S7: women's health

Question 1

List common features of breast disease

Answer 1

Physiological swelling and tenderness
Nodularity 
Breast pain
Palpable breast lumps
Nipple discharge, including galactorrhoea 
Breast infection and inflammation

Question 2

Describe physiological swelling and tenderness

Answer 2

Occurs during puberty
Breast enlargement, sometimes initially unilateral, is the first obvious sign of puberty in girls (8-13 years old)
Pubertal breast development = thelarche

Question 3

Describe nodularity

Answer 3

Bilateral symptoms often caused by benign breast disease
Symptoms are greatest about one week before menstruation and decrease when it starts
Often in the upper outer quadrant of the breast

Question 4

Compare cyclical mastalgia vs non-cyclical mastalgia

Answer 4

Cyclical mastalgia – some degree of tenderness and nodularity in the premenstrual phase is so common, may affect up to 2/3s of all menstruating women; rapidly resolves as menstruation starts
Non-cyclical mastalgia – ongoing discomfort and pain in the breast (can be due to medications)

Question 5

Compare malignant vs benign breast masses

Answer 5

Malignant – hard consistency, painless, irregular margins, fixation to skin/chest wall, skin dimpling, discharge: bloody & unilateral, nipple retraction may be present
Benign – firm/rubbery consistency, often painful, regular/smooth margins, mobile & not fixed, skin dimpling unlikely, discharge: green/yellow & bilateral, no nipple retraction

Question 6

Describe fibroadenomas

Answer 6

Benign tumours that are common in young women, with incidence peaking at 20-24 years of age
Most common type of breast lesion
Arise in breast lobules & are composed of fibrous and epithelial tissue
HRT increases the incidence

Question 7

Describe an intraductal papilloma

Answer 7

Small, wart-like growth that bumps out into the breast ducts near the nipple
Causes a bloody/sticky discharge
Any slight bump or bruise near the nipple can also cause the papilloma to bleed

Question 8

Describe duct ectasia

Answer 8

Dilatation of major ducts, filled with creamy secretion with periductal inflammation
May be asymptomatic or with nipple discharge, retracted nipple, acute inflammation, recurrent chronic inflammation with abscess formation
Treatment: surgical excision of the major duct, correction of nipple retraction

Question 9

Describe breast infections

Answer 9

Mastitis – generalised cellulitis of the breast, treated with antibiotics
Breast abscesses – present with point tenderness, erythema & fever, generally related to lactation, caused by staph or strep

Question 10

List when to refer people to a specialist breast clinic

Answer 10

Aged > 30 & have an unexplained breast lump with or without pain
Aged > 50 with any of the following symptoms in one nipple only:
-discharge
-retraction
-other changes of concern

Question 11

List when to consider referring people to a specialist clinic

Answer 11

Skin changes that suggest breast cancer
Aged > 30 with an unexplained lump in axilla
Consider non-urgent referral in people < 30 with an unexplained breast lump with/without pain

Question 12

Describe mammographic screening

Answer 12

Women 47-73 years
2 view mammograms every 3 years
Aim = detect small impalpable cancers and pre-invasive cancer
Look for asymmetric densities, parenchymal deformities & calcifications
Assess abnormalities using further imaging, core biopsy & FNAC

Question 13

Which breast conditions cause mammographic abnormalities?

Answer 13

Densities – invasive carcinomas, fibroadenomas, cysts

Calcifications – ductal carcinoma in situ (DCIS), benign changes

Question 14

Describe fibrocystic change in the breasts

Answer 14

May present as a mass or mammographic abnormality
Mass often disappears after fine needle aspiration
Can mimic carcinoma clinically & mammographically

Question 15

List different types of stromal tumours

Answer 15

Fibroadenoma 
Phylloides tumours
Lipoma
Leiomyoma
Hamartoma

Question 16

Describe gynaecomastia

Answer 16

Enlargement of male breast, unilateral/bilateral
Often seen at puberty and in elderly
Caused by relative decrease in androgen effect/increase in oestrogen effect
No increased risk of cancer

Question 17

Describe breast cancer

Answer 17

Most common cancer in UK
Approximately 95% are adenocarcinomas, others are very rare
Most common in the upper outer quadrant

Question 18

List risk factors for breast cancer

Answer 18

Gender 
Uninterrupted menses
Early menarche 
Late menopause
Obesity and high fat diet
Exogenous oestrogens 
Radiation
Geographic influence 
Hereditary

Question 19

List the two different classifications of breast carcinomas

Answer 19

In situ vs invasive

Ductal vs lobular

Question 20

Describe in situ carcinoma

Answer 20

Neoplastic population of cells limited to ducts & lobules by basement membrane, myoepithelial cells are preserved
Does not invade into vessels, hence can’t metastasise

Question 21

Describe ductal carcinoma in situ

Answer 21

Condition in which abnormal cells are found in the lining of the breast
Not spread outside the duct to other tissues in the breast

Question 22

How does invasive carcinoma differ from DCIS?

Answer 22

Neoplastic cells have invaded beyond BM into stroma
Usually presents as a mass/mammographic abnormality
Peau d’orange = involvement of lymphatic drainage of skin

Question 23

What is Paget’s disease?

Answer 23

Cells can extend to nipple skin without crossing BM
Unilateral red and crusting nipple
Eczematous or inflammatory conditions of the nipple should be regarded as suspicious, and biopsy performed to exclude Paget’s disease

Question 24

Describe investigations and diagnosis of breast cancer

Answer 24

Triple approach

1) Clinical – history, family history, examination
2) Radiographic imaging – mammogram and ultrasound
3) Pathology – core biopsy & FNAC

Question 25

How is invasive breast carcinoma classified?

Answer 25

Invasive ductal carcinoma (70-80%)
-well-differentiated type & poorly differentiated type
Invasive lobular carcinoma
Other types eg. tubular & mucinous (both have excellent prognosis)

Question 26

List factors which determine prognosis in breast disease

Answer 26

In situ or invasive
Tumour stage: TNM
Tumour grade
Histologic subtype 
Molecular classification & gene expression profile

Question 27

Describe the treatments for breast cancer

Answer 27

Breast surgery – mastectomy or breast conserving surgery
Axillary surgery – extent depending on whether there are involved nodes
Post-operative radiotherapy to chest and axilla
Chemotherapy
Hormonal treatment

Question 28

What is sentinel lymph node biopsy?

Answer 28

Reduces the risk of postoperative morbidity
Intraoperative lymphatic mapping with dye and/or radioactivity of the draining/’sentinel’ lymph node (one most likely to contain breast cancer metastases)
If sentinel node is negative, axillary dissection can be avoided

Question 29

How can survival from breast cancer be improved?

Answer 29

Early detection – awareness of disease, importance of family history 
Neoadjuvant chemotherapy 
Use of newer therapies 
Gene expression profiles
Prevention in familial cases