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Surgery > Breast > Flashcards

Breast Flashcards

1
Q

What positions should the patient sit in when undergoing a breast examination?

A
  • Sitting on side of bed with arms relaxed
  • With hands pressed to hips-> tenses chest wall
  • With hands behind head
  • Palpation performed whilst lying at 45 degrees and hands behind head
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2
Q

What causes peu d’orange?

A
  • Blocked lymphatic drainage-> superficial oedema + thickening
  • Dimples-> sweat ducts
  • Can be due to inflammatory breast cancer
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3
Q

What is important to look for on breast examination?

A

Asymmetry, scars, cosmetics, tethering, puckering, nipple eversion/inversion, discharge, erythema

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4
Q

What might be seen on examination in Paget’s disease of the nipple?

A
  • Erythematous scaly rash (like eczema)
  • Itchy and inflamed
  • Ulcers
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5
Q

How is a breast exam performed?

A
  • 3I’s + ask for chaperone
  • Inspection-> sat + relaxed, hands on hips and hands behind head
  • Can ask pt to point out abnormality
  • Palpate whilst lying at 45 degrees-> 4 quadrants, sub-areola, tail of axilla + axilla
  • Assess any lumps-> where, size, shape, consistency, margins, mobile/fixed, tender, skin colour, discharge
  • Examine neck-> cervical + supraclavicular LNs
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6
Q

What does the triple assessment consist of?

A
  • Clinical-> history + exam
  • Images-> mammogram
  • Histology-> biopsy
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7
Q

What is the anatomy of the breast

A
  • Mostly adipose tissue
  • Areola + nippe
  • Behind nipple-> ducts lead to lobules (where milk produced)
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8
Q

What features might raise suspicion of a breast cancer?

A
  • Hard, irregular, painless, fixed, tethered to skin/chest wall, nipple retraction, peu d’orange
  • Axillary lymphadenopathy
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9
Q

What is the 2 week wait referral criteria for breast cancer?

A
  • Age 30+ with unexplained lump
  • Age 50+ with unilateral nipple changes
  • Consider-> lump in axilla when >30 or skin changes suggestive of BC
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10
Q

What warrants a non-urgent referral for breast cancer?

A

Unexplained lump when <30

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11
Q

What is a fibroadenoma?

A

Common + benign stromal/epithelial breast duct tissue tumour-> not usually associated with cancer

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12
Q

What patient demographics do those with fibroadenomas typically have?

A

Age 20-40

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13
Q

What are the features of a fibroadenoma?

A
  • On exam-> small, mobile, painless, smooth, round, well circumscribed, firm, >3cm
  • Respond to oestrogen + progesterone
  • Not associated with cancer unless complex or +ve FH
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14
Q

What are fibrocystic breast changes?

A
  • Fibrous + cystic changes to stroma (connective tissues) + ducts + lobules
  • Benign
  • Respond to hormones-> fluctuate with menstrual cycle
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15
Q

What are the symptoms of fibrocystic breast changes?

A
  • Fluctuant lumps-> within 10 days of menstruation

- Lumpy, painful

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16
Q

How are fibrocystic breast changes managed?

A
  • Exclude cancer
  • NSAIDs
  • Avoid caffiene
  • Heat compresses
  • Hormonal-> tamoxifen, danazol
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17
Q

What are breast cysts?

A

Benign fluid filled lumps

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18
Q

What patient demographics do those with breast cysts typically have?

A
  • Age 30-50

- Perimenopausal

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19
Q

What are the features of breast cysts?

A
  • Smooth, well circumscribed, mobile, can be painful
  • Can fluctuate with cycle
  • Can slightly increase risk of breast cancer
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20
Q

How are breast cysts managed?

A
  • Assessment

- Aspiration or excision

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21
Q

What is fat necrosis of the breast?

A
  • Benign lump of localised degeneration + scarring of fat tissue-> may be oil cyst
  • Doesn’t increase risk of BC
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22
Q

What can trigger fat necrosis of the breast?

A

trauma, radiotherapy, surgery

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23
Q

What are the examination findings of fat necrosis of the breast?

A

Painless, firm, irregular, fixed to local tissues, dimpling/nipple inversion

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24
Q

How is fat necrosis of the breast investigated?

A
  • US/mammogram-> looks similar to BC

- May need biopsy

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25
Q

How is fat necrosis of the breast treated?

A
  • Conservative
  • Can resolve over time
  • Can excise if needed
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26
Q

What is a lipoma?

A

Benign tumour of adipose tissue-> can be anywhere in the body

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27
Q

What findings will be present in a lipoma?

A

Soft, painless, mobile lump with no skin changes

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28
Q

How is a lipoma managed?

A
  • Reassurance

- Removal

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29
Q

What is a galactocele?

A
  • Milk filled cysts-> lactiferous duct blocked + prevents draining
  • Often when stop breastfeeding
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30
Q

What does a galactocele feel like on examination?

A

Firm, mobile, painless, beneath areola

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31
Q

How is galactocele managed?

A
  • Usually resolves
  • Can drain
  • May need antibiotics
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32
Q

What is Phyllodes tumour?

A
  • Rare connective tissue (stromal) tumour-> large and fast growth
  • 50% benign, 25% borderline, 25% malignant
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33
Q

What age group usually gets Phyllodes tumour?

A

Ages 40-50

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34
Q

How is Phyllodes tumour managed?

A
  • Surgery ie wide excision
  • Can recur
  • Chemotherapy if malignant
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35
Q

What is gynaecomastia?

A

Enlargement of glandular breast tissue in males

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36
Q

What age group usually gets gynaecomastia?

A
  • Teens
  • > 50’s
  • Newborns
  • Due to circulating male hormones
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37
Q

What causes gynaecomastia?

A

Hormone imbalance between oestrogen + androgens

  • Idiopathic or physiological-> higher oestrogen in puberty
  • Hyperprolactinaemia-> stimulates tissue development
  • Obesity-> higher androgen to oestrogen conversion
  • Conditions-> testicular cancer, liver disease, hyperthyroid, hCG-secreting tumour
  • Reduced testesterone-> older, radiotherapy, surgery, Klienfelter’s, orchitis, testicular damage
  • Medications-> anabolic steroids, antipsychotics, digoxin, spironolactone, GnRH, opiates, alcohol
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38
Q

What drugs can cause gynaecomastia?

A

anabolic steroids, antipsychotics, digoxin, spironolactone, GnRH, opiates, alcohol

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39
Q

Why can hyperprolactinaemia cause gynaecomastia?

A
  • Prolactin stimulates glandular breats tissue development

- Dopamine inhibits so antagonists (antipsychotics) can cause gynaecomastia

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40
Q

Why can obesity cause gynaecomastia?

A
  • Aromatase in adipose converts androgens to oestrogen

- More adipose-> more conversion

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41
Q

How is gynaecomastia investigated?

A
  • Exam-> firm tissue behind areola
  • Testicular exam-> TC risk
  • Ask about-> sexual dysfunction, lumps, hyperthyroid, medications
  • Bloods-> U+Es, LFTs, TFTs, testosterone, sex hormone binding globulin (SHBG), oestrogen, prolactin, LH + FSH, AFP, b-hCG, karyotyping
  • Imaging-> breast US, mammogram + biopsy, testicular US, CXR
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42
Q

How is gynaecomastia managed?

A
  • Watchful waiting if healthy
  • Stop causative drugs
  • Breast clinic-> when unclear or BC suspected
  • Tamoxifen-> selective oestrogen receptor modulator
  • Surgery
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43
Q

What is galactorrhoea?

A
  • Breast milk production not associated with pregnancy or breastfeeding
  • In response to prolactin secretion
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44
Q

When might someone need thorough investigation for gynaecomastia?

A

If age <30, unexplained + rapid onset

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45
Q

What is the function of prolactin?

A
  • Produced in anterior pituitary + breast/prostate
  • Stimulates breast milk production
  • Regulates some immune function + metabolism
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46
Q

Why can dopamine antagonists cause galactorrhoea?

A
  • Da blocks prolactin secretion

- Use of DA antagonists (eg antipsychotics)-> raised prolactin

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47
Q

What is the physiology of milk production in pregnancy and breastfeeding?

A
  • Production starts in 2nd + 3rd trimester
  • Oestrogen + progesterone inhibit prolactin (in pregnancy)-> rapid drop after birth
  • Oxytocin-> stimulates secretion + released after birth
  • Tapers off when breastfeeding stops
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48
Q

What can cause galactorrhoea?

A

Hyperprolactinaemia usually

-Idiopathic, prolactinoma, endocrine (hypothyroid, PCOS), medications (DA antagonists)

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49
Q

What do patients usually present with alongside galactorrhoea and why?

A
  • Menstrual irregularities, reduced libido, erectile dynsfunction, gynaecomastia
  • GnRH production from hypothalamus suppressed-> reduced LH + FSH
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50
Q

What is a prolactinoma?

A

Pituitary gland tumour secreting excess prolactin

51
Q

What are the types of prolactinoma?

A
  • Microscopic ie <10mm

- Macroscopic ie >10mm

52
Q

What are the features of prolactinomas?

A
  • gynaecomastia
  • galactorrhoea
  • bitemporal hemianopia-> pressing on optic chiasm (above pituitary gland)
  • headaches
53
Q

What might cause non-milky breast discharge?

A
  • Mammary duct ectasia
  • Duct papilloma
  • Pus from breast abscess
54
Q

What are the investigations for galactorhhoea?

A
  • MRI-> gold std
  • Pregnancy test
  • Bloods-> prolactin, U+Es, LFTs, TFTs
55
Q

How is galactorrhoea managed?

A
  • Treat underlying cause
  • Dopamine agonists-> bromocriptine or cabergoline, block prolactin secretion, treat symptoms
  • -Prolactinoma-> trans-sphenoidal removal
56
Q

What is mammary duct ectasia?

A
  • Benign dilation of large ducts of breasts
  • ‘Ectasia’ = dilation
  • No BC risk
57
Q

How does mammary duct ectasia present?

A
  • Discharge of nipple-> intermittent white/grey/green
  • Tenderness, pain, nipple retraction/inversion, lump
  • May be incidental finding
58
Q

How is mammary duct ectasia diagnosed?

A
  • Triple assessment to exclude BC
  • Mammogram-> microcalcifications
  • Ductography-> mammo’ + contrast
  • Discharge cytology
  • Ductoscopy
59
Q

What are the risk factors for mammary duct ectasia?

A
  • Perimenopausal

- Smoking

60
Q

How is mammary duct ectasia managed?

A
  • May resolve without treatment
  • No BC risk
  • Symptoms-> warm compress
  • Antibiotics if infection
  • Surgery-> microdochectomy
61
Q

What is intraductal papilloma?

A
  • Warty lesion in breast duct due to epithelial cell proliferation
  • Benign but can be associated with hyperplasia + BC
62
Q

How does intraductal papilloma present?

A
  • Usually 35-55 years
  • Can be asymptomatic + incidental
  • Nipple discharge-> clear or bloody
  • Tender lump
63
Q

How is intraductal papilloma diagnosed?

A
  • Triple assessment

- Ductography-> shows filling defect ie doesn’t fill with contrast

64
Q

How is intraductal papilloma managed?

A
  • Excision

- Examine for hyperplasia + BC

65
Q

What is lactational mastitis?

A

Inflammation of breast tissue due to breastfeeding-> +/- infection

66
Q

What causes lactational mastitis?

A
  • Obstruction-> milk accumulation

- Infection-> bacteria in nipple backtracks, usually s.aureus

67
Q

What can prevent lactational mastitis?

A

Regular milk expression

68
Q

How does lactational mastitis present?

A

Pain, erythema, warmth, inflammation, nipple discharge, fever

69
Q

How is lactational mastitis managed?

A
  • Blockage-> continue to feed + breast massage + analgesia
  • Infection-> flucloxacillin/erythromycin, culture + sensitivities, fluconazole if suspect candida
  • Continue to breast feed
  • Abscess-> rare but may need incision + drainage
70
Q

Should mums continue to breastfeed in lactational mastitis?

A
  • Yes-> infection won’t harm baby + will clear mastitis

- Express milk to empty if left over or feeds difficult

71
Q

When does candida of the nipple often occur?

A

After antibiotics

72
Q

What are the complications of candida of the nipple?

A
  • Recurrent mastitis due to cracked skin (infection entrance)
  • Baby-> oral thrush + candida nappy rash
73
Q

What are the symptos of candida of the nipple?

A
  • Often bilateral
  • Sore, itchy, tender, cracked, flaky areola
  • Baby-> white in mouth, nappy rash
74
Q

How is candida of the nipple managed?

A
  • Topical miconazole after each feed

- Miconazole gel or nystatin for baby

75
Q

What is a breast abscess?

A
  • Bacterial infection causes collection of pus

- Can be lactational or not

76
Q

What is the pathophysiology of breast abscess?

A
  • Bacterial infection causes pus collection
  • Pus-> inflammation, dead WBCs + waste
  • Trapped + can’t drain-> increases + symptoms
77
Q

What are the risk factors for breast abscess?

A
  • Smoking
  • Damage-> eczema, candida, piercings
  • Breast disease-> cancer or drainage affected
78
Q

What bacteria commonly causes breast abscess?

A
  • Staph aureus
  • Strep
  • Enterococcus
  • Anaerobic-> bacteroides, anaerobic strep
79
Q

How does breast abscess present?

A
  • Over a few days
  • Swelling-> painful, tender, warm, erythema, fluctuant
  • Nipple changes, discharge, hardened skin/tissue
  • Muscle aches, fatigue, fever, sepsis
80
Q

How is breast abscess managed?

A
  • Depends on if lactational or not
  • Diagnosis clinical but can use US + MC&S
  • Lactational-> conservative, flucloxacillin
  • Non-lactational-> analgesia, treat underlying cause, broad-spectrum ABs (eg co-amoxiclav)
  • Refer to surgical for drainage
  • Continue breastfeeding
81
Q

Should patients continue breastfeeding with a breast abscess?

A

Yes-> not harmful

82
Q

What is the lifetime risk of developing breast cancer?

A

1 in 8 women+

83
Q

What are the risk factors for developing breast cancer?

A
  • Female, obesity, smoking, 1st degree FH, more dense tissue (glandular)
  • BRCA 1 + 2 tumour suppression gene mutations
  • Increased oestrogen exposure-> earlier periods, later menopause, COCP, HRT
84
Q

What is the BRCA1 gene and what does it increase the risk of?

A
  • On chromosome 17-> tumour suppressor gene
  • 70% get breast cancer by age 80
  • Also increases ovarian, bowel + prostate cancer risk
85
Q

What is the BRCA2 gene and what does it increase the risk of?

A
  • On chromosome 13-> tumour suppressor gene
  • 60% get breast cancer by age 80
  • Also increases ovarian cancer risk
86
Q

What is ductal carcinoma in situ (DCIS)?

A
  • Pre- or cancerous epithelial cells of ducts
  • Often picked up on screening
  • Localised to 1 area but can spread locally over years + become invasive
  • Good prognosis
87
Q

How is ductal carcinoma in situ (DCIS) managed?

A
  • Good prognosis

- Excise + adjuvant treatment

88
Q

What is lobular carcinoma in situ (LCIS)?

A
  • Pre-cancerous cells in lobules
  • Very rarely spreads
  • Increases risk of future cancers
89
Q

What are the symptoms of lobular carcinoma in situ (LCIS)?

A
  • Usually none

- Picked up on screening/biopsy

90
Q

How is lobular carcinoma in situ (LCIS) managed?

A

Close monitoring-> 6 monthly exam + yearly mammograms

91
Q

What is invasive ductal carcinoma NST?

A
  • Cancer of cells from breast ducts
  • NST-> no special/specific type eg can be medullary or mucinous
  • 80% of all invasive breast cancers
92
Q

What is the most common type of invasive breast cancers?

A

Invasive ductal carcinoma NST

93
Q

How is invasive ductal carcinoma NST investigated?

A

Mammogram-> visible

94
Q

What is invasive lobular carcinoma?

A
  • Invasive breast cancer of the lobules
  • 10% of invasive BCs
  • Not always visible on mammograms
95
Q

What is inflammatory breast cancer?

A
  • Rare + aggressive-> blocks lymph drainage + causes inflammation
  • 1-3% of BCs
  • Worse prognosis than others
96
Q

How does inflammatory breast cancer present?

A
  • Similar to mastitis/abscess + peau d’orange

- No response to antibiotics

97
Q

What is paget’s disease of the nipple?

A

Breast cancer involving the nipple-> DCIS or invasive

98
Q

How is paget’s disease of the nipple managed?

A
  • Biopsy + staging

- Treat accordingly

99
Q

What are some of the rarer types of breast cancer?

A
  • Medullary
  • Mucinous
  • Tubular
100
Q

Who is eligible for the breast cancer screening programme (low risk)?

A

50-70 year old women

101
Q

How often are women called for the breast cancer screening programme (low risk)?

A

Every 3 years

102
Q

What are some positives to the breast cancer screening programme?

A
  • Detect early + improve outcomes

- 1/100 diagnosed after screening

103
Q

What are some negatives to the breast cancer screening programme?

A

Anxiety, radiation exposure, missing cancer + false reassurance, unnecessary further tests

104
Q

Who meets the criteria for being high risk for breast cancer?

A
  • 1st degree FH of BC under 40 years
  • 1st degree male relative with BC
  • 1st degree relative with bilateral BC diagnosed age <50
  • 2 1st degree relatives with BC (any age)
105
Q

How are patients who are ‘high risk’ for breast cancer screened + managed?

A
  • Genetic counselling
  • Annual mammogram-> often from 30+
  • Chemoprevention-> tamoxifen or anastrozole
  • Bilateral mastectomy
  • Bilateral oophrectomy
106
Q

What imaging might be used when investigating breast cancer?

A
  • US-> <30’s as more dense tissue
  • Mammograms-> older + pick up calcifications
  • MRI-> when high risk
107
Q

When are lymph node assessments offered during breast cancer assessments?

A
  • After diagnosis
  • Offered US of axilla + US-guided biopsy
  • May get sentinel LN biopsy during surgery
108
Q

What is a sentinel lymph node biopsy?

A
  • Performed during BC surgery-> when US not show anything
  • Isotope contrast + blue dye injected into tumour
  • Travels to 1st LN as where tumour drains to
  • Biopsy
  • If cancer then can remove
109
Q

What receptors can be targetted in breast cancer treatment if the tumour is positive for these?

A
  • Oestrogen (ER)
  • Progesterone (PR)
  • Human epidermal growth factor (HER2)
110
Q

What is triple negative breast cancer?

A

Doesn’t respond to hormone treatments for ER, PR or HER2 receptors-> worst prognosis

111
Q

What is gene expression profiling?

A
  • Assessment of which genes are present within BC
  • Predicts risk of recurrence in distal mets within 10 years
  • Decide whether or not to give chemo
  • When to give-> early BC that’s ER +ve (but HER2 and LN -ve)
112
Q

Where does breast cancer commonly metastasise to?

A

2Ls 2Bs-> lungs, liver, bones, brain

113
Q

How is breast cancer assessed and staged?

A
  • Triple assessment
  • LN assessment + biopsy
  • MRI of breast + axilla
  • Liver US for mets
  • CT-TAP
  • Isotope scan for bony mets
  • TNM system used
  • MDT-> discuss tests + treatment decisions
114
Q

What are the surgical options for breast cancer?

A
  • Wide local excision + radiotherapy-> breast-conserving
  • Mastectomy +/- immediate or delayed reconstruction
  • Axillary clearance-> when LN cancer found, risk of lymphoedema
115
Q

When is radiotherapy given in breast cancer and how?

A
  • After breast-conserving surgery
  • To reduce recurrence risk
  • Eg every day for 3 weeks
  • High dose from multiple angles
116
Q

What are the potential side effects after radiotherapy for breast cancer?

A

Fatigue, local skin/tissue irritation, fibrosis + breast shrinking, long term skin colour change

117
Q

When is chemotherapy used in breast cancer?

A
  • Neoadjuvant-> shrink tumour before surgery
  • Adjuvant-> after to reduce recurrence
  • To treat mets or reccurent BC
118
Q

What hormone treatments are available for ER +ve breast cancer?

A
  • Tamoxifen (selective ER modulator)-> premenopausal women, blocks receptors in breast and stimulates in uterus + bones
  • Anastrozole (aromatase inhibitors)-> blocks conversion of androgens to oestrogen, usually post-menopausal
  • Fulvestrant-> ER downregulator
  • GnRH agonists
  • Ovarian surgery
  • Usually give for 5-10 years
119
Q

How does tamoxifen work?

A
  • Selective ER modulator
  • Blocks receptors in breast and stimulates in uterus + bones
  • Can prevent osteoporosis
120
Q

What are the risks associated with tamoxifen?

A

Increases risk of endometrial cancer

121
Q

What targetted treatments are available for HER2 +ve breast cancer?

A
  • Herceptin (trastuzumab)-> monoclonal antibody
  • Perjeta (pertuzumab)-> used alongside Herceptin
  • Nerlynx-> tyrosine kinase inhibitor
122
Q

How are breast cancer patients followed up post-treatment?

A
  • Yearly mammograms for 5 years at least

- Individual written care plan-> review dates, advice on recurrence, support

123
Q

What are the options for reconstructive breast surgery?

A
  • Immediate or delayed
  • Partial-> flap or fat tissue eg latissimus dorsi or transverse rectus abdominis
  • Reduction + reshaping
  • Implants-> minimal scarring but SE’s (harden, leakage etc)

Surgery (8 decks)

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