Breast

Question 1

What is the most common form of breast cancer?

Answer 1

Ductal carcinoma - in situ/invasive and show up on mammograms

Question 2

Apart from ductal what is the other main type of breast cancer?

Answer 2

Lobular - in situ/invasive, not always visible on mammograms

Question 3

What is inflammatory breast cancer?

Answer 3

Presents similarly to a breast abscess or mastitis, swollen, warm, tender breast with peau d’orange - worse prognosis and does not respond to antibiotics

Question 4

What is paget’s disease of the nipple?

Answer 4

Looks like eczema of the nipple/areolar, may have discharge or become inverted, may also have lump behind the nipple

Different to eczema because it affects nipple then areola as opposed to the opposite way round

Question 5

How likely are you to develop breast cancer if you have BRCA1/2?

Answer 5

1 = 60-80%
2 = 40%

Question 6

What is the inheritance pattern of BRCA1/2?

Answer 6

Autosomal dominant

Question 7

What are the risk factors for breast cancer?

Answer 7

Age, family history (1st degree relative), oestrogen exposure (early menarche, late menopause, never having child, not having breast fed), radiation to chest, HRT, COCP, obesity, smoking, past breast/ovarian cancer

Question 8

What are the signs and symptoms of breast cancer?

Answer 8

Lumps, nipple discharge, nipple inversion, skin tethering, skin in area red/hot, ulceration, systemic features

Question 9

What is the triple assessment?

Answer 9

Clinical examination - breast examination, ask about previous lumps, symptoms, family history etc.

Radiology:
USS <30 years old
Mammography and USS >30 years

Histology: fine needle aspiration or USS guided core biopsy

Question 10

What lymph node assessment is done in breast cancer?

Answer 10

Before surgery everybody is offered axillary USS and USS guided biopsy of any abnormal nodes

During surgery - done if no abnormal lymph nodes are found, uses sentinel lymph node biopsy

Question 11

What tests can be done to categorise breast cancer lumps?

Answer 11

Oestrogen receptor status and HER2 status - helps guide chemotherapy choice and prognosis

Question 12

What are the surgical options for removing breast cancer?

Answer 12

Lumpectomy, wide local excision, quadrantectomy, mastectomy +/- axillary clearance (if in axillary nodes)

Question 13

What are the risks are associated with axillary clearance?

Answer 13

Increases risk of chronic lymphedema in that arm

Question 14

What is the use of radiotherapy in breast cancer?

Answer 14

Allows for breast conserving surgery with equal outcomes to full mastectomy in patients with early breast cancer, also reduces local recurrence

Question 15

What are the side effects of radiotherapy?

Answer 15

General fatigue, local skin irritation and swelling, fibrosis and shrinking of breast tissue, long term skin colour changes, requires daily treatments for 3-5 weeks

Question 16

When the breast cancer is ER positive what medications can be given?

Answer 16

Pre-meopausal women = tamoxifen

Postmenopausal women = aromatase inhibitors e.g. anastrozole

Question 17

What is given to people with HER2 positive breast cancer?

Answer 17

Herceptin - monoclonal antibody that disrupts HER2 receptor

Given every 3 weeks for 1 year following initial treatment

Question 18

What are the contraindications to herceptin?

Answer 18

Congestive heart failure and other heart conditions

Question 19

What does neoadjuvant and adjuvant therapy mean?

Answer 19

Neoadjuvant - intended to shrink tumour prior to surgery

Adjuvant - after surgery to reduce recurrence

Question 20

What is the follow up for women after completing breast cancer treatment?

Answer 20

Total mastectomies - none required
Early breast cancer - yearly mammograms for 5 years, then based on risk category

Question 21

How often do women have breast screening and during what ages?

Answer 21

Every 3 years in women aged 50-70

Question 22

What is a fibroadenoma, how does it present and how is it treated?

Answer 22

Most common type of breast lump

Small, mobile, smooth, firm, well circumscribed lump

Hormone dependent and may regress naturally or after menopause - no treatment required

Question 23

What is a fibrocystic breast disease/fibroadenosis, how does it present and how is it treated?

Answer 23

Benign breast disease that is common in menstruating women, related to hormonal changes around menstrual cycle

Bilateral breast lumpiness, bilateral pain/tenderness, fluctuation in breast size - occurs prior to menstruating and resolves afterwards

Treatment - supportive clothing, NSAIDs, consider stopping hormonal contraception

Question 24

What is a breast cyst, how does it present and how is it treated?

Answer 24

A discrete collection of fluid in breast tissue, common between 30 and 60 years especially around menopause

Smooth, well circumscribed, mobile, possibly fluctuant lump, can be painful

Treatment = needle aspiration or local excision

Question 25

What is an intraductal papilloma, how does it present and how is it treated?

Answer 25

Benign warty lesion usually located behind the areola, women in 40s are more likely Small lump and a sticky blood stained discharge

Question 26

What is a breast abscess, how does it present and how is it treated?

Answer 26

An acute usually bacterial infection of the breast tissue, may be associated with fever, pus, discharge from the nipple, local erythema, tenderness an d heat Treat with antibiotics, may require incision and drainage surgically

Question 27

What is a fat necrosis, how does it present and how is it treated?

Answer 27

A lump formed by local degeneration/scarring of fat tissue, inflammatory reaction to local trauma or breast surgery A firm, irregular, fixed lump that may cause skin dimpling or nipple inversion May resolve spontaneously or treat with surgical excision

Question 28

What is a lipoma, how does it present and how is it treated?

Answer 28

Benign collection of fat Soft, painless and mobile lump can be up to 20cm in size Treat conservatively or surgical excision

Question 29

What is a phyllodes tumour, how does it present and how is it treated?

Answer 29

Large fast growing periductal stromal cell neoplasm, most common between 40 and 50 Can be benign, borderline or malignant so requires local excision

Question 30

What is the 2ww referral criteria for suspected breast cancer?

Answer 30

A discrete lump with fixation that enlarges or there is a family history Women over 30 with persistent breast or axillary lump or focal lumpiness after their menstrual period Previous breast cancer with new suspicious symptoms Skin or nipple changes suggestive of breast cancer Unilateral bloody nipple discharge

Question 31

What is the most common cause of mastitis?

Answer 31

Obstruction in the ducts and accumulation of milk - regularly expressing milk can prevent this from occurring

Question 32

Aside from accumulation of milk what is the other cause of mastitis?

Answer 32

Infection - bacteria enter at nipple and back track into duct causing infection and inflammation

Question 33

What is the most common bacterial cause of mastitis?

Answer 33

Staph aureus

Question 34

What are the symptoms of mastitis?

Answer 34

Unilateral breast pain and tenderness, erythema, warmth, inflammation, nipple discharge, fever

Question 35

What is the management of mastitis caused by blocked ducts?

Answer 35

Continue breastfeeding, expressing milk, breast massage, simple analgesia

Question 36

What is the management if infection is suspected in mastitis?

Answer 36

Flucloxacillin PO for 10-14 days (erythromycin if allergic) Still continue to breastfeed even if infection is suspected

Question 37

What is a side effect of antibiotic treatment associated with infective mastitis? (mum and baby)

Answer 37

Candida of the nipple - recurrent mastitis as it creates cracked skin and an entrance for infection Associated with oral thrush and candidal nappy rash in infant

Question 38

What are the symptoms of candida of the nipple?

Answer 38

Sore nipples bilaterally, nipple tenderness and itching, cracked areola

Question 39

How is candida of the nipple treated (mum and baby)?

Answer 39

Topical miconazole 2% to nipple after each breastfeed Oral miconazole gel or nystatin for baby

Question 40

What is duct ectasia, how does it present and what is the management?

Answer 40

Women around menopasue the breast ducts shorten and dilate Cheese like nipple discharge and slit like retraction of the nipple No treatment required