AS PACES Breast

Question 1

Breast Ca RF

Answer 1

BOOBYS	
Bleeding - early menarche (<13); late menopause (>55)
Oestrogen - OCP, HRT
Other breast disease - Ca, DCIS, atypic
Breast feeding - protective
Young - first child >35 + risk
Sister - FH

Question 2

Classifying Ca breast disease

Answer 2

Ductal Ca ±70%
Lobular Ca ±20%
Other Ca ±10% (mucinous, medullary, papillary)
Phylloides tumour

Question 3

Features of malignant lump

Answer 3

Irregular, nodular, poorly defines
Painless, tethered
Nipple involvement

Question 4

Indications for mastectomy

Answer 4

WLE + SNB will be ideal but sometimes not possible
If pt preference, multifocal disease, large lump in small breast
Large area DCIS
Nipple involvement

Question 5

Types of breast reconstruction

Answer 5

Implants: simpler technique, can be primary or delayed. Ddx cosmetic result not as good, requires plenty available skin, will lie higher then other breast. Implant leakage / infection can occur
Myocutaneous flaps: useful if little remaining tissue / muscle, good cosmetic effect, primary / delayed. Use of rectus impossible if pt has has abdominal surgery, increased blood loss, op time, complications. Flap necrosis and infection can occur

Question 6

Types of myocutaneous flaps

Answer 6

Latissimus dorsi –> pedicled (skin, fat, muscle, blood supply), LD mobilised and tunnelled, supplied by thoracodorsal A via sub-scapular A. May be augmented with implant
Transverse Rectus Abdominis Myocutaneous (TRAM) flap –> pedicled (inf epigastric A) or free (attached to internal thoracic A), no implant necessary and combined tummy tuck, CI if circulation poor (smoke, PVD, drink, DM), risk of abdominal hernia
Deep inferior epigastric perforator (DIEP) flap –> evolution of TRAM, free (skin and fat only, no muscle), less pain and hernias as muscle left, not always possible

Question 7

DDx gynaecomastia (3Ps)

Answer 7

1. Potions (marijuana, diazepam, anabolic roids, spirnonolactone, digoxin, captopril, verapamil, ranitidine)
2. Physiological (puberty, usually self resolving)
3. Pathological (hypogonadism - prolactinoma, RF, post orchitis, XXY; high oestogen - lung Ca, sex cord stromal Ca, CLD, thyrotoxicosis

Question 8

Ix gynaecomastia

Answer 8

Testicular Ca - AFP, bHCG
Hypogonadism - testosterone and LH levels
Prolactinoma - prolactin
TFTs