Breast Flashcards
What types of breast reconstruction are there?
Tissue expander
- silicone implants
Latissimus dori myocutaneous flap
Abdominal flaps
- Transverse rectus abdominis myocutaneous flap
- Deep inferior Epigastric Perforator flap
Nipple reconstruction
- tatoo
- skin flaps
surgery to reduce contralateral breast
What types of surgery may be carried out on the breast?
Lumpectomy
Wide local excision
Quadrantectomy
- quadrant is removed
Mastectomy
When is axillary clearance offered?
When invasive cancer cells are noted in the axilla.
What is a major complications of clearing the axillary nodes?
Lymphoedema
Mammograms vs Ultrasound:
Ultrasound:
- used more in younger women
- good at distinguishing solid lumps from cysts
Mammogram
- used more in elderly women
- picks up calcification better than US
What is done to assess the lymph nodes?
Ultrasound of the lymph nodes prior to surgery.
- if unusual them biopsy is taking
During surgery
- blue dye or radioactive isotope used to fine sentinel node
- this is biopsied.
- if clear - leave nodes, if positive then clear nodes
What tests are performed on all tumours?
ER testing
Her2 testing
*if these are both negative then Gene testing is offered.
What are some of the symptoms of radiotherapy to the breast?
General fatigue from the radiation Local skin irritation and tissue swelling Fibrosis of the breast Shrinking of the breast Long term skin discolouration of skin
When assessing the sentinel node, when is the radioactive isotope injected? and when is the blue dye injected?
Radioactive isotope - morning of surgery / day before surgery
Blue dye - prior to operation
- within 10-15mins will be present
What are the indications for mastectomy?
Large tumour on a small breast >1 tumour present on breast Diffuse DCIS Radiotherapy contraindicated Recurrence of cancer
When is neoadjuvant therapy indicated?
Very large tumours
- to shrink
What is the grade of the breast cancer based upon?
Nuclear pleomorphism
Number of mitosis
Degree of gland formation
What treatment is given to Her2 positive cancers and how is it given and what are some common side effects?
Trastuzumab
- IV or Subcut
- every 3 weeks for 1 year
Can effect heart - must be monitored and contraindicated in women with heart failure.
Side effects:
- tumour pain
- headaches
What treatment is given to ER positive cancers?
Premenopausal women = tamoxifen
Post-menopausal = Aromatase inhibitors (Letrozole
When is chemotherapy used in breast cancer?
Neoadjuvant - shrink tumour
adjuvant therapy - after surgery to reduce recurrence
For treatment control of metastatic disease
What are the pros and cons of breast implants?
Pro’s:
- minimal scars
- reasonable appearance
Con’s:
- cold
- don’t feel natural
- Long term effects - hardening, leakage, shape change
What is a con of Transverse rectus abdominal/ TRAM flap:
Abdominal Hernias
When working out the best management for patients with breast cancer, what type of meeting is there?
MDT
When is Adjuvant radiotherapy offered?
After WLE
After mastectomy if:
- positive margins
- >5cm tumour
>4 positive lymph nodes
What is a common side effect of adjuvant radiotherapy?
Cardiomyopathy
Invasive Ductal carcinoma can be further divided into what types?
Tubular, cribriform, medullary, mucinous, papillary
What is the single most important prognostic factor for breast cancer?
Lymph nodal status
What does the nottingham prognostic index take into account?
Size
Nodal status
Grade
How is DCIS managed?
WLE
Generally what is meant by grade and stage?
Grade refers to the amount of nuclear abnormalities and cellular changes.
Stage is the prognostic risk factors that reflect the likely hood of the patients outcomes, especially the involvement of metastasis - nodal status
Which types of invasive breast cancers show the best prognosis?
Tubular
Cribriform
Papillary
Which type of breast cancer tends to have columns of cells stacked upon each other?
invasive lobular carcinoma
What are the clinical symptoms of Paget’s disease?
Itchiness
Redness
Flaking/ thickened skin
What are the differentials for Paget’s disease of the nipple?
Eczema
If a patient comes in complaining of lumpy bumpy feeling in breast, which is associated with menstrual pain, what is the likely diagnosis? and what are characteristics of this change?
Fibrocystic changes
- cysts
- fibrosis
- hyperplasia
List some inflammatory conditions of the breast:
Acute Mastitis
- breast feeding
Fat necrosis
Granulomatous Mastitis
- TB
- Sarcoidosis
Mammary Duct ectasia
- greenish brown discharge
- can cause nipple retraction
What is another name for fibrocystic changes?
Fibroadenosis
On a mammogram which breast condition is likely to produce a halo sign?
Breast cyst
Can a family member or friend be used a sa chaperone?
No it has a to an impartial individual
What is the screening times for breast?
50- 70
- every 3 years
What pre-operative assessment can be done of the lymph nodes?
Ultrasound
When can a fibroadenoma be removed?
> 3cm
Where does breast cancer spread to?
Lymphatic spread
Bones
Brain
Liver
Lungs
When imaging for breast cancer, who gets what type of imaging?
<35 years old: Ultrasound
> 35 years old: mammogram
What blood tests do you want to do into breast cancer?
FBC
Bone profile
LFTs
ESR
Describe how the sentinel node is analysed:
It is cut out when Identified on surgery.
It is then sent for frozen section.
If positive then axillary clearance occurs or radiotherapy
What are some of the complications of breast surgery?
Damage to long thoracic nerve
- winging of scapula
Lymphoedema
Frozen shoulder
Haematoma
What is the histology grade of the tumour based upon?
Bloom richardson system
When is radiotherapy used post surgery?
WLE
Positive nodal status
Large tumour resection
Bone metastasis
What are the stages of breast cancer?
Stage 1: confined to breast
Stage 2: 1 node
Stage 3: Fixation to muscle, usually large amount of skin involvement
Stage 4: Fixation to chest wall. Metastasis
What are the symptoms of duct ectasia?
Peri-arelormass
Nipple discharge
- white
- green
Calcification on mammogram
When should surgery for a fibroadenoma be offered?
> 3cm
Family history of Ca
Patient choice
How should LCIS be managed?
Bilateral mastectomy
or
Close surveillance - usually need MRI for lesions
What are some causes of breast pain:
Menstrual cycle pain
Inflammatory
- Mastitis
- Duct ectasia
Trauma
- fat necrosis
Fibrocystic changes
What are some causes of nipple discharge?
Physiological - pregnancy
Duct ectasia
Intraductal papilloma
Paget’s disease
Galactorrhea
If the asymmetry or lump on the breast is not clear on physical examination, how can it be made more clear?
Ask patient to put hands on head.
To put hands on hips and lean forward
If there is tethering, what ligament is involved?
Ligament of cooper/ Suspensory ligament
Compare and contrast Paget’s disease and eczema:
Presence of lump Clear markings in paget's Nipple destroyed Occurs post menopause Unilateral, eczema is often bilateral
What investigations for staging should be done?
CT chest/ abdo/ pelvis
Technetium Bone scan
Head CT
What are the two views of the mammogram?
Cranial caudal
Oblique view
On US what would be suggestive of malignancy?
Vertical growth appearance
Irregular mass
Hypoechoic
Disadvantages of FNCA?
NO architecture
- so can’t see if it is invasive
Can’t get ER/ PR/ HER status
What is the aim of neoadjuvant therapy?
to down stage the cancer to allow for less invasive surgery
- WLE
If NPI is >5 what is the 5 year survival?
50%
What is the indications for neoadjuvant therapy?
Downstage for breast conservation
Downstage to make breast cancer operable if previously not operable
Inflammatory breast cancer
Improve cosmetics
What advise should be given to females post breast cancer?
Monthly self examination
Mammogram every year for 5 years
How much resection needs to be done in a WLE?
5cm
What is a major side effect of letrazole? (aromotase inhibitor)
Osteoporosis
