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Y3 Surgery > Breast > Flashcards

Breast Flashcards

1
Q

Define galactorrhea.
Who is it found in?
What is the most common cause?

A

bilateral, multi-ductal, milky white discharge from the nipples, not associated with pregnancy or lactation

most commonly adult women, also male infants due to maternal oestrogen exposure

hyperprolactinaemia

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2
Q

Causes of hyperprolactinaemic galactorrhoea include:

A

Idiopathic (40%)

Pituitary adenoma (prolactinoma)

Damage to the pituitary stalk- reduced dopamine inhibition to the pituitary ( surgical resection, multiple sclerosis, sarcoidosis, or TB)

Drug-Induced- SSRIs, anti-psychotics, H2-antagonists

Neurological - neurogenic pathways activated to inhibit dopamine levels ( e.g. varicella zoster or spinal cord injury)

Hypothyroidism- elevated TRH can stimulate prolactin related

Cushing’s disease, Acromegaly, and Addison’s disease

Renal failure or liver failure

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3
Q

Normoprolactinaemic galactorrhoea is less common and is typically idiopathic. How can it be diagnosed?

A

When all other causes of galactorrhea have been excluded

Normal blood markers and menstruation

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4
Q

What should you include in a hx and examination of galactorrhea? What investigations should you do?

A

Hx:
Ask about breast lumps, mastalgia and last menstrual period
Features of endocrine disease
Neurological sxs (e.g. headaches, visual disturbances)
Full drug hx

Examination:
Breast examination (often unremarkable)
Check for visual changes
Check for signs of hypothyroidism

Investigations:
b-HCG (preg test)
Serum prolactin levels, TFTs, LFTs, renal function tests
Further endocrine tests (IGF-1, ACTH) if indicated
MRI head with contrast if suspected pit. tumour
Breast imaging if palpable lumps/lymph nodes

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5
Q

What serum prolactin level suggests a prolactinoma (in absence of drug-related cause)?

A

Prolactin levels >1000 mU/L

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6
Q

Optimal management of galactorrhoea is determined by identifying and treating the underlying cause.

  1. How should you manage idiopathic normoprolactinaemic galactorrhoea?
  2. What about patients with non-resolving galactorrhea who are intolerant of medication?
A
  1. Often resolves spontaneously
    Can trial low-dose dopamine agonist
  2. Bilateral total duct excision is an option
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7
Q

Commonest cause of mastalgia?

A

cyclical mastalgia - pain associated with the menstrual cycle

bilateral, begins a few days before the beginning of menstruation and subsides at the end

very common

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8
Q

Around a third of mastalgia is non-cyclical pain. What can cause this?

A

medication- hormonal contraceptives, anti-depressants (e.g. sertraline), antipsychotic drugs (e.g. haloperidol)

extramammary pain - e.g. chest wall pain or shoulder pain.

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9
Q

First line treatment for mastalgia is simple analgesics and reassurance.

A second line agent is Danazol, by what pharmacological action does it exert its effect?

A

Anti-gonadotrophin

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10
Q

What should you ask in a hx of mastalgia?

A

Timing and association with menstrual cycle

lumps/skin changes

discharge/galactorrhea

fever

pregnancy and breastfeeding

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11
Q

Does mastalgia in isolation warrant imaging?

A

Mastalgia in isolation with no other clinical features is not an indication for imaging

The incidence of a breast malignancy associated with a presenting complaint of mastalgia is low

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12
Q

What is the breast triple assessment?

A

a hospital-based assessment clinic that allows for early and rapid detection of breast cancer

2 week wait referral

comprises of the history + examination, imaging, and histology

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13
Q

A 25yr old lady with a suspicious breast lump is referred to breast clinic for triple assessment. By what imaging modality would be best used as first line? Why?

A

USS

Ultrasound scanning is more useful in women <35 years and in men in identifying anomalies, due to the density of the breast tissue . This form of imaging is also routinely used during core biopsies.

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14
Q

How is mammography used to assess breast tissue?

A

Mammography involves compression views of the breast across two views (oblique and craniocaudal), allowing for the detection mass lesions or microcalcifications.

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15
Q

What is the difference between a core biopsy and FNA in assessing suspicious breast lumps?

A

A core biopsy provides full histology, allowing differentiation between invasive and in-situ carcinoma

FNA only provides cytology

Core biopsies can also generate important information about tumour grading and staging, and have a higher sensitivity and specificity than FNA for detecting breast cancer.

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16
Q

What breast lesions can fine needle aspirations be useful for?

A

cysts

FNA can be used in recurrent cystic disease to provide relief from symptoms and to enable cytology

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17
Q

identify the common benign breast tumour subtypes

A

Fibroadenoma
Adenoma
Papilloma
Lipoma
Phyllodes Tumours

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18
Q

What are fibroadenomas?
How do they present on examination?

A

most common benign breast growth that usually occurs in women of a reproductive age

proliferation of stromal and epithelial tissue of the duct lobules

highly mobile lesions - “breast mouse”
well-defined and rubbery on palpation
usually < 5cm diameter

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19
Q

How should confirmed fibroadenomas be managed?

A

they have a very low malignant potential :
- can be left in situ with routine follow up appointments over a 2 year period
- 30% will get smaller

main indications for excision :
>3cm in diameter or patient preference.

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20
Q

What is a ductal adenoma?

A

benign glandular tumour, typically occurring in the older female population

nodular lesions mimic malignancy - often escalated to triple assessment

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21
Q

What is an intraductal papilloma?
Where are they found?
How do they present?

A

benign breast lesion that usually occurs in 40-50yr old women

typically in the subareolar region (usually less than 1cm away from the nipple)

often present with bloody or clear nipple discharge, if large can present as a mass

can appear similar to ductal carcinomas on imaging and therefore usually require biopsy
sometimes excised to ensure no atypical cells or neoplasia

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22
Q

When is risk of breast cancer increased with intraductal papilloma? How is this managed?

A

Risk of breast cancer is only increased with multi-ductal papilloma

most are treated with microdochectomy

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23
Q

What are breast lipomas?
When may they be removed?

A

soft and mobile benign adipose tumours

usually asymptomatic, low malignant potential

only removed if causing compressive sxs or aesthetic issues

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24
Q

What are Phyllodes tumours?

A

rare fibroepithelial tumours comprised of both epithelial and stromal tissue

occur in older age group

often larger and can grow rapidly

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25
Q

How many Phyllodes tumours have malignant potential?
How many benign tumours will recur after excision? How does this affect the management?

A

1/3 have malignant potential

10% of benign tumours will recur after excision

most Phyllodes tumours should be widely excised (or mastectomy if large)

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26
Q

What is Gynaecomastia?
How often does it progress to breast cancer?

A

breast tissue development in males due to an imbalanced ratio of oestrogen and androgen activity

1% of cases- usually benign

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27
Q

What causes physiological gynaecomastia?

A

most commonly occurs in adolescence- delayed testosterone surge relative to oestrogen at puberty

Less commonly occurs in the older population - decreasing testosterone levels with increasing age

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28
Q

Pathological gynaecomastia results from changes in the oestrogen:androgen activity ratio.

What are the 4 main underlying pathologies?

A

Lack of testosterone :
Klinefelter’s syndrome, androgen insensitivity, testicular atrophy, or renal disease

Increased oestrogen levels:
liver disease, hyperthyroidism, obesity, adrenal tumours, or certain testicular tumours (e.g. Leydig’s cell tumours)

Medication: 25% of cases
e.g. digoxin, metronidazole, spironolactone, chemotherapy, goserelin, antipsychotics, or anabolic steroids

Idiopathic

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29
Q

How does gynaecomastia present on examination?

What must you also examine?

A

rubbery or firm mass (typically >2cm diameter)

starts from underneath the nipple and spreads outwards over the breast region

must also do a testicular exam, especially in young patients

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30
Q

What is the main differential for gynaecomastia? How can you test for it?

A

psuedogynaecomastia - adipose tissue in the breast region associated with being overweight

pinching to see if there is an obvious disc of breast tissue present

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31
Q

Tests are only necessary if the cause for gynaecomastia is unknown.

What investigations would you do?

A

Suspected malignancy - triple assessment

Unknown cause:
U&Es
LFTs
Hormone profile

LH high and testosterone low = testicular failure
LH low and testosterone low = increased oestrogen
LH high and testosterone high = androgen resistance or gonadotrophin-secreting malignancy

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32
Q

In most cases of gynaecomastia, reassurance may be enough. What medical tx is available to alleviate sxs?

A

Tamoxifen (esp for tenderness)

33
Q

Mastitis describes inflammation of the breast tissue, both acute or chronic.

How can mastitis be classified?

A

Mastitis can be classed by lactation status:

Lactational mastitis (more common) :
1/3 of breastfeeding women, more common with 1st baby
usually presents during the first 3 months of breastfeeding or during weaning
associated with cracked nipples and milk stasis

Non-lactational mastitis (less common):
often with other conditions such as duct ectasia (peri-ductal mastitis)
smoking is an important risk factor - damage to the sub-areolar duct walls and predisposing to bacterial infection

34
Q

How can you confirm a suspected breast abscess?
How can you manage?
Important complication of surgical management?

A

USS

prompt empirical antibiotics and US-guided needle therapeutic aspiration

incision and drainage under local if more advanced -can cause formation of a mammary duct fistula (a communication between the skin and a subareolar breast duct)

35
Q

Breast cysts are epithelial lined fluid filled cavities within the breast tissue, usually requiring no further management and self-resolve.

How can you investigate if there is diagnostic uncertainty?

Potential complications?

A

Investigations:
mammography - halo shape
USS - definitive diagnosis
persisting, symptomatic, or undeterminable cystic masses may be aspirated - cancer can be excluded if fluid is free of blood or lump disappears

Complications:
2-3 x greater risk of developing breast cancer
fibroadenosis (fibrocystic change) - multiple small cysts and fibrotic areas

36
Q

How can you manage cyclical pain associated with breast cysts?

A

high dose gamolenic acid (GLA) or danazol

37
Q

What is Mammary Duct Ectasia?
How can it be investigated and managed?

A

dilation and shortening of the major lactiferous ducts

common presentation in peri-menopausal women

often presents with coloured green/yellow nipple discharge, a palpable mass, or nipple retraction (slit-like)

Investigations:
mammography - dilated calcified ducts
histology - multiple plasma cells - plasma cell mastitis

Mx:
conservative or duct excision if unremitting nipple discharge

38
Q

Fat necrosis of the breast is ischaemic necrosis of fat lobules, associated with trauma in 40% of cases.

How does it present?

How is it investigated?

Management?

A

usually asymptomatic or presenting as a lump

typically firm initially and may then develop into a hard and irregular lump

less commonly : fluid discharge, skin dimpling, pain and nipple inversion

Investigations:
USS- hyperechoic mass
mammogram - mimics carcinoma
core biopsy is often taken to categorically rule out malignancy

Mx:
analgesia and reassurance

39
Q

Breast Carcinoma In Situ are neoplasms that are contained within the breast ducts and have not spread into the surrounding breast tissue.

What are the 2 types?

Which is more likely to progress to an invasive malignancy?

A

Ductal Carcinoma In Situ (DCIS) (more common) and Lobular Carcinoma In Situ (LCIS)

LCIS

40
Q

What is DCIS?

5 major types?

How does it present?

Tx?

A

most common type of non-invasive breast malignancy (20% of breast cancer)
malignancy of the ductal tissue that is contained within the basement membrane

comedo, cribriform, micropapillary, papillary, and solid (most lesions are mixed)

Picked up on screening - microcalcifications seen on mammography

Tx is surgical excision

41
Q

What is LCIS?

How does it present?

Tx?

A

Lobular Carcinoma in Situ (LCIS) is a non-invasive lesion of the secretory lobules of the breast that is contained within the basement membrane

usually diagnosed before menopause

asymptomatic - incidental finding during biopsy of the breast

Management is dependent on extent of disease:
- Low grade LCIS - monitoring
- Bilateral prophylactic mastectomy can be potentially indicated if individuals possess the BRCA1 or BRCA2 genes

42
Q

Invasive carcinoma of the breast can be classified into:

A

Invasive ductal carcinoma (70-80%)
Invasive lobular carcinoma (5-10%)
Other subtypes, such as medullary carcinoma, invasive micropapillary carcinoma, or metaplastic carcinoma

43
Q

Invasive ductal carcinoma (IDC) is the most common type of breast carcinoma. How does it present on microscopy?

A

nests and cords of tumour cells with associated gland formation

44
Q

Invasive lobular carcinoma (ILC) is the second most common type of breast cancer and is more common in older women. What is it characterised by?

A

diffuse (stromal) pattern of spread - makes detection more difficult
by the time of diagnosis, tumours can often be large

45
Q

Risk factors for invasive breast cancer?

A

Female sex and increasing age
Family history - BRAC1 / 2
Exposure to unopposed oestrogens -early menarche, late menopause, nulliparity, and 5 years + use of HRT
PMH of benign breast disease
Obesity, alcohol and smoking

46
Q

How may breast cancer present if symptomatic?

A

breast or axillary lump
asymmetry or swelling
abnormal nipple discharge / nipple retraction
skin changes (peau d’orange or Paget’s-like nipple changes)
mastalgia

47
Q

What clinicopathological staging system is widely used for primary breast cancer prognosis?

A

Nottingham Prognostic Index (NPI)

It is calculated by:

(Size x 0.2) + Nodal Status + Grade

48
Q

All breast malignancies are checked for their expression of which receptors?

A

Oestrogen Receptor (ER), Progesterone Receptor (PR), and Human Epidermal growth factor Receptor (HER2)

determines suitability of targeted adjuvant therapies (including endocrine and monoclonal antibody therapies)

tumours that are negative for all three receptors are associated with a poorer prognosis

49
Q

What breast cancer screening is currently available in the UK?

A

NHS breast cancer screening programme currently invites women aged 50-71yrs to have a mammogram every three years

50
Q

What is Paget’s disease of the nipple?
How can it be differentiated from eczema?

A

persistent roughening, scaling, ulcerating or eczematous change to the nipple

vast majority of Paget’s (85-88%) will also have an underlying neoplasm

Paget’s always affects the nipple and only involves the areola as a secondary event, whilst eczema nearly always only involves the areola and spares the nipple

51
Q

How can Paget’s disease of the nipple be investigated?
What is the first line management ?

A

Investigations:
punch biopsy, mammography and ultrasound of the breast

Mx:
operative, if possible - in all cases the nipple and areola will need to be removed

In cases associated with an underlying malignancy, radiotherapy may be necessary

52
Q

Breast conserving treatment is only suitable for individuals with localised operable disease and no evidence of metastatic disease.

What is the most common breast conserving tx?

A

A Wide Local Excision (WLE) - excision of the tumour, a 1cm margin of macroscopically normal tissue is taken along with the malignancy

only suitable for focal smaller cancers

53
Q

A mastectomy removes all the tissue of the affected breast. When would it be indicated?

A

multifocal disease
high tumour:breast tissue ratio
disease recurrence
patient choice

54
Q

Axillary surgery is most commonly performed alongside WLE and mastectomies, in order to assess nodal status and remove any nodal disease.

What is a sentinel node biopsy?

A

removing first lymph nodes into which the tumour drains

nodes are identified by injecting a blue dye with associated radioisotope into the peri-areolar skin

radioactivity detection and / or visual assessment (blue nodes) can identify the sentinel nodes, which can be removed and sent for histological analysis

55
Q

Axillary node clearance involves removing all nodes in the axilla. What are the complications of this procedure?

A

paraesthesia, seroma formation, and lymphoedema in the upper limb

56
Q

A risk-reducing mastectomy is an operation to remove healthy breast tissue in order to reduce the risk of developing breast cancer.

What patient factors confer high risk of developing breast cancer?

A

A strong family history of breast or ovarian cancer

Testing positive for genetic mutations, such as BRCA1 or BRCA2, PTEN, or TP53 mutations

Previous history of breast cancer

can refer patients to a genetic counsellor to discuss options

57
Q

Hormone treatments provide the biggest contributor in medical management to improved survival in breast cancer.

What options are available?
(explain how they work, suitable patients and ADRs)

A

Tamoxifen:
blockade of oestrogen receptors
pre-menopausal patients
increases risk of VTE operatively
increases risk of endometrial cancer

Aromatase inhibitors:
Examples: Anastrozole, Letrozole, or Exemestane
inhibit the action of aromatase, which normally converts androgens into oestrogens
post-menopausal patients as adjuvant therapy
increases risk of osteoporosis - DEXA scan before starting

Immunotherapy:
may be used in patients whose cancers express specific growth factor receptors
Herceptin for HER-2 +ve malignancies
Risk of cardiotoxicity

58
Q

What surgical reconstructive techniques are available in the oncoplastic treatment of breast malignancy?

A

therapeutic mammoplasty:
WLE combined with a breast reduction technique
nipple and areola preserved

flap formation

59
Q

How does the presence/absence of axillary lymphadenopathy determine surgical management of breast cancer?

A

women with no palpable axillary lymphadenopathy at presentation:
pre-operative axillary USS before primary surgery
if +ve then they should have a sentinel node biopsy to assess the nodal burden

in patients with clinically palpable lymphadenopathy:
axillary node clearance is indicated at primary surgery
this may lead to arm lymphoedema and functional arm impairment

60
Q

What factors favour Mastectomy V Wide Local Excision of breast cancer?

A

Mastectomy V Wide Local Excision

Multifocal tumour V Solitary lesion

Central tumour V Peripheral tumour

Large lesion in small breast V Small lesion in large breast

DCIS > 4cm V DCIS < 4cm

61
Q

What radiotherapy is offered after wide local excision?
After mastectomy?

A

WLE = always whole breast radiotherapy as this may reduce the risk of recurrence by around two-thirds

Mastectomy = radiotherapy is offered for T3-T4 tumours and for those with 4+ positive axillary nodes

62
Q

Who can Trastuzumab (Herceptin) not be used in?

A

Patients with heart disorders

63
Q

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if they are:

A

aged 30 + and have an unexplained breast lump with or without pain
or
aged 50 + with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern

64
Q

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer in people:

A

with skin changes that suggest breast cancer or
aged 30 and over with an unexplained lump in the axilla

65
Q

Who should you consider non urgent referral to breast clinic for?

A

people aged under 30 with an unexplained breast lump with or without pain

66
Q

commonest cause of blood stained nipple discharge in younger women?

A

Intraductal papilloma

Rarely associated with a palpable mass

Requires an USS and possibly galactogram

67
Q

When are FEC-D and FEC chemotherapy used?

A

FECD: when node +ve
FEC: node -ve but requires chemotherapy

68
Q

Common causative organism of breast abscesses?
Finding on examination?

A

Staphylococcus aureus

On examination there is usually a tender fluctuant mass

69
Q

What does the ‘snowstorm’ sign on ultrasound of axillary lymph nodes indicate?

A

extracapsular breast implant rupture

due to leakage of silicone, which then drains via the lymphatic system

70
Q

the first-line management of mastitis is to continue breastfeeding with simple analgesia/warm compresses. When would you treat medically?

A

if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection

oral flucloaxcillin 10-14 days

71
Q

What is fibroadenosis (fibrocystic disease, benign mammary dysplasia)?

A

Most common in middle-aged women
‘Lumpy’ breasts which may be painful. Symptoms may worsen prior to menstruation

72
Q

What is the chance of siblings and children of BRCA1 carrier to also have the gene?

A

50/50

73
Q

The presence of positive axillary lymph nodes and residual tumour at resection margins post-mastectomy are both indications for what tx?

A

adjuvant ipsilateral chest wall and regional lymph node radiotherapy

74
Q

progressive erythema and oedema of the breast in the absence signs of infection such as fever, discharge or elevated WCC and CRP suggests what?

A

inflammatory breast cancer (IBC)- rare but rapidly progressive breast cancer caused by obstruction of lymph drainage

managed with neo-adjuvant chemotherapy first-line, followed by total mastectomy +/- radiotherapy.

75
Q

Key things to do at the start of a breast exam besides intro and consent?

A

Position the patient at 45 degrees

Ensure a chaperone is present during the examination (family members not appropriate)

Ask the patient to remove their clothing to expose their chest, from above the waist

Provide a blanket for the patient to cover themselves when not required to expose the breasts

76
Q

What is involved in the inspection part of a breast examination?

A

Check for any obvious scars or masses present

Look for any skin changes or ulceration (erythema, puckering, or peau d’orange )

Look for any nipple changes (nipple discharge or inversion)

inspect axillae for obvious masses

Repeat examination with hands on head and hands on hips to accentuate any asymmetry

77
Q

What is involved in the palpation part of a breast examination?

A

Ask the patient to place both hands behind their head

Examine each quadrant of the breast in turn, including the axillary tail
Using a flat hand, press the breast against the underlying chest wall, rolling the underlying tissue

If you palpate lumps :
note their position, size, shape, consistency, overlying skin changes, and mobility
examine their fixity to pectoralis muscles by asking the patient to push against your hand with their hand outstretched

Examine both axilla in turn

Palpate for any lymphadenopathy
5 sets of axillary lymph nodes are present: apical, anterior, central, posterior, and medial

assess for potential metastasis:
Palpate the spine for tenderness
Palpate the abdomen for hepatomegaly
Percuss and auscultate the lungs for lung masses

78
Q

Further investigations following breast examination?

A

Mammography and / or ultrasound, if necessary
Biopsy (core needle or fine needle aspirate), if necessary

Y3 Surgery (8 decks)

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