Breast

Question 1

Breast cancer metastasises to bone in one spot vs several spots in the bones
Best Management?

Answer 1

One spot: Radiation Therapy (relieves pain and prevents fractures)
Several Spots: Anticancer therapy (hormonal treatment [tamoxifen] or chemotherapy)

Extra:
Bone pain — NSAIDS and opioid drugs; radioactive therapy (strontium or samarium)
May give bisphosphonate to slow cancer

Question 2

First line investigation for breast symptoms for
< 35y/o vs > 35 y/o

Answer 2

< 35 y/o: ultrasound (use MMG when US findings not consistent to clinical findings)
> 35 y/o: combination of MMG + breast US

Question 3

Pregnant or lactating with breast symptoms
1st line IX?

Answer 3

US preferred over MMG
MMG can be used only if US inconsistent with clinical findings
Still safe to use MMG (can detect most breast CAs well during pregnancy)

Question 4

Obesity premenopausal vs post menopausal risk for breast CA

Answer 4

Early life obesity in premenopausal — decreases risk (protective!)
Post menopausal obesity — increases risk of breast CA!

Question 5

How often should MMG be done as per Cancer Council Australia?

Answer 5

Every 2 years for all women aged 50-74 years old

If => 40 years old and concerned (i.e. due to family history), can perform MMG

Question 6

Paget’s Disease vs Eczema

Answer 6

Paget’s Disease (eczematous-looking, dry scabbing red rash of the nipple with ulceration of nipple and areola — always due to malignancy)
- unilateral
- older patients
- possible nipple discharge
- not pruritic/pustules
- deformity of nipple
- possible palpable lump

Eczema
- bilateral
- reproductive years/lactation
- no discharge
- pruritic + pustules
- normal nipple
- no lump

Question 7

Paget’s Disease
Treatment?

Answer 7

Breast-conserving surgery (lumpectomy/partial mastectomy/WLE)

OR a mastectomy
Total mastectomy for advanced cancers

Question 8

Arrange from good prognosis to worst prognosis:
Metastatic breast CA
Hodgkin Lymphoma
Non-Hodgkin Lymphoma
Metastatic Choriocarcinoma
Metastatic Seminoma

Answer 8

Good prognosis to worst prognosis:
- Metastatic seminoma of the testis (5-year survival rate of 95-100%)
- Hodgkin Lymphoma (5-year survival rate of 87%)
- Metastatic Choriocarcinoma (5-year survival rate of 80%)
- Non-Hodgkin Lymphoma (5-year survival rate of 71%)
- Metastatic breast CA (18-24 months) (5-year survival rate of 40%)

Question 9

Red Flags for Breast Cancer

Management?

Answer 9

• Hard and irregular lump
• Skin dimpling and puckering
• Skin oedema (‘peau d’ orange’)
• Nipple discharge
• Nipple distortion
• Nipple eczema (Paget’s disease)

MMG+US/FNAC/Excision Biopsy(!!) even if cytology is normal

Question 10

What to consider for patients with high-risk family history of breast and ovarian cancer?

Answer 10

1. Refer to cancer specialist or family cancer clinic for risk assessment, 2. genetic testing (BRCA gene screening) and management plan
2. Surveillance: regular clinical breast examination + annual breast imaging with MMG/MRI/US

Question 11

After doing US (< 40 y/o) or MMG (> 40y/o), refer to breast cancer screening clinic or surgeon?

Answer 11

Refer to breast surgeon for further evaluation once US/MMG report is received

Question 12

Vitamin A deficiency leads to what breast diseases?

Answer 12

Periductal Mastitis
AKA subareolar abscess

• affects young women / men,
• vitamin A (retinoids) deficiency and smoking — potential causes

[DIFFERENT FROM ductal ectasia (younger women, dilated ducts, toothpaste-like discharge)]

Question 13

Aromatase Inhibitors:
- Arimidex (anatrozole)
- Femara (letrozole)
- Aromasin (exemestane)

Used to treat breast CA and ovarian CA in post menopausal women.
- blocks aromatase (enzyme that converts androgen to estrogen)

Side effects?

Answer 13

MOST COMMON side effects are symptoms of menopause:
Hot flashes
Night sweats
Vaginal dryness

Other possible side effects:
Muscle and joint pain
Speeds up bone thinning —> osteoporosis
May raise cholesterol

Compared to tamoxifen and raloxifene:
DVT (less than tamoxifen)
Stroke (less than tamoxifen)
Endometrial cancer (less than tamoxifen)
Osteoporosis (MORE THAN TAMOXIFEN)

Question 14

Triple Test

Answer 14

1. Clinical exam
2. Imaging: MMG +/- breast US
3. FNAC +/- Core Biopsy

Question 15

Intermittent thin or milky discharge or nonlactational (usually serous) nipple discharge is…

Answer 15

Usually physiological

Frequently bilateral and arises from multiple ducts

Cause: stimulation of the nipple or to drugs (estrogen, tranquillisers)

Question 16

Galactorrhea
Common cause?

Answer 16

Hormonal imbalance (hyperprolactinanemia, hypothyroidism)
Drugs (OCPs, phenothiazine, antihypertensive, tranquillisers)
Trauma to chest

Nature: bilateral, arising from multiple ducts

Question 17

Pathologic Nipple Discharge

Answer 17

Bloody, serous, green-grey, yellow

Spontaneous, unilateral, often localised to a single nipple duct

Identify the source:
If mass noted > biopsy
If no mass > terminal duct excision of the involve duct(s)

Question 18

What are the characteristics of a malignant breast lesion on ultrasound?

Answer 18

• Hypoechogenicity
• Irregular and ill-defined border
• Spiculated margins
• Being taller than broader
• Posterior acoustic shadowing
• Microcalcifications

If any above is seen, proceed

Question 19

Does FNAC or Core Biopsy offer a more definitive diagnosis?

Answer 19

Core Biopsy
- avoids inadequate sampling
- usually able to distinguish between invasive vs in situ cancer

However, FNAC is more convenient and minimally invasive.

Question 20

Advice for asymptomatic woman, 50-69 years old on HRT for breast cancer screening?

Answer 20

ALL asymptomatic women, 50-69 years old&raquo_space; (MMG) screen every 2 years
Regardless of whether on HRT or not

40s and 70s are eligible to attend for FREE breast screening as well

Question 21

Quickest and most effective way to diagnose a breast cancer?

Answer 21

FNAC
Most accurate when experienced cytologists are available

Although less sensitive than core biopsy.
CB is ix of choice in evaluation of microcalcifications or if FNAC provides scarce material

MMG and US is mainstay for screening, not for definitive diagnosis.

Question 22

Ultrasound is preferred for the initial diagnosis of breast abnormalities for patient 30 years and younger because of…?

Answer 22

Dense breast tissue
MMG will not be able to detect small lesions and can lead to false negative results

Question 23

How long should a patient wait to do MMG/US if FNA was done first? Why wait?

Answer 23

2-weeks should be waited because small hematomas from needle aspiration can cause false-positive

Question 24

Is nipple discharge always an abnormal finding?

Answer 24

Always an abnormal finding EXCEPT in late pregnancy or the postpartum period

Question 25

7 types of nipple discharge
(MPlusX)

Answer 25

Milky: white discharges sometimes fat globules seen under microscopy
Multicoloured gummous: sticky discharge
Purulent: pus with white cells seen under microscopy
Watery: colourless
Serous: faintly thin discharge
Serosanguineous: thin, clear discharge with pink tint, RBCs seen under microscopy
Bloody (sanguinous): pure blood

Question 26

Watery, serous, serosanguinous or bloody nipple discharge

Answer 26

Intraductal papillomas — most common cause of these discharges

Question 27

Nipple discharge seen in ductal ectasia

Answer 27

Multicoloured and sticky discharge
Toothpaste like discharge (classic description)