Breast

Question 1

Fibroadenoma - Sy, Ix, Mx

Answer 1

Sy - common, firm, smooth, mobile lump, painless. Usually in younger women, especially on COCP.

Ix - USS conclusive.

Mx - reassure, excise if large.

Question 2

Breast cyst - Sy, Ix

Answer 2

Sy - common, esp perimenopausal, benign fluid filled round lump, mobile, occasionally painful.

Ix - USS - fluid filled, confirmed by FNA clear fluid if risidual mass do core biopsy.

Question 3

Infective mastitis/breast abscess - Path, sy, Mx

Answer 3

Path - staph aureus.

Sy - hot painful swelling of breast.

Mx - Abx, drainage if abscess.

Question 4

Duct ectasia - Sy, Mx

Answer 4

Sy - typically perimenopausal, blocked ducts so secretions stagnate, green/brown/bloody d/c +- nipple retraction and lump.

Mx - none needed.

Question 5

Fat necrosis - Sy, Ix, Mx

Answer 5

Sy - fibrosis and calcification following injury, firm lump.

Ix - USS/mammography.

Mx - none once confirmed.

Question 6

Breast Ca - RF, path, Ix, staging, Mx, Screening

Answer 6

RF - FH, age, oestrogen exposure, obesity, BRCA genes.

Path - DCIS - premalignant, microcalcification on mamography. LCIS - rarer, multifocal. Invasive ductal more common than lobular.

Ix - all lumps should undergo triple assessment -
Clinical examination
Radiology (USS if <35, USS and mamography if over)
Histology/cytology - FNA if cystic lump - if clear reassure, if bloody cytology, if risidual lump core biopsy. Core biopsy if solid lump.

Staging - 1=breast, 2=LN, 3=muscle, 4=chest wall/distant mets.

Mx - Surgery - wide local excision or mastectomy with sentinal biopsy. Radiotherapy if invasive. Chemo - adjuvant/neoadjuvant. Herceptin (traztuzumab) if Her positive. If E positive tamoxifen, anastrazole (aromatase inhib - post menopausal), goserelin (GTRH anologue in pre).
Palliate if stage 3-4.

Screening - 2 view mammography every 3yrs for women 47-73. Ref to geneticist if one first degree relative female <40, male, bilateral <50, two first degree/one first on one second, esp if Jewish ancestry.

Question 7

Mastalgia - Sy, cause, Mx

Answer 7

Sy - Usually cyclical starting a few days before menstruation in both breasts.

Cause - cyclical due menstruation, non-cyclical usually due to drugs (contraceptives, SSRIs) or MSK. Rarely cancer.

Mx - If reassuring no Ix are required, analgesia.

Question 8

Pagets disease of the nipple - Sy, path, Mx

Answer 8

Sy - rough redness of the nipple, itchy, may ulcerate, painful caused by ductal skin mets. DDX eczema (normally spares the nipple, would never be first presentation).

Path - vast majority have underlying ductal cancer or DCIS.

Mx - surgical excision.

Question 9

Gynaecomastia

Answer 9

C - Steroids, low testosterone, obesity, spironolactone.