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Surgery > breast > Flashcards

breast Flashcards

1
Q

who should be screened with mammography

A

free for all women over 40

for screening to be useful and effective, you need to be obtaining a diagnosis that will allow for a likelihood of survival of at least 10 years (since expected mortality is age 85, stop screening at 75)

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2
Q

what views are used in screening mammography

A

2 views

medial/lateral/oblique to include axial tail and cranial-caudal

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3
Q

are screening and diagnostic mammography the same thing?

A

no

screening is two views

diagnostic is done after an abnormality is detected (i.e palpable lump or abnormal screening mammogram)–> has several views including lateral and magnification/cone views

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4
Q

describe the elements of a breast history

A
  1. lump–> duration, tenderness, change with menses
  2. nipple discharge–> color, spontaneous, unilateral or bilateral
  3. nipple inversion or scaling
  4. breast dimpling, ulceration, erythema, edema
  5. symptoms of distant mets disease
  6. gyne history–> age of menarche, menopaus; parity; age at first pregancy; breast feeding; use of OCPs or hormone replacement therapy
  7. PMHx–> previous history of breast disease, recent breast trauma, prior radiation, family history
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5
Q

what elements make up a complete breast exam

A

both breasts

both axillae and supraclavicular fossae

lungs and liver and vertebral percussion tenderness (if indicated

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6
Q

what is the most common cancer for women

A

breast

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7
Q

DDx of a breast mass

A

Vascular–> hematoma, AVM

Inflammatory–> mastitis, abscess

Neoplasm–> benign (fibroadenoma) or malignant (breast or non breast) primary or secondary

Degenerative/deficiency/drugs

Idiopathic, intox

Congenital–> breast bud

Autoimmune/allergic–> non infectious mastitis

Traumatic–> fat necrosis

Endocrine–> fibrocystic change, cysts, gynecomastia

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8
Q

screening for ages 50-74 with no family history

A

every 2 years

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9
Q

screening for ages 50-74 with family history

A

annually

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10
Q

screening for ages 40-49 with no family history

A

discuss with MD

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11
Q

how much does screening reduce mortality from breast cancer

A

30% reduction

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12
Q

screening for ages 40-49 with family history

A

offered every 2 years

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13
Q

screening for ages above 74

A

discuss with MD

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14
Q

how does the accuracy of mammograms change with age

A

more accurate as you get older because breast less dense

30% less accurate under age 40

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15
Q

screening for ages below 40

A

not recommended unless high risk requires referral

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16
Q

major risk factors for breast cancer

A
  1. being female
  2. family history of breast cancer in 1st degree relative especially if premenopausal or bilateral or ovarian cancer in 1st degree relative (most women who are dx have no family history)
  3. known BRCA1/2 mutation carrier
  4. personal history of lobular carcinoma in situ (LCIS)
  5. atypical hyperplasia
  6. previous chest wall irradiation to developing breast
  7. mammographic density greater than 75% of the breast volume
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17
Q

what is the most common abnormality found on mammography

A

micro calcifications (not palpable)

worry about calcifications that are irregular and clumped together (more than 10 in one area)

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18
Q

moderate risk factors for breast cancer

A

older age

personal history of breast cancer

north american/european descent

hyperplasia without atypia

some mammographic density

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19
Q

lesser risk factors for breast cancer

A

family history of post menopausal breast cancer

nulliparity

later age at menopause or early age at menarche

post menopausal obesity

alcohol consumption and diet

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20
Q

what factor might make you consider a breast lump to be malignant

A

taller than wide in breast tissue

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21
Q

how do breast cysts present

A

likely due to estrogen stimulation, common between ages 40-60/premenopausal

may be multiple or solitary, fluctuate in size and degree of tenderness and the menstrual cycle

are mobile, may be ill defined, usually round, not always fluctuant

may recur after aspiration so reassess in 6 weeks

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22
Q

how do you investigate a breast mass

A
  1. imaging (U/S, mammogram)
  2. clinically guided FNA, aspiration (can be done as family doc without local) for immediate diagnosis and treatment
  3. core biopsy gets architecture to tell you if a cancer is invasive or not
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23
Q

how do you do an FNA in clinic

A

22 gauge needle, 10 cc syringe, alcohol swab and bandaid, urine specimen container

only gathers cells but can say whether benign or malignant

fluid enters if its at least partially a cyst–> examine the fluid and re-examine the breast

  • -green tinged or straw colored fluid/clear cloudy is normal
  • -re-examine the breast to be sure the mass is gone
  • -if the fluid is normal and the mass is gone, discard the sample
  • -old blood or persistence of the mass, send fluid for cytology and arrange breast imaging
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24
Q

describe what fibrocystic breast changes are in the breast

A

common manifestation of normal breast physiological changes related to the menstrual hormone cycle that occurs in almost all women–> usually lumpiness (no discrete lump) with pain and fluctuates with cycle

microscopic cysts embedded in dense fibrous tissue of the breast gives a “lumpy” or nodular quality without a discrete mass –> imaging is normal

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25
Q

management of breast fibrocystic changes

A

reassurance–> no increased risk of malignancy

manage pain and diet–> reduce salt, caffeine intake, dietary fat intake

severe mastalgia responds to hormonal manipulation (sometimes over OCPs, danazole, tamoxifen)

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26
Q

if 50% of your relatives have breast cancer, what is your lifetime risk?

A

50%

send this women for BRCA mutation testing

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27
Q

if your mother has breast cancer, what is your lifetime risk?

A

30%

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28
Q

BRCA positive women have what risk for breast cancer

A

85% or greater risk

curable with mastectomies

29
Q

what is lobular carcinoma in situ and how is it detected

A

detected by doing biopsy for other reasons i.e fibroadenoma

LCIS implies a greater personal risk (1% a year) of developing breast cancer in either breast

not a mass–> it is an insidious pathological finding

30
Q

is a tissue confirmation necessary if radiology says a breast lump is consistent with a fibroadenoma?

A

not always if very young or very typical physical exam and imaging

yes if older patient, solid and cystic components, atypical features on physical and imaging (irregular margins, lobulation etc)

31
Q

what kind of tissue diagnosis is needed for a fibroadenoma

A

FNA biopsy showing benign cells is enough if not worried

if concerned you can get a core biopsy

32
Q

what is the natural history of a breast fibroadenoma

A

if less than 3cm in diameter–> 1/3 get smaller, 1/3 remain stable, 1/3 enlarge

may enlarge during pregnancy

risk of malignancy in adenoma is less than the chance of cancer in the rest of the breast

remove if enlarging, symptomatic or at patient request

generally follow with U/S imaging for growth

33
Q

what is the “triple test” for breast lump

A

clinical assessment
imaging
cytology

if all three are benign, lesion is probably benign (98%) and can be followed

if any aspect of the triple test is inconclusive or suspicious, needs further workup

34
Q

what is lactational mastitis

A

secondary infection due to obstructed milk ducts

35
Q

management of lactational mastitis

A

directed massage to facilitate emptying, continued nursing, abx to cover staph aureus

may progress to an asbcess, requiring serial aspirations and continued abx

36
Q

how do you manage a breast abscess

A

typically requires drainage with serial aspirations or incisions

may need IV abx if systemically unwell

culture fluid to guide abx

can continue nursing

37
Q

how do you manage simple breast cysts

A

leave them alone and follow

dont need to do anything

38
Q

what is non lactational mastitis

A

much less common and associated with smoking

tends to be recurrent ad associated with draining sinuses at the areolar margin

typically has periareolar mastitis and abscess formation

treat recurrent disease with surgical resection of involved ducts

39
Q

what causes gynecomastia

A

imbalance of estrogen and testosterone, may be unilateral or bilateral

40
Q

what is the etiology of gynecomastia

A
  1. natural increases in estrogen due to puberty, aging etc or extra causes of increased estrogen i.e obesity
  2. meds–> antiandrogens, anti ulcer meds, anxiolytics, tricyclics, digoxin, CCBs, some abx
  3. drugs–> alcohol, anabolic steroids, marijuana, amphetamines, heroin, methadone
  4. disease–> hypogonadism, hormone producing tumours, hyperthyroidism, renal or liver failure
41
Q

how do you investigate gynecomastia

A

U/S anf mammogram looking for breast tissue

42
Q

how do you manage gynecomastia

A

reassurance if developmental

otherwise treat underlying disease or stop drug use

not associated with increased cancer risk

symptom control

surgical resection of requested

43
Q

what abx to use for mastitis/breast abscess

A

keflex

44
Q

what is the most common cause of spontaneous, unilateral, uniductal serious or bloody nipple discharge with normal mammogram?

A

intraductal papilloma (98%)

45
Q

what is intraductal papilloma

A

benign growth in the duct

46
Q

how do you investigate intraductal papilloma

A

U/S and mammogram to exclude underlying cancer–> do mammogram with all bloody discharge

galactogram is optional (mammogram study with contrast to look at ductal system)

cytology of discharge doesnt change management so not necessary

47
Q

treatment of intraductal papilloma

A

surgical excision of the involved duct (also helps exclude intraductal papillary cancer)

48
Q

what is bilateral milky discharge?

A

galactorrhea–> physiologic, drug related, or pituitary prolactinoma (must do serum prolactin to rule out prolactinoma)

49
Q

what is bilateral green/yellow multiductal sometimes foul nonspontaneous discharge

A

dialted retroareolar ducts filled with debris, related to fibrocystic changes

stop smoking and stop squeezing

50
Q

how would you investigate a 55 year old woman with enlarging mass in right breast over months with indrawing of overlying skin

A
  1. bilateral diagnostic mammogram
  2. U/S of involved breast
  3. core biopsy–> important! (FNA cant confirm invasive disease)
  4. then confirm STAGING to exclude mets disease–> bone scan only if patient has lymph node spread
51
Q

what is the management for breast cancer

A
  1. lumpectomy/partial mastectomy with radiation treatment (reduce risk of recurrence)
    -or-
  2. mastectomy with or without reconstruction (if multiple cancer sites, cant do radiation etc)
    AND
  3. management of axilla
    –> sentinel node biopsy if clinically node negative on exam or U/S, axillary dissection if node positive
52
Q

how do you do a sentinel node biopsy

A

inject with radioactive technetium and dye that maps nodes and then gamma probe to find the radioactive nodes

53
Q

what is the adjuvant therapy for breast cancer

A

treatment given without evidence of cancer to decrease recurrence risk

given after lumpectomy to reduce recurrence risk, to axilla or breast or chest wall after mastectomy with positive nodes or other high risk of recurrence

adjuvant chemo/systemic therapy is given to patients who are at high risk for occult mets (tumour larger than 2cm, grade 2-3, lymphovascular invasion, positive nodes)

adjuvant tumour factors include menopausal status, comorbidities and ability to tolerate treament, tumour ER status, tumour Her 2 status

54
Q

are lumpectomy and mastectomy equal in cure rates?

A

only when you do lumpectomy PLUS adjuvant radiation…if you do both its equal and mastectomy

lumpectomy alone isnt the same –> chance of recurrence with lumpectomy alone is about 30% (compared to 5-7% with radiation)

higher risk of complications with mastectomy so usually offer lumpectomy

55
Q

who can’t get radiation (and thus need mastectomy)

A

connective tissue disorders (SLE especially…get vasculitis) or previous radiation i.e or lymphoma

56
Q

how do you stage breast cancer

A

TNM staging

stage 1–> small with negative nodes

stage 2–> 2-5 cm with or without positive nodes

stage 3–> any tumour with fixed nodes, maybe supraclavicular, maybe fixed in muscle or skin

stage 4–> cancer with distant mets

57
Q

how do invasive ductal carcinoma and invasive lobular carcinoma differ

A

ductal–> malignant cells originate from the ductal epithelium

lobular–> malignant cells originate from the lobular cells (higher chance of bilateral malignancy and can be harder to see on mammogram)

58
Q

who needs chemo?

A

if there is lymph node involvement–> i.e if sentinel node biopsy shows an active node

also probably hormone treatment

59
Q

how do you stage cancer

A

with CXR and liver enzymes –> further investigations if abnormal

bone scan only if patient has lymph node involvement

60
Q

how common is male breast cancer

A

less than 1% of breast cancer

usually in older men with major risk factors being BRCA mutation and family history

investigation same as for women (U/S and mammogram)

61
Q

management of male breast cancer

A

surgery is mastectomy with SLNB or ALND depending on clinical node status

adjuvant therapy is same as for women

62
Q

what is ductal carcinoma in situ

A

malignancy cells in the ducts that have not crossed the basement membrane

if untreated–> progression to invasive cancer (but otherwise survival rate is 98%)

most DCIS is NOT palpable and is diagnosed from an abnormal mammogram–> typical features are pleomorphic, clustered, branched, microcalcifications without a mass

63
Q

investigations for DCIS

A

in non palpable lesions–> mammographic core biopsy to get a diagnosis and excision at once

can also use fine wire guided excisional biopsy

64
Q

how do you manage DCIS

A

not usually invasive so SLNB not always needed unless high grade, extensive, palpable, suspicious for invasion

surgical excision with clear margins and adjuvant radiation

may need mastectomy and reconstruction if extensive

65
Q

what is lobular carcinoma in situ

A

usually incidental finding on core biopsy done for something else

not visible on imaging

associated with increased further risk of breast cancer anywhere in breast–> 20-30% over 15 years

66
Q

management of LCIS

A

ongoing screening (most common)

chemoprevention–> i.e tamoxifen (only reduces risk… to about 10-15%

bilateral mastectomies

67
Q

what is paget’s disease of the nipple

A

rare (1%) pathologic diagnosis of a typical malignant cell (paget’s cells) in the epidermis of the nipple

presents with unilateral scaling, flaking, crusting or thickening of the nipple or areola

looks like dermatitis or other skin lesions

often accompanied by unilateral redness, tenderness, discharge, maybe nipple inversion

68
Q

how do you assess paget’s disease of the nipple

A

biopsy the nipple (scrape, punch, incision etc)

mammogram to exclude underlying breast cancer (most have underlying cancer)

with unilateral nipple skin symptoms, especially if unresponsive to steroids, needs to be biopsied

69
Q

how do you manage paget’s disease of then nipple

A

if all imaging is negative, treat with central lumpectomy with or without radiation

underlying cancer is treated like any other cancer with mastectomy and SNLB

Surgery (20 decks)

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