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Surgery Two > 6 - Breast > Flashcards

6 - Breast Flashcards

1
Q

Workup for breast CA

A

Focused H/P
Dx MMG with f/u U/S
Bx (FNA, Core Bx, incisional vs excisional Bx)
MRI prior to surgery

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2
Q

Purpose of ducts?

A

Stores milk and connects the nipple

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3
Q

SE’s of XRT

A 
Lethargy
N/V
Dry skin
Breast TTP
Lymphedema of arm
Lung scarring
Cardiomyopathy
Myalgias
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4
Q

What is BI-RADS?

A

Breast Imaging Reporting and Data System

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5
Q

All patients receive what prior to surgery?

A

MRI (Eval tumor size, lesion quanity, guides TXT plan)

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6
Q

Fibrocystic changes will present with:

A

Bilateral breast pain
Nipple d/c
Correlate w/ menses (TTP peaks during luteal phase)

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7
Q

Workup for fibrocystic changes:

A

CBE during phases of menstrual cycle
MMG
Bx (FNA, core needle, or open)

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8
Q

Not necessarily risk factors for breast CA: 6

A 
Nursing
2nd degree relative fam hx
OCP’s
Boob job
Hx of mastitis
Fibrocystic breast
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9
Q

BI-RADS - Biopsy proven malignancy

A

6

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10
Q

Is breast US useful in screening?

A

No

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11
Q

Sentinel node bx and lumpectomy

A

Inject radio-nucleatide dye (uptake into mass/lymph)
Preop - scan ID’s sentinel node for excise (axillary)
Surgeon - ID’s node w/ gamma probe and excised
If 1st node NEG - likely no spread or axillary dissect

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12
Q

BI-RADS - 2

A

2 - benign findings (vascular Ca++, stable lesions, etc…)

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13
Q

Pathology - Human epidermal growth factor receptor (HER2) treated with: 2

A

Anticlonal antibodies

Poor prognosis 2/2 rapid metastasis

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14
Q

Pathology - progesterone receptor (PR) treated with:

A

Antiprogesterones

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15
Q

When is breast US normally used?

A

If mass found on MMG
Differs - cystic vs solid mass or (Guides FNA/Bx)
-smooth walled = likely benign
-irregularly shaped = req W/U

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16
Q

Radical mastectomy

A

Breast, skin, pectoralis, lymph nodes removed
Usually major blood loss
Decreased arm fx due to muscle gone (lymphedema)

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17
Q

Adjuvant chemo/xrt

A

Txt after surgery

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18
Q

Txt for fibrocystic changes (NbNv-F)

A 
No caffeine 
Bra support
NSAIDs (Rarely - tamoxifen, danasol)
Vit E / Primrose oil
Failure - SubQ mastectomy
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19
Q

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

A

tumor mets to axillary lymph nodes

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20
Q

Features of a BI-RADS 2? (WLC-S)

A

Well-circumscribed homogenous mass
Large or Dense / macrocalcifications
Calcified blood vessels
Stable benign findings havent changed form prev MMG

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21
Q

Txt for fibroadenoma

A

Observe (Benign Exam, MMG, FNA)

>35yo, elective excise per pt

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22
Q

Describe XRT

A

Radiation therapy - targeted (tangential)

Start XRT 2-6 wks POST surgery, 5x/wk, for 6-8 wks

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23
Q

Breast cancer pain is often?

A 
Often painless (hence the importance of screening) 
(some painful however)
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24
Q

W/U nipple d/c?

A 
Inspection / palpation (mass)
Dx MMG
Peri-areolar U/S
Cytology
HCG, prolactin, FSH, LH thyroid fx
Refer to surgery
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25
BI-RADS - Highly suggestive of malig (definitely Bx)
5
26
Limitations of MMG?
Dense breasts -> difficult to image Breast implants can obscure findings Uses ionizing radiation
27
Other reconstruction / cosmetic option (besides TRAM)
Tissue expander | Gradually increase saline volume to stretch skin, then permanent implant is placed at desired size.
28
BI-RADS - 6
6 - Biopsy proven malignancy
29
Risk factors for breast CA: 5
``` Females and >age 1st degree relative fam hx High dietary fat BRCA1 - 60% lifetime risk BRCA 2 - 30% lifetime risk ```
30
BI-RADS - negative or normal
1
31
Patient positions for clinical breast exam
Supine and Sitting - lean forward - arms raised - pectoralis flex
32
Probably causes of breast pain: (MF-PIC)
``` Mondor’s Dz Fibrocystic breasts Pregnancy Infection Costochondritis ```
33
What happens if you injure the thoracodorsal nerve?
Latissimus dorsi
34
What is Mondor’s Dz?
Trauma to chest wall vein after trauma / surgery
35
Breast abscess
Raised TTP mass near nipple - Fever/chills - Sweats/WBC^
36
Paget’s dz of the breast? 5
Ductal carcinoma involving the nipple +/- palpable mass Nipple itch/burn Eczematoid / crusted lesion on nipple/areola Any refrac lesion (top) abx or CCS >1 week > refer surg
37
Acute breast abscess usually due to?
Lactating breast Chronic? Normally duct ectasia (thick, green black sticky discharge, older women)
38
Pathology - estrogen receptor (ER) treated with:
Antiestrogens
39
Incisional and excisional Bx
Both for palpable mass - Performed in OR -Incisional - piece taken - PVT seratoma/good cosmetic OR -Excisional - entire mass removed with “clean margins” > sent to pathologist - can remove in-situ or non-metastisized mass in one surgery
40
BI-RADS - probably benign (repeat in 6 mos)
3
41
Common breast complaints (DAMP-G)
``` D/C ABNL MMG Mass Pain Gynecomastia (dudes) ```
42
What is galactorrhea? W/U?
Bilateral milky d/c in non-lactating women Not ass/w breast CA Check for hyperprolactinemia or hypothyroidism Dx MMG and F/U U/S PRN
43
BI-RADS - 0
0 - additional imaging needed
44
BI-RADS - 1
1 - negative or normal
45
Core Bx
Local anesth Spring-loaded w/w/out U/S-guidance “Fired” through mass, slide > pathology
46
Is MMG a substitute for CBE/SBE?
No
47
MC presentation of breast CA:
Found lump during SBE Painless, unilateral, w/out nipple d/c Hard mass w/ irregular margins
48
Fibroadenoma presents how?
Young-F w/ decreased incidence closer to menopause Smooth or slightly lobulated 1-3cm diameter
49
TRAM
Transverse Rectus Abdominus Muscle | -Flap used to reproduce breast mound after mastectomy
50
BI-RADS - 5
5 - Highly suggestive of malignancy (definitely Bx)
51
Inflammatory breast CA presents with:
Breast erythema/edema w/out palpable mass usually -confused with mastitis - does NOT respond to ABX Non-lactating women (High DDx) Highly malignant
52
Screening MMG
Prelim- Not as detailed as a dx MMG | Pt has no S/S and has a NL PE
53
What is Macromastia? Presents
Breast hypertrophy - Bra staps dig into shoulders - Upper back pain, poor posture - Chronic dermatitis under breasts - Difficult to find fitting clothes
54
Male breast CA:
Usually older men BRCA2 oncogene ass/w Often involves the nipple
55
MC palpable breast masses?
FA- Fibroadenoma FC- Fibrocystic changes FN- Fat necrosis Gyn- Gynecomastia
56
Bilateral gynecomastia causes?
1. Increased Estrg - Testicular tumors, lung cancer, starved, thyrotoxicosis 2. Decreased Test - Klinefelters, 2/2 testicular failure 3. Rx causes - ESTG, Anabolic steroid, Cimetidine, Digoxin, Bud, INH
57
BI-RADS - 3
3 - probably benign (repeat in 6 mos)
58
Imaging for breast complaints
1st - Dx MMG | 2nd - U/S
59
What is the ratio of lobes:ducts
10-20:1
60
Needle localized Bx
For non-palpable mass seen on MMG or U/S Two parts: 1- in clinic (local anesth) - wire insert w/ US or CT guide THEN 2 - taken to OR for excision of tissue > pathology
61
What are the two standard views for MMG?
Craniocaudal (CC) Mediolateral (CL) (Spot compressions w/ specific site magnification)
62
Goal of MMG’s
Detect breast CA before it becomes palpable
63
What normally left in place after major breast removal?
Drains, to prevent seromas
64
Rx causing Nipple d/c: (A-SCAN)
``` A-Antipsychotics S-Sedatives C-Cimetidine A-Anti-HTN N-Narcotics ```
65
MC breast CA type:
Infiltrating ductal carcinoma
66
What are the fx unit of the breast and its purpose?
Lobes are the fx unit | produce milk
67
Most nipple d/c are:
Benign- (MC) intraduct papilloma/mammary duct ectasia | Malig - <15% - ductal carcinoma in situ
68
MC type of breast CA?
Ductal carcinoma | Lobular carcinoma is rare
69
Management for breast pain (O-DEAD)
``` OCP (stabilize hormones) Dx MMG w/ f/u US Exercise Avoid narc, diuretics, iodine, tamoxifen, danazol Decreased caffeine ```
70
Difference between incisional vs excisional Bx?
Inc - take a piece of the mass | Exc - take whole mass (lumpectomy)
71
Complications of breast reduction mammoplasty (Mostly all surgeries) (I-BUN)
``` (Dreaded four) Infection Bleeding Undesired cosmetic outcome Numbness ```
72
Triple negative breast CA: and TXT? 4
Most are BRCA1 (+) Negative for ER, PR, and HER2 (hence “triple negative) Most aggressive breast CA, worst prognosis Mainstay txt with chemotherapy
73
What is ductal carcinoma in situ?
Cancerous lesion and must be removed | After excision, XRT remaining breast tissue
74
Fibrocystic changes MC population?
Women during childbearing ages
75
Txt for breast abscess
Stop nursing Admit IV ABX I/D or Bx
76
What to examine with CBE?
4 quads and tail of Spence (pt point to complaint)
77
Drains are no longer needed when drainage is
<30mL/D
78
Modified radical mastectomy: MRM
- Tissue, nipple, axillary nodes removed - Muscle spared Retains some skin for reconstruction
79
Diagnostic MMG
Follow-up on lesion found during screening or abnormal exam
80
BI-RADS - additional imaging needed
0
81
BI-RADS - Suspicious (consider Bx)
4
82
What Rx/substances to avoid if CC is breast pain? | (TIDD-N) and?
``` T- Tamoxifen I- Iodine D- Diuretics D- Danazol N- Narcotics and Caffeine ```
83
Bilateral gynecomastia points - 7
Decreased androgen production as dudes age -Estg increased -Test decreased - due to Rx No nipple d/c MMG and U/S PRN Reassurance and routine consult with general surgery
84
Txt for acute mastitis
ABX (staph and strep coverage) Moist heat Continue pump/nursing
85
BI-RADS - 4
4 - Suspicious (consider Bx)
86
MRI is helpful for: (EGD-G)
Eval tumor size Guide txt plan Doesn’t req breast compression Good for dense tissue/implants
87
Invasive testing for breast complaints?
Bx > Tissue dx > path report
88
Are most breast masses serious?
No - 80% are benign (i.e. fibroadenoma)
89
Tumor marker/tissue Dx findings?
ER - Estg receptor PR - Prog receptor HER2 - Human epidermal growth factor receptor x3 NEG breast cancer (MC BRCA-1)
90
FNA procedure basics
W/ local anesth - create negative pressure w/ needle/syringe > slide to pathology
91
Features of benign breast pain?
NL PE and pain is Cyclical Bilateral Diffuse (non-focal)
92
Unilateral gynecomastia points - 4
Normally young dudes Benign (No nipple d/c) Usually goes away but teenagers are impatient -sub-q mastectomy (Nipple/skin spared)
93
What is lobular carcinoma in situ?
Marker for CA Still encapsulated in the lobe 30% chance of developing CA
94
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
95
Name 2 pre-invasive breast cancers?
Lobular Carcinoma In-Situ | Ductal Carcinoma In-Situ
96
Presentation of acute mastitis
Lactating women Cellulitis around nipple w/out mass Grows staph or strep
97
Neoadjuvant chemo/XRT
Txt prior to surgery to debulk tumors
98
What happens if you injure the long thoracic nerve?
Winged scapula
99
Chronic breast abscess usually due to?
Duct ectasia (widen duct) - Thick/Sticky green /lack D/C - 40-60YOF
100
Extra nipples called? Noticed when? TXT?
Supranumerary nipple Noticed during preggo - occurs along milk ducts Benign -excise
101
BI-RADS - benign findings (vascular Ca++, stable lesions, etc...)
2
102
Later signs of breast CA:
``` Skin dimpling Nipple retraction Fixation to chest Axillary LAD Peau d’ orange ```

Surgery Two (9 decks)

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