Breast

Question 1

Define galactorrhea.
Who is it found in?
What is the most common cause?

Answer 1

bilateral, multi-ductal, milky white discharge from the nipples, not associated with pregnancy or lactation

most commonly adult women, also male infants due to maternal oestrogen exposure

hyperprolactinaemia

Question 2

Causes of hyperprolactinaemic galactorrhoea include:

Answer 2

Idiopathic (40%)

Pituitary adenoma (prolactinoma)

Damage to the pituitary stalk- reduced dopamine inhibition to the pituitary ( surgical resection, multiple sclerosis, sarcoidosis, or TB)

Drug-Induced- SSRIs, anti-psychotics, H2-antagonists

Neurological - neurogenic pathways activated to inhibit dopamine levels ( e.g. varicella zoster or spinal cord injury)

Hypothyroidism- elevated TRH can stimulate prolactin related

Cushing’s disease, Acromegaly, and Addison’s disease

Renal failure or liver failure

Question 3

Normoprolactinaemic galactorrhoea is less common and is typically idiopathic. How can it be diagnosed?

Answer 3

When all other causes of galactorrhea have been excluded

Normal blood markers and menstruation

Question 4

What should you include in a hx and examination of galactorrhea? What investigations should you do?

Answer 4

Hx:
Ask about breast lumps, mastalgia and last menstrual period
Features of endocrine disease
Neurological sxs (e.g. headaches, visual disturbances)
Full drug hx

Examination:
Breast examination (often unremarkable)
Check for visual changes
Check for signs of hypothyroidism

Investigations:
b-HCG (preg test)
Serum prolactin levels, TFTs, LFTs, renal function tests
Further endocrine tests (IGF-1, ACTH) if indicated
MRI head with contrast if suspected pit. tumour
Breast imaging if palpable lumps/lymph nodes

Question 5

What serum prolactin level suggests a prolactinoma (in absence of drug-related cause)?

Answer 5

Prolactin levels >1000 mU/L

Question 6

Optimal management of galactorrhoea is determined by identifying and treating the underlying cause.

1. How should you manage idiopathic normoprolactinaemic galactorrhoea?
2. What about patients with non-resolving galactorrhea who are intolerant of medication?

Answer 6

1. Often resolves spontaneously
   Can trial low-dose dopamine agonist
2. Bilateral total duct excision is an option

Question 7

Commonest cause of mastalgia?

Answer 7

cyclical mastalgia - pain associated with the menstrual cycle

bilateral, begins a few days before the beginning of menstruation and subsides at the end

very common

Question 8

Around a third of mastalgia is non-cyclical pain. What can cause this?

Answer 8

medication- hormonal contraceptives, anti-depressants (e.g. sertraline), antipsychotic drugs (e.g. haloperidol)

extramammary pain - e.g. chest wall pain or shoulder pain.

Question 9

First line treatment for mastalgia is simple analgesics and reassurance.

A second line agent is Danazol, by what pharmacological action does it exert its effect?

Answer 9

Anti-gonadotrophin

Question 10

What should you ask in a hx of mastalgia?

Answer 10

Timing and association with menstrual cycle

lumps/skin changes

discharge/galactorrhea

fever

pregnancy and breastfeeding

Question 11

Does mastalgia in isolation warrant imaging?

Answer 11

Mastalgia in isolation with no other clinical features is not an indication for imaging

The incidence of a breast malignancy associated with a presenting complaint of mastalgia is low

Question 12

What is the breast triple assessment?

Answer 12

a hospital-based assessment clinic that allows for early and rapid detection of breast cancer

2 week wait referral

comprises of the history + examination, imaging, and histology

Question 13

A 25yr old lady with a suspicious breast lump is referred to breast clinic for triple assessment. By what imaging modality would be best used as first line? Why?

Answer 13

USS

Ultrasound scanning is more useful in women <35 years and in men in identifying anomalies, due to the density of the breast tissue . This form of imaging is also routinely used during core biopsies.

Question 14

How is mammography used to assess breast tissue?

Answer 14

Mammography involves compression views of the breast across two views (oblique and craniocaudal), allowing for the detection mass lesions or microcalcifications.

Question 15

What is the difference between a core biopsy and FNA in assessing suspicious breast lumps?

Answer 15

A core biopsy provides full histology, allowing differentiation between invasive and in-situ carcinoma

FNA only provides cytology

Core biopsies can also generate important information about tumour grading and staging, and have a higher sensitivity and specificity than FNA for detecting breast cancer.

Question 16

What breast lesions can fine needle aspirations be useful for?

Answer 16

cysts

FNA can be used in recurrent cystic disease to provide relief from symptoms and to enable cytology

Question 17

identify the common benign breast tumour subtypes

Answer 17

Fibroadenoma
Adenoma
Papilloma
Lipoma
Phyllodes Tumours

Question 18

What are fibroadenomas?
How do they present on examination?

Answer 18

most common benign breast growth that usually occurs in women of a reproductive age

proliferation of stromal and epithelial tissue of the duct lobules

highly mobile lesions - “breast mouse”
well-defined and rubbery on palpation
usually < 5cm diameter

Question 19

How should confirmed fibroadenomas be managed?

Answer 19

they have a very low malignant potential :
- can be left in situ with routine follow up appointments over a 2 year period
- 30% will get smaller

main indications for excision :
>3cm in diameter or patient preference.

Question 20

What is a ductal adenoma?

Answer 20

benign glandular tumour, typically occurring in the older female population

nodular lesions mimic malignancy - often escalated to triple assessment

Question 21

What is an intraductal papilloma?
Where are they found?
How do they present?

Answer 21

benign breast lesion that usually occurs in 40-50yr old women

typically in the subareolar region (usually less than 1cm away from the nipple)

often present with bloody or clear nipple discharge, if large can present as a mass

can appear similar to ductal carcinomas on imaging and therefore usually require biopsy
sometimes excised to ensure no atypical cells or neoplasia

Question 22

When is risk of breast cancer increased with intraductal papilloma? How is this managed?

Answer 22

Risk of breast cancer is only increased with multi-ductal papilloma

most are treated with microdochectomy

Question 23

What are breast lipomas?
When may they be removed?

Answer 23

soft and mobile benign adipose tumours

usually asymptomatic, low malignant potential

only removed if causing compressive sxs or aesthetic issues

Question 24

What are Phyllodes tumours?

Answer 24

rare fibroepithelial tumours comprised of both epithelial and stromal tissue

occur in older age group

often larger and can grow rapidly

Question 25

How many Phyllodes tumours have malignant potential? How many benign tumours will recur after excision? How does this affect the management?

Answer 25

1/3 have malignant potential 10% of benign tumours will recur after excision most Phyllodes tumours should be widely excised (or mastectomy if large)

Question 26

What is Gynaecomastia? How often does it progress to breast cancer?

Answer 26

breast tissue development in males due to an imbalanced ratio of oestrogen and androgen activity 1% of cases- usually benign

Question 27

What causes physiological gynaecomastia?

Answer 27

most commonly occurs in adolescence- delayed testosterone surge relative to oestrogen at puberty Less commonly occurs in the older population - decreasing testosterone levels with increasing age

Question 28

Pathological gynaecomastia results from changes in the oestrogen:androgen activity ratio. What are the 4 main underlying pathologies?

Answer 28

Lack of testosterone : Klinefelter’s syndrome, androgen insensitivity, testicular atrophy, or renal disease Increased oestrogen levels: liver disease, hyperthyroidism, obesity, adrenal tumours, or certain testicular tumours (e.g. Leydig’s cell tumours) Medication: 25% of cases e.g. digoxin, metronidazole, spironolactone, chemotherapy, goserelin, antipsychotics, or anabolic steroids Idiopathic

Question 29

How does gynaecomastia present on examination? What must you also examine?

Answer 29

rubbery or firm mass (typically >2cm diameter) starts from underneath the nipple and spreads outwards over the breast region must also do a testicular exam, especially in young patients

Question 30

What is the main differential for gynaecomastia? How can you test for it?

Answer 30

psuedogynaecomastia - adipose tissue in the breast region associated with being overweight pinching to see if there is an obvious disc of breast tissue present

Question 31

Tests are only necessary if the cause for gynaecomastia is unknown. What investigations would you do?

Answer 31

Suspected malignancy - triple assessment Unknown cause: U&Es LFTs Hormone profile LH high and testosterone low = testicular failure LH low and testosterone low = increased oestrogen LH high and testosterone high = androgen resistance or gonadotrophin-secreting malignancy

Question 32

In most cases of gynaecomastia, reassurance may be enough. What medical tx is available to alleviate sxs?

Answer 32

Tamoxifen (esp for tenderness)

Question 33

Mastitis describes inflammation of the breast tissue, both acute or chronic. How can mastitis be classified?

Answer 33

Mastitis can be classed by lactation status: Lactational mastitis (more common) : 1/3 of breastfeeding women, more common with 1st baby usually presents during the first 3 months of breastfeeding or during weaning associated with cracked nipples and milk stasis Non-lactational mastitis (less common): often with other conditions such as duct ectasia (peri-ductal mastitis) smoking is an important risk factor - damage to the sub-areolar duct walls and predisposing to bacterial infection

Question 34

How can you confirm a suspected breast abscess? How can you manage? Important complication of surgical management?

Answer 34

USS prompt empirical antibiotics and US-guided needle therapeutic aspiration incision and drainage under local if more advanced -can cause formation of a mammary duct fistula (a communication between the skin and a subareolar breast duct)

Question 35

Breast cysts are epithelial lined fluid filled cavities within the breast tissue, usually requiring no further management and self-resolve. How can you investigate if there is diagnostic uncertainty? Potential complications?

Answer 35

Investigations: mammography - halo shape USS - definitive diagnosis persisting, symptomatic, or undeterminable cystic masses may be aspirated - cancer can be excluded if fluid is free of blood or lump disappears Complications: 2-3 x greater risk of developing breast cancer fibroadenosis (fibrocystic change) - multiple small cysts and fibrotic areas

Question 36

How can you manage cyclical pain associated with breast cysts?

Answer 36

high dose gamolenic acid (GLA) or danazol

Question 37

What is Mammary Duct Ectasia? How can it be investigated and managed?

Answer 37

dilation and shortening of the major lactiferous ducts common presentation in peri-menopausal women often presents with coloured green/yellow nipple discharge, a palpable mass, or nipple retraction (slit-like) Investigations: mammography - dilated calcified ducts histology - multiple plasma cells - plasma cell mastitis Mx: conservative or duct excision if unremitting nipple discharge

Question 38

Fat necrosis of the breast is ischaemic necrosis of fat lobules, associated with trauma in 40% of cases. How does it present? How is it investigated? Management?

Answer 38

usually asymptomatic or presenting as a lump typically firm initially and may then develop into a hard and irregular lump less commonly : fluid discharge, skin dimpling, pain and nipple inversion Investigations: USS- hyperechoic mass mammogram - mimics carcinoma core biopsy is often taken to categorically rule out malignancy Mx: analgesia and reassurance

Question 39

Breast Carcinoma In Situ are neoplasms that are contained within the breast ducts and have not spread into the surrounding breast tissue. What are the 2 types? Which is more likely to progress to an invasive malignancy?

Answer 39

Ductal Carcinoma In Situ (DCIS) (more common) and Lobular Carcinoma In Situ (LCIS) LCIS

Question 40

What is DCIS? 5 major types? How does it present? Tx?

Answer 40

most common type of non-invasive breast malignancy (20% of breast cancer) malignancy of the ductal tissue that is contained within the basement membrane comedo, cribriform, micropapillary, papillary, and solid (most lesions are mixed) Picked up on screening - microcalcifications seen on mammography Tx is surgical excision

Question 41

What is LCIS? How does it present? Tx?

Answer 41

Lobular Carcinoma in Situ (LCIS) is a non-invasive lesion of the secretory lobules of the breast that is contained within the basement membrane usually diagnosed before menopause asymptomatic - incidental finding during biopsy of the breast Management is dependent on extent of disease: - Low grade LCIS - monitoring - Bilateral prophylactic mastectomy can be potentially indicated if individuals possess the BRCA1 or BRCA2 genes

Question 42

Invasive carcinoma of the breast can be classified into:

Answer 42

Invasive ductal carcinoma (70-80%) Invasive lobular carcinoma (5-10%) Other subtypes, such as medullary carcinoma, invasive micropapillary carcinoma, or metaplastic carcinoma

Question 43

Invasive ductal carcinoma (IDC) is the most common type of breast carcinoma. How does it present on microscopy?

Answer 43

nests and cords of tumour cells with associated gland formation

Question 44

Invasive lobular carcinoma (ILC) is the second most common type of breast cancer and is more common in older women. What is it characterised by?

Answer 44

diffuse (stromal) pattern of spread - makes detection more difficult by the time of diagnosis, tumours can often be large

Question 45

Risk factors for invasive breast cancer?

Answer 45

Female sex and increasing age Family history - BRAC1 / 2 Exposure to unopposed oestrogens -early menarche, late menopause, nulliparity, and 5 years + use of HRT PMH of benign breast disease Obesity, alcohol and smoking

Question 46

How may breast cancer present if symptomatic?

Answer 46

breast or axillary lump asymmetry or swelling abnormal nipple discharge / nipple retraction skin changes (peau d’orange or Paget’s-like nipple changes) mastalgia

Question 47

What clinicopathological staging system is widely used for primary breast cancer prognosis?

Answer 47

Nottingham Prognostic Index (NPI) It is calculated by: (Size x 0.2) + Nodal Status + Grade

Question 48

All breast malignancies are checked for their expression of which receptors?

Answer 48

Oestrogen Receptor (ER), Progesterone Receptor (PR), and Human Epidermal growth factor Receptor (HER2) determines suitability of targeted adjuvant therapies (including endocrine and monoclonal antibody therapies) tumours that are negative for all three receptors are associated with a poorer prognosis

Question 49

What breast cancer screening is currently available in the UK?

Answer 49

NHS breast cancer screening programme currently invites women aged 50-71yrs to have a mammogram every three years

Question 50

What is Paget’s disease of the nipple? How can it be differentiated from eczema?

Answer 50

persistent roughening, scaling, ulcerating or eczematous change to the nipple vast majority of Paget’s (85-88%) will also have an underlying neoplasm Paget's always affects the nipple and only involves the areola as a secondary event, whilst eczema nearly always only involves the areola and spares the nipple

Question 51

How can Paget's disease of the nipple be investigated? What is the first line management ?

Answer 51

Investigations: punch biopsy, mammography and ultrasound of the breast Mx: operative, if possible - in all cases the nipple and areola will need to be removed In cases associated with an underlying malignancy, radiotherapy may be necessary

Question 52

Breast conserving treatment is only suitable for individuals with localised operable disease and no evidence of metastatic disease. What is the most common breast conserving tx?

Answer 52

A Wide Local Excision (WLE) - excision of the tumour, a 1cm margin of macroscopically normal tissue is taken along with the malignancy only suitable for focal smaller cancers

Question 53

A mastectomy removes all the tissue of the affected breast. When would it be indicated?

Answer 53

multifocal disease high tumour:breast tissue ratio disease recurrence patient choice

Question 54

Axillary surgery is most commonly performed alongside WLE and mastectomies, in order to assess nodal status and remove any nodal disease. What is a sentinel node biopsy?

Answer 54

removing first lymph nodes into which the tumour drains nodes are identified by injecting a blue dye with associated radioisotope into the peri-areolar skin radioactivity detection and / or visual assessment (blue nodes) can identify the sentinel nodes, which can be removed and sent for histological analysis

Question 55

Axillary node clearance involves removing all nodes in the axilla. What are the complications of this procedure?

Answer 55

paraesthesia, seroma formation, and lymphoedema in the upper limb

Question 56

A risk-reducing mastectomy is an operation to remove healthy breast tissue in order to reduce the risk of developing breast cancer. What patient factors confer high risk of developing breast cancer?

Answer 56

A strong family history of breast or ovarian cancer Testing positive for genetic mutations, such as BRCA1 or BRCA2, PTEN, or TP53 mutations Previous history of breast cancer can refer patients to a genetic counsellor to discuss options

Question 57

Hormone treatments provide the biggest contributor in medical management to improved survival in breast cancer. What options are available? (explain how they work, suitable patients and ADRs)

Answer 57

Tamoxifen: blockade of oestrogen receptors pre-menopausal patients increases risk of VTE operatively increases risk of endometrial cancer Aromatase inhibitors: Examples: Anastrozole, Letrozole, or Exemestane inhibit the action of aromatase, which normally converts androgens into oestrogens post-menopausal patients as adjuvant therapy increases risk of osteoporosis - DEXA scan before starting Immunotherapy: may be used in patients whose cancers express specific growth factor receptors Herceptin for HER-2 +ve malignancies Risk of cardiotoxicity

Question 58

What surgical reconstructive techniques are available in the oncoplastic treatment of breast malignancy?

Answer 58

therapeutic mammoplasty: WLE combined with a breast reduction technique nipple and areola preserved flap formation

Question 59

How does the presence/absence of axillary lymphadenopathy determine surgical management of breast cancer?

Answer 59

women with no palpable axillary lymphadenopathy at presentation: pre-operative axillary USS before primary surgery if +ve then they should have a sentinel node biopsy to assess the nodal burden in patients with clinically palpable lymphadenopathy: axillary node clearance is indicated at primary surgery this may lead to arm lymphoedema and functional arm impairment

Question 60

What factors favour Mastectomy V Wide Local Excision of breast cancer?

Answer 60

Mastectomy V Wide Local Excision Multifocal tumour V Solitary lesion Central tumour V Peripheral tumour Large lesion in small breast V Small lesion in large breast DCIS > 4cm V DCIS < 4cm

Question 61

What radiotherapy is offered after wide local excision? After mastectomy?

Answer 61

WLE = always whole breast radiotherapy as this may reduce the risk of recurrence by around two-thirds Mastectomy = radiotherapy is offered for T3-T4 tumours and for those with 4+ positive axillary nodes

Question 62

Who can Trastuzumab (Herceptin) not be used in?

Answer 62

Patients with heart disorders

Question 63

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if they are:

Answer 63

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

Question 64

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer in people:

Answer 64

with skin changes that suggest breast cancer or aged 30 and over with an unexplained lump in the axilla

Question 65

Who should you consider non urgent referral to breast clinic for?

Answer 65

people aged under 30 with an unexplained breast lump with or without pain

Question 66

commonest cause of blood stained nipple discharge in younger women?

Answer 66

Intraductal papilloma Rarely associated with a palpable mass Requires an USS and possibly galactogram

Question 67

When are FEC-D and FEC chemotherapy used?

Answer 67

FECD: when node +ve FEC: node -ve but requires chemotherapy

Question 68

Common causative organism of breast abscesses? Finding on examination?

Answer 68

Staphylococcus aureus On examination there is usually a tender fluctuant mass

Question 69

What does the 'snowstorm' sign on ultrasound of axillary lymph nodes indicate?

Answer 69

extracapsular breast implant rupture due to leakage of silicone, which then drains via the lymphatic system

Question 70

the first-line management of mastitis is to continue breastfeeding with simple analgesia/warm compresses. When would you treat medically?

Answer 70

if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection oral flucloaxcillin 10-14 days

Question 71

What is fibroadenosis (fibrocystic disease, benign mammary dysplasia)?

Answer 71

Most common in middle-aged women 'Lumpy' breasts which may be painful. Symptoms may worsen prior to menstruation

Question 72

What is the chance of siblings and children of BRCA1 carrier to also have the gene?

Answer 72

50/50

Question 73

The presence of positive axillary lymph nodes and residual tumour at resection margins post-mastectomy are both indications for what tx?

Answer 73

adjuvant ipsilateral chest wall and regional lymph node radiotherapy

Question 74

progressive erythema and oedema of the breast in the absence signs of infection such as fever, discharge or elevated WCC and CRP suggests what?

Answer 74

inflammatory breast cancer (IBC)- rare but rapidly progressive breast cancer caused by obstruction of lymph drainage managed with neo-adjuvant chemotherapy first-line, followed by total mastectomy +/- radiotherapy.

Question 75

Key things to do at the start of a breast exam besides intro and consent?

Answer 75

Position the patient at 45 degrees Ensure a chaperone is present during the examination (family members not appropriate) Ask the patient to remove their clothing to expose their chest, from above the waist Provide a blanket for the patient to cover themselves when not required to expose the breasts

Question 76

What is involved in the inspection part of a breast examination?

Answer 76

Check for any obvious scars or masses present Look for any skin changes or ulceration (erythema, puckering, or peau d’orange ) Look for any nipple changes (nipple discharge or inversion) inspect axillae for obvious masses Repeat examination with hands on head and hands on hips to accentuate any asymmetry

Question 77

What is involved in the palpation part of a breast examination?

Answer 77

Ask the patient to place both hands behind their head Examine each quadrant of the breast in turn, including the axillary tail Using a flat hand, press the breast against the underlying chest wall, rolling the underlying tissue If you palpate lumps : note their position, size, shape, consistency, overlying skin changes, and mobility examine their fixity to pectoralis muscles by asking the patient to push against your hand with their hand outstretched Examine both axilla in turn Palpate for any lymphadenopathy 5 sets of axillary lymph nodes are present: apical, anterior, central, posterior, and medial assess for potential metastasis: Palpate the spine for tenderness Palpate the abdomen for hepatomegaly Percuss and auscultate the lungs for lung masses

Question 78

Further investigations following breast examination?

Answer 78

Mammography and / or ultrasound, if necessary Biopsy (core needle or fine needle aspirate), if necessary