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MBBS Surgery > Breast > Flashcards

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
Q

SE of Chemo

A 
NandV
myelosuppression
oral mucositis
cardiomyopathy
peripheral sensory neuropathy
26
Q

Hormonal therapy

  • classes
  • MOA
  • SE
A
  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
Q

Targeted therapy in breast CA

  • name
  • MOA
  • SE
A
  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
Q

mgx of lobular ca in situ (LCIS)

A

risk inc 1%/ year

  • life long surveillance: annual mammogram + PE
  • chemoprevention with tamoxifen (5y)
  • b/l total mastec
29
Q

Screening for breast CA

- what about high risk groups

A

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
Q

Pagets vs eczema

- investigation?

A 
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
Q

Gynaecomastia

  • causes
  • inx
A

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
Q

What are you looking for on breast biopsy

A
  • features of malignancy
  • breach of basement membrane
  • histological subtype
  • degree of differentiation
  • immunohistochemistry: HER2 and ER status
33
Q

Skin changes in breast CA

A 
F+PURE
fixation of skin to lump
peau d orange
ulcerating, fungating
retraction of skin/ dimpling (invasion into Cooper ligament)
erythema
34
Q

Nipple changes in breast CA

A 
discharge (bloody)
deviation
depression
destruction
discolouration
displacement
dermatitis
35
Q

BRCA 1 and 2

  • genetics
  • what is the risk like
A

tumor suppressor gene a/w 80% of hered breast CA but only 5% of all breast CA

AD inheritance
incomplete penetrance

36
Q

BRCA 1

  • breast cancer features
  • what other cancers
A

ER/PR neg (triple neg), high grade, poorly diff

Other CA: ovarian, endometrial, prostate

37
Q

BRCA 2

  • breast cancer features
  • what other cancers
A

ER/PR positive
well differentiated

Other CA: male breast CA, colon, pancreatic, stomach, gall bladder, malenoma, prostate CA

38
Q

Risk reduction strategies for BRCA 1 and 2

A
  • bilateral salpingo-oophorectomy (red risk of ovarian CA)
  • bilateral prophylactic mastectomy
  • chemoprophylaxis (tamoxifen): red risk by 50%
39
Q

Criteria for genetic counselling

A
  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
Q

Staging for Breast Ca

- T stage

A 
T1: <2cm
T2: 2-5cm
T3: >5cm
T4: 
a chest wall
b skin (peau, ulcer, satellite lesion)
d inflam breast CA
41
Q

Staging for Breast CA

  • DCIS
  • Early Breast CA
  • Locally Advanced BC
  • Advanced BC
A

DCIS: Tis
EBC: Stage I, II
LA: Stage III
ABC: Stage IV

42
Q

Staging for Breast CA

0, I, II, III, IV

A 
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
Q

Cx of axillary clearance

A
  • 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
Q

Indication for post op radio

A
  • ALL BCT
  • Mastec: size >5, T4, positive sx margins, >4 axillary LN, chest wall involvement
  • > 4 pathologically involved nodes
45
Q

Indication for

  • neoadjuvant chemo
  • adjuvant chemo
A

Neo:

  • downsize for BCT
  • Stage II/ III HER2 pos or triple neg cancer

Ad chemo:
- stage III or Local advanced BC

46
Q

phyllodes

  • how many malignant
  • mgx
A

10% malignant
Tx: WLE with 1cm margin
no role for ALND and chemoradiation

47
Q

follow up for breast CA

A
  • 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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