Revision - Breast

Question 1

What drives fibrocystic breast changes?

Answer 1

Female hormones: oestrogen & progesterone

Common in women of menstruating age

Question 2

When do Fibrocystic Breast Changes tend to appear? When do they tend to resolve?

Answer 2

Symptoms usually occur prior to menstruating (within 10 days) and resolve once menstruation begins

Question 3

Referral for an unexplained breast lump in women:

a) <30 y/o
b) ≥30 y/o

Answer 3

a) non-urgent referral
b) urgent referral (2ww)

Question 4

Presentation of a ductal papilloma?

Answer 4

• Nipple discharge – clear or blood-stained
• Tenderness or pain
• Palpable lump –> Usually found <1cm from nipple

Question 5

Management of ductal papilloma?

Answer 5

1) Complete surgical excision is required

2) After removal, tissue is examined for atypical hyperplasia or cancer that may not have been picked up on biopsy

Question 6

What is a fibroadenoma?

Answer 6

Type of benign breast tumour - most common cause of a breast mass

‘breast mice’

Question 7

When are fibroadenomas most common?

Answer 7

1) During menses

2) During pregnancy

3) Using COCP

Question 8

What 2 types of tissue does a fibroadenoma contain?

Answer 8

1) Stromal

2) Epithelial

Question 9

Where are fibroadenomas typically found?

Answer 9

Outer quadrant of breast

Question 10

What do fibroadenomas respond to?

Answer 10

Female hormones (oestrogen & progesterone)

Question 11

Difference between fibroadenoma & fibrocystic changes?

Answer 11

Fibrocystic changes usually presents with multiple bilateral lumps

Question 12

What is a Phyllodes tumour?

Answer 12

Rare tumour of the connective tissue (stroma) i.e. fibroepithelial tumours

Question 13

What age group do Phyllodes tumours typically affect?

Answer 13

Occurring most often between ages 40-50.

Question 14

Which 2 features characterise a Phyllodes tumour?

Answer 14

Large & fast growing

Question 15

Management of Phyllodes tumour?

Answer 15

1) Surgical removal of tumour and surrounding tissue (wide excision)

2) Can reoccur after removal

3) Chemotherapy in malignant/metastatic tumours

Question 16

Is a mutation in BRCA1 or BRCA2 a higher risk for breast cancer?

Answer 16

BRCA 1

Question 17

What cells is LCIS confined to?

Answer 17

Acini cells of the breast

Question 18

What is the most common cancer in the UK?

Answer 18

Breast cancer

Question 19

What is the most common type of breast cancer?

Answer 19

Invasive ductal carcinoma

Recently renamed ‘No Special Type (NST)’

Question 20

What is Paget’s disease of the nipple?

Answer 20

An eczematoid change of the nipple associated with an underlying breast malignancy

Question 21

What is inflammatory breast cancer?

Answer 21

Where cancerous cells block the LYMPH DRAINAGE resulting in an inflamed appearance of the breast.

Question 22

2ww referral for breast cancer?

Answer 22

1) ≥30y/o with unexplained breast lump

or

2) ≥50y/o with any of the following symptoms in ONE nipple:
a) discharge
b) retraction
c) other changes of concern

Consider a suspected 2ww referral in people:
- with skin changes that suggest breast cancer or
aged 30 and over with an unexplained lump in the axilla.

Question 23

Which type of non-invasive breast cancer is found:
a) only in one breast (unilateral)
b) in both breasts (bilateral)

Answer 23

a) DCIS
b) LCIS

Question 24

What type of breast cancer causes peau d’orange?

Answer 24

Inflammatory breast cancer (due to blockage of lymph drainage)

Question 25

What is inflammatory breast cancer often msitaken for?

Answer 25

Infection/mastitis/abscess

Question 26

Prognosis of inflammatory breast cancer?

Answer 26

Worse than other breast cancers as tends to be more aggressive and spread more quickly

Question 27

What is Paget’s disease of the nipple often associated with?

Answer 27

An underlying in-situ or invasive cancer.

Question 28

Who is offered mammograms and how often?

Answer 28

Currently 50-70 y/o, every 3 years Screening is being expanded to 47-73 y/o

Question 29

When is anastrozole contraindiated in the chemoprevention of breast cancer in postmenopausal women?

Answer 29

Patients with severe osteoporosis

Question 30

What is required to distinguish between Paget’s and eczema?

Answer 30

Punch biopsy

Question 30

What is often seen in an intraductal papilloma?

Answer 30

Unilateral bloody discharge

Question 31

What can mammograms pick up that may be missed by US?

Answer 31

Calcifications

Question 32

What are the 2 options for biopsy in breast cancer triple assessment?

Answer 32

1) Core biopsy 2) Fine needle aspiration

Question 33

Why is a sentinel lymph node biopsy performed in breast cancer?

Answer 33

A sentinel lymph node biopsy may be used during breast cancer surgery where the initial ultrasound does not show any abnormal nodes.

Question 34

When is radiotherapy used in breast cancer?

Answer 34

Radiotherapy is usually used in patients with breast-conserving surgery to reduce the risk of recurrence.

Question 35

What can be used in premenopausal women to help protect their ovaries from premature ovarian failure which is a potential side effect of the chemotherapy?

Answer 35

GnRH agonist e.g. goserelin

Question 36

How long is tamoxifen/aromatase inhibitors given for in women with oestrogen-receptor positive breast cancer?

Answer 36

5-10 years

Question 37

Which monoclonal antibody is used for breast cancers that express HER2?

Answer 37

Trastuzumab (Herceptin)

Question 38

Notable side effect of Herceptin?

Answer 38

Cardiotoxicity

Question 39

Which type of non-invasive breast cancer typically occurs in pre-menopausal women?

Answer 39

LCIS

Question 40

What size fibroadenomas can be referred for removal?

Answer 40

>3cm

Question 41

What investigation should all women with breast cancer with no palpable axillary lymphadenopathy at presentation have before their primary surgery in breast cancer?

Answer 41

A pre-operative axillary US If negative, then they should have a sentinel node biopsy to assess the nodal burden

Question 42

Mx of patients with breast cancer who present with clinically palpable lymphadenopathy?

Answer 42

axillary node clearance is indicated at primary surgery

Question 43

What is recommended after a woman has had a wide-local excision for breast cancer?

Answer 43

Whole breast radiotherapy

Question 44

What does a 'snowstorm' sign on US of axillary lymph nodes indicate?

Answer 44

extracapsular breast implant rupture.

Question 45

In what size tumour can a wide local excision (breast conserving surgery) be considered?

Answer 45

<4cm

Question 46

Mx of duct ectasia?

Answer 46

No specific treatment

Question 47

What is a key risk factor for duct ectasia?

Answer 47

Smoking

Question 48

What is the histological description of a fibroadenoma?

Answer 48

1) Duct-like structures lined by regular, low columnar cells 2) Separated by loose fibrous tissue 3) Well degined margins

Question 49

Appropriate next mx step in a pregnant woman with a breast lump?

Answer 49

Triple assessment

Question 50

Prior to surgery in breast cancer, what determines management?

Answer 50

The presence/absence of axillary lymphadenopathy

Question 51

Mx of breast cancer in women with NO palpable axillary lymphadenopathy at presentation?

Answer 51

They should have a pre-op axillary US before their primary surgery If negative --> should have a sentinel lymph node biopsy to assess nodal burden

Question 52

Mx of breast cancer in women who present with clinically palpable lymphadenopathy?

Answer 52

Axillary node clearance is indicated at primary surgery

Question 53

What 2 types of surgical options may women with breast cancer have?

Answer 53

1) Wide local excision 2) Mastectomy

Question 54

How does the location of the lesion determine if a wide local excision or mastectomy is offered in breast cancer?

Answer 54

Central tumour --> mastectomy Peripheral tumour -->wide local excision

Question 55

How does the size of a DCIS determine if a wide local excision or mastectomy is offered in breast cancer?

Answer 55

DCIS <4cm: wide local excision Mastectomy: >4cm

Question 56

When should women be offered breast reconstruction after breast cancer surgery?

Answer 56

Women should be offered breast reconstruction to achieve a cosmetically suitable result regardless of the type of operation they have.

Question 57

What further treatment is recommended after a woman has had a wide local excision?

Answer 57

Whole breast radiotherapy --> may reduce the risk of recurrence by around 2/3

Question 58

What further treatment is recommended after a woman has had a mastectomy?

Answer 58

Radiotherapy is offered for T3-T4 tumours and for those with 4 or more positive axillary nodes.

Question 59

3 key side effects of tamoxifen?

Answer 59

1) increased risk of endometrial cancer 2) VTE 3) menopausal symptoms