Diseases of the Breast - 3a

Question 1

What proportion of women experience mastalgia (breast pain) during their lives?

Answer 1

1/2

Question 2

What proportion of women develop breast cancer?

Answer 2

1/8

Question 3

How many women in the UK are affected by breast cancer each year?

Answer 3

46,000

15,000 deaths

Question 4

What are the most common areas of metastasis of breast cancer?

Answer 4

Brain
Liver
Lung
Bone

Question 5

What proportion of women with breast cancer develop metastatic disease?

Answer 5

25%

Question 6

What should be included in the history of breast disease?

Answer 6

Detailed description of the presenting complaint including duration and any aetiological factors
Risk factors for cancer
Drug History
Menopause Status
General Health

Question 7

What are suspicious symptoms for breast cancer? (7)

Answer 7

Painless lump
Skin distortion
Bloody nipple discharge
Recent onset nipple inversion
Axillary lymphadenopathy
Ulceration
Paget's disease of the nipple

Question 8

What are risk factors for breast cancer?

Answer 8

> Age

Family history of breast and ovarian cancer - Age of diagnosis and number of affected relatives

Question 9

What are the relevant features of the drug history when enquiring about breast cancer?

Answer 9

HRT and duration of use

Use of anti-coagulation may conta-indicate breast lump biopsy

Question 10

What are the relevant features of the menopausal status when enquiring about breast cancer?

Answer 10

Certain conditions such as cysts and cyclical mastalgia are associated with pre-menopausal women

Question 11

What are the relevant features of the general health of the patient when enquiring about breast cancer?

Answer 11

Assess fitness for treatment options

Symptoms of metastatic disease

Question 12

What are the inspection stages to a breast examination?

Answer 12

Get a chaperone or doctor to supervise
Wash hands
Attain Consent
Ask about any mastalgia

Start with patient seated, undressed to the waist
Inspect for lumps, distortion, tethering and nipple retraction

Ask patient to raise the arms about the head and re-inspect. This will enhance and sometimes reveal any tethering/distortion not apparent with the arms at rest.

Ask the patient to put their hands on their hips and press in to contract the pectoral muscles, again revealing any tethering

Question 13

What are the palpation stages to a breast examination?

Breast
Axilla
Supraclavicular Nodes
Matastatic Disease

Answer 13

Ask the patient to recline on the couch and start the physical examination on the unaffected side.

Breasts: Using the flat of the fingers systematically examine the breast tissue by gently compressing the tissue against the chest wall. Do not pinch the breast tissue. Work around the clock and don’t forget the sub-areolar area. In a larger breasted lady, ask her to put her hand behind her head to allow the breast to be spread over the chest wall and facilitate examination.
If you find a lump a set of criteria should be considered (other question).

Axilla: The left axila should be examined with the right hand, using the left hand and forearm to support the patient’s arm along it’s length and vice versa. The patient’s arm should be supported level with the axilla, horizontally. This allows the pectoral muscles to relax and permits you to feel the high axillary nodes. Gently examine behind the pectoralis major, feeling high into the axilla.

Supraclavicular Nodes: These should always be checked for nodal metastases although they are an uncommon and late finding.

Metastatic disease: Present in 5% of new diagnosis. Bony tenderness, hepatomegaly, pleural effusions. These should be assessed only in cases of suspected malignancy.

Question 14

When examining a breast lump, what would you be looking to assess?

Answer 14

Where in the breast it is
What is the consistency - cancers tend to be hard
Smooth or irregular - cancers tend to be irregular
How big it is - measure with a ruler or callipers
Is it mobile relative to the skin, rib cage or pectoral muscles (test this by trying to move the lump before and during the patient, contracting her pectoral muscles-ask her to press her hand against her hip)
Is the overlying skin intact or ulcerated
Is there associated discharge - you may gentle squeeze the nipple yourself after asking permission, OR ask the patient to do this to demonstrate it for you.

Question 15

How is the x-ray exposure of an mammogram justified?

Answer 15

The risk is low and is out-weighed by the diagnostic benefits, even in the screening context

Question 16

What is the effect of HRT on the mammographic appearance of the breast?

Answer 16

In post-menopausal women the breast becomes predominantly fatty and ‘black’ on a mammogram with increased age.
The hormonal stimulus to the breast makes the appearance more dense and glandular and less effective at detecting cancer.

Question 17

Why may is mammography contra-indicated in women <40 years of age?

Answer 17

The breasts are so dense and granular that mammography is of little value and is only used in exceptional circumstances.

Question 18

What are the clinical indications for mammography? (6)

Other indications? (3)

Answer 18

Clinically suspicious lump in patients >= 40 yo
Breast cancer where mammography was not previously performed (any age)
Residual lump following cyst aspiration
Single duct blood stained nipple discharge
Nipple skin change
Triennial mammograms as part of the National Breast Screening Programme

Women at increased familial risk between ages 40-50 (annual screening)
Histology on a breast biopsy indicative of increased risk of subsequent cancer development (Annual until age 50)
Breast cancer and DCIS follow up

Question 19

Between what ages does the triennial mammogram as part of the National Breast Screening Programme take place?

Answer 19

47-73

Question 20

Who will undergo annual mammography screening?

Answer 20

Women aged 40-50 with increased familial risk

Histology on a breast biopsy indicative of increased risk of subsequent cancer development.

Question 21

What findings on breast biopsy would be indicative of increased risk of subsequent cancer development?

Answer 21

Atypical ductal hyperplasia

Lobular carcinoma in situ

Question 22

What are the contra-indications to mammography?

Answer 22

Breast pain without a lump
Symmetrical thickening
Before commencing HRT
Women <40 years unless diagnosed with previous breast cancer.

Question 23

How do neoplastic lesions appear on a mammogram?

Answer 23

An irregular spiculated mass.

A mass, often with spiculation or more subtle irregularity.
Microcalcification may also be present (associated with ductal carcinoma in situ)
Distortion of the surrounding breast parenchyma is also a frequent finding.

Question 24

How is ultrasound used in the investigation of breast lumps?

Answer 24

Useful adjunct to assessing a lump or mammographic abnormality.
Its use is not restricted to patients over the age of 40 and it is excellent in distinguishing solid versus cystic structures.
It is not useful as a screening tool, just for assessing known lesions or suspicious areas.

Question 25

What is the appropriate investigation for a palpable breast mass in a person under 25 years of age?

Answer 25

Histology or cytology only.
No imaging if clinically feels benign.
Ultrasound if clinically indeterminate or suspicious.
Risk of malignancy negligible in this age group.

Question 26

What is the appropriate investigation for a palpable breast mass in a person aged 25-40 years?

Answer 26

Breast ultrasound plus histology or cytology.

Question 27

What is the appropriate investigation for a palpable breast lump in a person aged >40 years?

Answer 27

Mammography and ultrasound and either histology or cytology: Triple assessment.

Question 28

What is the role of magnetic resonance imaging (+/- contrast) in the investigation of a breast lump?

Answer 28

In patients 30-50 with high familial risk (such as BRCA gene carriage) may be offered annual MRI screening. (20-70 years if a Li Fraumeni tp53 gene)
mutation carrier)
May be used in addition to Mammography and UTS in the evaluation of possible recurrent breast cancer foling breast conservation treatment of breast cancer. Very useful for detecting axillary recurrence.
Malignant axillary node with no palpable or imaging identified breast primary - so called occult breast primary
Evaluation of breast implants for rupture, appearance of silicone leakage is pathognoic on MRI
To assess the extent of lobular varient breast cancer which has a diffuse spreading pattern and may be difficut to gauge size with conventional imaging.
To assess for multifocality prior to neoadjuvant chemotherapy to permit breast breast conservation and to assess the pattern of regression after neoaduvant chemotherapy (concentric or fragmentation)

Question 29

What contrast may be used with an MRI to detect breast cancer?

Answer 29

IV gadolinium, black to white.

Question 30

What are the advantages and disadvantages of MRI?

Answer 30

No radiation

Cost
Equipment scarcity