Breast Cancer

Question 1

List the benign breast diseases:

Answer 1

Fibroadenoma
Adenoma
Mastitis
Breast cysts
Fat necrosis
Papilloma
Lipoma
Mammillary duct ectasia

Question 2

List the breast diseases with malignant potential

Answer 2

Paget’s disease
Carcinoma in suit (ductile / lobular)
Phyllodes tumours

Question 3

List the malignant breast diseases

Answer 3

Invasive breast carcinoma (lobular / ductal)

Question 4

What are the features of fibroadenoma?

Answer 4

Highly mobile
Women of reproductive age
No malignant potential
Comprised of stromal and epithelial tissue

Question 5

What are the features of adenoma?

Answer 5

Benign glandular tumour
Older women
Commonly referred to triple assessment

Question 6

What are the features of papilloma?

Answer 6

40-50 age group
Commonly biopsied (appears similar to DCIS on imaging)
Commonly in subareolar region

Question 7

What are the features of lipoma?

Answer 7

Soft and mobile
Only removed if significantly growing

Question 8

What are the features of mastitis?

Answer 8

Inflammation of breast tissue
Commonly associated with infection (staph aureus)
Associated with cellulitis
Mostly in pre-menopausal women

Question 9

What are the presenting features of mastitis?

Answer 9

Tenderness
Erythema
Swelling
Nipple retraction or discharge

Question 10

How is mastitis classified?

Answer 10

Lactational mastitis (associated with cracked nipple and milk stasis)
Non-lactational mastitis (associated with central inflammation)

Question 11

How can duct ectasia and non-lactational mastitis be differentiated?

Answer 11

Duct ectasia - older women, less marked inflammation
Non-lactational mastitis - pre-menopausal women, more marked inflammation

Question 12

What are the management options for mastitis?

Answer 12

Early broad spectrum Abx (co-amoxiclav)
Lactational mastitis - continued drainage / feeding

Question 13

What is a potential complication of mastitis and how is it treated?

Answer 13

Abscess
- confirm via USS
- Abx + needle aspiration

Question 14

What are the features of breast cysts?

Answer 14

Epithelial lined fluid filled cavities
Typically in pre-menopausal age group

Question 15

What are the presenting features of breast cysts?

Answer 15

Distinct smooth mass
+/- tenderness

Question 16

What are the investigations of choice for breast cysts?

Answer 16

USS = definitive diagnosis
Mammography
Aspiration (disappears and free of blood = non-cancerous)
Cytology if still uncertain

Question 17

What are the potential complications of breast cysts and how are they treated?

Answer 17

x2-3 more likely to develop breast cancer
Cyclical breast pain - treat with gamolenic acid or danazol
Fibrocystic changes > tenderness and asymmetry

Question 18

What is the management of breast cysts?

Answer 18

Self-limiting

Question 19

What are the features of mammillary duct ectasia?

Answer 19

Shortening and dilatation of major lactiferous ducts
Menopausal women

Question 20

What are the presenting features of mammillary duct ectasia?

Answer 20

Green / yellow nipple discharge
Symmetrical slit-like nipple retraction
Palpable mass

Question 21

What are the investigations indicated for mammillary duct ectasia?

Answer 21

Mammography (calcified lactiferous ducts)

Question 22

What are the management options of mammillary duct ectasia?

Answer 22

Conservative management

Question 23

What are the features of fat necrosis?

Answer 23

Acute inflammatory response > ischaemic changes => fat lobules
Due to trauma, surgery, radiological intervention

Question 24

What are the presenting features of fat necrosis?

Answer 24

Asymptomatic
Can present with chronic fibrotic change

Question 25

What are the investigations indicated for fat necrosis?

Answer 25

Core biopsy (r/o malignancy)

Question 26

What are the management options for fat necrosis?

Answer 26

Self-limiting Analgesia and reassurance

Question 27

What are the features of Paget's disease of the nipple?

Answer 27

Roughening, reddening, slit ulceration of nipple Underlying malignancy in majority

Question 28

What are the presenting features of Paget's disease of the nipple?

Answer 28

Itching / redness of the nipple +/- areolar Flaking of thickened skin Painful and sensitive skin Nipple > areola (eczema will spare nipple)

Question 29

What are the investigations indicated for Paget's disease of the nipple?

Answer 29

Biopsy Mammogram

Question 30

What are the indicated investigations for ductal carcinoma in situ?

Answer 30

Mammogram (microcalcifications often identified in screening programme) Biopsy

Question 31

What is the management of ductal carcinoma?

Answer 31

Complete wide excision

Question 32

What are the indicated investigations for lobular carcinoma in situ?

Answer 32

Biopsy (typically identified incidentally)

Question 33

What is the indication for bilateral prophylactic mastectomy?

Answer 33

BRCA1 / BRCA2 +ve lobar carcinoma in situ

Question 34

What is the screening programme offered to women for breast cancer?

Answer 34

Women 50-70 offered mammogram every 3 years OR Women <50: prev cancer, 1st degree relative with cancer <50, have known BRCA1/2 or TP53 gene

Question 35

What are the risk factors of developing breast cancer?

Answer 35

Female Age BRCA1/2 Family history (1st degree relative - BRCA/2) Prev benign breast disease Obesity Alcohol ^ exposure to oestrogen (early menarche, late menopause, the pill, not breastfeeding, 1st pregnancy >30y/o, nulliparity, HRT)

Question 36

What are the management options for invasive breast carcinoma?

Answer 36

Surgery - breast (wide local excision, mastectomy), axilla (sentinel lymph node biopsy, clearance) Adj therapy - chemotherapy, 5-10 years: tamoxifen (SERM- premenopausal) / anastrozole (aromatase inhibitor - postmenopausal), 1 year: herceptin (MCAb - HER2 Y)

Question 37

What forms of chemoprotection are offered to high-risk individuals?

Answer 37

Tamoxifen Anastrozole Risk-reducing / prophylactic bilateral mastectomy +/- bilateral oophrectomy

Question 38

What are the 2WW referral criteria for breast cancer?

Answer 38

Unexplained breast lump / lump in axilla, 30 or above Unilateral nipple changes, 50 or above Skin changes suggestive of cancer

Question 39

What is the purpose of USS in the investigation of breast lumps?

Answer 39

Used in women younger than 30 y/o Distinguishes hard from soft e.g. cancer / fibroadenoma from cyst

Question 40

What is the purpose of MRI in the investigation of breast lumps?

Answer 40

Used for screening in high risk individuals Used to further assess size and features of a tumour

Question 41

What receptors are involved in targeted breast cancer treatment?

Answer 41

Oestrogen (ER), Progesterone (PR), Human epidermal growth factor (HER2)

Question 42

Where are the common sites of metastases in breast cancer?

Answer 42

Lung, Liver Bone, Brain

Question 43

What tumour marker is most commonly associated with breast cancer?

Answer 43

CA 15-3