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Flashcards in Breast Deck (25):
1

Adjuvant treatment of breast cancer
A Aminoglutethimide
B Anastrozole
C Cisplatin
D LHRH analogues
E Modified radical mastectomy
F Raloxifene
G Tamoxifen
H Trastuzumab
I 5-fluorouracil, epirubicin and cyclophosphamide plus Trastuzumab
Select the most appropriate treatment for the following patient:
A 2 cm mass is located in the upper outer quadrant of the right breast of a 60-year-old female. Lumpectomy with sentinel node sampling reveals a node negative breast carcinoma with positive immunostaining for oestrogen receptors.

A firm 2.5 cm mass is palpable in the upper outer quadrant of the right breast of a 52-year-old woman. There are no palpable axillary lymph nodes. A lumpectomy with sentinel node sampling is performed and histology reveals a node negative invasive ductal carcinoma which has positive immunohistochemical staining for HER2/neu (c-erb B2). Staining for oestrogen receptors is negative.

First case: Anastrazole

Adjuvent endocrine therapy confers no benefit on oestrogen receptor negative (ER-negative) tumours (60% are ER-positive).

Adjuvent hormone therapy should only be given after adjuvent chemotherapy has been completed.

Adjuvent chemotherapy gives a 6.4% 10 year survival advantage in node-negative patients aged 50 - 69. Epirubicin CMF is the current 'gold standard'.

In the second case the positive C-erb B2 (HER2/neu) staining (which indicates a poor prognosis) suggests that epirubicin CMF adjuvent chemotherapy would be appropriate. Adding trastuzumab (Herceptin) (monoclonal antibody) to adjuvent chemotherapy may be beneficial.

2

Investigations in Breast diseases
A Computed assisted mammography
B Culture of discharge
C Ductography
D Fine needle aspiration cytology
E Genetic counselling and testing
F Mammography
G Stereotactic biopsy
H Ultrasonography
Select the most appropriate investigation for each of the following patients.
A 25-year-old woman attends clinic with an inflamed areola. She has no family history of breast cancer and has had no previous breast problems. On examination, she has a seropurulent ulcer with no underlying mass.

A 45-year-old woman presents with discharge from one duct which is not blood stained. Imaging has excluded malignancy as a cause.

A 55-year-old woman presents with lumps in the left breast and axilla. Ultrasound and mammography are both reported to be normal.

A 30-year-old woman presents for her breast examination to rule out breast carcinoma. Her sister and mother were both diagnosed with breast cancer at 40- and 55-years-old respectively. Examination and ultasound are normal.

Culture of discharge
Ductography
FNA
Genetic counselling

Investigation in breast disease depends on the age, presentation and risk of malignancy.

Mammography is less productive in younger more fibrous breasts as identification of lesions on mammograms depends on alterations of architecture, mass effects and type of calcifications which are difficult to identify in the fibrous breasts.

The 25-year-old has an ulcer on her areola which at that age is most likely to be inflammatory.

Any single duct discharge, at 45 years, needs to be investigated for ruling out malignancy. Technically a retroareolar biopsy is the best way to investigate it. Ultrasound may not pick up very small abnormalities which could become obvious by ductography.

The next lady needs a FNAC (ideally a clinical core biopsy) as she has a lump that is felt but not seen on imaging and so cannot have a sterotactic biopsy.

The 30-year-old has a very strong family history with one sibling having had cancer diagnosed at 40 and her mother having had cancer. She qualifies for genetic counselling and testing as indicated.

3

Complications of breast carcinoma
A Cerebral metastases
B Hypercalcaemia
C Lymphangitis carcinomatosis
D Lymphoedema
E Pathological fracture
F Spinal cord compression
G Venous thrombosis
The following patients have a diagnosis of breast carcinoma.
From the list provided, choose the most likely complication that would explain each presentation.
A 68-year-old female treated for carcinoma of the breast has presented with headache, blurring of vision and worsening confusion. On examination, papilloedema is present.

A 65-year-old lady presents with sudden pain in the right leg. This occurred while out shopping. She has been taking tamoxifen following treatment for carcinoma breast four years ago. On examination she has a shortened and externally rotated right leg which is particularly painful on passive movement.

1: Metastases to brain, liver and bone occur in association with breast carcinoma.

The patient described presents with features of increasing intracranial pressure supported by the papilloedema.

2: This woman with leg pain has typical features of fractured neck of femur.

In this case, with the history of breast cancer, a pathological fracture should be considered.

4

Which of the following is true of autosomal dominant breast cancer?
(Please select 1 option)
BRCA2 mutation is associated with increased risk of pancreatic cancer
It accounts for nearly half of all breast cancer cases in the United States
It can be detected by hybridisation with a single oligonucleotide probe
Penetrance is close to 100%, with nearly all gene carriers developing breast cancer by age 80
Autosomal dominant breast cancer affects females but not males

An estimated 5-10% of breast cancers are inherited. Autosomal dominant inheritance is the main means of inheritance and the BRCA1 and BRCA2 mutations are two such genes.

BRCA1 is also associated with increased risk of pancreatic cancer, and BRCA2 is associated with pancreatic cancer, prostate cancer and melanoma.

It is important to remember that inheritance of these mutations leads to an increased risk of developing a malignancy, not the certainty of developing a malignancy.

5

Diagnosis of benign breast disease
A Breast abscess
B Breast cyst
C Fat necrosis
D Fibroadenoma
E Lymphoma
F Mastalgia
G Phyllodes tumour
Please select the most appropriate diagnosis of breast diseases from the options below.
You may use each option once, more than once, or not at all.
A 24-year-old lady complains of cyclic breast pain. Examination is unremarkable.

A 26-year-old lady presents with a hard irregular lump which has been there for two weeks following a car crash.

A 25-year-old lady presents with a 1-2 cm smooth and mobile lump.

Mastalgia is common in young women, especially around their period. The problem is usually benign and simple analgesics should be prescribed.

Fat necrosis is hard, craggy and painful and hence mimics breast cancer; however, because the woman was in a car crash two weeks previously, the history suggests trauma to the breast. A smooth mobile lump in a woman aged 40-50 should be treated suspiciously. However, in the absence of an option of breast cancer, the most likely diagnosis is a phyllodes tumour.

Fibroadenoma usually occurs in younger women and is a benign mobile mass which can be removed for cosmetic purposes.

6

Breast Disease
A Abscess
B Carcinoma
C Cyst
D Fat necrosis
E Fibroadenoma
F Lipoma
G Mammary duct ectasia
H Paget's disease of the nipple
I Papilloma
J Phyllodes tumour
Match each of the following stems to one of the listed conditions:
Occurs in middle aged women and develops in the lactiferous ducts just below the nipple. Form a lumpy mass and associated with a bloody discharge.

Red scaly eczematous nipple which may be associated with underlying carcinoma.

Usually found in women below 35-years-old. Presents as firm rubbery non-tender masses which may slip away during palpation.

Rare condition caused by trauma to the breast. It forms a firm irregular mass.

Usually found in climacteric women, present with chronic inflammation of the breast with a creamy protein rich (green) discharge.

Papilloma
Papillomas develop in the lactiferous ducts and are associated with a worrying bloody discharge.

Paget's disease is a skin cancer associated with longstanding eczematous disease of the nipple/areolar region.

Most are smooth or slightly lobulated and are usually 2-3 cm in diameter. They usually present between 16 and 24 years of age, and decrease in incidence approaching the menopause.

They may present has 'hard' calcified masses in the elderly. Approximately 10% of fibroadenomas are multiple.

They are diagnosed by triple assessment:

Clinical examination
Mammography or ultrasound
Fine needle aspiration cytology or core biopsy.

Fat necrosis often follows trauma and is associated with a hard mass. The preceding history of trauma should help secure the diagnosis.

Mammary duct ectasia
Mammary duct ectasia is a benign breast condition in which the milk ducts beneath the nipple become dilated and sometimes inflamed. It occurs most often in women during or after menopause.

7

Breast pathology
A Breast abscess
B Carcinoma
C Duct ectasia
D Fat necrosis
E Fibroadenoma
F Galactocele
G Lipoma
H Phyllodes tumour
I Pregnancy
J Sebaceous cyst
K Tuberculous abscess
For the following scenarios determine the most likely diagnosis:
A 30-year-old breastfeeding woman comes to clinic complaining of a painful left breast associated with chills. On examination the left breast appears erythematous, hot, oedematous and tender.

A 36-year-old woman presents to clinic experiencing a painful right nipple. The retroareolar area is erythematous and there is nipple retraction. You also notice a thick creamy nipple discharge. On palpation the woman feels the tenderness is originating from behind the nipple. There is no lymphadenopathy.

A 25-year-old breastfeeding woman presents with swelling in her left breast. On examination the 1 cm mass is smooth, soft and mobile, and causes the woman a small degree of pain on palpation. There is no lymphadenopathy.

A 48-year-old woman presents to clinic having noticed a lump in her left breast. On examination the 2 cm lump is firm in consistency, rather irregular and appears attached to the overlying skin.

A 56-year-old woman attends clinic having noticed a lump in her left breast. One month ago she was involved in a road traffic accident. On examination you notice the overlying skin is bruised. There is a small, hard, painless swelling in the right upper quadrant of the breast which appears to be fixed to the overlying skin. There is no lymphadenopathy.

A breast abscess occasionally complicates mastitis which is a common occurrence in breastfeeding women. The most common infective organism is Staphylococcus aureus.

Duct ectasia is a general term literally meaning a widening of the major ducts just behind the nipple. It is caused by a variety of chronic inflammatory processes, usually in pre-menopausal women. The ducts may become calcified, showing up on mammograms, and may produce creamy, protein-based fluid which can discharge through the nipple. As the disease progresses, sclerosis can occur, causing nipple retraction, which would widen the differential diagnosis to carcinoma.

Galactoceles are common causes of smooth, fluctuant lumps in lactating women. They are caused when a lactiferous duct becomes plugged with thick milk protein. They often cause only minimal pain and are sterile so there are no signs of inflammation. They usually self-resolve once lactation has finished.

Carcinomas are often hard, irregular swellings, which may be fixed to the skin or more deeply. There is often peau d'orange (skin dimpling), and occasionally Paget's disease of the nipple. Examination of the axillary lymph nodes is essential if carcinoma is suspected.

Fat necrosis is an uncommon condition that can arise after trauma to the breast or sometimes after radiotherapy or surgery. It is caused by haemorrhage, followed by cystic degeneration and then calcification of the cysts, leading to a firm lump that is tethered to the skin. This makes the condition difficult to differentiate from a carcinoma and a breast clinic referral would be indicated.

8

A 66-year-old lady presents to the breast clinic complaining of a lump in her right breast.
On examination she has a 3 × 3 cm hard mass in the breast with skin dimpling and palpable lymphadenopathy in the right axilla. A mammogram is reported as showing a malignant lesion in the breast.
What is the most appropriate next step in this lady's management?
(Please select 1 option)
Core biopsy or fine needle aspiration of the mass
Excision biopsy of the mass
Mastectomy and axillary clearance
Mastectomy and axillary sentinel node biopsy
Ultrasound of the breast

All breast lesions should undergo triple assessment (clinical, radiological and histological) prior to definitive treatment.

As such, FNA or core biopsy needs to be undertaken as the next step in management.

9

A 50-year-old lady presents to the breast clinic complaining of a lump in her left breast which has appeared suddenly in the last two weeks.
She reports suffering peri-menopausal symptoms. She has no significant past medical or family history. Examination reveals a well circumscribed, fluctuant 1.5 cm oval lump.
What is the most likely diagnosis?
(Please select 1 option)
Breast cancer
Breast cyst
Fibroadenoma
Galactocele
Mondor's disease

In this lady's age group the most common cause of a breast lump would be a breast cyst. Her history (rapid onset) and clinical examination findings support this diagnosis.

Breast cancer should be included in the differential diagnosis, but is less likely.

Breast cysts usually occur in the last decade of reproductive life due to involution of the breast tissue.

Fibroadenomas are more common in earlier reproductive years.

Galactoceles affect ladies who are breast feeding.

Mondor's disease is thrombophlebitis of the superficial veins of the breast.

10

Lymphatic drainage of the breasts
A Apical group of axillary lymph nodes
B Central group of axillary lymph nodes
C Infraclavicular lymph nodes
D Lateral group of axillary lymph nodes
E Parasternal lymph nodes
F Pectoral group of axillary lymph nodes
G Subareolar plexus
H Subscapular group of axillary lymph nodes
I Supraclavicular lymph nodes
From the given list of lymph nodes select the most applicable to the scenarios below:
Lymph drainage arises here.

The majority of lymph drains here initially.

Medial lymph is most likely to drain here.

Subareolar plexus
Pectoral group of axillary lymph nodes
Parasternal lymph nodes

The majority of lymph drains into the subareolar plexus and then into the pectoral group of axillary lymph nodes. Seventy five per cent of lymph drains to this group of lymph nodes.

Some lymph drains directly to the parasternal lymph nodes.

When examining the breast it is important to examine carefully the axilla and the supra- and subclavicular lymph nodes.

11

A 51-year-old female is four hours post wide local excision of the left breast and axillary node clearance for breast cancer. She complains of increasing pain from the left breast.
On examination the breast is swollen and tender. Only one drain has been placed in the axilla.
What is the most appropriate management in this case?
(Please select 1 option)
Analgesia and observe
Stop low molecular weight heparin
Surgical wash out and control and haemostasis
Ultrasound guided needle aspiration
Unguided needle aspiration

Haematoma formation is more common following breast conserving surgery for cancer.

Surgical drains may be left in the wound to evacuate bleeding which occurs following closure of the wound. However, meticulous haemostasis should be obtained prior to closure of the wound as the drain may become blocked.

Haematoma formation stretches the overlying skin causing pain. Eventually if the wound is not opened and the patient has normal clotting bleeding will stop by tamponade.

Aspiration is usually unsuccessful as the haematoma is clotted and cannot be removed via a needle.

Surgical control of the bleeding is indicated if the overlying skin is becoming necrotic or the wound has opened spontaneously.

12

A 28-year-old female presents eight weeks post-partum with a painful, swollen, erythematous right breast.
On examination there is fluctuance in the right upper outer quadrant adjacent to nipple areolar complex. The overlying skin is red and tender.
What is the most appropriate management for this patient?
(Please select 1 option)
Excision of abscess cavity
Incision and drainage
Intravenous antibiotics
Mammograghic guided needle aspiration
Ultrasound guided needle aspiration

Post-partum breast abscess occurs in breastfeeding mothers. They usually result from Staphylococcus aureus introduced through cracks in the nipple-areolar complex and are usually situate peripherally. Infection may also result at weaning due to engorgement of the breast or from the child developing teeth.

Early breast infections (that is, before pus forms) may be treated successfully with antibiotics. When pus forms the treatment is ultrasound guided needle aspiration (mammography requires compression of the painful breast between radiographic plates and is therefore contraindicated).

Surgical incision and drainage may result in a mammory-cutaneous fistula and is only indicated if the abscess is very loculated, fails to respond to repeated guided aspirations or if the overlying skin is necrotic.

13

Causes of gynaecomastia
A Drug-induced
B Haemochromatosis
C Klinefelter’s syndrome
D Liver disease
E Myotonic dystrophy
F Physiological
G Renal failure
H Testicular tumour
I Thyrotoxicosis
Select the most likely underlying diagnosis in the following patients who present with gynaecomastia:
A 13-year-old male is brought to the clinic by his parents who are concerned as he has developed a slightly enlarged left breast. He is otherwise well and has progressed normally in school. On examination, he has normal height and weight characteristics and has a small amount of breast tissue in the left breast, which is non-tender. He has scanty pubic hair and testicular volumes of approximately 7 mls bilaterally with developing penis.

A 16-year-old male attends clinic concerned regarding poor pubertal development and breast enlargement. He is otherwise well, has just completed schooling but without any qualifications after being in the remedial class. On examination he is tall and is of normal weight, has modest bilateral gynaecomastia, small testicular volumes bilaterally and small penis size. There is only scanty pubic hair but no axillary hair.

Physiological gynaecomastia is common at puberty occurring in as many as 25%. It is characteristically unilateral and when bilateral is usually asymmetrical. It usually resolves spontaneously and reassurance is generally all that is required.

Klinefelter's syndrome is characterised by tall stature, gynaecomastia and below average intelligence. Karytotype is XXY and there is a primary hypogonadism with low testosterone and elevated luteinising hormone/follicle-stimulating hormone (LH/FSH) (primary testicular failure).

14

A 24-year-old lady presents with a tender swelling in her left breast.
She had been breast feeding her baby for three weeks and was well up until four days prior to admission when she noted a painful swelling developing. On examination there was a tender, erythematous, warm, fluctuant mass in the left breast.
What is the likely diagnosis?
(Please select 1 option)
Abscess
Carcinoma
Cyst
Duct ectasia
Fibroadenoma

Lactational breast abscesses are usually seen during the first month of breast feeding.

They are usually staphylococcal and often respond to antibiotic therapy.

If the abscess does not settle then it should be aspirated under ultrasound control.

If it does not settle or recurs then formal incision and drainage may be required.

15

Causes of Gynaecomastia
A Bronchogenic carcinoma
B Drug-induced
C Haemochromatosis
D Klinefelter’s syndrome
E Liver disease
F Myotonic dystrophy
G Physiological
H Renal failure
I Testicular tumour
J Thyrotoxicosis
Select the most likely underlying diagnosis in the following patients who present with gynaecomastia:
A 31-year-old male presents with tender breast swelling. He is a non-smoker, drinks modest quantities of alcohol and has no past medical history of note. On examination he has modest tender gynaecomastia. He has normal secondary sexual characteristics and examination is normal other than a hydrocele of the left testis.

A 67-year-old male presents with breast soreness and impotence. He has a past history of hypertension and diabetes for which he takes metformin, bendroflumethiazide, lisinopril and spironolactone. He drinks little alcohol and is a non-smoker. On examination he has bilateral gynaecomastia, has a blood pressure of 150/90 mmHg and examination of the systems is normal except for background diabetic retinopathy. Testicular examination is normal and he has microalbuminuria on urine testing.

Testicular tumours such as teratoma or seminoma are both associated with gynaecomastia which may be the initial presenting complaint.

Drug causes of gynaecomastia include spironolactone, digoxin and oestrogens.

Spironolactone's actions are antiandrogenic.

Microalbuminuria is not a cause of gynaecomastia as it is one of the earliest detectable features of diabetic nephropathy.

Chronic renal failure is usually profound before gynaecomastia is noticeable.

Impotence may be due to both spironolactone and the other antihypertensives.

16

Complications of breast carcinoma
A Cerebral metastases
B Hypercalcaemia
C Lymphangitis carcinomatosis
D Lymphoedema
E Pathological fracture
F Spinal cord compression
G Venous thrombosis
From the list below select the most likely complication that would explain the presentation of the following patients who have a diagnosis of breast carcinoma.
A 55-year-old female who underwent mastectomy and lymph node clearance for carcinoma of the left breast three years ago presents with a swollen limb and decreased hand movements.

A 60-year-old female treated for stage 2 carcinoma of the breast 30 months ago presents with thirst, confusion and constipation.

A 42-year-old female on primary hormonal treatment for advanced carcinoma has presented to the surgery having collapsed in a shopping centre. She has noticed weakness of both legs and difficulty in walking up the stairs over the last three months. She is found to have retention of urine.

Lymphoedema
Hypercalcaemia
Spinal Cord compression

Complications of breast carcinoma can be related to the disease itself but also a consequence of the treatment employed.

Lymphoedema is not uncommon and may represent impaired lymph drainage related to the surgery itself or carcinomatous impairment of lymph drainage.

Hypercalcaemia may arise as a consequence of bony infiltration or from the release of ectopic PTHrp. Symptoms include:

thirst
bone pains
polyuria
abdominal pains
constipation
together with depression.

Advanced carcinomatous deposits may occur in the vertbrae or spinal cord and present with an advancing paraparesis. Signs would include

extensor planatar responses
weakness
increased tone
exaggerated reflexes.
A sensory level may also be found.

17

Breast cancer risk is increased in association with which of the following factors?
(Please select 1 option)
During pregnancy
Early age at first pregnancy
Late menarche
Late menopause
Multiparity

Breast cancer is predominately a disease of women and the risk increases as age increases.

The risks are also greater in those women who have previously suffered with breast cancer and in Caucasian woman compared to woman of African descent.

Other risk factors include genetic causes (family history, both maternal and paternal, particularly first degree relatives. Five to 10% of breast cancers are hereditary, as a result of mutations in BRCA1 and BRCA2 genes).

There are also hormonal causes. Women who start their periods at an early age or experience a late menopause have a slightly higher risk of developing breast cancer. Conversely, being older at the time of the first menstrual period and early menopause tend to protect one from breast cancer. Having a child before age 30 years may provide some protection, and having no children may increase the risk for developing breast cancer.

Other risk factors include lifestyle and dietary causes (breast cancer rates are higher in countries with high dietary intake of fat and obesity. Alcohol abuse also appears to elevate the risk of breast cancer).

18

In the axilla, which of the following statements is correct?
(Please select 1 option)
A rich anastomosis permits the distal axillary artery to be ligated
Lymph nodes enlargement may be due to an abscess in the epigastric region of the abdominal wall
Section of the long thoracic nerve will affect adduction
T1 supplies sensation to the skin of the lateral wall
The axillary artery lies anterior to pectoralis minor

The intercostobrachial nerve (T2) supplies sensation to the lateral axillary wall. The axillary artery lies high in the axilla, above the axillary vein and behind pectoralis minor.

The axillary artery does have a rich anastomosis of vessels allowing the second part of the axillary artery to be ligated. If the long thoracic nerve is divided, a winged scapula will result (nerve supply to serratus anterior), but if the thoracodorsal nerve is divided (nerve supply to latissimus dorsi) there will be weakness of shoulder adduction.

Due to the extensive flow of lymph from the anterior abdominal wall, there may be enlarged axillary lymph nodes.

19

Concerning the epidemiology of female breast cancer in the United Kingdom, which of the following is true?
(Please select 1 option)
It is the leading cause of deaths from cancer in females
The incidence is approximately 50 per 100,000 of the population
The incidence is higher in Asians than Caucasians
The lifetime risk is approximately 10%
There is an approximate 50% five year survival associated with the diagnosis

Breast cancer is the commonest cause of cancer in females, but is the second leading cause of deaths from cancer (leading cause is lung cancer) due to the success associated with therapy (approximately 80% 5 year survival).

It is commoner in Caucasians than other ethnicities, with an incidence of roughly 100-150 per 100,000 population and is associated with an approximate 10% lifetime incidence.

20

Breast cancer risk is increased in which of the following circumstances?
(Please select 1 option)
Immediately after a pre-term delivery
In a pregnancy complicated by pre-eclampsia
In microprolactinomas
In pregnancy complicated with a smaller placenta
In prolonged breast feeding

Breast cancer risk is transiently increased immediately after a pregnancy, more so in full term pregnancy.

Breast cancer risk is reduced if pregnancy is complicated by high blood pressure, pre-eclampsia or smaller placenta. Every year of breast feeding decreases the risk by 4%.

There is no increased risk attributable to microprolactinomas; in fact, one might expect the risk to be reduced as a consequence of the reduced oestrogen secretion with hyperprolactinaemia.

21

Which of the following statements is true regarding pregnancy following breast cancer?
(Please select 1 option)
Chemotherapy with cyclophosphamide does not affect future fertility
Early pregnancy loss is more likely
Radiotherapy following mastectomy is associated with premature ovarian failure
Resumption of menstruation following treatment confirms restoration of fertility
Treatment of stage I breast cancer is associated with impaired future fertility

Treatment of early stage I and II breast cancer should not be associated with any detrimental effect on future fertility, but fertility is impaired following chemotherapy.

As few as 7% of women are fertile after breast cancer chemotherapy. Cyclophosphamide affects resting cells.

The resumption of menstruation does not mean that fertility will be unimpaired, although it is a good sign.

Chemotherapy following surgery may be associated with premature ovarian failure but not axillary radiotherapy.

22

Which of the following is true of mammographic screening for breast cancer?
(Please select 1 option)
Has been shown to reduce mortality from breast cancer in women over the age of 50
Has no evidence to support screening beyond the age of 70
Is associated with a false positive rate of approximately 15%
Should be offered more frequently to women on HRT

Mammographic screening for breast cancer has a high sensitivity and specificity, with a false positive rate of less than 10% in younger females, which is even better in older women (5%).

Screening is advocated every two to three years in women above the age of 50. There is no evidence to support more frequent screening.

Women beyond 70 years of age have an increased risk of breast cancer and it may be more readily demonstrated in this age group with mammography.

23

Which of the following is true regarding benign breast disease?
(Please select 1 option)
Cyclical mastalgia is an uncommon reason for referral to the breast clinic
Atypical lobular hyperplasia is associated with an increased risk of breast cancer
Duct ectasia is less common in smokers
Fibroadenomas are derived from the breast connective tissue
Lactational breast abscesses are usually due to Streptococcus pyogenes

Cyclical mastalgia is the commonest reason for presentation and is usually evident from the history of pain related to the menstrual cycle. It is exacerbated by progestogens.

Fibroadenomas are derived from the breast lobule.

Breast abscess is most commonly due to Staphylococcus aureus infection.

Lactational breast abscesses are usually due to Staphylococcus aureus.

Duct ectasia is more common in smokers.

24

In the axilla, which of the following is true?
(Please select 1 option)
Damage to the intercostobrachial nerve causes sensory loss over the lateral part of the arm
The long thoracic nerve may be damaged in mastectomy
The pectoral lymph nodes drain chiefly the upper limb
The posterior cord of the brachial pexus lies posterior to the first part of the axillary artery
The tendon of latissimus dorsi lies posterior to the tendon of teres major

The pectoral lymph nodes lie along the medial wall of the axilla and receive drainage from the upper trunk and the major part of the breast.

The lateral lymph nodes in the axilla receive drainage from the upper limb.

All three cords (lateral, medial and posterior) of the brachial plexus lie above and lateral to the second part of the axillary artery.

The latissimus dorsi muscle is a large flat triangular muscle that sweeps over the lumbar region and lower thorax and ends as a flattened tendon about 7 cm long, anterior to teres major. Its nerve supply is the from the thoracodorsal nerve.

The long thoracic nerve can be damaged during an axillary dissection, causing a winged scapula.

If the intercostobrachial nerve is damaged patients will complain of medial upper arm numbness.

25

Which of the following is correct regarding the female breast?
(Please select 1 option)
Drains approximately 40% of its lymph to the axillary lymph nodes
Has a subareolar lymph plexus
Has approximately 90% of its lymph passing to the posterior infraclavicular nodes
Is firmly attached to the pectoralis major muscle
Lateral part drains predominately to the para-sternal nodes

The female breast extends from the second to the sixth rib in the mid clavicular line, overlying pectoralis major.

Beneath the breast there is a condensation of superficial fascia which acts as a posterior capsule for the breast.

There is a subareloar lymphatic plexus.

Most of the lymph of the breast drains to the axilla, with lymph from the lateral breast draining into the axillary and infraclavicular nodes.

Medially the lymph drains through the intercostal spaces into the parasternal (internal thoracic) nodes.

However lymph from the breast may drain into any of the lymphatic basins and if one pathway becomes blocked another is utilised.