Benign and Malignant Breast Conditions

Question 1

Occurrence of breast cancer?

Answer 1

Most common cancer in women

Question 2

Different histological types of breast malignancies?

Answer 2

There are 24, 7 of which are in-situ and 17 are invasive

Each type has unique characteristics, behaviour, prognosis and optimum treatment varies

Question 3

Most common types of breast cancer?

Answer 3

For both invasive and in-situ breast carcinoma, 80% of cases are DUCTAL TYPE

Question 4

Risk factors for breast cancer?

Answer 4

Female gender

Increasing age

Gene mutations and FH of breast cancer

PMH of breast cancer

Atypical ductal or lobular hyperplasia

Lobular carcinoma in-situ

Atypical epithelial hyperplasia

Nulliparity and birth of 1st child >30 years of age

Post-menopausal obesity

Alcohol consumption ≥1 time a day

Early menarche and late menopause

Question 5

PC of breast cancer?

Answer 5

50% are asymptomatic and present via the screening route

50% are symptomatic:
• Lump (50%)
• Dimpled or depressed skin
• Nipple change 
• Bloody discharge
• Texture change
• Colour change

Question 6

Diagnosis of breast carcinoma?

Answer 6

Mammography

USS, part. in young woman or any woman with mammographically dense breasts

Definite diagnosis - image-guided core-needle biopsy

Question 7

PC and diagnosis of DCIS?

Answer 7

Usually non-palpable but perceived on mammography as malignant calcifications

Definite diagnosis - biopsy

Question 8

What is lobular carcinoma-in-situ?

Answer 8

Thought to be a tumour marker with assoc. increased risk of eventual invasive carcinoma, usually of the ductal types

Question 9

Spread of lobular carcinoma-in-situ?

Answer 9

Spreads diffusely, so often not apparent by palpation or imaging until it reaches an advanced stage

Question 10

Important factors when considering histology of the biopsy?

Answer 10

1. Invasive VS non-invasive
2. Ductal VS lobular
3. Degree of differentiation
4. Receptor status

Question 11

Treatment of breast cancer?

Answer 11

Local:
• Surgery
• Radiotherapy

Systemic:
• Chemotherapy (adjuvant or neoadjuvant)
• Hormonal therapy, like SERMs (selective estrogen receptor modulators, e.g: tamoxifen), AIs (aromatase inhibitors), GnRH antagonists, oophorectomy
• Targeted therapies, e.g: Herceptin for HER2 over-expression

Question 12

Types of surgery for breast cancer?

Answer 12

Breast-conserving surgery (BCS) - preferred treatment; it is a wide local excision +/- oncoplastic procedure
Radiotherapy is an essential part of this therapy

Modified mastectomy - removes entire breast, overlying skin and axillary lymph nodes; pectoralis major muscle is preserved (this is the modification), as it it allows wound healing and potentially allows reconstruction
With mastectomy, most are candidates for breast reconstruction

Question 13

What are ANDIs?

Answer 13

Abberations in the normal development and involution of the breast, e.g:
• Fibroadenoma
• Cysts
• Papilloma

Question 14

Occurrence of fibroadenoma?

Answer 14

Most common benign neoplasm of the breast

Can occur at any age but usually early reproductive life

Question 15

PC of fibroadenoma?

Answer 15

Palpable mass in EARLY REPRODUCTIVE years of life

It is rubbery-firm, mobile and smooth, with distinct borders

Usually non-tender

Question 16

Diagnosis of fibroadenoma?

Answer 16

Confirmed with ultrasound core biopsy

Question 17

Risks assoc. with fibroadenoma?

Answer 17

NOT pre-malignant

Question 18

Mx of fibroadenoma?

Answer 18

Tend to remain unchanged or decrease in size and become non-palpable after menopause (falling oestrogen levels)

Some women may want excision:
• Open lumpectomy
• Percutaneous vacuum-assisted core biopsy

Question 19

Differences between fibroadenomes and the uncommon Phyllodes tumour?

Answer 19

Similar to fibroadenomas in PC and cytology

Often larger (3-6cm)

Tend to occur in older women (35-40 years of age), rather than during early reproductive years

Question 20

Histological types of Phyllodes tumour?

Answer 20

Benign

Indeterminate

Malignant

Question 21

Mx of Phyllodes tumour?

Answer 21

Excision with wide, clear, surgical margins

Careful follow-up

Question 22

Issues assoc. with Phyllodes tumour?

Answer 22

Metastasis is rare

Question 23

What is mastalgia?

Answer 23

Breast pain, which is a common breast symptom for women during their reproductive years

NOTE - ensure the pain is not of non-breast aetiology, i.e: anterior chest wall pain

Question 24

Pattern of mastalgia?

Answer 24

1. Cyclic (usually) - usually diffuse and most intense during the intermediate pre-menstrual phase of the cycle; usually bilateral but can be unilateral
2. Non-cyclic (can occur) - usually localised, often persistent and less response to treatment that cyclic variant

Question 25

Issues assoc. with mastalgia?

Answer 25

Rarely assoc. with malignancy, unless there is a palpable breast mass

Question 26

Non-breast aetiologies of anterior chest wall pain?

Answer 26

``` Achalasia Angina Cervical radiculitis Cholecystitis Cholelithiasis Coronary artery disease Costochondritis (AKA Tietze syndrome) Fibromyositis Hiatus hernia Myalgia Neuralgia Osteomalacia Phantom pain Pleurisy Psychological pain PE Pulmonary infarct Rib fracture Sickle cell disease Trauma TB ```

Question 27

Ix of mastalgia?

Answer 27

Examination Mammogram for a woman ≥35 years of age

Question 28

Mx of mastalgia?

Answer 28

Reassure the patient that symptoms are physiological, if cyclic variant, and that there is no evidence of cancer; most require no further treatment Advise simple measures: • Well-fitting, firm bra • Regular exercise Other therapies effective for mastalgia: • Evening primrose oil • Tamoxifen • Topical NSAIDs

Question 29

Occurrence of cysts?

Answer 29

Palpable breast cysts commonly occur during late reproductive years NOTE - cysts are not pre-malignancy per se

Question 30

Examination features of a cyst?

Answer 30

Typically palpable, clearly defined, soft, mobile and smooth with distinct borders Cysts are often slightly tender, esp. before menstruation May be multiple and/or bilateral

Question 31

Ix and Mx of cyst?

Answer 31

FNA - aspirate as much fluid as possible; only grossly bloody fluid requires cytologic evaluation After FNA, palpate the area of the cyst to ensure that there is no residual mass

Question 32

What is a papilloma?

Answer 32

Benign, intracystic papillary proliferation that can occur within a cyst and is often assoc. with BLOODY CYST FLUID

Question 33

When is an intracystic carcinoma suspected?

Answer 33

When the fluid is grossly bloody or there is a residual mass after aspiration USS-guided core biopsy is recommended for histological diagnosis of any intracystic solid lesion or irregular cystic wall

Question 34

Describe normal nipple discharge

Answer 34

Usually clear, yellow and watery It can be elicited from the nipples of most women of reproductive age; this is physiological

Question 35

Pathological nipple discharge?

Answer 35

Bloody discharge, part. from a single duct, should be evaluated

Question 36

Most common cause of spontaneous nipple discharge?

Answer 36

Intraductal papilloma(s), which are benign lesions i.e: nipple discharge is rarely a sign of malignancy, unless there is an assoc. palpable mass

Question 37

Treatment of intraductal lesions?

Answer 37

All are excised and histologically evaluated, in order to ensure that it is not the rare intraductal carcinoma

Question 38

Ix of pathological nipple discharge?

Answer 38

Mammography USS Surgical excision of discharging ducts (usually required to establish pathological cause and to relieve the discharge)

Question 39

PC of Paget's disease of the nipple?

Answer 39

Can present as an erythematous WEEPING lesion on the nipple surface and areola However, it usually presents as a dry, scaly, eczematous lesion This can be perceived as nipple discharge

Question 40

Ix for Paget's disease of the nipple?

Answer 40

Histologic tissue biopsy (incisional or punch biopsy) Often, there is an underlying palpable mass or a radiological abnormality

Question 41

What is mastitis?

Answer 41

Inflammation of the breasts; there are 2 main types 1. Puerperal mastitis (pregnancy or lactation-related) - common; mainly caused by Staph. aureus 2. Non-puerperal mastitis - uncommon and, in post-menopausal women, it is rare; assoc. SMOKING Organisms are mixed, e.g: S. aureus, Peptostreptococcus magnus and/or Bacteroides fragilis are common bacterial pathogens 3. Chronic mastitis - uncommon and can be assoc. with sub-areolar abscess

Question 42

PC of mastitis?

Answer 42

Fever Erythema, induration, tenderness and swelling

Question 43

Mx of puerperal mastitis?

Answer 43

Flucloxacillin 500mg PO, every 6 hours for 7 days OR Augmentin 625mg PO, every 8 hours for 7 days NOTE - must treat with a full course of antibiotics effective against S. aureus Patient should be examined every 3 days to be certain that infection is responding and for evidence of abscess formation If lack of response, change antibiotic

Question 44

Advice on breastfeeding with mastitis?

Answer 44

Continue if already begun and/or the infected breast can be pumped, until mastitis clears

Question 45

Ix for mastitis?

Answer 45

Cultures are useless

Question 46

Complications of mastitis?

Answer 46

Breast abscess

Question 47

PC of breast abscess?

Answer 47

Flocculent, and sometimes, bulging mass, usually located in the central area of the mastitis

Question 48

Ix of breast abscess?

Answer 48

USS confirms fluid-filled (pus) center Aspiration with a gauge needle, using LA, is diagnostic and can be therapeutic, if all pus is removed; it is sent for analysis

Question 49

Mx of breast abscess?

Answer 49

Aspiration may have to be repeat every 3 days, part. if there is >10ml of pus initially aspiratied If repeated aspirations are ineffective, open surgical dependent drainage under general anaesthesia is required Continue antibiotics until all evidence of inflammation (cellulitis) has cleared

Question 50

Mx of non-puerperal mastitis?

Answer 50

Augmentin 625mg PO, every 8 hours for 7 days, is usually effective OR Cephalexin 500mg PO, every 6 hours for 7 days Re-examine patient every 3 days, until infection clears

Question 51

Complications of chronic mastitis?

Answer 51

Peri-areolar fistulae can occur (must be surgically excised when inflammation is quiescent)

Question 52

Potential cause of mastitis that is unresponsive to antibiotics?

Answer 52

Consider inflammatory carcinoma, part. if it spreads over the entire breast

Question 53

What is an adenolipoma?

Answer 53

Unusual variant of a lipoma; it is BENIGN PC as a smooth palpable mass, with a characteristic mammographic pattern

Question 54

What is apocrine metaplasia of the epithelial cells?

Answer 54

Can occur in the lining of a breast cyst; the cells enlarge and are eosinophilic BENIGN

Question 55

What is ductal hyperplasia?

Answer 55

Benign histological process, however, if the hyperplasia is atypical, assoc. with an increased risk of carcinoma and may begin the transformation for DCIS and eventual invasive ductal carcinoma

Question 56

What is fat necrosis?

Answer 56

Pathological cell death of fat, often secondary to breast trauma, e.g: seat belt injury, but not always It can mimic cancer on examination but has a distinct appearance on mammography

Question 57

Mx of fat necrosis?

Answer 57

Usually subsides spontaneously but may leave a residual lesion of mammography

Question 58

What is a galactocoele?

Answer 58

Palpable, milk-filled cyst that is most commonly assoc. with pregnancy or lactation

Question 59

Ix and Mx of a galactocoele?

Answer 59

FNA to diagnose and drain

Question 60

Ix for a lipoma?

Answer 60

Can be palpable on examination Thin, smooth border on mammography Biopsy shows only adipose cells

Question 61

What is Mondor's disease?

Answer 61

Phlebitis and subsequent clot formation in the superficial (skin) veins of the breast Usually assoc. with a Hx of breast trauma, e.g: surgery

Question 62

PC of Mondor's disease?

Answer 62

Firm, vertical, cord-like structure

Question 63

Mx of Mondor's disease?

Answer 63

Lesions usually resolves spontaneously in 8-12 weeks