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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
Q

Fibrocystic changes are common in:

A

Women during childbearing ages

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26
Q

Fibrocystic changes will present with:

A

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

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27
Q

Workup for fibrocystic changes:

A

CBE during different phases of menstrual cycle

MMG

Bx (FNA, core needle, or open)

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28
Q

Txt for fibrocystic changes

A

No caffeine (womp womp)

Support bras

NSAIDs

Vit E / Primrose oil

Rarely (tamoxifen, danasol, SubQ mastectomy)

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29
Q

Nipple discharge:

A

Pt hx important - unilateral or bilateral, color, spontaneous, relation to menses, meds, associated with a mass?

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30
Q

Workup for nipple discharge?

A 
Inspection / palpation 
Palpable mass
Diagnostic MMG
Peri-areolar US
Cytology
HCG, prolactin, FSH, LH thyroid function
Refer to surgery
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31
Q

Most nipple discharges are:

A

Benign - most intraductal papilloma or mammary duct ectasia

Less than 15% are ductal carcinoma in situ

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32
Q

What is galactorrhea?

A

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

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33
Q

Unilateral gynecomastia

A

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
Q

Bilateral gynecomastia

A

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
Q

Screening MMG

A

Not as detailed as a diagnostic MMG

36
Q

Diagnostic MMG

A

Follow-up on lesion found during screening or abnormal exam

37
Q

Goal of MMG’s

A

Detect breast CA before it becomes palpable and, theoretically, earlier detection relates to improved chance of survival

38
Q

Is MMG a substitute for CBE/SBE?

A

No

39
Q

What are the two standard views for MMG?

A

Craniocaudal (CC)

Mediolateral (CL)

40
Q

Limitations of MMG?

A

Dense breasts -> difficult to image

Breast implants can obscure findings

Uses ionizing radiation

41
Q

What is BI-RADS?

A

Breast Imaging Reporting and Data System

42
Q

BI-RADS categories

A

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
Q

Features of a BI-RADS 2?

A

Well-circumscribed homogenous mass

Large / macrocalcifications

Dense calcifications

Calcified blood vessels

Stable benign findings which have not changed form previous MMG

44
Q

When is breast US normally used?

A

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
Q

Is breast US useful in screening?

A

No

46
Q

MRI is helpful for:

A

Evaluating tumor size
Guiding surgical treatment plan

Doesn’t require compression of the breast

Good for dense tissue or those with implants

47
Q

Risk factors for breast CA:

A

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
Q

Not necessarily risk factors for breast CA:

A 
Breastfeeding
More distant relative with breast CA
OCP’s
Boob job
Hx of mastitis
Fibrocystic breast
49
Q

MC presentation of breast CA:

A

Found lump during SBE

Painless, unilateral, without nipple discharge

Hard mass with irregular margins

50
Q

Later signs of breast CA:

A 
Skin dimpling
Nipple retraction
Fixation to chest 
Axillary lymphadenopathy
Peau d’ orange
51
Q

Workup for breast CA

A

Focused H and P

Diagnostic MMG with f/u US

Bx (FNA, Core Bx, incisional or excisional Bx)

MRI prior to surgery

52
Q

Difference between incisional vs excisional Bx?

A

Inc - take a piece of the mass

Exc - take whole mass (lumpectomy)

53
Q

Core Bx

A

Spring-loaded

Can be done with or without US-guidance

“Fired” through the mass, sample sent to pathology

54
Q

Needle localized Bx

A

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
Q

Incisional and excisional Bx

A

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
Q

Pathology - estrogen receptor (ER) treated with:

A

Antiestrogens

57
Q

Pathology - progesterone receptor (PR) treated with:

A

Antiprogesterones

58
Q

Pathology - Human epidermal growth factor receptor (HER2) treated with:

A

Anticlonal antibodies

Poor prognosis 2/2 rapid metastasis

59
Q

Triple negative breast CA:

A

Most are BRCA1 (+)

Negative for ER, PR, and HER2 (hence “triple negative)

Most aggressive breast CA, worst prognosis

Mainstay txt with chemotherapy

60
Q

MC breast CA type:

A

Infiltrating ductal carcinoma

61
Q

What is lobular carcinoma in situ?

A

Marker for CA
Still encapsulated in the lobe
30% chance of developing CA

62
Q

What is ductal carcinoma in situ?

A

Cancerous lesion and must be removed

After excision, XRT to remaining breast tissue

63
Q

What’s the deal with Paget’s dz of the breast?

A

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
Q

Inflammatory breast CA presents with:

A

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
Q

Male breast CA:

A

<1% of breast all breast CA cases occur in men

Usually older guys

BRCA2

Often involves the nipple

66
Q

Sentinel node bx and lumpectomy

A

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
Q

Modified radical mastectomy:

A

MRM

Remove all breast tissue, nipple, axillary nodes

Spares underlying muscle

Retains some skin for reconstruction

68
Q

Radical mastectomy

A

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
Q

Neoadjuvant chemo/XRT

A

Txt prior to surgery to debulk tumors

70
Q

Adjuvant chemo/xrt

A

Txt after surgery

71
Q

What is the most important prognostic variable concerning breast CA txt?

A

Whether the tumor has metastasized to the axillary lymph nodes

72
Q

What normally left in place after lumpectomy?

A

Drains, to prevent seromas

73
Q

Drains are pulled out when drainage is less than _____ ml/24H

A

30

74
Q

What happens if you injure the long thoracic nerve?

A

Winged scapula

75
Q

What happens if you injure the thoracodorsal nerve?

A

Latissimus dorsi (issues with that muscle, I guess - doesn’t specify)

76
Q

Describe XRT

A

Radiation therapy - targeted (tangential)

2 to 6 weeks AFTER surgery,
5 times a week,
For 6 to 8 weeks

77
Q

SE’s of XRT

A 
Lethargy
N/V
Dry skin
Breast tenderness
Lymphedema of the arm
Lung scarring
Cardiomyopathy
Myalgias
78
Q

TRAM

A

Transverse Rectus Abdominus Muscle

Flap can be used to reproduce the breast mound after mastectomy

79
Q

Other reconstruction / cosmetic option (besides TRAM)

A

Tissue expander

Gradually increase saline content, then once the size is where you want it, permanent implant is placed

80
Q

Of course my breasts are fake

A

The real ones tried to kill me

Senior - Surgery 2 (9 decks)

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