Breast

Question 1

Breast Lumps

Answer 1

Clinical Features: Smooth margins

First Investigation:
1. PE.
2. US (<35yo)
3. Mammography (>35yo)

Best Investigations:
1. FNAC
2. Core Biopsy

Management:
1. Observation.
2. Excision

Question 2

Fibroadenoma

Answer 2

Clinical Features: Mobile, non-tender

First Investigation: US

Best Investigations:
1. FNAC.
2. Core Biopsy

Management: Reassure/Review in 3 months

Question 3

Breast cysts

Answer 3

Clinical Features: Smooth, mobile, painful (sometimes)

First Investigation:
1. PE.
2. US (<35yo)
Mammography (>35yo)

Best Investigations:
1. FNAC.
2. Core Biopsy

Management:
1. Aspiration under US.
2. Excisional biopsy if the fluid has blood

Answer 4

Clinical Features:

First Investigation:

Best Investigations:

Management:

Question 5

Fibrocystic disease

Answer 5

Clinical Features:
- 1 or > lumps <1cms
- watery/bloody discharge

First Investigation:
1. PE.
2. US (<35yo)
Mammography (>35yo)

Best Investigations:
>1cm: FNAC/Biopsy

Management:
1. Primrose oil, Vitamin B1, B6, B12
2. NSAIDS
3. Danazol/Tam

Question 6

Fat Necrosis

Answer 6

Clinical Features: Previous trauma

First Investigation:
1. PE
2. US (<35yo)
Mammography (>35yo)

Best Investigations: FNAC

Management:
1. Observation
2. Excision

Question 7

Intraductal Papilloma

Answer 7

Clinical Features:
1. Watery/Bloody discharge
2. Just 1 duct compromised

First Investigation:
1. PE.
2. US (<35yo)
Mammography (>35yo)

Best Investigations:
1. FNAC
2. Core Biopsy
3. Breast Ductography (specific)

Management: Surgery

Question 8

Mammary Duct Ectasia

Answer 8

Clinical Features:
- Discharge: Sticky, toothpaste-like green
- Multiple points

First Investigation: Mammography

Best Investigations: Ductal lavage (Cytology)

Management: Excisional biopsy

Question 9

Phyllodes Tumour

Answer 9

Clinical Features: Mobile mass that grows rapidly

First Investigation: Mammography

Best Investigations: US with core biopsy

Management:
Benign: Wide local excision
Malignant: Simple total mastectomy w/wo axillary node dissection

Question 10

Breast Cancer

Question 11

Management of px with breast cancer spread to one area of bone

Answer 11

• Radiotherapy

Question 12

Management of px with breast cancer spread to several places in bones

Answer 12

• anticancer therapy with hormonal treatment
• chemotherapy

Question 13

Investigation of choice for breast symptoms under the age of 35

Answer 13

US

Question 14

Investigation of choice for breast symptoms over the age of 35

Answer 14

US as well as mammography

Question 15

Protective factors of breast cancer in pre-menopausal women

Answer 15

• Obesity

Question 16

Increased risk of Breast Cancer is in pre-menopausal women

Answer 16

• Avoiding breastfeeding
• Smoking
• Family history of breast cancer
• Decreased fruits and vegetables in diet

Question 17

Breast cancer screening age group

Answer 17

• 50-74 (mammograms every two years)
• Woman 40 years of age specifically asking due to family history of risk BC

Question 18

Features of Paget’s disease

Answer 18

• eczematous-looking
• dry scabbing nipple rash
• nipple ulceration
• nipple skin thickening
• dilated duct of the breast

Question 19

Paget’s disease differential dx

Answer 19

• Ductal carcinoma in situ

Question 20

Paget’s disease management

Answer 20

• lumpectomy (breast conserving surgery)
• partial mastectomy or wide local incision
• Total mastectomy only if indication of disease is severe

Question 21

Breast cancer prognosis

Answer 21

• 2nd most common cancer to cause death in women (after lung cancer)
• 40% of women with recurrent or metastatic breast cancer survive at
  > 5 years
• survival for patients with metastatic (stage IV) breast cancer is 18 to 24 months

Question 22

Px in high risk of breast cancer (Jewish, bilateral breast cancer in family, below 50 y/o) management

Answer 22

-Advise referral to a cancer specialist or family cancer clinic for risk assessment,
possible genetic testing and management plan.
-Ongoing surveillance strategies may include regular clinical breast examination, and annual breast imaging with mammography, MRI or ultrasound.
BRCA gene testing would be required after thorough assessment at family cancer
clinic in the area.

NOTE: all of these have to be done together

Question 23

Breast disease caused by Vitamin A deficiency

Answer 23

Periductal mastitis

Question 24

Periductal mastitis causes

Answer 24

• Smoking
• Vitamin A deficiency

Question 25

Periductal mastitis features

Answer 25

- separate entity from duct ectasia - affects young women - dilated ducts - **sticky toothpaste-like discharge**

Question 26

Treatment of breast cancer and ovarian cancer in postmenopausal women

Answer 26

Aromatase inhibitor (Arimidex)

Question 27

Side effects of aromatase inhibitors

Answer 27

- **symptoms of menopause** (hot flashes, night sweats, and vaginal dryness) - muscle and joint pain - raised cholesterol – Deep vein thrombosis (less than tamoxifen). – Stroke (less than tamoxifen). – Endometrial cancer (less than tamoxifen). – Osteoporosis (more than tamoxifen)

Question 28

Referral to breast surgeon indications

Answer 28

– Inflammatory breast conditions that are not resolving after two weeks of antibiotics treatment. – Eczematoid changes of the nipple-areolar skin which persists longer than two weeks and does not respond to topical treatment. – Spontaneous unilateral bloody or serous discharge from a single duct in women over 60 years of age. – Bloody aspirate from a cyst in breast – A woman with a positive triple test with any one of the three components

Question 29

Triple test refers to

Answer 29

– Medical history and clinical breast examination. – Imaging such as mammography and or breast ultrasound. – Non-excisional biopsy-Core biopsy and or Fine needle biopsy NOTE: If the triple test is **negative**, there is **no need to refer** the patient to the breast surgeon

Question 30

Causes of galactorrhoea

Answer 30

Physiologic or pathologic Hormonal imbalance - hyperprolactinemia - hypothyroidism Drugs - OCP - Phenothiazines - antihypertensives - tranquilisers Chest trauma

Question 31

Physiological nipple discharge

Answer 31

Serous bilateral discharge usually cause by stimulation of the nipple Drugs - oestrogen - tranquilisers

Question 32

Pathological nipple discharge

Answer 32

Unilateral spontaneous discharge can be bloody, grey-green or serous, Breast lesions - duct ectasia (discharge in many duct) - papilloma (discharge in 1 duct) - fibrocystic disease Cancer

Question 33

Approach to lumps

Answer 33

1. physical examination 2. imaging (FNAC, US, mammography depending on age) 3. if indicated, biopsy and histological studies

Question 34

Malignant lesion clinical findings

Answer 34

- stony-hard consistency of the lesion - irregular borders - being non-tender - immobility - and skin changes (dimpling, oedema). Ulceration of the skin is seen in advanced disease. Lymphadenopathy but it could be absent in early disease

Question 35

Malignant lesion findings on US

Answer 35

- Hypoechogenicity - Irregular and ill-defined borders - Spiculated margins - Being taller than broader - Posterior acoustic shadowing - Microcalcifications

Question 36

Fibroadenoma features

Answer 36

- Most common benign breast lump - 20-30 years - Well defined, round with even surface, regular margins, rubbery or soft in consistency, freely mobile, non-tender - Does not increase the risk of cancer

Question 37

Fibroadenoma management

Answer 37

Depends on patient’s preference - Can be safely left behind with reassurance and periodic review. - Surgery – excision done usually under GA if patient wants.

Question 38

Vitmain D deficiency can cause what type/s of cancer?

Answer 38

colon prostate breast (Ductal carcinoma in situ)

Question 39

H/o Non proliferative breast lesions in a female (Fibrocystic diseases)

Answer 39

No risk of Ca breast