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Surgery > Breast > Flashcards

Breast Flashcards

1
Q

3 positions to examine patient in?

A

relaxed with arms by sides
hands on hips
hands behind the head

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2
Q

General inspection of breasts?

A

asymmetry
scars
cosmetic augmentation
tethering, fixation of puckering of overlying skin
nipple eversion/inversion
nipple discharge
skin colour
peau d’orange skin
Paget’s disease of the nipple

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3
Q

What is peau d’orange skin?

A

thickened and dimpled appearance of the skin which may be associated with inflammatory breast cancer

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4
Q

What is Paget’s disease of the nipple?

A

erythematous, scaly rash of the nipple region, resembling eczema
may indicate underlying breast malignancy

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5
Q

Assessing a lump?

A

location
size
shape
consistency
margins
mobile or fixed
tenderness
skin colour
nipple discharge

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6
Q

Triple assessment of breast lump?

A

clinical assessment
imaging
histology

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7
Q

Clinical features of breast lump suggestive of cancer?

A

hard, irregular, painless, fixed in place
tethered to skin or chest wall
nipple retraction
skin oedema and dimpling (peau d’orange)

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8
Q

When to refer for 2 week wait suspected cancer pathway?

A

woman over 30 with unexplained breast lump
woman over 50 with unilateral nipple changes

consider in:
woman over 30 with unexplained axilla lump
skin changes suggestive of breast cancer

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9
Q

What is a fibroadenoma?

A

common benign tumours of stromal or epithelial breast duct tissue

‘breast mouse’

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10
Q

Features of fibroadenoma?

A

more common in younger women (hormone dependent)

painless
smooth
mobile
round
well-circumscribed
firm
usually up to 3cm diameter

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11
Q

What are fibrocystic breast changes?

A

fluctuating changes of the breast with the menstrual cycle due to ducts and lobules of the breast becoming fibrous and cystic in response to female hormones

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12
Q

Symptoms of fibrocystic breast changes?

A

lumpiness
mastalgia
fluctuation of breast size

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13
Q

Mx of fibrocystic breast changes?

A

exclude cancer

wear a supportive bra
NSAIDs
avoid caffeine
applying heat to the area
hormonal treatments under specialist guideline

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14
Q

What are breast cysts?

A

most common cause of breast lumps
benign, individual fluid-filled lumps

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15
Q

Features of breast cysts?

A

most common between 30 and 50

smooth
well-circumscribed
fluctuant
mobile

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16
Q

Mx of breast cysts?

A

exclude cancer
aspiration if painful

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17
Q

What is fat necrosis?

A

benign lump formed by localised degeneration and scarring of fat tissue within the breast, typically in response to trauma

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18
Q

Features of fat necrosis?

A

painless
firm
irregular
fixed in local structures
skin dimpling or nipple inversion may be present

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19
Q

Mx of fat necrosis?

A

exclude cancer (imaging may not be enough to exclude, histology may be necessary)

conservative management typically

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20
Q

What is a lipoma?

A

benign tumour of adipose tissue

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21
Q

Features of a lipoma?

A

soft
painless
mobile
do not cause skin changes

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22
Q

What is a galactocele?

A

breast milk filled cysts when the lactiferous duct is blocked, preventing the gland from draining milk

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23
Q

What is Phyllode’s tumour?

A

rare tumour of the stromal tissue of the breast
large and fast-growing

50% benign, 25% borderline, 25% malignant

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24
Q

Mx of Phyllode’s tumour?

A

wide excision of the tumour
chemotherapy in malignant or metastatic tumours

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25
Q

Two types of mastalgia?

A

cyclical
non-cyclical

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26
Q

Features of cyclical breast pain?

A

typically occurs 2 weeks before menstruation (luteal period)

bilateral and generalised pain
heaviness
aching

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27
Q

Causes of non-cyclical breast pain?

A

idiopathic
medications (contraceptives)
infection
pregnancy

referred from:
costochondritis
post-herpetic neuralgia

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28
Q

Diagnosis of mastalgia?

A

breast pain diary

exclude:
cancer
mastitis
pregnancy

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29
Q

Mx of cyclical breast pain?

A

wear a supportive bra
NSAIDs
heat to the area
avoid caffeine
hormonal treatment under specialist guidance

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30
Q

What is gynaecomastia?

A

enlargement of the glandular breast tissues in males

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31
Q

Causes of gynaecomastia?

A

idiopathic, medications, raised oestrogen, raised prolactin, decreased testosterone

raised oestrogen levels:
obesity
testicular cancer (Leydig cell tumour)
liver cirrhosis
liver failure
hyperthyroidism
hCG secreting tumour (SCLC)

raised prolactin levels:
dopamine antagonists (antipsychotics)
prolactinoma

reduced testosterone levels:
older age
hypothalamus or pituitary causes
Klinefelter
orchitis
testicular damage

medications:
anabolic steroids
antipsychotics
digoxin
spironolactone
GnRH analogues
opiates
marijuana
alcohol

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32
Q

Medications that cause gynaecomastia?

A

steroids (incr. oestrogen)
antipsychotics (incr. prolactin)
digoxin (stimulates oestrogen receptors)
spironolactone (decr. testosterone)
GnRH
opiates
marijuana
alcohol

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33
Q

Assessment of gynaecomastia?

A

distinguish from pseudogynaecomastia due to obesity

establish cause:
meds
testicular exam
signs of chronic liver disease
signs of testosterone deficiency
signs of hyperthyroidism

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34
Q

Investigations in gynaecomastia?

A

not always necessary

U&Es
LFTs
TFTs
testosterone
SHBG
prolactin
LH and FSH
oestrogen
b-hCG
karyotyping (47XXY)

breast US
mammogram
biopsy
testicular US
CXR

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35
Q

Mx of gynaecomastia?

A

treat underlying cause
conservative mx
tamoxifen
surgery

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36
Q

What is galactorrhoea?

A

breast milk production not associated with pregnancy or breast-feeding

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37
Q

What hormones are responsible for breast milk?

A

prolactin stimulates breast milk production
oxytocin stimulates breast milk secretion

dopamine, oestrogen and progesterone inhibit prolactin

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38
Q

Causes of hyperprolactinaemia?

A

idiopathic
prolactinoma
hypothyroidism
PCOS
medications (dopamine antagonists)

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39
Q

Presentation of hyperprolactinaemia?

A

galactorrhoea
amenorrhoea
reduced libido
erectile dysfunction
gynaecomastia

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40
Q

What are prolactinomas?

A

tumours of the pituitary gland that secrete excessive prolactin

microprolactinoma (<10mm)
macroprolactinoma (>10mm)

41
Q

Association with prolactinoma?

A

MEN 1

42
Q

Adverse effects of macroadenomas of the pituitary?

A

headache
bitemporal hemianopia

43
Q

Investigations for galactorrhoea?

A

pregnancy test
serum prolactin
U&Es
LFTs
TFTs

MRI brain

44
Q

Mx of galactorrhoea?

A

treat underlying cause

dopamine agonists (bromocriptine, cabergoline) to treat symptoms of hyperprolactinaemia
trans-sphenoidal removal of pituitary adenoma

45
Q

What is mammary duct ectasia?

A

dilation of the large ducts in the breast, with inflammation leading to intermittent nipple discharge

46
Q

RFs for mammary duct ectasia?

A

perimenopausal women
smoking

47
Q

Presentation of mammary duct ectasia?

A

nipple discharge (white, grey, green)
tenderness or pain
nipple retraction or inversion
breast lump
pressure on lump may cause nipple discharge

48
Q

Diagnosis of mammary duct ectasia?

A

exclude breast cancer (triple assessment)

microcalcifications on mammogram (not specific to duct ectasia)
ductography
nipple discharge cytology
ductoscopy

49
Q

Mx of mammary duct ectasia?

A

may resolve without treatment, does not have any association with cancer

reassurance
symptomatic management of mastalgia
antibiotics if infection
surgical excision of the affected duct in problematic cases

50
Q

What is an intraductal papilloma?

A

warty lesion that grows within the ducts of the breast due to proliferation of epithelial cells

benign tumours but can be associated with atypical hyperplasia and cancer

51
Q

Presentation of intraductal papillomas?

A

35-55 most common
clear or blood-stained nipple discharge
tenderness or pain
palpable lump

52
Q

Diagnosis of intraductal papilloma?

A

triple assessment

ductography (‘filling defect’)

53
Q

Mx of intraductal papilloma?

A

complete surgical excision
examination for atypical hyperplasia that was not picked up on biopsy

54
Q

What is lactational mastitis?

A

inflammation of the breast with or without infection
common complication of breast-feeding

55
Q

Causes of lactation mastitis?

A

obstruction and accumulation of milk
infection (staph aureus most common)

56
Q

Presentation of mastitis?

A

unilateral pain and tenderness
erythema in focal area
local warmth and inflammation
nipple discharge
fever

57
Q

Mx of lactational mastitis?

A

due to obstruction:
conservative
continue breastfeeding
breast massage
heat packs, warm showers, simple analgesia

due to infection:
antibiotics (flucloxacillin first-line)
encourage to keep breast feeding
if feeding difficult, express milk

58
Q

Complication of lactational mastitis?

A

breast abscess

59
Q

What is candida of the nipple?

A

fungal infection of the nipple that occurs after a course of antibiotics
leads to recurrent mastitis

typically presents with oral thrush and candida nappy rash in the infant

60
Q

Mx of candida of the nipple?

A

topical miconazole 2% to each nipple after breastfeeding
miconazole or nystatin for the baby

61
Q

What is a breast abscess?

A

collection of pus within an area of the breast, typically caused by a bacterial infection

62
Q

Types of breast abscesses?

A

lactational
non-lactational

63
Q

RFs for breast abscesses?

A

breast feeding
mastitis
smoking
damage to the nipple
underlying breast disease

64
Q

Causes of breast abscess?

A

staph aureus most common
streptococcal
enterococcal
anaerobic bacteria

65
Q

Presentation of breast abscess?

A

swollen, fluctuant, tender lump
nipple changes
purulent nipple discharge
pain
tenderness
warmth
erythema
hardening of skin and tissue
swelling
systemic symptoms

66
Q

Mx of breast abscess?

A

antibiotics
US
incision and drainage
microscopy, c&s of drained fluid
continue breast feeding

67
Q

Risk factors for breast cancer?

A

female gender
BRCA 1 and BRCA 2 gene mutations
TP53 gene mutations
prior chest wall radiation
FHx
lifetime oestrogen exposure (early menarche, late menopause, nulliparity, no breastfeeding)
smoking
obesity
COCP
combined HRT

68
Q

Types of breast cancer?

A

DCIS
LCIS
Invasive ductal carcinoma
Invasive lobar carcinoma
Inflammatory breast cancer
Paget’s disease of the nipple

medullary
mucinous
tubular

69
Q

What is DCIS?

A

ductal carcinoma in situ
pre-cancerous or cancerous epithelial cells in the breast ducts

localised to a single area

70
Q

Prognosis of DCIS?

A

around 30% become IDC
potential to spread locally
good prognosis if fully excised and adjuvant radiation used

71
Q

What is LCIS?

A

lobar carcinoma in situ
pre-cancerous condition occurring in pre-menopausal women

72
Q

Prognosis of LCIS?

A

represents increased risk of breast cancer in the future
monitored 6 monthly with exams and yearly mammograms

73
Q

What is invasive ductal carcinoma?

A

aka no specific type
80% of invasive breast cancers
can be seen on mammograms

74
Q

What is invasive lobular carcinoma?

A

originate in cells from breast lobular tissue
10% of invasive breast cancer
not always visible on mammograms

75
Q

What is inflammatory breast cancer?

A

1-3%
presents similarly to mastitis or breast abscess
worst prognosis

76
Q

Downsides to breast screening?

A

anxiety and stress
radiation exposure
false negatives
unnecessary tests and treatments

77
Q

Screening for breast cancer?

A

mammogram every 2 years from 50-70

78
Q

High-risk FHx for breast cancer?

A

1st degree relative with breast ca <40
1st degree male relative with breast ca
1st degree relative with bilateral breast ca <50
2 1st degree relatives with breast ca

79
Q

Mx of high-risk patients?

A

genetic counselling
annual mammogram (30 onwards)
chemoprevention (tamoxifen if pre-menopause, anastrozole if post-menopause)
bilateral mastectomy and oophorectomy

80
Q

Presentation of breast cancer?

A

hard, irregular, fixed lump
lumps tethered to skin or chest wall
nipple retraction
skin dimpling or oedema (peau d’orange)
lymphadenopathy (axilla NB!!!!!!!)

81
Q

Imaging options for breast cancer?

A

US in under 30 years (if palpable lump, distinguish between solid and cyst)
mammogram in older women (calcifications)
MRIs for further assessment

US axilla
sentinel lymph node biopsy

82
Q

Breast cancer receptors?

A

ER
PR
HER2

triple negative breast cancer carries the worst prognosis as limits treatment options

83
Q

Common sites of metastases in breast cancer?

A

lung
liver
brain
bone

84
Q

Surgery options in breast cancer?

A

breast-conserving surgery + radiation
mastectomy

axillary clearance

85
Q

Hormonal treatment in ER positive breast cancer?

A

tamoxifen (selective oestrogen receptor modulator) in pre- and peri-menopausal women

anastrozole (aromatase inhibitor) in post-menopausal women

86
Q

Side Effects of tamoxifen?

A

increased risk of endometrial cancer
increased risk of VTE
protective against osteoporosis

87
Q

Side Effects of anastrozole?

A

osteoporosis

88
Q

Targeted treatment of HER2+ breast cancer?

A

trastuzumab (Herceptin)
Pertuzumab
Neratinib

89
Q

Reconstructive surgery options?

A

immediate reconstructive (at time of mastectomy)
delayed reconstructive

90
Q

Reconstructive surgery following breast-conserving surgery?

A

may not be necessary
partial reconstruction (flap or fat tissue to fill the gap)
reduction and reconstruction

91
Q

Reconstructive surgery following mastectomy?

A

breast implants
flap reconstruction (latissimus dorsi, transverse rectus abdominus, deep inferior epigastric perforator)

92
Q

Indications for mastectomy?

A

patient preference
large tumour in small breast
multifocal, multicentric disease
inability to achieve clear margins (2 tries)
in breast recurrence after WLE and radiation (can’t have radiation again)
inability to have radiation

93
Q

Indications for axillary node clearance?

A

node positive at presentation
sentinel lymph node positive

94
Q

Complications of axillary node clearance?

A

lymphoedema
winging of scapula (long thoracic nerve damage)
paraesthesia of upper arm (intercostobrachial nerve)
damage to thoracodorsal nerve (latissimus dorsi -> extension, rotation and adduction of arm)

95
Q

When is breast conserving surgery suitable?

A

2mm clear margin
suitable for radiotherapy
impalpable lesions can be localised (magnet, wire)

96
Q

DCIS vs LCIS malignant change?

A

DCIS precursor to malignancy in ipsilateral breast
LCIS not pre-malignant but may be lead to malignancy in either breast

97
Q

How do mammograms work?

A

2 views of breasts - oblique and lateral
mass, microcalcifications, spiculations suspicious
not effective in higher density breasts (younger women)

98
Q

Poor prognostic factors in breast cancer?

A

size
bilateral
LN involvement
distal metastases
triple negative
high grade
inflammatory breast cancer
TP53 mutations

99
Q

4 areas to examine in the breast?

A

4 quadrants
subareolar space
tail of spence
axilla

Surgery (10 decks)

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