A 67-year-old woman presents to the breast clinic with a 5 cm mass in the left breast and a

lymph node mass in the axilla. Core biopsies of both together with radiological
confirmation reveal a grade 3 invasive ductal carcinoma with axillary metastasis.
She has a mastectomy and level 3 axillary dissection.
Which one of the following is most accurate for this procedure?
1) Division of the intercostobrachial nerves is an obligate part of a thorough axillary
clearance
2) To enter the axilla, the clavipectoral fascia on the edge of pectoralis major should be
divided
3) Inadvertant division of the thoracodorsal nerve will lead to a winged scapula Level
II nodes are those lying lateral to pectoralis minor
4) An anaesthetic patch on the upper medial arm is a recognised complication

Explanation
An anaesthetic patch on the upper medial arm is a recognised complication
Division of the intercostobrachial nerve (T2) during the procedure can cause an
anaesthetic patch on the upper medial arm and can be a complication of axillary dissection.
Division of the intercostobrachial nerves is an obligate part of a thorough axillary clearance
The intercostobrachial nerve and its branches are identified during axillary dissection as
they cross the axilla. Their division is not an obligate part of the axillary clearance and
efforts should be made to preserve the larger trunks if possible.
To enter the axilla, the clavipectoral fascia on the edge of pectoralis major should be
divided
To enter the axilla the surgeon needs to retract the pectoralis major muscle medially to
expose pectoralis minor and the clavipectoral fascia. Incision of the clavipectoral fascia at
the edge of pectoralis minor allows entry into the axillary fat and nodes.
Inadvertant division of the thoracodorsal nerve will lead to a winged scapula
The thoracodorsal nerve, also known as middle subscapular or long subscapular
nerve,supplies the latissimus dorsi muscle. It is a division of the long thoracic nerve, the
motor supply of the serratus anterior muscle, which causes a winged scapula.
Level II nodes are those lying lateral to pectoralis minor
Level I lymph nodes lie inferior to the pectoralis minor muscle.
Level II axillary lymph nodes lie posterior to the pectoralis minor muscle.
Level III axillary lymph nodes lie medial to the pectoralis minor muscle.
558
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You are in the breast clinic, the patient you are with has a suspicious breast lump. Her
mother also had breast cancer, but she is unsure of any additional detail.
What is the most common type of breast cancer histologically?
1) Lobular
2) Tubular
3) Mucinous
4) Medullary Ductal

Explanation
Ductal

Ductal carcinoma, not otherwise specified (NOS), is the most common histological form of
invasive breast cancer, accounting for 70–80% of invasive breast cancers. Based on the
extent of nuclear polymorphism and some other characteristics, invasive ductal carcinoma
can be subdivided into: grade 1 – well differentiated; grade 2 – moderately
differentiated; and grade 3 – poorly differentiated.
Lobular

According to the World Health Organisation (WHO), the prevalence of lobular carcinoma is
5–15%.
Tubular

The prevalence of pure tubular invasive carcinoma of the breast is <2%.

Mucinous

Mucinous carcinoma is quite a rare histological form of invasive breast cancer with a
prevalence of 2%.
Medullary

Medullary carcinoma is a histological form of invasive cancer with a prevalence of 1–7%.

789

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Breast cancer is the most common cancer affecting women in the United Kingdom. There
are both familial and lifestyle risks for developing this disease.
Which one of the following statements is true about risk factors for breast cancer?

1) The incidence of breast cancer rises steeply up to 40–45 years of age, then falls
2) An early menarche lowers your risk of breast cancer
3) A woman having her first child in her mid to late thirties still has a lower risk of
breast cancer than a nulliparous woman
4) In the UK, the risk of any woman developing breast cancer is 12.5%
5) The identification of BRCA1 and BRCA2 genes confers an increased risk of breast
cancer only

Explanation
In the UK, the risk of any woman developing breast cancer is 12.5%

According to cancer research UK data from 2012, the lifetime risk of a woman developing
breast cancer in the UK is 1 in 8, ie 12.5%, whereas for a man this has been calculated at
around 1 in 870 people.

The incidence of breast cancer rises steeply up to 40–45 years of age, then falls

The risk of developing breast cancer increases with age.

Incidence rates of breast cancer rise steeply after the age of 30–35 and level off around the
age of 50. At this point, the incidence continues to rise at a slower rate until the age of 69.
After this, there is evidence that incidence drops slightly between the age of 70–74 and
then rises again, plateauing at >85.
An early menarche lowers your risk of breast cancer

Prolonged exposure to oestrogen is a risk factor for developing breast cancer. Therefore, an
early menarche and a late menopause increase the risk of developing breast cancer.

A woman having her first child in her mid to late thirties still has a lower risk of breast
cancer than a nulliparous woman

Nulliparity increases the risk of breast cancer. Having a child at an early age is a protective
factor against developing breast cancer. However, a woman who has had her first child in
her mid to late thirties is at higher risk of breast cancer than a nulliparous woman. Breast
cancer risk increases about 3% every year older a woman is when she first gives birth. It is
thought that pregnancy reduces the susceptibility of mammary tissue to somatic
mutations,so conferring protection against breast cancer.

The identification of BRCA1 and BRCA2 genes confers an increased risk of breast cancer
only
The identification of BRCA1 and BRCA2 mutations confers an increased risk of breast
cancer and other cancers. BRCA1 and BRCA2 are tumour suppressor genes.
BRCA1 mutations increase the risk of breast cancer, ovarian cancer, prostate cancer and
some forms of pancreatic and colon cancer.
BRCA2 mutations increase the risk of breast cancer, ovarian cancer, prostate cancer,
Fanconi’s anaemia, melanoma and pancreatic cancer.
790

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A 45-year-old woman was found to have a 4-cm diameter, non-tender mass in her right
breast. The mass appeared to be fixed to the chest wall. Another 2-cm, non-tender mass
was palpable in the axilla. A chest X-ray revealed multiple nodules in both lungs, ranging in
size from 0.5 cm to 2 cm.
Which one of the following classifications best describes the stage of her disease?

1) T1 N1 M0
2) T1 N0 M1
3) T2 N1 M0
4) T3 N0 M0
5) T4 N1 M1

Explanation
T4 N1 M1

This woman has a large invasive primary tumour with axillary node and lung metastases
making this a classification of T4 N1 M1.
T4 because this primary tumour has spread to the chest wall, N1 because there are axillary
nodes where the disease has spread, and M1 because there is metastasis to another part of
the body, here evident as multiple lung nodules.
The staging of breast cancer has been summarised below for a better understanding.
TNM staging of breast cancer:
T
Tx
Tumour size cannot be assessed
Tis
DCIS
T1
Tumour equal to or less than 2 cm across
T2
Tumour diameter >2 cm but <5 cm
T3
Tumour diameter >5 cm
T4
Tumour spread to chest wall and or overlying skin
N
Nx
Lymph nodes can not be assessed
N0
No cancer cells in any nearby nodes
N1
Evidence of cancer cells in the axillary nodes
N2–N3
Evidence of cancer cells in other nodes surrounding the breast
M
M0
No sign of metastasis
M1
Metastasis of the cancer to another organ

T1 N1 M0

This nomenclature would characterise a primary breast tumour of maximal diameter equal
to or less than 2 cm with evidence of disease in the axillary nodes, but no evidence of
metastasis to another organ system.

T1 N0 M1

This nomenclature would characterise a primary breast tumour of maximal diameter equal
to or less than 2 cm, with no evidence of disease in nearby nodes, but evidence of
metastasis to another organ system.

T2 N1 M0

This nomenclature would characterise a primary breast tumour of maximal diameter

bigger than 2 cm and smaller than 5 cm, with metastasis to the axillary nodes, but no
evidence of metastasis to other organs.

T3 N0 M0

This nomenclature characterises a primary tumour with a maximal diameter of >5 cm, with
no metastasis to any lymph nodes or other organ systems.
791
A 45-year-old woman underwent fine-needle aspiration biopsy of a suspicious area that
was noticed on routine mammographic screening. The biopsy revealed cells that
were suspicious for a malignancy. An excisional breast biopsy yielded a diagnosis of lobular
carcinoma in situ (LCIS) of the breast.
Which one of the following statements regarding this woman’s malignancy is
correct?

1) A family history of breast cancer is unlikely

2) Oestrogen receptor assay of this neoplasm will probably be negative
3) Paget's disease of the nipple probably preceded this lesion
4) This neoplasm will remain localized
5) The opposite breast might also be involved

Explanation
The opposite breast might also be involved

At diagnosis, the disease is multifocal in the ipsilateral breast in up to 50% of cases and
bilateral, affecting the contralateral breast, in 20–30% of the cases.

A family history of breast cancer is unlikely

Lobar carcinoma in situ and invasive lobar carcinoma often have a family history of breast
cancer (genetic link) and occurs predominantly in pre-menopausal women. Mean age of
presentation is 45 years of age.

Oestrogen receptor assay of this neoplasm will probably be negative

Molecular studies have shown that LCIS and invasive lobar carcinoma are usually
oestrogen receptor positive, HER-2 receptor negative and are negative for the expression
of E-cadherin, allowing cells to have a diffuse pattern and not stick together in a lump,
making diagnosis difficult.

Paget's disease of the nipple probably preceded this lesion

Lobar carcinoma in situ is usually asymptomatic with no preceding abnormalities and most
are detected incidentally on histological assessment of breast tissue that was biopsied for
other reasons. One kind of LCIS, pleomorphic LCIS, can present as microcalcifications on
mammography.

This neoplasm will remain localised

Lobular carcinoma in situ means cellular changes in the acini or the terminal ductules of
the breast lobules also known as milk producing ducts, without stromal invasion. There is a
lifetime risk of LCIS leading to invasive breast carcinoma of 20–25%.
A 32-year-old woman presented to the surgical out-patient clinic with a palpable lump in
her right breast that had appeared recently. On enquiry, she mentioned that she has been
taking oral contraceptives for many years.
Which one of the following conditions is most likely to be associated with oral
contraceptive use?

1) Acute mastitis
2) Cyst formation
3) Fat necrosis
4) Galactocele
5) Hypertrophy

Explanation
Cyst formation

Breast cysts are fluid filled and develop as a result of fluid accumulation and entrapment in
the glandular breast tissue. They are a very common benign condition of the breast,
relating to normal hormonal breast tissue changes. They most commonly occur in women
in the ages of 35–50 and tend to disappear after the menopause. They present as palpable
lumps that are usually smooth, firm and mobile. Some can be tender.
Some women have the tendency to develop recurrent cysts.
Most breast cysts resolve on their own but if they are causing troublesome symptoms
or arevery large then aspiration is recommended.
Taking the oral contraceptive or hormone replacement therapy can increase the risk of
developing breast cysts.
Differential diagnosis for a breast lump: (FBC):
F – Fibroadenoma
B – Breast cyst
C – Carcinoma of the breast
Investigation of a breast lump:
The buzzword here is triple assessment that consists of HRT:
H – History and examination
R – Radiology: ultrasound or mammography
T – Tissue diagnosis: cytology or biopsy

Acute mastitis
Mastitis is a condition associated with pain in the breast, erythaema and inflammation. It is
most commonly seen in breast-feeding women and is associated with a build-up of milk in
the breast ducts. If infected it is treated with a course of antibiotics.

Fat necrosis

Fat necrosis is a benign inflammatory process occurring in the breast usually following
trauma, either accidental or surgical or following radiotherapy. It presents as a palpable,
painless mass or incidentally on mammography.
At the histological level there are foamy histiocytes, macrophages and other inflammatory
cells causing fibrosis and tissue necrosis.

Galactocele

A galactocoele is a common benign breast lesion commonly seen in breast-feeding women,

mainly after they stop lactation. It presents as a painless breast lump that develops over
weeks to months. It can be multinodular and/or bilateral. It occurs due to blockage of a
lactiferous duct. In the majority of cases these resolve on their own.

Hypertrophy

Breast hypertrophy or macromastia usually presents in adolescence and is characterised

by bilateral rapid breast enlargement. Patients present with neck pain, shoulder and back
pain.
794
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A 32-year-old woman is referred for mastectomy with immediate reconstructive breast
surgery having been diagnosed with left breast cancer.
Which one of the following increases the risk of breast cancer?
1) Body mass index (BMI) <30
2) Cyclical mastalgia
3) Having a phyllodes tumour
4) Multiparity
5) A single previous fibroadenoma

Explanation
Having a phyllodes tumour

A phyllodes tumour, also called a cystosarcoma phyllodes, is a fibroepithelial tumour that

resembles a fibroadenoma. It is fast growing and women commonly present with a large
breast mass. This mass can be either benign or malignant and it is sometimes difficult to
differentiate. It is a locally invasive tumour with a tendency to recur. Up to 25% of the
benign tumours have a malignant transformation.
Body mass index (BMI) <30

It is a BMI of >30, ie clinical obesity, after menopause that increases the risk of breast
cancer. Interestingly, pre-menopausal obesity is a protective factor.
Cyclical mastalgia

Cyclical mastalgia is pain in the breast tissue relating to hormonal changes in the menstrual
cycle. This condition usually starts within 2 weeks of the menstrual period and improves
with the onset of the woman’s menstrual period. This can resolve spontaneously and recur.
It is not however a risk factor for developing breast cancer.
Multiparity

Pregnancy, especially if the woman had her first full term delivery before the age of 20,
offers protection to the woman by reducing the susceptibility of the mammary cells to
somatic mutations. Therefore, being multiparous, is a protective factor for breast cancer
and being nulliparous is a risk factor.
Of note, if a woman had her first full term delivery after the age of 35 then she is at a higher
risk of developing breast cancer than a nulliparous woman.

A single previous fibroadenoma

A single previous fibroadenoma does not increase a woman’s risk of developing breast
cancer. There have been some studies in the literature, however, that suggest that women
who present with multiple fibroadenomas or complex fibroadenomas have a relative risk of
developing breast cancer of 2.
797
You are preparing a lecture on breast cancer for fourth year medical students. You want to
improve their clinical examination skills.
In which area of the breast are lesions most likely to be found?
1) Central or subareolar region
2) Multifocal
3) Upper inner quadrant (UIQ)
4) Lower inner quadrant (LIQ)
5) Upper outer quadrant (UOQ)

Explanation
Upper outer quadrant (UOQ)
The upper outer quadrant is where most breast lesions arise, accounting for 45% of all
breast lesions.
Central or subareolar region
About 25% of all lesion arise in the central or subareolar region of the breast.

Multifocal

In one-third of the cases the lesions are multifocal on presentation.

Upper inner quadrant (UIQ)
The upper inner quadrant of the breast is where 15% of breast lesions arise.
Lower inner quadrant (LIQ)
The lower inner quadrant is where 5% of all breast lesions arise.
798
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A 68-year-old woman presents with a left breast lump. Examination reveals a firm irregular
painless lump in the upper outer quadrant. Further examination reveals that this is
malignant in origin and she undergoes a wide local excision and an axillary clearance. In
theatre, all lymph nodes lateral to pectoralis minor are removed.

What level of lymphatic clearance is this?

1) Full clearance
2) Level 1
3) Level 2
4) Level 3
5) Level 4

Explanation
Level 1
This patient has had a level 1 axillary lymph node clearance as this involves removal of the
axillary nodes lateral and inferior to the pectoralis minor muscle.
Full clearance
Only level 3 node dissection is considered a full clearance.
Level 2
A level 2 axillary node dissection involves the lymph nodes found deep or posterior to the
pectoralis minor muscle.
Level 3
A level 3 axillary node clearance, also referred to as a full clearance, involves surgical
removal of the lymph nodes superior & medial to the pectoralis minor muscle.
Level 4
There are only three surgical levels of axillary nodes.
799
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A 22-year-old woman is referred by her GP to the rapid access breast clinic with a lump in
her left breast. She says that it has been present for about 8 weeks now and is painless.
There is no bleeding or discharge from her nipples. On examination, there is a 2-cm sized,
firm, mobile and smooth lump in the upper outer quadrant of her left breast. There is no
palpable axillary lymphadenopathy. Her paternal aunt died from breast cancer at the age of
62.
From the options below choose the one that you think is the most likely diagnosis in
this patient.
1) Cystosarcomma phyllodes
2) Fibroadenoma
3) Fibrocystic disease
4) Mondor’s disease
5) Paget’s disease

Explanation
Fibroadenoma
Fibroadenomas are the most common benign lesions seen in young women (<30 years).
They account for 90% of breast masses found in women under the age of 19 years. They
arise from the breast lobule and contain both stromal and epithelial elements. They present
clinically as a firm, smooth, mobile, painless mass of 1–5 cm in maximal diameter.
Fibroadenomas can enlarge during pregnancy and can be multiple at presentation in 10–
15% of cases.
They tend to occur most commonly in the upper outer quadrant of the breast. On
radiography they appear well circumscribed, discrete, homogeneous lesions. Diagnosis is
usually with a biopsy under ultrasound guidance and if no atypical features are found it can
be followed radiographically. If atypical features are found or lesions are large and
symptomatic then surgical excision is preferred. The risk of malignant transformation of
a fibroadenoma is <1%.
Cystosarcomma phyllodes
A cystosarcoma phyllodes, also known as a phyllodes tumour, is a fibroepithelial tumour
that resembles a fibroadenoma. It is fast growing and women commonly present with a
large breast mass. This can be either benign or malignant and it is sometimes difficult to
differentiate. It is a locally invasive tumour with a tendency to recur. Up to 25% of the
benign tumours undergo a malignant transformation.
It usually occurs in women between the age of 40–60 years. They are surgically excised and
are not sensitive to either chemotherapy or radiotherapy.
Fibrocystic disease
This is a benign breast conditions that is very common, mostly presenting in young pre-
menopausal women, with mastalgia and tender nodules. It is usually multifocal and
bilateral.
Mondor’s disease
Mondor’s disease is a very rare condition associated with thrombophlebitis in the
subcutaneous veins of the anterior chest and presents as a sudden, red and tender
subcutaneous cord, which will eventually become a fibrous band that can cause skin
retraction. It is a self-limited condition but has been associated with breast cancer.
Paget’s disease
Paget’s disease of the breast usually affects the nipple and the areola and usually presents
in women aged 50–60. It presents with eczematous changes in the nipple and surrounding
area like: erythaema, scaling and crusting. In most cases it is associated with malignant
duct cells and therefore should always be treated with high suspicion and investigated
accordingly.
800
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A 52-year-old woman’s breast biopsy histology shows poorly differentiated duct epithelial
cells that do not breach the basement membrane. Her case is being discussed at the breast
MDT.
What is the best classification of this breast pathology?
1) Phyllodes tumour
2) Ductal carcinoma in situ
3) Lobular carcinoma in situ
4) Fibroadenoma
5) Von Willebrand’s disease (vWD)

Explanation
Ductal carcinoma in situ
Ductal carcinoma in situ (DCIS) is the most common form of non-invasive breast cancer, in
which abnormal cells are found and are limited to the ductal lining, without invasion
through the basement membrane into the surrounding stroma.
Phyllodes tumour
A phyllodes tumour, also called cystosarcoma phylloides, is a large, fast-growing tumour
arising from the stromal cells. About 50% of these are benign, with the remaining either
borderline or malignant. They are more common in women with a history of
fibroadenomas and are not sensitive to chemotherapy or radiation.
Lobular carcinoma in situ
Lobular carcinoma in situ (LCIS) means cellular changes in the acini or the terminal
ductules of the breast lobules also known as glandular cells, without stromal invasion.
There is a lifetime risk of LCIS leading to invasive breast carcinoma in 20–25% of cases.
Fibroadenoma
Fibroadenoma is a common benign tumour composed of both epithelial and stromal
tissues, commonly seen in young women. It presents as a palpable, smooth lump. If they are
multiple or complex they increase the relative risk of developing breast cancer by 2.

Von Willebrand’s disease (vWD)

Von Willebrand’s disease is an inherited haemorrhagic disorder associated with a

deficiency in von Willebrand factor.
802
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A 25-year-old woman breast-fed her first baby for almost 1 year with no difficulties and no
complications. She is pregnant again and wants to do the same for her next child.
Which one of the following cellular processes that occurred in the breast during
pregnancy allowed her to nurse the infant for this period of time?

1) Ductal epithelial metaplasia

2) Epithelial dysplasia
3) Lobular hyperplasia
4) Stromal hypertrophy
5) Steatocyte atrophy

Explanation
Lobular hyperplasia

During pregnancy high oestrogen and progesterone levels stimulate the lobules of the
breast to increase in numbers. It is lobular hyperplasia that allows this woman to nurture
her infant, as lobular tissue or glandular tissue is the milk-producing part of the breast.

Ductal epithelial metaplasia

Ductal epithelial metaplasia is not a physiological process.

Epithelial dysplasia

Epithelial dysplasia is a pre-malignant change and this is not part of a physiological

process.

Stromal hypertrophy

Stroma forms the connective tissue of the breast that supports the lobules. Stromal
hypertrophy occurs during pregnancy as well but as stroma is not the
tissue that producesmilk, it is not stromal hypertrophy that allows this woman to nurture
her infant.

Steatocyte atrophy

Steatocyte atrophy is a condition in which steatocytes, and therefore breasts, decrease in

size secondary to weight loss or poor nutrition. It is commonly seen in patients with
anorexia nervosa.
803
You are in the breast endocrine clinic reviewing a patient with a breast cancer detected
through the National Breast Screening Programme. She wants to discuss the significance of
the testing she has had done and has questions.
Which one of the following is correct regarding this programme?
1) Has led to a major increase in benign breast biopsies
2) Screens women in the UK from the age of 55 to 73 years only
3) Screens women every 5 years
4) Is carried out on all women aged between 45 and 65 years of age
5) Has increased the proportion of carcinoma in situ (CIS) disease detected

Explanation
Has increased the proportion of carcinoma in situ (CIS) disease detected

Mammography is very sensitive in detecting breast abnormalities and with the screening
programme there has been a steep rise in the detection of early stage disease, carcinoma in
situ.
Has led to a major increase in benign breast biopsies

The National Breast Screening Programme has not led to a major increase in benign breast
biopsies, in fact the percentage of biopsy samples with benign or non-atypical lesions has
actually decreased since the introduction of screening.
Screens women in the UK from the age of 55 to 73 years only

The National Breast Screening Programme screens women between the ages of 50–70
every 3 years, with the first invitation being received before a woman’s 53rd birthday.
However, in some areas of England, as part of a trial to extend the programme women
between the age of 47–73 are invited to screening. Women above the age of 70 can self-
refer to their local screening unit to have further screening. Additionally, women aged 47
and above with a family history of breast cancer can be referred for official risk
stratification and, if found to be high risk, will be offered screening from the age of 47
onwards.
Screens women every 5 years

The National Breast Screening Programme screens women every 3 years.

Is carried out on all women aged between 45 and 65 years of age

All women between the age of 50 and 70 registered with a GP are invited for screening 3-
yearly. In some areas, as part of a trial to extend the programme, women between the age
of 47–73 are invited.
804
You are in the breast endocrine clinic reviewing a patient with a lump detected
via screening. She wants to discuss the significance of the testing she has had done and has
questions.
Regarding the breast screening programme in the UK, which one of the following is
correct?
1) It uses mammography (an X-ray of the breast)
2) It uses a combination of serum tumour markers and ultrasound
3) Only women aged between 50 and 70 are invited for screening
4) Women aged over 70 are not eligible for screening
5) The aim is to prevent breast cancer developing

Explanation
It uses mammography (an X-ray of the breast)

Breast screening uses mammography, taking two X-rays of each breast at different planes, one from
above and one lateral.
It uses a combination of serum tumour markers and ultrasound

While ultrasound scan (USS) is used in the young for detection of tumours
the National Breast Screening Programme uses mammography to detect breast abnormalities.
Only women aged between 50 and 70 are invited for screening

Women between the age of 50 and 70 are invited to screening every 3 years.
In some parts of England in an aim to extend the screening programme, women aged 47–49
and 71–73 are also included in the invitation for screening.
Additionally, women with a strong family history can be referred to clinic where they will
have their risk stratified and may be offered screening from the age of 47.
Women aged over 70 are not eligible for screening

Women above the age of 70 can walk into a breast screening centre and request screening
every 3 years. Additionally, in some parts of England in an effort to extend the screening
programme, women aged 71–73 are invited for screening.
The aim is to prevent breast cancer developing

The breast screening programme aims to detect breast cancers at an early stage, before
they grow or cause clinical symptoms, and hopefully when they are more easily
treatable toreduce mortality from breast cancer.
Unfortunately the screening programme does not prevent cancer form developing.
805
You are seeing a young woman in the breast clinic who has presented with mastalgia.
You’ve reassured her but she is concerned regarding her risk of developing breast cancer in
the future.
Which one of the following is associated with a risk of developing breast cancer?
1) Early menopause
2) Pre-menopausal obesity
3) Breast hyperplasia
4) Late menarche
5) Multiparity

Explanation
Breast hyperplasia

A woman with previous breast hyperplasia is at risk of developing breast cancer. Breast
hyperplasia is a proliferative breast disease involving overgrowth of the ductal/or lobular
cells. It is usually diagnosed incidentally with screening and is a histological diagnosis.
Moderate hyperplasia without atypical cells increases the risk of developing breast cancer
by 1.5–2 times, whereas atypical hyperplasia increases the risk of developing breast cancer
by 3–4 times.
Other risk factors that increase the risk of developing breast cancer include the following:

• increasing age
• inherited mutations in BRCA1/BRCA2 genes
• family history of breast or early ovarian cancer
• exposure to ionising radiation before the age of 30
• first pregnancy after the age of 35
• early menarche
• late menopause
• alcohol consumption
• postmenopausal obesity
• prolonged use of HRT.

Early menopause

It is prolonged exposure to oestrogen that increases the risk of developing breast cancer.
Therefore risk factors include early menarche (before the age of 12) and late menopause
(after the age of 55).
Pre-menopausal obesity

It is postmenopausal obesity that increases the risk of developing breast cancer.

Interestingly, it has been shown in studies that premenopausal obesity is a protective
factor against developing breast cancer.
Late menarche

It is prolonged exposure to oestrogen that increases the risk of developing breast cancer.
Therefore risk factors include early menarche (before the age of 12) and late menopause
(after the age of 55).

Multiparity

Pregnancy is a protective factor against breast cancer development. The exact mechanism
this occurs is still unclear but it is thought to decrease the susceptibility of mammary cells
to somatic mutations. The earlier the first full-term birth the greater the protection, with
women having their first child before the age of 20 having their risk reduced by 50%.
Multiparity protects against breast cancer with nulliparity increasing the risk. However, it
is worth noting that women who have their first full-term pregnancy after the age of 35 are
at increased risk of developing breast cancer, higher than nulliparous women.
807

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You have been asked to see a 63-year-old woman in the follow-up breast clinic who is 2.5
years following her diagnosis of a 34 mm invasive lobular breast cancer. She is asking you
questions about her diagnosis.
Which one of the following is most likely to be correct regarding a diagnosis of breast
cancer?
1) It is predominantly an invasive lobular type
2) It is less common in the nulliparous woman
3) It is associated with upper socioeconomic class
4) In men there will be a familial tendency in the majority of cases
5) Lobular cancers tend to be more often multifocal than ductal cancers

Explanation
Lobular cancers tend to be more often multifocal than ductal cancers

Lobular invasive carcinoma is more often multifocal and bilateral at diagnosis than ductal
invasive carcinoma.
It is predominantly an invasive lobular type

70–80% of all breast cancer diagnoses are of the ductal invasive carcinoma type. Lobular
invasive carcinoma is the second most common type of breast cancer accounting for about
5–15% of diagnoses.
It is less common in the nulliparous woman

Pregnancy is thought to protect against breast cancer by making the mammary cells less
susceptible to somatic mutations. Therefore, being nulliparous is considered to increase a
woman’s risk of developing breast cancer.

It is associated with upper socioeconomic class

There is evidence in the literature that it is lower socioeconomic status that increases the
risk of developing breast cancer. Why this factor is important, however, remains unclear.

In men there will be a familial tendency in the majority of cases

Both in men and women a family history is positive in about 10% of cancer cases. The
remaining 90% arise in patients with no family history.
813

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You are explaining the importance of screening to a 56-year-old woman in the breast clinic.
She presented with breast pain that was found to be benign.
Which one of the following statements is correct regarding screening for breast
cancer in the UK?
1) It is directed at women between the ages of 45 and 64 years
2) It has revealed that at least 20% of tumours detected in the screened population were not
clinically palpable
3) Is performed by a two view double read mammogram and an examination of the breasts by
a suitably trained clinician
4) It has on average detected tumours in about 2% of the screened population
5) It requires a mammogram screening every 2 years in the screened population

Explanation
It has revealed that at least 20% of tumours detected in the screened population were not clinically
palpable

40.5% of the tumours detected in 2014–2015 were invasive but had a maximal diameter of
<15 mm and therefore were too small to be clinically palpable.
It is directed at women between the ages of 45 and 64 years

The National Breast Screening Programme invites all women registered with a GP in the
ages of 50–70. In some areas in England as part of a trial to extend the screening
programme women from the age of 47–73 are invited.
Is performed by a two view double read mammogram and an examination of the breasts by a
suitably trained clinician

The NHS Breast Screening Programme involves 3-yearly mammography with a two-view
double read mammogram, a cranio-caudal and a lateral oblique view. It does not however
include a breast examination.
It has on average detected tumours in about 2% of the screened population

It has on average detected tumours in about 0.8% of the screened population (8.3 per 1000
women screened).
It requires a mammogram screening every 2 years in the screened population

The NHS Breast Screening Programme requires women in the screening population to
attend every 3 years for mammography. This includes two X-rays of each breast, a cranio-
caudal and a lateral oblique view.
814

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A 63-year-old woman has just been diagnosed with a small left-sided breast cancer. There
is no evidence of a genetic link to this breast cancer however, unsurprisingly, she asks you
about risk factors and the chances that her two daughters might contract the disease.
What one factor may constitute a risk for the daughters?

1) Breast-feeding for over 18 months

2) Currently being pregnant
3) Having more than one child
4) Having children before the age of 30
5) Nulliparity

Explanation
Nulliparity

Women who have never had a full-term pregnancy or had their first full term pregnancy
after the age of 35 have an increased risk of breast cancer.
Other risk factors that increase the risk of developing breast cancer include the following:

• increasing age
• inherited mutations in BRCA1/BRCA2 genes
• family history of breast or early ovarian cancer
• exposure to ionising radiation before the age of 30
• first pregnancy after the age of 35
• early menarche
• late menopause
• alcohol consumption
• postmenopausal obesity
• prolonged use ofhormone replacement therapy (HRT).

Breast-feeding for over 18 months

Breast feeding is a protective factor for breast cancer, if the woman breast-feeds for a
prolonged period (>6 months). The exact mechanism why this is, has not yet been elicited.
It is thought to either occur by reducing circulating levels of oestrogen while breast-feeding
or cell changes in the breast tissue making them less susceptible to mutations.
Currently being pregnant

Pregnancy offers protection against breast cancer as it is thought to reduce the

susceptibility of breast cells to somatic mutations if the first full-term pregnancy is under
the age of 30.

Having more than one child

Being multiparous offers protection against breast cancer if women have their children at
an early age.

Having children before the age of 30

Having children before the age of 30 is actually protective against breast cancer because
pregnancy is thought to reduce the susceptibility of mammary cells to somatic mutations.
However, having a first born child after the age of 35 increases the risk of developing
breast cancer, therefore it is thought that protection is age related. As such, the earlier the
first full-term pregnancy the greater the protection.
815

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You have just seen a young woman in the breast clinic complaining of severe
constant right-sided breast pain which is affecting her life but also causing her anxiety.
What is the second most common cause of mastalgia?
1) Cyclical
2) Cancer
3) Idiopathic
4) Previous trauma
5) Trigger point

Explanation
Trigger point

The second most common cause of breast pain is musculoskeletal pain arising from a
trigger point in the pectoralis major, inferior to the breast. This pain is felt as a
hyperirritable and hypersensitive spot on the muscle referring pain to the breast and can
cause nipple hypersensitivity. Other causes of breast pain include: medication side-
effect (HRT, oral contraceptive pill, antidepressants, antipsychotics), breast trauma,
mastitis, sclerosingadenosis, cancer, benign breast tumours/cysts, Tietze’s syndrome,
costochondritis, thoracic outlet syndrome, idiopathic mastalgia.
Cyclical

Cyclical mastalgia is the most common cause of breast pain and occurs for up three-
quarters of the menstrual cycle, relating to cyclical hormonal changes. Pain is present
usually for the 2 weeks leading to the menstrual period and then settles with menstruation.
It is usually bilateral, self-resolves, but can be recurring. It can be managed with evening
primrose oil.
Cancer

Breast pain can be caused by cancer but this is not the second most common cause of
mastalgia.
Idiopathic

Breast pain can be idiopathic, but this is not the second most common cause of mastalgia.
Previous trauma

Previous trauma can cause breast pain but this is not the second most common cause of
mastalgia.
816

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You are seeing a 55-year-old woman who has been on tamoxifen for 2 years for a 33 mm
node-positive invasive ductal carcinoma of the breast. She is now biochemically post-
menopausal and you are thinking about switching her to anastrozole.

What one factor should you bear in mind regarding prescribing tamoxifen?
1) It is a recognised cause of post-menopausal vaginal bleeding
2) It is an aromatase inhibitor and as such is a treatment of choice this patient
3) It is always ineffective in patients with oestrogen receptor-negative breast cancer
4) It is predominantly excreted unchanged through the kidneys
5) It is the adjuvant treatment of choice for post-menopausal breast cancer

Explanation
It is a recognised cause of post-menopausal vaginal bleeding

Even though tamoxifen in an antagonist of the oestrogen receptor in breast tissue it is an

agonist of the oestrogen receptors on the endometrium. Therefore, it can lead to
endometrial proliferation, hyperplasia, formation of an endometrial polyps and
endometrial cancer. Any of the above causes can present as postmenopausal vaginal
bleeding.
Other common side-effects associated with the use of tamoxifen include: hot flushes,
vaginal discharge, fluid retention, pruritus vulvae, menstruation suppression in
premenopausal women, gastro-intestinal disturbances etc.
It has also been reported to increase the risk of venous thromboembolism in patients
undergoing surgery or periods of immobility.
It is an aromatase inhibitor and as such is a treatment of choice this patient

Tamoxifen is a selective oestrogen receptor (ER) modulator (SERM) that binds the
oestrogen receptor on breast tissue and acts as an antagonist to oestrogen, blocking the
latter from binding and exerting its effects on DNA synthesis and therefore inhibits tumour
growth. For the treatment of breast cancer the dosage is 20 mg once daily on days 2, 3,
4and 5 of the menstrual cycle. It is the treatment of choice for ER-positive breast tumours
in premenopausal women. Given the patient is now postmenopausal, guidelines
recommend changing tamoxifen to an aromatase inhibitor such as anastrozole or letrozole.
It is always ineffective in patients with oestrogen receptor-negative breast cancer

5–10% of oestrogen receptor-negative tumours have shown sensitivity to tamoxifen

treatment.
It is predominantly excreted unchanged through the kidneys

Tamoxifen is a pro-drug that is metabolised in the liver by the cytochrome P450 enzymes
to its active metabolites. It is excreted in the bile, urine and faeces.
It is the adjuvant treatment of choice for post-menopausal breast cancer

Tamoxifen is the adjuvant treatment of choice for premenopausal breast cancer that is ER
positive. For post-menopausal breast cancer the adjuvant treatment of choice is aromatase
inhibitors.
817

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A 22-year-old woman is seen in the breast clinic with a lump in her left breast. She
undergoes triple assessment.

What is the main use of fine-needle aspiration?

1) It is only used when a pathologist is present to report results immediately

2) Its primary use is therapeutic
3) It is used to differentiate between in-situ and invasive disease
4) It provides tissue for histology
5) It provides cells for cytology

Explanation
It provides cells for cytology

Fine-needle aspiration provides cells for cytology. A pathologist examines these cells to
identify any signs of atypia or abnormalities.
Investigation of a breast lump: the buzzword here is triple assessment (HRT):

• H – History and examination

• R – Radiology: Ultrasound or mammography
• T – Tissue diagnosis: cytology or biopsy

It is only used when a pathologist is present to report results immediately

If used in the context of a comprehensive one-stop clinic, a pathologist is present to review

the cells and report results immediately. However, a sample can be collected in another
setting with fine-needle aspiration (FNA) and examined by the pathologist at a later stage.

Its primary use is therapeutic

Fine-needle aspiration is primarily used for diagnosis, to detect the presence of abnormal
cells. However, it can in some cases be used therapeutically for example in aspiration of a
simple breast cyst.
It is used to differentiate between in-situ and invasive disease

It cannot be used to differentiate between in situ and invasive disease as the cells obtained
by fine-needle aspiration do not retain the architecture they had originally in the lesion and
appear as scattered cells.
It provides tissue for histology

Fine-needle aspiration provides cells for cytology. The sample cannot be used for
histological evaluation as the cells appear scattered and do not maintain the spatial
arrangement they had in the original tissue. Tissue from histology is obtained from a core
biopsy or from surgical excision of the lesion.
859

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You have been asked to see an unfortunate young woman in the Emergency Department
who has presented with a 2 × 2 cm probable abscess in her right breast. It is tender and
fluctuant and clearly needs treatment. She is 2 months post partum and still breast-feeding.
Which one statement is true regarding breast abscesses?

1) Breast abscesses occur in all ages - there is no commonly seen history

2) They are most common in women of child-bearing age and are always caused
by streptococci
3) They occur most commonly in menopausal women and are caused
by Staphylococcus aureus infection
4) They occur most commonly in women of childbearing age, in puerperium and
during breastfeeding
5) They occur most commonly in diabetic woman who are breastfeeding

Explanation
They occur most commonly in women of childbearing age, in puerperium and during breastfeeding

Breast abscesses occur most commonly in women of child-bearing age, especially in the
puerperium and during breast-feeding; 10–33% of breast-feeding mothers will develop
mastitis and about 1 in 10 of these women will have an abscess. They are treated with
ultrasound-guided drainage or surgical incision and drainage alongside adequate antibiotic
therapy.

Breast abscesses occur in all ages - there is no commonly seen history

Breast abscesses occur predominantly in women of child-bearing age, especially around

the puerperium and during breast-feeding. Fissuring of the nipple from the nurturing child
allows entry of bacteria, most commonly Staphylococcus aureus, and infection in the form of
mastitis ensues. In 5–10% of these cases the infection can lead to the formation of a breast
abscess. The lactational abscesses tend to be peripheral and most common in the upper,
outer quadrant of the breast.
Non-lactational abscesses, are found in the central, subareolar and the lower quadrants of
the breast and can be secondary to periductal mastitis, diabetes mellitus, rheumatoid
arthritis, trauma, and steroid use.
They are most common in women of child-bearing age and are always caused by streptococci

Breast abscesses occur most commonly in women of child-bearing age, especially in the
puerperium and during breast feeding. The most common pathogen associated with breast
abscesses is Staphylococcus aureus, however Staphylococcus epidermidis and some
streptococci have also been described as causative agents.
They occur most commonly in menopausal women and are caused by Staphylococcus
aureus infection
Breast abscess occur predominantly in women of reproductive age and are rare in
menopausal women

They occur most commonly in diabetic woman who are breastfeeding

Diabetes is a risk factor predisposing to peripheral non-lactational abscesses found in the

lower quadrants of the breast.
2330

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You have been asked to see an elderly woman as an add-on to your breast cancer clinic by
the breast-care nurses. She has previously had a wide local excision and axillary dissection
and now has gross lymphoedema.
Why would axillary dissection be performed in this patient?

1) It is an important tool in the staging and treatment of the Axilla in breast cancer
2) It is the only effective treatment of symptomatic axillary disease
3) It is proven to substantially prolong survival
4) It usually yields involved lymph nodes in the treatment of ductal carcinoma in situ
5) It is therapeutic in all patients

Explanation
It is an important tool in the staging and treatment of the Axilla in breast cancer

Axillary dissection is a surgical procedure that is used as an important tool in the staging
and treatment of axillary disease in breast cancer. It identifies, examines and removes
nodes if necessary.

It is the only effective treatment of symptomatic axillary disease

Radiotherapy is also an effective treatment for symptomatic axillary disease. The difference
is that radiotherapy does not offer diagnostic information.

It is proven to substantially prolong survival

Axillary node dissection has prognostic information and decreases the chance of
symptomatic axillary disease. There is, however, no proven substantial prolongation in
survival due to carrying out axillary node dissection.

It usually yields involved lymph nodes in the treatment of ductal carcinoma in situ

Axillary dissection rarely yields affected lymph nodes in the treatment of ductal carcinoma
in situ (DCIS) as this is premalignant disease restricted to the ductal epithelium and does
not invade through the basement membrane and into the surrounding stroma.

It is therapeutic in all patients

Axillary dissection is an important tool in the examination, diagnosis and treatment of

axillary disease associated with breast cancer. It is only therapeutic in patients with a
positive sentinel node biopsy, therefore in patients with proven axillary node disease.
2331
A 45-year old woman, who has a 3-month old daughter and is breast-feeding, attends
outpatients with a finding of a new breast lump. She is concerned it may be a malignancy.

How should she be managed?

1) Lumps are common in breast feeding woman and she should be re-assured and
reviewed in 6 months
2) Radiological imaging and clinical examination in the first instance
3) Mammogram in combination with tissue biopsy
4) Mammogram in combination with tissue cytology and clinical examination
5) Radiological imaging in combination with tissue biopsy, clinical examination and
lymph node staging

Explanation
Radiological imaging and clinical examination in the first instance
In this woman the most likely diagnosis is a galactocoele associated with the elevated
circulating levels of prolactin. In the first instance a clinical examination and radiological
imaging is required. With the increased density of the breast tissue, there is a decreased
sensitivity of mammography therefore ultrasound may be the most appropriate mode of
investigation.
Lumps are common in breast feeding woman and she should be re-assured and reviewed
in 6 months
Breast masses are commonly encountered in pregnancy and during breast-feeding. These
are most commonly benign, however an unexplained breast lump in a woman over the age
of 30 requires a 2-week wait referral for assessment under the suspected cancer
pathway;3% of breast cancers are diagnosed during pregnancy.
Benign pathologies associated with pregnancy and breast-feeding are lactational adenoma,
fibroadenomas and galactocoele.
Mammogram in combination with tissue biopsy
Imaging either in the form of a mammogram or ultrasound along with a clinical
examination should be used at a first instance. The need for a tissue biopsy will depend on
the results of the clinical examination and imaging studies.
Mammogram in combination with tissue cytology and clinical examination
Imaging either in the form of a mammogram or ultrasound along with a clinical
examination should be used at a first instance. The need for a tissue biopsy or cytology will
depend on the results of the imaging studies and clinical examination.
Radiological imaging in combination with tissue biopsy, clinical examination and lymph
node staging
Imaging either in the form of a mammogram or ultrasound along with a clinical
examination should be used at a first instance. The need for a tissue biopsy or cytology will
depend on the results of the imaging studies and clinical examination. Lymph node staging
is only required if there is confirmation of malignant disease.
 2341

A 19-year old woman presents to clinic having undergone genetic testing for breast cancer
given her strong family history. She is noted to be positive for the BRCA1 gene.
How should you advise her?
1) BRCA1 gene is responsible for apoptosis of normal breast cells
2) Highest carrier rates of BRCA1 mutations occur in the black population
3) She has approximately 50% chance of developing breast cancer by age 50
4) She has a 100% chance of developing breast cancer by age 50
5) She is protected against developing ovarian cancer

Explanation
She has approximately 50% chance of developing breast cancer by age 50

A woman with a BRCA1 mutation has a risk of developing breast cancer by the age of 50 of
about 50%, increasing to 80% by the age of 90.
BRCA1 gene is responsible for apoptosis of normal breast cells
BRCA1 gene is a gene located on chromosome 17, encoding for a tumour suppressor
protein, a protein involved in repair of breaks in double-stranded DNA.
Highest carrier rates of BRCA1 mutations occur in the black population
Prevalence of BRCA1 mutations are similar in women of African, Hispanic, Asian and White
origin. It is present in approximately 1–4% of the population.
She has a 100% chance of developing breast cancer by age 50
BRCA1/BRCA2 mutations account for the majority of inherited breast cancers but are not
the only genes associated with the disease.
She is protected against developing ovarian cancer
Women with mutations in the BRCA1 gene have a 35–60% chance of developing ovarian
cancer, whereas women with mutations in the BRCA2 gene have a risk of 12–25% of
developing ovarian cancer.
2346
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A 67-year-old woman with known breast cancer is seen in your clinic regarding breast
reconstruction options. She has a lot of anxiety about the cosmetic impact of her procedure.
Which one of the following regarding free tissue transfer is correct?

1) There are fewer complications than with local paedicled options

2) Only the abdomen can be used as a donor site
3) It is better to perform a free flap after adjuvant radiotherapy treatment has been
completed
4) Flap necrosis can occur in the outer zones of donor skin as perfusion here is not as
reliable as in the centre
5) A free flap is contraindicated because of the patient's age

Explanation
Flap necrosis can occur in the outer zones of donor skin as perfusion here is not as reliable
as in the centre
Flap necrosis may be partial or total and is a significant complication of flap reconstruction,
reported in the literature at a variable rate of 5–30% (although this is improving). Partial
flap necrosis occurs when the arterial blood supply is insufficient to cover the oxygen
demands of the tissue flap (inflow problem) or where there is venous congestion or
thrombosis (outflow problem). It was found to occur primarily in the outer zones of the
donor skin, as these are less perfused than the centre of the tissue, and early recognition is
essential to salvage as much of the flap as possible

There are fewer complications than with local paedicled options

Free tissue transfer is a longer operation, associated with a higher risk of complications
when compared with a local paedicled flap reconstruction. Additionally, paedicled flaps
remain connected to their original blood supply reducing the risk of complications from
hypoxia of the tissue. For a free flap reconstruction, the vessels are completely
disconnected and reattached to the chest wall vessels.
Only the abdomen can be used as a donor site
Autologous free flaps can be harvested from the back (latissimus dorsi, thoracodorsal
artery perforator (TDAP) flap) abdomen (transverse rectus abdominis myocutaneous
(TRAM) flap, deep inferior epigastric artery perforator (DIEP) flap), buttock (inferior
gluteal artery perforator (IGAP) flap) and thighs (transverse upper gracilis (TUG) flap).

It is better to perform a free flap after adjuvant radiotherapy treatment has been completed

Radiotherapy promotes scarring in the breast tissue and may affect the blood vessel wall
composition, which can in turn affect the success of a free flap reconstruction. This is
because free tissue transfer requires a micro-anastomosis of arteries and veins from the
free flap to the recipient site (chest vessels, internal mammary arteries usually). Pre-
reconstruction radiotherapy injures the vessels and complicates the dissection and
anastomosis therefore, if possible a free flap reconstruction should be performed before
radiotherapy treatment.

A free flap is contraindicated because of the patient's age

Age should not act as a barrier in the exploration of options for breast reconstruction post
breast cancer and can include a free flap reconstruction.
2348
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A 33-year-old woman is seen in your clinic. She has already undergone mastectomy for
breast cancer and wishes to have a pedicled myocutaneous flap reconstruction.
Which one of the following is correct?
1) It is associated with a higher rate of failure as compared to free flap reconstruction
2) The latissimus dorsi flap is based on the thoracodorsal vessels
3) The latissimus dorsi flap is based on the circumflex scapular artery
4) She should expect a small vertical scar on her back
5) A ‘B’ cup breast is the largest that can be feasibly produced by this type of
reconstruction

Explanation
The latissimus dorsi flap is based on the thoracodorsal vessels
The latissimus dorsi muscle can be used as a pedicled myocutaneous flap for breast
reconstruction. Its primary source of blood supply is the thoracodorsal artery, a terminal
branch of the subscapular artery. The artery remains attached to the flap to ensure
adequate blood supply. It also receives blood supply from the segmental perforating
branches of the intercostal and lumbar arteries, but these are small and can be damaged
during harvest of the muscle.
It is associated with a higher rate of failure as compared to free flap reconstruction
A pedicled myocutaneous flap reconstruction (usually TRAM or LD) is associated with a
reduced rate of failure when compared with free flap reconstruction.
The latissimus dorsi flap is based on the circumflex scapular artery
The latissimus dorsi flap based on the thoracodorsal artery, arising from the subscapular
artery. The circumflex scapular artery also arises from the subscapular artery and supplies
the deltoid and the long head of the triceps.
She should expect a small vertical scar on her back
It should be explained to the patient that a skin paddle is taken with the muscle, therefore a
long scar can be expected. Some surgeons prefer to do this in the vertical orientation so
that the scar can be hidden by the bra line, while others prefer an oblique scar that have a
reduced risk of scar hypertrophy.
A ‘B’ cup breast is the largest that can be feasibly produced by this type of reconstruction
The latissimus dorsi flap reconstruction is usually considered an option for women with
small- to medium-sized breasts. This is firstly because it does not provide a large amount of
donor tissue (muscle and fat) for reconstruction, but is also usually due to the fact that
women without substantial abdominal fat are not able to undergo DIEP (gold standard) or
TRAM based reconstructions – therefore the LD flap is the next best option. It can be
combined with an implant with or without a dermal sling to produce higher breast volumes
if required. In some cases, a C cup can be achieved if an extended flap is obtained.
2350
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A 46-year-old pre-menopausal woman presents with a rapidly growing lump in her left
breast. There is no associated nipple discharge or ulceration.
Which one of the following is the likely diagnosis?
1) Phyllodes tumour
2) Ductal carcinoma
3) Fibroadenoma
4) Breast cyst
5) Paget's disease

Explanation
Phyllodes tumour
A cystosarcoma phyllodes, also known as a phyllodes tumour, is a fibroepithelial tumour
that resembles a fibroadenoma. It is fast growing and women commonly present with a
large breast mass. This can be either benign or malignant and it is sometimes difficult to
differentiate. It is a locally invasive tumour with a tendency to recur. Up to 25% of the
benign tumours undergo a malignant transformation. Prevalence of malignant phyllodes
tumours increase with age. It usually occurs in women between the age of 40–60 years.
They are surgically excised and are not sensitive to either chemotherapy or radiotherapy.
Ductal carcinoma

Ductal carcinoma is the most commonly diagnosed form of breast cancer and infiltrates the
surrounding tissue through the basement membrane of the ducts. The patient may remain
asymptomatic or present with a breast lump that is immobile, hard and usually painless.
Peak presentation is around the age of 50–60 and it presents as a speculated hyperdense or
an ovulated lesion on mammography.
Fibroadenoma

Fibroadenomas are the most common benign lesions seen in young women (<30 years).
They account for 90% of breast masses found in women under the age of 19 years. They
arise from the breast lobule and contain both stromal and epithelial elements. They present
clinically as a firm, smooth, mobile, painless mass of 1–5 cm in maximal diameter.
Fibroadenomas can enlarge during pregnancy and can be multiple at presentation in 10–
15% of cases. They tend to occur most commonly in the upper outer quadrant of the breast.
On radiography they appear well circumscribed, discrete, homogeneous lesions. Diagnosis
is usually with a biopsy under ultrasound guidance and if no atypical features are found it
can be followed up radiographically. If atypical features are found or lesions are large and
symptomatic then surgical excision is preferred. The risk of malignant transformation of a
fibroadenoma is <1%.
Breast cyst
Breast cysts are fluid filled and develop as a result of fluid accumulation and entrapment in
the glandular breast tissue. They are a very common benign condition of the breast,
relating to normal hormonal breast tissue changes. They most commonly occur in women
aged 35–50 and tend to disappear after the menopause. They present as palpable lumps
that are usually smooth, firm and mobile. Some can be tender. Some women have the
tendency to develop recurrent cysts. Most breast cysts resolve on their own but if it is
causing troublesome symptoms or is very large then aspiration is recommended. Taking
the oral contraceptive or hormone replacement therapy can increase the risk of developing
breast cysts.

Paget's disease

Paget’s disease of the breast usually affects the nipple and the areola and usually presents
in women aged 50–60. It presents with eczematous changes in the nipple and surrounding
area such as: erythema, scaling and crusting. In most cases it is associated with malignant
duct cells and therefore should always be treated with high suspicion and investigated
accordingly.
2352
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A 34-year-old woman undergoes an ultrasound examination of a breast cyst.
Which one of the following features on ultrasound is consistent with this diagnosis?
1) Irregular wall
2) Serrated anterior border
3) Black hypoechoic centres without internal echoes
4) Blood vessels running through them
5) Pulsatile

Explanation
Black hypoechoic centres without internal echoes
Breast cysts are common in young and peri-menopausal women and are caused by a
blocked terminal acinus leading to duct dilatation proximal to the acinus. They are benign
lesions classified according to size into microcysts (if <3 mm in maximal diameter) and
macrocysts (if >3 mm in maximal diameter). Radiographic features of a simple breast cyst
include any of the following:

• well circumscribed
• smooth walled
• anechoic/hypoechoic centres with no internal echoes
• sharp borders (both anterior and posterior).

Irregular wall

A simple breast cyst has a regular, smooth wall. If ill-defined they are not simple cysts.
Serrated anterior border

A simple breast cyst has a sharp anterior and posterior border.

Blood vessels running through them
A simple breast cyst does not have associated blood vessels running through it.
Pulsatile

A simple breast cyst is not pulsatile.

2353
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A 37-year-old with a history of benign breast disease enquires about her risk of
developing malignant breast disease. Her mother died from breast cancer.
Which one of the following is associated with the highest risk of developing
malignant breast disease?
1) Sclerosing adenosis
2) Duct ectasia
3) Fibroadenoma
4) Apocrine metaplasia
5) Lobular carcinoma in situ

Explanation
Lobular carcinoma in situ

Lobular carcinoma in situ means pre-malignant cellular changes in the acini or the terminal
ductules of the breast lobules, without stromal invasion. There is a lifetime risk of lobular
carcinoma in situ (LCIS) leading to invasive breast carcinoma of 20–25%, therefore close
monitoring and follow up are indicated.
Sclerosing adenosis

Sclerosing adenosis is a proliferative condition of the breast where there is an increased

number of acini and glands in the terminal lobular units and presents as multiple, small,
firm but tender lumps in the breast. In general, any benign breast condition is associated
with a small increase of breast cancer.
Duct ectasia

Duct ectasia is a benign breast disease that presents in middle-aged to elderly women with
nipple discharge, a palpable subareolar mass with non-cyclical pain. There is often
microcalcification on a mammogram. It is not thought to be associated with an increased
risk of breast cancer.
Fibroadenoma

A fibroadenoma is a benign breast condition and it is not thought to increase the risk of
lifetime breast cancer if solitary. However, having multiple or recurrent fibroadenomas is
thought to be associated with an increased relative risk of developing breast cancer.
Apocrine metaplasia

Apocrine metaplasia is a benign breast condition mostly seen in women over the age of 50
and is associated with fibrocystic breast changes. If associated with hyperplasia there is a
small increase of developing breast cancer.
2354
You are attending a lecture on breast cancer. The presenter lists a variety of
pathologies and you are asked which type is most common.
Which one of the following is the correct answer?
1) Ductal
2) Lobular
3) Mucinous
4) Papillary
5) Medullary

Explanation
Ductal

Ductal carcinoma NOS (not otherwise specified) is the most common histological form of
invasive breast cancer, accounting for 70–80% of breast cancers. Based on the extent of
nuclear polymorphism and some other characteristics invasive ductal carcinoma can be
subdivided into: grade 1 – well-differentiated; grade 2 – moderately differentiated; and
grade 3 – poorly differentiated.
Lobular

Lobular carcinoma accounts for 5–15% of breast cancer cases.

Mucinous

Mucinous carcinoma is quite a rare histological form of breast cancer with a prevalence of
2%.
Papillary

Papillary carcinoma accounts for 1–2% of breast cancers.

Medullary

Medullary carcinoma is a histological form of breast cancer with a prevalence of 1–7%.

2355

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A 41-year-old woman who is 6 weeks postpartum presents with a tender periareolar lump
with nipple retraction. She has no family history of breast disease.
Which one of the following is the most likely diagnosis?
1) Abscess
2) Cyst
3) Fibroadenoma
4) Intraductal papilloma
5) Malignancy

Explanation
Abscess

The most likely diagnosis of a breast lump in the puerperium and during breast-feeding is a
breast abscess. These are painful, with a short history and associated with skin erythema,
breast congestion and constitutional symptoms like fever and vomiting. They are most
commonly caused by Staphylococcus aureus. Lactational abscesses are usually found in the
upper outer quadrant of the breast, whereas non-lactational abscesses are found in the
areolar and inferior quadrants of the breast. Non-lactational peripheral abscesses are
associated with conditions like diabetes mellitus and rheumatoid arthritis. In the case from
this question the periareolar inflammation has caused fibrosis and nipple retraction.
Cyst

Breast cysts are fluid filled and develop as a result of fluid accumulation and entrapment in
the glandular breast tissue. They are a very common benign condition of the breast,
relating to normal hormonal breast tissue changes. They most commonly occur in women
in the ages of 35–50 and tend to disappear after the menopause. They present as palpable
lumps that are usually smooth, firm and mobile. Some can be tender. Most breast cysts
resolve on their own but if it is causing troublesome symptoms or is very large then
aspiration is recommended. Taking the oral contraceptive or hormone replacement
therapy can increase the risk of developing breast cysts.
Fibroadenoma

Fibroadenoma is the most common benign lesion seen in young women (<30), containing
both stromal and epithelial elements. Presentation is with a firm, smooth, mobile, painless
mass. It can change size during the menstrual cycle and pregnancy. On radiography they
appear well circumscribed, discrete, homogeneous lesions. The risk of malignant
transformation of a fibroadenoma is <1%.
Intraductal papilloma

An intraductal papilloma is a benign lesion arising in the ducts of the breast, presenting in
perimenopausal and postmenopausal women with a serosanguinous or bloody nipple
discharge. They arise in the subareolar region. They are surgically excised and carry a
lifetime relative risk of 1.5–2 of developing invasive breast carcinoma.
Malignancy

Breast masses are commonly encountered in pregnancy and during the puerperium and
breastfeeding. These are most commonly benign, however an unexplained breast lump in a
woman over the age of 30 requires a 2-week wait referral for assessment under the
suspected cancer pathway; 3% of breast cancers are diagnosed during pregnancy. Benign
pathologies associated with pregnancy and breastfeeding are lactational adenoma,
fibroadenomas and galactocoele.
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A 28-year-old woman presents with a 2-week history of discomfort and a lump in the 6
o’clock region adjacent to the nipple-areolar complex. The lump is painful and there is
a pus-like discharge from the nipple. She is a BRCA2 carrier, has mild asthma
and smokes 12 cigarettes a day.
Which one of the following is the most likely diagnosis?

1) Fat necrosis
2) Fibroadenoma
3) Harmatoma
4) Intraductal papilloma
5) Periductal mastitis

Explanation
Periductal mastitis
Periductal mastitis is a benign breast condition seen in young women with smoking being a
risk factor. It presents with pain (non-cyclical), pus-like nipple discharge, an inverted
nipple and a periareolar mass. If not treated early an abscess or fistula (between the duct
and the skin) can occur. It improves with antibiotics but smoking cessation is important for
resolution. The fact that she is a BRCA2 carrier is a ‘red herring’ in this scenario but
indicates that she requires close monitoring, as she has 45% risk of developing breast
cancer by the age of 70.

Fat necrosis

Fat necrosis is a benign inflammatory process occurring in the breast usually following
trauma, either accidental or surgical, or following radiotherapy. It presents as a palpable,
painless, ill-defined mass or incidentally on mammography.
Fibroadenoma
Fibroadenoma is the most common benign lesion seen in young women (<30), containing
both stromal and epithelial elements. Presentation is with a firm, smooth, mobile, painless
mass. It can change size during the menstrual cycle and pregnancy. On radiography they
appear well circumscribed, discrete, homogeneous lesions. The risk of malignant
transformation of a fibroadenoma is <1%.
Harmatoma
A breast hamartoma, also known as a fibroadenolipoma, is a rare, benign breast lesion. It is
composed of all tissues found in breast tissue: fibrous, glandular and fatty tissue
surrounded by a connective tissue capsule.
Intraductal papilloma
An intraductal papilloma is a benign lesion arising in the ducts of the breast, presenting in
perimenopausal and postmenopausal women with a serosanguinous or bloody nipple
discharge. They arise in the subareolar region. They are surgically excised and carry a
lifetime relative risk of 1.5–2 of developing invasive breast carcinoma (ductal).
 A 23-year-old woman presents with a painless mobile lump in the left outer breast. It has
been present for the last 9 weeks and seems to fluctuate in size with her menstrual cycle.
What is the likely diagnosis?
1) Abscess
2) Blocked Montgomery Gland
3) Fibroadenoma
4) Mondor’s Disease
5) Sebaceous cyst

Explanation
Fibroadenoma
Fibroadenomas are the most common benign lesions seen in young women (<30 years).
They account for 90% of breast masses found in women under the age of 19 years. They
arise from the breast lobule and contain both stromal and epithelial elements. They present
clinically as a firm, smooth, mobile, well defined, painless mass of 1–5 cm in maximal
diameter. Fibroadenomas are slow growing and size can fluctuate with hormonal
influences. Their size fluctuates during the menstrual cycle, pregnancy and breastfeeding.
They tend to occur most commonly in the upper outer quadrant of the breast. On
radiography they appear well circumscribed, discrete, homogeneous lesions. Diagnosis is
usually with a biopsy under ultrasound guidance and if no atypical features are found it can
be followed up radiographically. If atypical features are found or lesions are large and
symptomatic then surgical excision is preferred. The risk of malignant transformation of a
fibroadenoma is <1%.
Abscess
Abscesses occur in women of reproductive age, most commonly in the puerperium and
during breastfeeding. These are painful, with a short history and associated with skin
erythema, breast congestion and constitutional symptoms like fever, vomiting. They are
most commonly caused by Staphylococcus aureus. Lactational abscesses are usually found
in the upper outer quadrant of the breast, whereas non-lactational abscesses are found in
the areolar and inferior quadrants of the breast. Non-lactational peripheral abscesses are
associated with conditions like diabetes mellitus and rheumatoid arthritis.
Blocked Montgomery Gland
Montgomery glands are situated in the areolar area. They are ‘isolated sebaceous glands’ ie
without associated hair. This condition is rare and presents with an erythematous, tender
papule of around 1–2 mm in maximal diameter in the areolar region.
Mondor’s Disease
Mondor’s disease is a very rare condition associated with thrombophlebitis in the
subcutaneous veins of the anterior chest and presents as a sudden, red and tender
subcutaneous cord, which will eventually become a fibrous band that can cause skin
retraction. It is a self-limited condition but has been associated with breast cancer.
Sebaceous cyst
A sebaceous cyst arises in the skin usually secondary to a blocked sebaceous gland and
therefore appears on examination fixed to the skin. It is slow growing and does not
fluctuate in size during the menstrual cycle.
A 64-year-old woman is referred to your breast clinic following screening with an
impalpable 11 mm carcinoma in the upper outer aspect of her right breast. Lymph nodes
are negative on ultrasound of the axilla and the tumour is a grade 2 invasive ductal
carcinoma (ER/PR +ve, HER-2 –ve).
Which one of the following statements is true regarding the UK breast screening
service?
1) Screening is carried out by all hospitals with a breast unit in the UK
2) Screening for breast cancer is for women between the ages of 55 – 75 in the UK
3) Screen detected breast cancers tend to have a higher proportion of invasive when compared
to non-invasive breast cancers but caught at an early stage
4) Screening is undertaken every 2 years for post-menopausal women
5) Screening is undertaken using 2 view mammograms double read by 2 consultant
radiologists

Explanation
Screening is undertaken using 2 view mammograms double read by 2 consultant radiologists

The NHS Breast Screening Programme involves 3-yearly mammography with a two-view
doubly read mammogram, a cranio-caudal and a lateral oblique view. These are taken by
female radiographers and are read by two consultant radiologists. Further testing is
arranged if deemed required.
Screening is carried out by all hospitals with a breast unit in the UK

Screening is carried out nationally in dedicated locally appointed screening centres.

Screening for breast cancer is for women between the ages of 55 – 75 in the UK

In the UK, the National Breast Screening Programme, invites all women registered with a
GP from the ages of 50–70 to participate by having screening every 3 years. The first
invitation should arrive before a woman’s 53rd birthday. However. In some parts of
England as a trial with the aim to extend the programme, women between the ages of 47–
49 and 70–73 are invited. Women above the age of 70 can self-refer, if they want to
continue having screening, to their local screening centre.
Screen detected breast cancers tend to have a higher proportion of invasive when compared to non-
invasive breast cancers but caught at an early stage

Most of the screen-detected cancers are non-invasive. In 2014–2015 40.5% of screen-

detected cancers were invasive however most tend to be <15 mm in maximal diameter,
therefore identified before they would be clinically palpable and as such have a better
probability of cure.
Screening is undertaken every 2 years for post-menopausal women
Screening is undertaken every 3 years for all women (pre-menopausal or post-
menopausal) between the ages of 50–70 years.
You are treating a 62-year-old patient with a 3 cm primary breast tumour. She has
undergone imaging, demonstrating that the tumour does not extend into the chest wall or
skin, but that there are lytic lesions in the left femur and hemipelvis. The ipsilateral internal
mammary nodes and axillary nodes are positive.
What TNM stage is this tumour?
1) T2N2 M1
2) T2N3M1
3) T3N1M0
4) T3N2M1
5) T4N3M1

Explanation
T2N3M1

The UICC TNM classification system is a way of internationally classifying the extent of
oncological disease. The T refers to the primary tumour, the N refers to the status of the
lymphatics and whether the disease has spread to the lymph nodes and the M refers to
metastases in other organ systems, separate from where the primary tumour was found. In
this case the classification would be T2N3M1 because the tumour size is >2 cm but <5 cm in
maximal diameter, N3 because there is evidence of disease in the ipsilateral axillary and
internal mammary nodes and M1 because there is evidence of distal metastases in the
femur and pelvis.

Tx Tumour size cannot be assessed

Tis Ductal carcinoma in situ (DCIS

T1 Tumour equal to or less than 2 cm across

T2 Tumour diameter >2 cm but <5 cm

T3 Tumour diameter >5 cm

T4 Any size with tumour spread to chest wall and or overlying skin

NX Lymph nodes cannot be assessed

N0 No cancer cells in any nearby nodes

N1 Evidence of cancer cells in the axillary nodes (mobile)

N2 Evidence of cancer cells in axillary nodes (fixed)

N3 Evidence of cancer cells in other surrounding lymph nodes (eg internal mammary nodes)

M0 No sign of metastasis

M1 Metastasis of the cancer to another organ

T2N2 M1
This would be appropriate for a breast tumour of >2 cm but <5 cm in maximal diameter,
with metastasis only to the ipsilateral axillary nodes and distal system metastasis. Given
there is evidence of disease in the ipsilateral internal mammary nodes T2N3M1 is the correct
classification.
T3N1M0

This classification describes a breast tumour of >5 cm in maximal diameter with evidence
of cancer cells in the ipsilateral axillary nodes, with these remaining mobile, and no
evidence of other organ systems being affected, ie no distal metastasis.
T3N2M1

This classification describes a tumour of >5 cm in maximal diameter, with evidence of

disease in fixed ipsilateral axillary nodes and evidence of distal metastasis.
T4N3M1

This classification describes a breast tumour of any size that has infiltrated into the chest
wall and/or overlying skin, with spread to fixed ipsilateral axillary nodes and other lymph
node groups such as internal mammary lymph nodes with distal metastasis.
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