: not having any children
• Previous radiation to the chest
• Familial breast cancer- 5% of cases: BRCA1/2: harmful mutation gives 60-80% chance lifetime risk of Bca. Mutation also has associations with ovarian and pancreatic cancers.
• Age, Obesity, EtOH consumption, Fatty diet

Question 18

Give the presenting SCTF of breast cancer.

Answer 18

S: increased size, lump, skin changes
C: hard lump, irregular margins, redness, non-compressible
T: Generally painless, inflammatory breast Ca: painful, warm
F: tethered to underlying tissue, not free to move.

Symptoms of metastases: bone pain, SOB, rarely neuro

Question 19

Give 6 skin changes associated with breast cancer

Answer 19

• Peau d’orange
• Armpit skin thickening
• Nipple discharge
• Nipple inversion
• Crust- Paget’s
  skin dimpling

Question 20

What is the investigation structure for breast cancer?

Answer 20

Triple assessment

• Clinical examination
• Imaging: USS<35>mammogram
• Tissue diagnosis: FNA, core biopsy

Question 21

In staging a breast cancer, where are the 3 likely metastasis locations? What investigations are necessary for them? (4)

Answer 21

Liver, lungs, bone

• Liver USS
• CXR
• CT brain/ chest
• Bone scan

Bloods: FBC, U&E, calcium, bone profile, LFTs, ESR

Question 22

Management of breast cancer depends on the stage and grade. Give two types of medication used and an example of each.

Answer 22

• ER antagonists: tamoxifen

- Aromatase inhibitors: letrozole

Question 23

How does the likelihood of a lateral neck lump being malignant change with age?

Answer 23

• Children, >75% lateral neck lumps are benign

- Adults, >75% lateral neck lumps are malignant.

Question 24

What are the differentials for the following presentations for a midline neck lump:

• Deep lump (1)
• Superficial (4)
• Moves on swallowing(1)
• Moves on tongue protrusion (1)

Answer 24

• Deep: thyroid
• Superficial: lipoma, epidermal cyst, dermoid cyst, abscess
• Moves on swallowing: thyroid gland
• Moves on tongue protrusion: thyroglossal cyst

Question 25

What is a Phylloides tumour?

Answer 25

Fast growing fibroepithelial mass (stroma and epithelial involvement). Can be benign or malignant