Blackboard EMQs Breast Flashcards
A 20 year old female finds a mass in her right breast. Her GP notes that this 1 to 2cm mass is firm but mobile and sends her to the one stop breast clinic. After ultrasound, the doctor wants to be doubly sure of the diagnosis and orders an invasive test.
Choose the most appropriate option A. Fibroadenoma B. Excision biopsy C. Oestrogen receptor positivity D. Core needle biopsy E. Infiltrating ductal carcinoma F. Lack of aneuploidy G. FNA H. Fibrocystic disease I. Axillary lymph node metastases J. Paget’s disease
G. FNA
This sounds like a fibroadenoma which tends to be asymptomatic and found incidentally, typically in a patient <40 years old. It is a mobile mass, firm, painless and can also be described as smooth and rubbery. After history and examination, the first test to order is either a mammogram or an ultrasound scan. This depends on the woman’s age. USS is often considered the test of choice for patients <35 as younger women have a density of breast tissue which limits how sensitive mammography is. (The false negative rate has been reported to be as high as 52% in those <35 with a palpable malignant mass). A breast biopsy can also be considered and it tells us here that she has had another procedure – biopsy will show epithelial and stromal elements.
FNA is done in this case as it is easy to perform, relatively painless (compared to the 8-14G needle of a core needle biopsy!), and is enough to be diagnostic. An FNA involves a 22-25G needle (to give you an indication, the needles used for venepuncture are 21G with the butterfly device being 23G). This is inserted into the mass and cells are extracted. They can then be put onto a slide and reviewed by a cytopathologist. The disadvantage of this procedure is the inability to show histology (and therefore cannot differentiate DCIS from invasive malignancy).
A firm 2 to 3cm mass is palpable in the upper outer quadrant of the right breast of a 52 year old woman. After a mammogram, which shows a focus of microcalcification. The consultant wants to know the histology.
Choose the most appropriate option A. Fibroadenoma B. Excision biopsy C. Oestrogen receptor positivity D. Core needle biopsy E. Infiltrating ductal carcinoma F. Lack of aneuploidy G. FNA H. Fibrocystic disease I. Axillary lymph node metastases J. Paget’s disease
D. Core needle biopsy
A core needle biopsy is needed to assess tissue architecture and comment on histology – you cannot comment on the histology from a FNA. You use a 8-14G needle which gives a larger tissue sample than FNA (but it is more painful). Hormone receptor studies can also be performed on needle biopsy samples. It is generally the method of choice of diagnosing breast mass histology.
An excision biopsy basically entails removal of the whole breast mass for histological diagnosis – it is invasive, and if the lump is benign, then it is obviously unnecessary. An operating room is needed and it is even more painful than FNA or core biopsy. Unless the consultant surgeon has God-like powers of analysis and special powers or wants to be struck off the medical register, this is not a procedure that is done at least until a needle biopsy is done first. Even if it is malignant, cutting it out may require another procedure after it has been cut out, like axillary clearance. However, if needle biopsy shows atypical hyperplasia or radial scars (atypical cells on biopsy) then you do need to cut it out to rule out malignancy.
Breast carcinoma is diagnosed on biopsy of the right breast of a 52 year old female. Which feature of her carcinoma after a definitive operation & histology suggests a worse prognosis?
Choose the most appropriate option A. Fibroadenoma B. Excision biopsy C. Oestrogen receptor positivity D. Core needle biopsy E. Infiltrating ductal carcinoma F. Lack of aneuploidy G. FNA H. Fibrocystic disease I. Axillary lymph node metastases J. Paget’s disease
I. Axillary lymph node metastases
There is a program called Adjuvant! Online which calculates the patient’s prognosis based on information such as age, co-morbidities, tumour size, grade, oestrogen receptor status and number of positive axillary LNs. The latter predicts a worse prognosis. Aneuploidy is an abnormal number of chromosomes – for example, Down syndrome is an example of trisomy 21, an aneuploidy. Oestrogen receptor (ER/OR) positive status is better for prognosis as hormones which block the effects of oestrogen like tamoxifen can be used, as these ER+ve cancer cells are dependent on oestrogen for growth.
A 61 year old female has noted a rough, reddened appearance of the nipple which persists despite application of a corticosteroid cream. The most likely cause of this “persistent eczema”?
Choose the most appropriate option A. Fibroadenoma B. Excision biopsy C. Oestrogen receptor positivity D. Core needle biopsy E. Infiltrating ductal carcinoma F. Lack of aneuploidy G. FNA H. Fibrocystic disease I. Axillary lymph node metastases J. Paget’s disease
J. Paget’s disease
Paget’s disease of the breast is a presentation of DCIS. It presents as an eczematous rash or ulceration, if left untreated. There may be bleeding from the nipple or excoriation of the nipple, which are typical presenting signs of Paget’s disease of the breast.
A 35 year old woman presents with bilateral pain in her breasts which is worse just before her period. There is diffuse nodularity throughout both her breasts on examination.
Choose the most appropriate option A. Fibroadenoma B. Excision biopsy C. Oestrogen receptor positivity D. Core needle biopsy E. Infiltrating ductal carcinoma F. Lack of aneuploidy G. FNA H. Fibrocystic disease I. Axillary lymph node metastases J. Paget’s disease
H. Fibrocystic disease
Fibrocystic breasts are characterised by ‘lumpy’ breasts associated with pain which fluctuates with the menstrual cycle (it is worse during the luteal phase of menses). Risk factors include obesity, nulliparity, HRT and late onset menopause and first childbirth. It is a diagnosis of exclusion, and is considered to be an exaggerated physiological phenomenon rather than a disease. Symptoms typically arise between the 3rd and 4th decases of life. There may also be a nipple discharge, which can be suspicious if bloody or profuse etc and may indicate the presence of an intraductal papilloma, cancer, or duct ectasia. Cysts can be aspirated if symptomatic (asymptomatic or small ones do not require intervention). If the aspirate is straw coloured and completely aspirated, there is no need for cytology, but if the aspirate is bloody, cytology or biopsy is needed to exclude cancer. There is improvement of mastalgia and cysts at menopause and until then it runs a chronic relapsing course.
A 40 year old lady with multiple painful lumps in her breast, which are painful & tender premenstrually.
Choose the most likely cause of the symptoms A. Carcinoma of the breast B. Fibroadenosis C. Lipoma D. Fibroadenoma E. Gynaecomastia F. Sebaceous cyst G. Breast cyst H. Duct ectasia I. Breast abscess
B. Fibroadenosis
Fibrocystic breasts are characterised by ‘lumpy’ breasts associated with pain which fluctuates with the menstrual cycle (it is worse during the luteal phase of menses). Risk factors include obesity, nulliparity, HRT and late onset menopause and first childbirth. It is a diagnosis of exclusion, and is considered to be an exaggerated physiological phenomenon rather than a disease (54% of clinically normal breasts are found on autopsy to have fibrocystic changes). Symptoms typically arise between the 3rd and 4th decases of life. There may also be a nipple discharge, which can be suspicious if bloody or profuse etc and may indicate the presence of an intraductal papilloma, cancer, or duct ectasia. Cysts can be aspirated if symptomatic (asymptomatic or small ones do not require intervention). If the aspirate is straw coloured and completely aspirated, there is no need for cytology, but if the aspirate is bloody, cytology or biopsy is needed to exclude cancer. There is improvement of mastalgia and cysts at menopause and until then it runs a chronic relapsing course.
A 25 year old lady with a discrete, non-tender, mobile lump in one breast.
Choose the most likely cause of the symptoms A. Carcinoma of the breast B. Fibroadenosis C. Lipoma D. Fibroadenoma E. Gynaecomastia F. Sebaceous cyst G. Breast cyst H. Duct ectasia I. Breast abscess
D. Fibroadenoma
This is a fibroadenoma which tends to be asymptomatic and found incidentally, typically in a patient <40 years old. It is a mobile mass (sometimes called breast mice), firm, painless and can also be described as smooth and rubbery. It is benign with epithelial and stromal elements.
A 35 year old lady is generally unwell with a tachycardia & a fever. A segment of the right breast is painful, tender, red & warm.
Choose the most likely cause of the symptoms A. Carcinoma of the breast B. Fibroadenosis C. Lipoma D. Fibroadenoma E. Gynaecomastia F. Sebaceous cyst G. Breast cyst H. Duct ectasia I. Breast abscess
I. Breast abscess
Breast abscess presents with mastalgia and fever. Breast infection typically affects women who are lactating and the most commonly implicated pathogen is staphylococcus aureus. The painful, hard and red lump indicates the development of an abscess. Antibiotic therapy is indicated with surgical intervention such as aspiration and drainage with possible duct excision. Prompt management of mastitis when it presents will usually lead to a good timely resolution and prevent the development of complications such as an abscess. An USS can help to identify the underlying abscess which usually forms a hypoechoic lesion. Needle aspiration can be used both therapeutically and diagnostically and can be guided by ultrasound.
A 14 year old boy with bilateral breast enlargement.
Choose the most likely cause of the symptoms A. Carcinoma of the breast B. Fibroadenosis C. Lipoma D. Fibroadenoma E. Gynaecomastia F. Sebaceous cyst G. Breast cyst H. Duct ectasia I. Breast abscess
E. Gynaecomastia
This is a boy who has enlarged breasts. Normal to see gynaecomastia in puberty. Other causes include liver disease and as a side effect of drugs such as digoxin, spironolactone and cimetidine.
A 40 year old lady with a green nipple discharge & tender lumpiness beneath the areola.
Choose the most likely cause of the symptoms A. Carcinoma of the breast B. Fibroadenosis C. Lipoma D. Fibroadenoma E. Gynaecomastia F. Sebaceous cyst G. Breast cyst H. Duct ectasia I. Breast abscess
H. Duct ectasia
Duct ectasia happens because the lactiferous duct gets blocked. Ectasia means widening. It can mimic breast cancer as the discharge can be bloody sometimes and signs can include nipple inversion. The green nipple discharge is typical in EMQs. It is a self limiting condition.
A 40 year old lady with a hard lump in the right breast. The skin overlying the lump has an orange peel appearance.
Choose the most likely cause of the symptoms A. Carcinoma of the breast B. Fibroadenosis C. Lipoma D. Fibroadenoma E. Gynaecomastia F. Sebaceous cyst G. Breast cyst H. Duct ectasia I. Breast abscess
A. Carcinoma of the breast
Patients with breast cancer, on examination (familiarise yourself with how to conduct a breast exam), tend to demonstrate a firm hard lump which may be associated with axillary lymphadenopathy, skin changes such as the orange peel (peau d’orange) and nipple changes/discharge. The skin changes here are most likely associated with locally advanced cancer. Many breast cancers are also diagnosed on routine mammography which can show microcalcifications, in the absence of a palpable mass. MRI is more sensitive but less specific so is recommended only in patients who are at high risk, such as BRCA1/2 mutation, history of chest radiation or certain syndromes like Cowden’s or Li-Fraumeni. FNA is also useful in rapid diagnosis, although is operator dependent when it comes to how sensitive and specific it is, and a core biopsy is preferred in most cases for diagnosis as it can differentiate pre-invasive and invasive disease. Treatment is MDT involving surgeons, oncologists, radiation oncologists etc. Do you know about the current NHS breast screening programme?
A 48 year old women presents with mild breast pain which improves in the days after her menstrual period. Her breasts are lumpy on examination.
What is the correct diagnosis? A. Fat necrosis B. Breast abscess C. Breast cancer D. Necrotising fasciitis E. Raynaud’s phenomenon F. Fibroadenoma G. Costochondritis H. Galactocoele I. Diabetic breast lesion J. Mondor’s disease K. Fibrocystic changes L. Phylloides tumour
K. Fibrocystic changes
Fibrocystic breasts are characterised by ‘lumpy’ breasts associated with pain which fluctuates with the menstrual cycle (it is worse during the luteal phase of menses). Risk factors include obesity, nulliparity, HRT and late onset menopause and first childbirth. It is a diagnosis of exclusion, and is considered to be an exaggerated physiological phenomenon rather than a disease (54% of clinically normal breasts are found on autopsy to have fibrocystic changes). Symptoms typically arise between the 3rd and 4th decases of life. There may also be a nipple discharge, which can be suspicious if bloody or profuse etc and may indicate the presence of an intraductal papilloma, cancer, or duct ectasia. Cysts can be aspirated if symptomatic (asymptomatic or small ones do not require intervention). If the aspirate is straw coloured and completely aspirated, there is no need for cytology, but if the aspirate is bloody, cytology or biopsy is needed to exclude cancer. There is improvement of mastalgia and cysts at menopause and until then it runs a chronic relapsing course.
A 17 year old school girl presented with breast pain , changed from dull ache to severe continuous throbbing pain. The breast feels hot on palpation and she complains of hot flushes. On examination the whole breast is tender and engorged and nipple is tender.
What is the correct diagnosis? A. Fat necrosis B. Breast abscess C. Breast cancer D. Necrotising fasciitis E. Raynaud’s phenomenon F. Fibroadenoma G. Costochondritis H. Galactocoele I. Diabetic breast lesion J. Mondor’s disease K. Fibrocystic changes L. Phylloides tumour
B. Breast abscess
Breast abscess presents with mastalgia and fever. Breast infection typically affects women who are lactating and the most commonly implicated pathogen is staphylococcus aureus. The painful, hot, engorged and red breast suggests the possible development of an abscess. Antibiotic therapy is indicated with surgical intervention such as aspiration and drainage with possible duct excision. Prompt management of mastitis when it presents will usually lead to a good timely resolution and prevent the development of complications such as an abscess. An USS can help to identify the underlying abscess which usually forms a hypoechoic lesion. Needle aspiration can be used both therapeutically and diagnostically and can be guided by ultrasound.
A 20 year old woman presented with a painless lump. On examination there was a 5cm smooth firm mass, which is highly mobile.
What is the correct diagnosis? A. Fat necrosis B. Breast abscess C. Breast cancer D. Necrotising fasciitis E. Raynaud’s phenomenon F. Fibroadenoma G. Costochondritis H. Galactocoele I. Diabetic breast lesion J. Mondor’s disease K. Fibrocystic changes L. Phylloides tumour
F. Fibroadenoma
This is a fibroadenoma which tends to be asymptomatic and found incidentally, typically in a patient <40 years old. It is a mobile mass (sometimes called breast mice), firm, painless and can also be described as smooth and rubbery. It is benign with epithelial and stromal elements.
A 40 year old female presented with a lump in the breast, enlargement of breasts, no pain. There is a history of the lump changing in size. On examination the lump is found in the upper outer quadrant, moderately hard and mobile. It lacks skin or deep attachment.
What is the correct diagnosis? A. Fat necrosis B. Breast abscess C. Breast cancer D. Necrotising fasciitis E. Raynaud’s phenomenon F. Fibroadenoma G. Costochondritis H. Galactocoele I. Diabetic breast lesion J. Mondor’s disease K. Fibrocystic changes L. Phylloides tumour
C. Breast cancer
There is a painless lump here which changes in size. Breast cancer progressively increases in size regardless of the menstrual cycle, unlike fibrocystic breasts which may vary in size with the menstrual cycle. When examining the breasts, they should first be examined sat upright to inspect for any changes in skin colour, any dimpling and asymmetry. The axilla, supra and infra-clavicular nodes should also be checked for any nodal metastases. Then, with the patient supine (and arm behind the head), the breast tissue should be felt and the tissue at the beneath the nipple.
Many breast cancers are also diagnosed on routine mammography which can show microcalcifications, in the absence of a palpable mass. MRI is more sensitive but less specific so is recommended only in patients who are at high risk, such as BRCA1/2 mutation, history of chest radiation or certain syndromes like Cowden’s or Li-Fraumeni. The estimated cumulative lifetime incidence of breast cancer in those with BRCA mutations is 87%. FNA is also useful in rapid diagnosis, although is operator dependent when it comes to how sensitive and specific it is, and a core biopsy is preferred in most cases for diagnosis as it can differentiate pre-invasive and invasive disease. Treatment is MDT involving surgeons, oncologists, radiation oncologists etc. Treatment with less than a total mastectomy will require radiotherapy to the remaining breast tissue afterwards.
