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Breast Flashcards

1
Q

Breast lump differentials

A

Painful

  • CA
  • fibroadenosis, abscess, mastitis, galactocele, fat necrosis, cyst

Painless

  • CA
  • cyst, fibroadenoma, phyllodes tumour, fibroadenosis
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2
Q

Scoring for breast radio imaging (mammogram)

A

BIRADS - Breast Imaging - Reporting and Data System

0 : incomplete, further imaging or information is required.
1 : negative – symmetrical, no masses, architectural disturbances, calcifications
2 : benign findings, e.g. fibroadenomas, simple cyst, lipomas
3 : probably benign; short interval follow-up needed
4 : suspicious for malignancy
5 : highly suspicious for malignancy
6 : known biopsy-proven malignancy

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3
Q

Management of breast cyst

A

asymp: watch and wait
symptomatic: aspirate
- not palpable after aspiration - TCU 1/12
- if (1) recur (2) does not resolve completely with aspiration (3) yield bloody aspiration&raquo_space; send for MMG + US TRO intra-cystic tumour

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4
Q

Fibroadenoma

  • features
  • mgx
A 
smooth, firm, rubbery, v mobile
no pain
enlarge during pregnancy,
involute during menopause
if <2cm leave
>2cm/ enlarge: excise
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5
Q

Fibrocystic change AKA firbroadenosis

  • features
  • mgx
A

smooth, lumpy/ cobblestone, mobile
change with menstrual cycle
pain +/-
re-examine on day 10 of menses

persistent dominant mass > MMG+US+biopsy TRO CA

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6
Q

Differentials for nipple discharge

  • bloody
  • straw/ serous
  • green/brown/black
  • purulent
  • white/milky
  • blood stained
A

blood: intraductal papilloma, ductal CA, fibroadenosis

straw/serous: ductal papilloma, CA, or mammary ductal ectasia

green/brown: mammary ductal ectasia

purulent: lactational mastitis, breast abscess
white: drug related galactorrhea, spontanous galactorrhea, lactation

blood stain: Paget, dermatitis

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7
Q

intraductal papilloma mgx

A

inx: ductogram
tx: microdochectomy, major duct excision

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8
Q

Mammogram findings

  • DCIS
  • IDC
A

DCIS: clustered pleomorphic calcifications, straight line
IDC: spiculated mass

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9
Q

Causes of galactorrhea

A

drug causes:

  • delete dopamine: TCA, methyldopa, benzo
  • block dopamine R: haloperidol
  • estrogen effect: digitalis

Pit prolactinoma
IX: serum prolactin, CT/MRI
TX: bromocriptine, resect prolactinoma

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10
Q

Vasculature of breast

A

Arterial supply

  • int thoracic artery
  • axillary artery
  • subscapular artery
  • IC arteries

Venous supply

  • int thoracic vein
  • long thoracic vein
  • axillary vein
  • IC vein
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11
Q

Lymphatic of breast

A

Axillary nodes 75%
- level I, II, III in relation to pec minor
Internal mammary nodes 20%
Inter-pectoral nodes (rotter)

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12
Q

RF Breast CA

A 
BREAST
BRCA
Radiation
Estrogen (early menarche, late menopause, child >30, nulliparity, HRT - E&amp;P >5y)
Age/ alcohol
Size
Tx cancer/ previous biopsy
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13
Q

Triple assessment

A
  1. clinical exam
  2. radiological: MMG/US/MRI
  3. Histopatho: cytology/ biopsy
    all 3 concordant for benign >99% rule out CA
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14
Q

Common areas of CA on MMG

A

CC view: upper lateral quadrant

MLO: oblique milky way

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15
Q

MMG findings

  • malignant
  • benign
A

malignant:

  • spiculation
  • linear, small, thin, branching calcificatoins
  • irregular borders
  • archi distortion
  • ductal asymmetry
  • asym density
  • multiple clusters

Benign:

  • radial scar
  • fat necrosis (oil cyst)
  • milk of calcium (microcalcifications appear discoid on cc view, sickle shaped on MLO)
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16
Q

Breast US findings

  • malignant
  • benign
A

malignant: BITCH
- borders: spiculated, microlobulation, angular margins
- Internal calcifications
- taller than wide
- central vascularity
- hypo echoic nodule/ pos acoustic shadowing

benign

  • ellipsoid
  • macrolobulations
  • hyperechoic
  • smooth, well circumscribed
  • thin echogenic capsule
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17
Q

ductal vs lobular carcinoma insitu

A

BOTH: malignant cells arising from terminal duct-lobular unit, confined by BM

ductal:

  • positive for E cadherin
  • distort lobular architecture
  • low recurrence rate

lobular

  • neg for E cadherin
  • do not distort lobular architecture
  • not considered premalignant but inc risk of ca
  • bilateral, multicentric
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18
Q

Mgx of DCIS

A

lumpectomy + rad
partial mastec
simple mastec
adjuvant RT, hormone therapy

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19
Q

Krukenburg tumour

A

CA in ovary mets from GI source/ pylorus but sometimes from breast

20
Q

Criteria for wide excision breast sx

A
  • T2 or below (<5cm), no skin or chest wall involvement
  • only 1 tumor (not multicentric)
  • no mets
  • appropriate tumor size to breast ratio (cosmesis)
  • MUST agree to post op RT (no CI: pregnancy, previous breast RT, severe collagen tissue disorder)
21
Q

blue dye (methylene blue) vs radioisotope dye (technetium 99) in pregnancy

A

do not use blue dye
- teratogenic

(side note: blue dye on breast last for 4w, first few days, post op urine may be green - normal)

(pps: dual method give the highest accuracy)

22
Q

Options for breast reconstruction

A

prosthesis/ implant

muscle flap from rectus abdominis (TRAM) or latissimus dorsi myocutaneous flap (LDMF)

23
Q

Cx of mastectomy and axillary clearance

A

Immediate

  • injury to axillary vessels
  • injury to nerve (long thoracic n - scapula winging from serratus anterior weakness, thoracodorsal n - lat dorsi, medial pectoral nerve)

Early

  • axillary nerve thrombosis
  • haemorrhage, hematoma
  • wound infx
  • seromas
  • flap necrosis
  • pain and numbness in upper arm and axilla
  • restricted shoulder mobility

Late

  • lymphatic fibrosis
  • lymphedema
24
Q

SE of radiotherapy

A

ST:

  • skin irritation
  • tiredness
  • breast swelling
  • cough

LT:

  • skin pigmentation
  • rib #
  • angiosarcoma
  • RT induced CA

Rad to axilla:

  • lymphedema
  • axillary fibrosis
25
SE of Chemo
``` NandV myelosuppression oral mucositis cardiomyopathy peripheral sensory neuropathy ```
26
Hormonal therapy - classes - MOA - SE
1. Selective Estrogen Receptor Modulators (SERMS): Tamoxifen SE: - menopausal symptoms: hot flushes, HR rise, sweating) - endometrial ca - DVT, PE - stroke use daily for 5 years, with carry on effect after 2. Aromatase inhibitors: lanastrazole, letrozole, exemestane - inhibit peripheral conversion of testosterone and androstenedione to estrodiol - only for post menopausal women - SE: msk pain, osteoporosis, HLD (give bisphosphonates)
27
Targeted therapy in breast CA - name - MOA - SE
1. Herceptin (trastuzumab) - IV for 1 year - target Her2neu - SE: cardiomyopathy, pulmonary toxicity infusion reactions febrile neutropenia 2. Avastin - VEGF receptors 3. Lapatinib (her1/ her2)
28
mgx of lobular ca in situ (LCIS)
risk inc 1%/ year - life long surveillance: annual mammogram + PE - chemoprevention with tamoxifen (5y) - b/l total mastec
29
Screening for breast CA | - what about high risk groups
MMG 40-49: yearly >50: once every 2 years High risk: - start 5-10y before youngest member - 25-30yo for BRCA - screen: mthly BSE, 6mthly CBE, US, MRI, annual mammogram
30
Pagets vs eczema | - investigation?
``` Pagets: - unilateral - destroy nipple - underlying DCIS or invasive CA - often negative PE/ MMG > do MRI, punch/ full wedge biopsy - if lump felt: ICA - if no lump: DCIS Eczema: - bilateral - nipple normal - no underlying lump - dramatic improvement with steroids ``` (do punch biopsy or full thickness wedge biopsy of nipple)
31
Gynaecomastia - causes - inx
DOPING NO Drugs - spironolactone, cimetidine, TCAs Organ failure - liver, renal failure, hyperthyroidism Physiological - neonates, puberty, elderly Idiopathic Nutrition - malnutrition G-hypogonadism - klinefelter ``` Neoplasm - male breast ca - testicular ca - bronchial ca - prolactinoma Others ``` INX - MMG, u/s, biopsy - testicular u/s, AFP, beta HCG - liver panel, renal panel, thyroid panel - test, estradiol, LH/FSH/ prolactin
32
What are you looking for on breast biopsy
- features of malignancy - breach of basement membrane - histological subtype - degree of differentiation - immunohistochemistry: HER2 and ER status
33
Skin changes in breast CA
``` F+PURE fixation of skin to lump peau d orange ulcerating, fungating retraction of skin/ dimpling (invasion into Cooper ligament) erythema ```
34
Nipple changes in breast CA
``` discharge (bloody) deviation depression destruction discolouration displacement dermatitis ```
35
BRCA 1 and 2 - genetics - what is the risk like
tumor suppressor gene a/w 80% of hered breast CA but only 5% of all breast CA AD inheritance incomplete penetrance
36
BRCA 1 - breast cancer features - what other cancers
ER/PR neg (triple neg), high grade, poorly diff Other CA: ovarian, endometrial, prostate
37
BRCA 2 - breast cancer features - what other cancers
ER/PR positive well differentiated Other CA: male breast CA, colon, pancreatic, stomach, gall bladder, malenoma, prostate CA
38
Risk reduction strategies for BRCA 1 and 2
- bilateral salpingo-oophorectomy (red risk of ovarian CA) - bilateral prophylactic mastectomy - chemoprophylaxis (tamoxifen): red risk by 50%
39
Criteria for genetic counselling
1. Family History  ≥ 2 relatives with breast cancer, one under 50  ≥ 3 relatives with breast cancer, any age  Previously identified BRCA 1 / 2 mutation in the family  Pancreatic cancer with breast and/or ovarian in same side of family  Ashkenazi Jewish ancestry (1-3% incidence) 2. Personal History  Breast cancer diagnosed ≤ 40 years or younger (regardless of tumour sub-type)  Ovarian / Fallopian Tube cancer  Male breast cancer**  Triple negative breast cancer diagnosed at age ≤ 60 years
40
Staging for Breast Ca | - T stage
``` T1: <2cm T2: 2-5cm T3: >5cm T4: a chest wall b skin (peau, ulcer, satellite lesion) d inflam breast CA ```
41
Staging for Breast CA - DCIS - Early Breast CA - Locally Advanced BC - Advanced BC
DCIS: Tis EBC: Stage I, II LA: Stage III ABC: Stage IV
42
Staging for Breast CA 0, I, II, III, IV
``` 0: Tis I: T1 N0 II: T1,2,3, N0 T0,1,2 N1 III: T3N1 anyT, N2/3 T4 any N IV: M1 ```
43
Cx of axillary clearance
- nerve injury: thoracodorsal nerve (weak arm adduction), long thoracic nerve, intercostobrachial nerve (numb to medial arm and axilla) - axillary vein thrombosis (swelling of arm) - lymphatic fibrosis - lymphedema/ lymphangiosarcoma - frozen shoulder - bleeding/ infection
44
Indication for post op radio
- ALL BCT - Mastec: size >5, T4, positive sx margins, >4 axillary LN, chest wall involvement - >4 pathologically involved nodes
45
Indication for - neoadjuvant chemo - adjuvant chemo
Neo: - downsize for BCT - Stage II/ III HER2 pos or triple neg cancer Ad chemo: - stage III or Local advanced BC
46
phyllodes - how many malignant - mgx
10% malignant Tx: WLE with 1cm margin no role for ALND and chemoradiation
47
follow up for breast CA
- post tx mammogram 1y after initial mammogram - annual mammogram for c/l breast - regular gyne f/u

MBBS Surgery (18 decks)

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