Breast disease

Question 1

What would you like to know in a breast Hx?

Answer 1

 Features about lump and breast changes
 Constitutional symptoms of breast cancer are less common
 Family history of cancer, particularly: breast cancer and ovarian cancer, as well as male breast and prostate cancer.
 Personal history of breast disease: atypical ductal hyperplasia is a premalignant change, lobular/ductal carcinoma in situation
 Radiation exposure e.g. Hodgkin’s lymphoma
 Minor risk factors
o Past parity/breast feeding (prior to 35 – protective)
o Age of menarche/menopause (natural/artificial), HRT,
o Obesity
o Ethnic background
o Smoking, alcohol
 General surgical: blood thinners, medications, allergies, social history
 I.e. breast, family history, personal history, surgical history.
 Cyclic mastalgia is more likely to be benign

Question 2

What is the most common cause of tender breast lump that is not varied with menstrual cycle?

Answer 2

Fibroadenoma (tends to present from teens-30s (most common))

 Could also consider a cyst
 Redness and pain suggests inflammatory breast cancer or mastitis. Other breast cancers are typically painless.
 Fibroadenomas and cysts can be somewhat tender on palpation.

Question 3

How should you examine a breast?

Answer 3

o Offer chaperone
o General inspection &
- movements with both exposed (arms, underneath, leaning forwards). -Look for symmetry, nipple deviation and changes
o Examine axilla
o Palpate normal breast first.
o Use systematic approach to not miss tissue, including axillary tail of the breast
o Examine axilla lying, as well as supraclavicalar nodes
o Also examine the lungs, for hepatomegaly, feel for spinal tenderness.

Question 4

What Ix should you do in a young female with tender breast lump that does not vary with menstrual cycle?

Answer 4

o Ultrasound of both breasts if younger than 30yo (dense breast tissue for mammogram): Look for lump, multifocality, other lumps, lymph nodes
o Would not routinely order a mammogram in the absence of an abnormal US or other risk factors (difficult to interpret in this age group anyway)

Question 5

What are the US features of a breast fibroadenoma?

Answer 5

Oval shaped

well circumscribed

hypoechoic (but not anechoic; not pure fluid).

On top of US: order a biopsy if looking to definitively rule out malignant change
o Core biopsy allows for assessment of the tissue architecture
o Patient preference may be for an excisional biopsy

Question 6

What is the most likely diagnois for a young woman with a tender breast mass & pain fluctuates, worsening immediately before periods & settles with the onset of menses.

Answer 6

 Most likely: fibrocystic change
 Small cysts that are tender and typically fluctuate with the menstrual cycle.
 Baseline imaging: ultrasound and mammogram to rule out.

Question 7

In what age group is fibrocystic change the most common cause of breast lumps?

Answer 7

Women of 30-40s

Question 8

How do you treat the breast lump pain from fibrocystic changes?

Answer 8

decreasing caffeine intake, vitamin B6 (3 months), evening primrose oil (anecdotal evidence, safe).

For problematic pain, can use tamoxifen and androgen drugs.

Follow up to make sure that pain is settling.

Question 9

What is the most likely diagnosis of a sudden breast lump appearance with mild tenderness in the area prior to developing a lump?

Answer 9

A Simple cyst

Question 10

What are the US features of a simple cyst?

Answer 10

Posterior acoustic enhancement – suggestive of fluid

anechoic

well-circumscribed.

Question 11

How do you Ix a simple cyst?

Answer 11

• US
• Would not biopsy, but might drain (for symptomatic relief).
  would not recommend sending off unless there is blood (other than traumatic or if tissue changes are suspected).
• Would still do a mammogram

Question 12

What are the DDx for a 49 year old woman presenting with 2 months of unilateral nipple discharge?

Answer 12

• ductal carcinoma
• duct ectasia (duct enlargement)
• papilloma (growth in a duct - can be associated with cancer or DCIS: either via direct transformation or may be associated with adjacent cancer.)

Question 13

What would you like to know in a breast discharge Hx?

Answer 13

 History of nipple discharge: features (presence of milk, pus),
 Discharge is not typically cyclical.
 Spontaneous vs. expressible.
 Other features of the breast lump: erythema, skin changes, nipple retraction (possible in chronic infection), pain, masses associated

Question 14

What Ix would you do for a breast discharge case?

Answer 14

 Bilateral mammogram
 Ultrasound (although usually reserved for lumps) is also helpful for examining retro-nipple lesions, looking for a mass

Question 15

What are the causes of a bloody nipple discharge?

Answer 15

1. Hyperplastic lesions (most common)
2. Duct ectasia
3. Pregnancy

Question 16

What are the causes of a serous nipple discharge?

Answer 16

1. Hyperplastic lesions (most common)

2. Duct ectasia

Question 17

What are the causes of a watery nipple discharge?

Answer 17

1. Hyperplastic lesions (most common)

2. Duct ectasia

Question 18

What are the causes of a coloured opalescent nipple discharge?

Answer 18

1. Duct ectasia (most common)

2. Cyst

Question 19

What are the causes of a milky nipple discharge?

Answer 19

1. Physiological (most common)

2. Galactorrhoea of endocrine origin

Question 20

How do you Rx bloody nipple discharge?

Answer 20

o Single duct in young woman keen to breastfeed: can remove single duct
o Multiple ducts tend to require removal of the entire duct system (cannot breast feed).

Question 21

What are the following Ix for a breast lump found on a mammogram?

Answer 21

mammogram -> ultrasound -> biopsy if mass found on US.

Question 22

Prognosis of a grade 1 cancer in breast

Answer 22

Very good prognosis

Grade 1: low grade & grade 1 cancers are likely to be oestrogen receptor positive (better management)

Question 23

What are the US features of a malignant breast cancer?

Answer 23

	spiculated (not well circumscribed)
	invasive appearance. 
	hypo-echoic (not anechoic)
	poorly circumscribed
	posterior acoustic shadowing.

Question 24

(5) Important oestrogen exposure Hx in breast cancer

Answer 24

• Nulparity, 1st child after 30yo
• Early menarche
• Late menopause
• OCP use
• Obesity (>30 BMI)

Question 25

What cancers are BRCA1 & 2 associated with?

Answer 25

BRCA1: breast, ovarian, prostate

BRCA2: (3 cancers from BRCA1) + endometrial, pancreatic

Question 26

What should you ask in breast Hx?

Answer 26

• Size
• Site
• How many
• when they first noticed, how long it has been there for, progression
• Change of texture, enlarging?
• any lymph nodes felt
• changes of skin overlying
• nipple retraction, discharge (colour, bloody)
• tenderness of nipple/breast. Does it vary with menstruation?
• trauma, recent infections (mastitis), breast feeding
• last mammogram & its results
• constitutional symptoms (but Breast cancer may NOT present with loss of weight & night sweats)
• on bloodthinners? (planning for biopsy soon)
• previous breast lump? biopsy results?

Breast cancer is NOT painful.

Question 27

Findings of breast cancer on mammogram

Answer 27

• microcalcification (radicular radiation) c.f. macro is benign. US to double check. Common finding for referral
• irregular larger lesions
• asymmetry between breasts

Question 28

US differences of mass vs. fluid/cyst

Answer 28

Mass: hypoechoic. Posterior shadowing (dark)

Fluid/cyst: anaechoic. Posterior acoustic enhancing (light)

Question 29

Triple standard for Ix breast cancer

Answer 29

1. Physical breast exam performed by a qualified breast surgeon/individual
2. A form of imaging (mammogram for elderly, US for young)
3. A US guided biopsy (core biopsy)

Question 30

Rx of breast cancer

Answer 30

• Radiological staging by CT & bone scan only in symptomatic patients (otherwise high false positives).
• depends on result of ER, PR & Her2 from core biopsy

Wide local excision +/- sentinal node biopsy: with a clear surgical margin

Question 31

(2) Rx options for ER, HR +ve breast cancer
- indications
- SE of both
- Rx/prevention for the SE

Answer 31

1. SERMs (most commonly used) e.g. Tamoxifen
   - can be used in both pre & post menopause women
2. Aromatase inhibitors (reduce oestrogen production altogether) e.g. Letrozole
   - only in post menopause women
   - increased risk of ovarian cancer
   - less endometrial hyperplasia & VTE

Both (-): osteoporosis, menopausal symptoms, venous thromboembolism

Hence give bisphophonate & denosumab for bone prophylaxis. Check bone density yearly

Question 32

Rx for Her2 positive breast cancer

Answer 32

Brand name: Herceptin (Trastuzumab)

Question 33

First line chemotherapy for breast cancer

Answer 33

Adriamycin + cytoxane

Question 34

Indication for total mastectomy

Answer 34

• If not treated well by others
• previous radiation
• C/I to radiation: Scleroderma, Pacemaker
• personal preference (extensive FMHx)

Question 35

Examples of types of breast mass

• benign
• pre-malignant
• malignant

Answer 35

1. Benign
   - fibroadenoma
   - Phylloides tumours (large version of fibroadenoma but can be malignant)
   - fibrocystic breast
   - fat necrosis (traumatic injury related)
   - abscess
   - duct ectasia
   - adenoma
2. Pre-malignant
   - atypical ductal hyperplasia (more concerning. higher risk of breast cancers overall although the lesion itself may not turn cancerous) -> mandate surgical excision
   - atypical lobular hyperplasia
   - lobular carcinoma in situ (incidental finding usually. Can increase risk of breast cancer). one of its subtypes can look like a DCIS
3. Malignant
   - Primary breast carcinoma.
   a. Invasive ductal carcinoma (70-80% of breast cancers). Arise from the ducts
   b. Invasive lobular carcinoma (5-10% of breast cancers)
   c. Mixed invasive ductal & lobular carcinoma (rare)
   d. Ductal carcinoma in situ (85% insitu carcinomas of breast). Classified as malignant c.f. LCIS.
   - Metastatic breast carcinoma (very rare)

Question 36

Do you get a sentinel node biopsy for DCIS?

Answer 36

No sentinel node biopsy for DCIS unless the pt wants mastectomy (as DCIS is still in situ and has not invaded yet)

Question 37

What are the (3) systemic Rx for breast cancer?

Answer 37

1. Endocrinological. e.g. Tamoxifen
2. Immunological. e.g. Herceptin
3. Chemotherapy. e.g. adriamycin