Breast

Question 1

Breast Cancer

Answer 1

Affects 1/10 women
 20 000 cases/yr in UK
 Commonest cause of cancer death in females 15-54
 Second commonest cause of cancer deaths overall

Question 2

Breast Cancer RF aetiology

Answer 2

Family Hx
 10% Ca breast is familial
(One 1st degree relative = 2x risk)

5% assoc. c¯ BRCA mutations
 BRCA1 (17q) → 80% breast Ca, 40% + ov Ca
 BRCA2 (13q) → 80% breast Ca

Oestrogen Exposure 
 Early menarche, late menopause
 HRT, OCP (Million Women Study)
 First child >35yrs
 Obesity

Other RF
 Proliferative breast disease w atypia
 Previous Ca breast
 ↑ age (v. rare <30)
 Breast feeding is protective

Question 3

Breast Cancer Types

DCIS/LCIS

Answer 3

 Non-invasive pre-malignant condition
 Microcalcification on mammography
 10x ↑ risk of invasive Ca

Question 4

Breast Cancer Types Invasive Ductal Carcinoma

Answer 4

Invasive Ductal Carcinoma, NST/NOS
 Commonest: ~70% of cancers
 Feels hard (scirrhous)

Question 5

Breast cancer Other subtypes (not DCIS, LCIS, Invasive ductal carcinoma)

Answer 5

 Invasive lobular: ~20% of cancers
 Medullary: affects younger pts, feels soft
 Colloid/mucinous: occur in elderly
 Inflammatory: pain, erythema, swelling, peau d’orange
 Papillary

Question 6

Breast Cancer Types

Phyllodes Tumour

Answer 6

 Stromal tumour

 Large, non-tender mobile lump

Question 7

Breast Cancer Spread

Answer 7

Direct extension → muscle and/or skin

Lymph → p’eau d’orange + arm oedema

Blood →
 Bones: bone pain, #, ↑Ca
 Lungs: dyspnoea, pleural effusion
 Liver: abdo pain, hepatic impairment
 Brain: headache, seizures

Question 8

Breast Cancer Screening

Answer 8

 Every 3yrs from 47-73
 Craniocaudal and oblique views
 ↓ breast Ca deaths by 25%
 10% false negative rate.

Question 9

Breast Cancer Presentation

Answer 9

Lump: commonest presentation of Ca breast
 Usually painless
 50% in upper outer quadrant
 ± axillary nodes

Skin changes
 Paget’s: persistent eczema
 Peau d’orange

Nipple
 Discharge
 Inversion

Mets
 Pathological #
 SOB
 Abdominal pain
 Seizures

May present through screening

Question 10

Breast Cancer Skin changes

Answer 10

 Cysts
 Fibroadenomas
 DCIS
 Duct ectasia

Question 11

Triple Assessment Breast Cancer

Answer 11

Any Breast Lump
Hx + Clinical Examination

Radiology
 <35yrs: US
 >35ys: US + mammography

Pathology
Solid lump: tru-cut core biopsy
Cystic lump: FNAC (green / 18G needle)
 Reassure if clear fluid
 Send cytology if bloody fluid
 Core biopsy residual mass
 Core biopsy if +ve cytology

Question 12

Breast Cancer other Ix

Answer 12

Bloods
 FBC, LFTs, ESR, bone profile

Imaging: help staging
 CXR
 Liver US
 CT scan
 Breast MRI: multifocal disease or c¯ implants
 Bone scan and PET-CT

May need wire-guided excision biopsy

Question 13

Breast Cancer Staging

Answer 13

Clinical Staging
 Stage 1: confined to breast, mobile, no LNs
 Stage 2: Stage 1 + nodes in ipsilateral axilla
 Stage 3: Stage 2 + fixation to muscle (not chest wall)
LNs matted and fixed, large skin involvement
 Stage 4: Complete fixation to chest wall + mets

TNM Staging
 Tis (no palpable tumour): CIS
 T1: <2cm, no skin fixation
 T2: 2-5cm, skin fixation
 T3: 5-10cm, ulceration + pectoral fixation
 T4: >10cm, chest wall extension, skin involved
 N1: mobile nodes
 N2: fixed nodes

Question 14

Breast Cancer Management Surgery

Answer 14

2 options
WLE + Radiotherapy (80% treated as such)
Mastectomy
 Typically large tumours >4cm
 Multifocal or central tumours
 Nipple involvement
 Pt. choice
 Not radical: no longer used
 Same survival, but WLE has ↑ recurrence rate

Question 15

Breast Cancer Mx Sentinal Node Biopsy

Answer 15

Gold Standard
 Sentinal Node = first node that a section of breast drains to.
 If clinically –ve axillary LNs, no need for further dissection

Procedure
 Blue dye / radiocolloid injected into tumour
 Visual inspection / gamma probe @ surgery to ID SN
 SN removed and sent for frozen section
 If node +ve → axillary clearance or radiotherapy

Question 16

Breast Cancer other axillary options (not sentinal node biopsy

Answer 16

Axillary sampling
 Removal of lower nodes
 Clearance or DXT if +ve

Axillary clearance
 Can be done to various levels

Question 17

Surgical Complications Breast Cancer

Answer 17

Surgical Complications
 Haematoma, seroma
 Frozen shoulder
 Long-thoracic nerve palsy
 Lymphoedema

Question 18

Breast Cancer Systemic Rx

chemo/radio

Answer 18

Radiotherapy
 Post-WLE: ↓ local recurrence
 Post-mastectomy: only if high risk of local recurrence
 Large, poorly differentiated, node +ve
 Axillary: node +ve disease
 Palliation: bone pain

Chemotherapy
 Pre-menopausal, node +ve, high grade or recurrent
tumours.
 Neo-adjuvant chemo improves survival in large tumours
 6 x FEC: 5-FU, Epirubicin, Cyclophosphamide
 Trastuzumab (anti-Her2) is used if Her2+ve
 SE: cardiac toxicity

Question 19

Breast Cancer Systemic Rx

Endocrine

Answer 19

Used in ER or PR +ve disease: ↓ recurrence, ↑ survival
 5yrs of adjuvant therapy

Tamoxifen
 SERM: antagonist @ breast, agonist @ uterus
 SE: menopausal symptoms, endometrial Ca

Anastrazole
 Aromatase inhibitor → ↓ oestrogen
 Better cf. tamoxifen if post-men (ATAC trial)
 SE: menopausal symptoms

If pre-menopausal and ER+ve may consider ovarian
ablation or GnRH analogues (e.g. goserelin)

Question 20

Treating Advanced Disease (Stage 3-4) Breast Cancer

Answer 20

 Tamoxifen if ER+ve
 Chemo for relapse
 Her2+ve tumours may respond to trastuzumab

Supportive
 Bone pain: DXT, bisphosphonates, analgesia
 Brain: occasional surgery, DXT, steroids, AEDs
 Lymphoedema: decongestion, compression

Question 21

Breast Cancer Reconstruction

Answer 21

Offered either at 1O surgery or as delayed procedure.

Implants - silastic or saline inflatable

Lat dorsi myocutaneous flap
 Pedicled flap: skin, fat, muscle and blood supply
 Supplied by thoracodorsal A. via subscapular A.
 Usually used w an implant

Transverse rectus abdominis myocutaneous flap
 Gold-standard
 Pedicled (inf. epigastric A.)
 Or free: attached to internal thoracic A
 No implant necessary and combined tummy tuck
 CI if poor circulation: smokers, obese, PVD, DM
 Risk of abdominal hernia

Nipple Tattoo

Question 22

Mastalgia

Answer 22

Cyclical 
 ~35yrs
 Pre-menstrual pain
 Relieved by menstruation
 Commonly in upper outer quadrants bilaterally 

Non-cyclical
 ~45yrs
 Severe lancing breast pain (often left)
 May be assw back pain

Rx
 Reassurance + good bra for most
 1st line: EPO (contains gamma-linoleic acid)
 OCP
 Topical NSAIDs (e.g. ibuprofen)
 Bromocriptine
 Danazol
 Tamoxifen

Question 23

Acute Mastitis

Answer 23

Usually lactating

Presents - painful, red breast
May > abscess (lump near nipple)

Rx - fluclox alone in early stages
Fluclox + I&D if fluctuant abscess

Question 24

Fat necrosis

Answer 24

Assw previous trauma
painless,palpable, non-mobile mass
May calcify > simulating cancer

Rx - Analgesia, no follow up needed

Question 25

Duct Ectasia

Answer 25

Post menopausal 50-60 Slit like nipple (oft bilateral) +/- periareolar mass thick white green discharge may be calcified on mammography Rx Need to distinguish from Ca Surgical duct excision if mass present or discharge troublesome Close follow up

Question 26

Periductal Mastitis

Answer 26

Smokers 30y Painful erythematous subarealar mass assw inverted nipple +/- purulent discharge May > abscess or discharging fistula Rx - broad spectrum abx

Question 27

Benign mammary dysplasia

Answer 27

30-50y benign Pre-menstrual breast nodularity + pain, often in upper outer quadrant > tender lumpy breasts Aberration of normal development + involution - Fibroadenosis - Cyst formation - Epitheliosis (hyperplasia) - Papillomatosis Rx Triple assessment reassurance, analgesia, good bra, evening primrose oil Danazol occasionally

Question 28

Cystic Disease (benign breast lesions)

Answer 28

perimenopausal >40 benign Distinct, fluctuant round mass, oft painful Rx - aspiration gree, brown fluid persistence or blood > triple assessment

Question 29

Duct papilloma

Answer 29

40-50 years benign Common cause of bloody discharge - not usually palpable Triple assessment Excise due to ^risk of ca

Question 30

Fibroadenoma (breast)

Answer 30

<35 years (rare postmenopause) ^black Commonest benign tumour Stromal tumour painless mobile rubbery mass, oft multiple + bilateral popcorn calcification Rx Reassure + follow up if <2.5cm Shell out surgically - >2.5cm - FH breast Ca - Pt choice

Question 31

Phyllodes tumour

Answer 31

50+ stromal tumour Large, fast growing mass mobile, non-tender Epithelial + connective tissue elements Rx - Wide local excision

Question 32

Ductal Carcinoma In Situ (malignant)

Answer 32

Presents as Microcalcification on mammogram Rarely assoc. with symptoms: - lump - discharge - eczematous change = Paget’s disease → Ca @ 1%/yr (10x ↑ risk) in ipsilateral breast Rx - WLE + radio - Extensive or multifocal > mastectomy + reconstruction + SNB

Question 33

Paget's Disease of the breast

Answer 33

Unilateral, scaly, erythematous, itchy +/- palpable mass (invasive carcinomas) Rx - usually underlying invasive or DCIS breast cancer - mastectomy + radio +/- chemo/endo

Question 34

Lobular Carcinoma In situ

Answer 34

Incidental biopsy finding (no calcification) oft bilateral (20-40%) young women ^risk ca in both breasts Rx Bilateral prophylactic mastectomy or lose watching w mammographic screening