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Senior - Surgery 2 > 6 - Breast > Flashcards

6 - Breast Flashcards

1
Q

Anatomy review

A

Milk made in alveoli cells of the lobules -> travels down the duct to the nipple

Appx 10-20 lubules per duct

One set of lobules with a single duct for collection is called a lobe

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2
Q

MC type of breast CA?

A

Ductal carcinoma

Lobular carcinoma is rare

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3
Q

Common breast complaints

A 
Pain
Mass
Discharge
Gynecomastia (dudes)
Abnormal mammo
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4
Q

Imaging for breast complaints

A

Diagnostic MMG

US

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5
Q

Invasive testing for breast complaints?

A

Tissue dx - if prior biopsy, get report

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6
Q

Txt for breast complaints

A

Aspirate

Refer to surgery

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7
Q

Patient positions for clinical breast exam

A

Sitting leaning forward

Sitting with arms raised

Sitting with pectoralis muscles flexed

Supine

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8
Q

What to examine with CBE?

A

All four quadrants including tail of Spence

All tissue, nipple and lymph nodes

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9
Q

Features of benign breast pain?

A

Cyclical
Bilateral
No focal area

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10
Q

Diagnostic problem breast CA?

A

Often painless (hence the importance of screening)

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11
Q

Management for breast pain

A

Diagnostic MMG c f/u US

Oral contraceptives (stabilize hormones)

Encourage exercise

Avoid: narc, diuretics, iodine, tamoxifen, danazol

Decreased caffeine

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12
Q

Probably causes of breast pain:

A 
Pregnancy
Infection
Fibrocystic breasts
Costochondritis 
Mondor’s Dz
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13
Q

What is Mondor’s Dz?

A

Trauma of chest wall vein after trauma / surgery

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14
Q

Presentation of acute mastitis

A 
Cellulitis around the nipple
No mass (abscess)

Culture it out -> usually staph or strep

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15
Q

Workup for acute mastitis

A

Complete CBE

C and S

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16
Q

Txt for acute mastitis

A

ABX (staph and strep coverage)
Localized moist heat

Continue to drain breast (pump or continue to breast feed)

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17
Q

Breast abcess

A

Raised tender mass near the nipple

Fever chills swears leukocytosis

Acute? Normally lactating breast

Chronic? Normally duct ectasia (thick, green black sticky discharge, older women)

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18
Q

Txt for breast abscess

A

Stop nursing

Admit

IV ABX

I and D

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19
Q

What is Macromastia?

A

Breast hypertrophy

Bra staps dig into shoulders

Upper back pain, poor posture

Chronic dermatitis under breasts

Difficult to find fitting clothes

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20
Q

Complications of breast reduction

A

Infection
Bleeding
Numbness
Undesired cosmetic outcome

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21
Q

Extra nipples?

A

Yup, it’s a thing.

Supranumerary nipple

Often noticed during pregnancy - can occur anywhere along the milk line

Totally benign - just excise it

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22
Q

Are most breast masses serious?

A

80% are benign (i.e. fibroadenoma)

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23
Q

Fibroadenoma

A

Smooth or slightly lobulated

Appx 1-3cm in diameter

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24
Q

Txt fro for fibroadenoma

A

Leave it alone, as long is it’s benign by exam, MMG, and FNA

If they’re over 35yrs, excise it if the patient wants

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25
Fibrocystic changes are common in:
Women during childbearing ages
26
Fibrocystic changes will present with:
Bilateral breast pain, nipple discharge and palpable mass Correlate with menses and tenderness peaks during luteal phase Usually concerned about CA - reassure pt that these are benign
27
Workup for fibrocystic changes:
CBE during different phases of menstrual cycle MMG Bx (FNA, core needle, or open)
28
Txt for fibrocystic changes
No caffeine (womp womp) Support bras NSAIDs Vit E / Primrose oil Rarely (tamoxifen, danasol, SubQ mastectomy)
29
Nipple discharge:
Pt hx important - unilateral or bilateral, color, spontaneous, relation to menses, meds, associated with a mass?
30
Workup for nipple discharge?
``` Inspection / palpation Palpable mass Diagnostic MMG Peri-areolar US Cytology HCG, prolactin, FSH, LH thyroid function Refer to surgery ```
31
Most nipple discharges are:
Benign - most intraductal papilloma or mammary duct ectasia Less than 15% are ductal carcinoma in situ
32
What is galactorrhea?
Bilateral milky discharge in non-lactating women Not associated with breast CA Check for hyperprolactinemia or hypothyroidism Diagnostic MMG and follow up US if warranted
33
Unilateral gynecomastia
Normally young dudes Benign Usually goes away on its own but for teenage boys this is hell, so you can do a subcutaneous mastectomy for them
34
Bilateral gynecomastia
Decreased androgen production as dudes age Normally without discharge Causes: testicular tumors, lung CA, starvation, thyrotoxicosis, klinefelters, roids, weeds, INH MMG and US (if warranted) Reassurance and routine consult with general surgery
35
Screening MMG
Not as detailed as a diagnostic MMG
36
Diagnostic MMG
Follow-up on lesion found during screening or abnormal exam
37
Goal of MMG’s
Detect breast CA before it becomes palpable and, theoretically, earlier detection relates to improved chance of survival
38
Is MMG a substitute for CBE/SBE?
No
39
What are the two standard views for MMG?
Craniocaudal (CC) Mediolateral (CL)
40
Limitations of MMG?
Dense breasts -> difficult to image Breast implants can obscure findings Uses ionizing radiation
41
What is BI-RADS?
Breast Imaging Reporting and Data System
42
BI-RADS categories
0 - additional imaging needed 1 - negative or normal 2 - benign findings (vascular Ca++, stable lesions, etc...) 3 - probably benign (repeat in 6 mos) 4 - Suspicious (consider Bx) 5 - Highly suggestive of malignancy (definitely Bx) 6 - Biopsy proven malignancy
43
Features of a BI-RADS 2?
Well-circumscribed homogenous mass Large / macrocalcifications Dense calcifications Calcified blood vessels Stable benign findings which have not changed form previous MMG
44
When is breast US normally used?
If there is a mass found on MMG Helps distinguish between cystic or solid mass (smooth-walled = likely benign, irregularly-shaped = needs further workup) Can also be used to guide needle Bx or aspiration
45
Is breast US useful in screening?
No
46
MRI is helpful for:
Evaluating tumor size Guiding surgical treatment plan Doesn’t require compression of the breast Good for dense tissue or those with implants
47
Risk factors for breast CA:
Females (100x more common than men) Advancing age First-degree relative with breast CA High dietary fat BRCA1 - 60% lifetime risk BRCA 2 - 30% lifetime risk
48
Not necessarily risk factors for breast CA:
``` Breastfeeding More distant relative with breast CA OCP’s Boob job Hx of mastitis Fibrocystic breast ```
49
MC presentation of breast CA:
Found lump during SBE Painless, unilateral, without nipple discharge Hard mass with irregular margins
50
Later signs of breast CA:
``` Skin dimpling Nipple retraction Fixation to chest Axillary lymphadenopathy Peau d’ orange ```
51
Workup for breast CA
Focused H and P Diagnostic MMG with f/u US Bx (FNA, Core Bx, incisional or excisional Bx) MRI prior to surgery
52
Difference between incisional vs excisional Bx?
Inc - take a piece of the mass Exc - take whole mass (lumpectomy)
53
Core Bx
Spring-loaded Can be done with or without US-guidance “Fired” through the mass, sample sent to pathology
54
Needle localized Bx
For non-palpable mass Two parts: 1- in clinic - wire inserted under US or CT guidance THEN 2 - taken to OR for excision of tissue
55
Incisional and excisional Bx
Both for palpable mass Performed in OR Incisional - piece taken - better cosmetic outcome Excisional - entire mass removed with “clean margins” - sent to pathologist - can remove in-situ or non-metastisized mass in one surgery
56
Pathology - estrogen receptor (ER) treated with:
Antiestrogens
57
Pathology - progesterone receptor (PR) treated with:
Antiprogesterones
58
Pathology - Human epidermal growth factor receptor (HER2) treated with:
Anticlonal antibodies Poor prognosis 2/2 rapid metastasis
59
Triple negative breast CA:
Most are BRCA1 (+) Negative for ER, PR, and HER2 (hence “triple negative) Most aggressive breast CA, worst prognosis Mainstay txt with chemotherapy
60
MC breast CA type:
Infiltrating ductal carcinoma
61
What is lobular carcinoma in situ?
Marker for CA Still encapsulated in the lobe 30% chance of developing CA
62
What is ductal carcinoma in situ?
Cancerous lesion and must be removed After excision, XRT to remaining breast tissue
63
What’s the deal with Paget’s dz of the breast?
Ductal carcinoma involving the nipple May or may not have palpable mass Nipple itching/burning Eczematoid / crusted lesion on the nipple or areola Any lesion refractory to topical abx or steroids >1 week should be referred to surgery
64
Inflammatory breast CA presents with:
Erythema and edema of breast tissue usually without palpable mass Can be confused with mastitis - does NOT respond to ABX Non-lactating women Highly malignant
65
Male breast CA:
<1% of breast all breast CA cases occur in men Usually older guys BRCA2 Often involves the nipple
66
Sentinel node bx and lumpectomy
Inject dye See hot spots in mass and nodes Go in and take the node, if it has CA, gotta remove the axillary lymph node chain If negative, no dissection necessary - external beam radiation is used, instead
67
Modified radical mastectomy:
MRM Remove all breast tissue, nipple, axillary nodes Spares underlying muscle Retains some skin for reconstruction
68
Radical mastectomy
Removes all of the breast, overlying skin, pectoralis muscles, and lymph nodes Usually major blood loss Decreased function of arm More lymphedema of the arm
69
Neoadjuvant chemo/XRT
Txt prior to surgery to debulk tumors
70
Adjuvant chemo/xrt
Txt after surgery
71
What is the most important prognostic variable concerning breast CA txt?
Whether the tumor has metastasized to the axillary lymph nodes
72
What normally left in place after lumpectomy?
Drains, to prevent seromas
73
Drains are pulled out when drainage is less than _____ ml/24H
30
74
What happens if you injure the long thoracic nerve?
Winged scapula
75
What happens if you injure the thoracodorsal nerve?
Latissimus dorsi (issues with that muscle, I guess - doesn’t specify)
76
Describe XRT
Radiation therapy - targeted (tangential) 2 to 6 weeks AFTER surgery, 5 times a week, For 6 to 8 weeks
77
SE’s of XRT
``` Lethargy N/V Dry skin Breast tenderness Lymphedema of the arm Lung scarring Cardiomyopathy Myalgias ```
78
TRAM
Transverse Rectus Abdominus Muscle Flap can be used to reproduce the breast mound after mastectomy
79
Other reconstruction / cosmetic option (besides TRAM)
Tissue expander Gradually increase saline content, then once the size is where you want it, permanent implant is placed
80
Of course my breasts are fake
The real ones tried to kill me

Senior - Surgery 2 (9 decks)

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