Breast Flashcards
Miller Payne classification
1 - No response 2 - <30% 3 - 30-90% 4 - >90% response 5 - No residual cancer
What is the BiRADs and what to do with each of the scores
0 - incomplete exam
1 - negative
2- Benign
3- Likely benign (<2% chance of malignancy) - short interval follow up 6 months
4- Suspicious - biopsy recommended
5- Highly suspicious of malignancy >95% chance
6 - biopsy proven malignancy
Stages of lymphoedema
Assess the softness vs firmness of the limb to gauge - increased fibroadipose tissue with worsening lymphoedma.
Severe has >40% increased limb volume
Mod - 20-40%
0 - not apparently clinically - subclinical latent phase
1 - clinically apparent, resolves with 24 hours of elevation, accumulation of protein rich fluid. Pitting oedema no fibrosis
2 - Some deposition of fibrofatty tissue, evolving dermal fibrosis. “spontaneously irreversible lymphoedema”
3 - lymphostatic elephantitis
Van Nuys prognostic index
Age <40, 40-60, >60
Size >40, 16-40, <15mm
Margin <1 mm, 1-9 mm, >10 mm
Histology - non high, +comedo necrosis, High + necrosis
<7 - excise
7-9 = medium risk - recommend excision + RTx
>9 - mastectomy
How do you class implant capsular contracture
Baker classification
1 - breast feels and looks normal 2 - feels a bit firm but looks normal 3- firm and looks abnormal 4- painful and hard 3 and 4 are usually removed
Advantages and disadvantages of immediate recon
No time without breast
Enables skin sparing mastectomy - superior cosmesis
- retain inferior mammary fold
One op
Risk of complications which could potentially delay adjuvant treatment
Long procedure
Need to find the time with two teams available
Inferior cosmesis if has adjuvant radiation -
Limited time to think over options
Advantages and disadvantages of delayed recon
Allows all adjuvant Treatment to be completed
Allows time for woman to adjust to mastectomy and diagnosis. More time for decisions to be made
Cannot preserve skin
Tissue expander or flap based
Contraindications for recon
Avoid if Severe obesity (>30-35)- high rates of complications from prolonged procedure- but not absolute contraindication
Severe comobrid unresectable cancer
Advise smoking cessation
What features to assess in phyllodes to determine if benign, borderline or malignant
Stromal cellular atypia
Mitotic activity
Margins
Stromal overgrowth
Types of phyllodes
50% benign
25% borderline
25% malignant
Grading dcis
According to nuclear size (large = higher grade), pleiomorphism
Low
Intermediate
High grade +/- comedo necrosis
Definition of dcis and difference with adh
Clinal proliferation of neoplastic luminal cells that fill the terminal duct lobular units but do not breach the basement membrane
ADH doesn’t completeLy fill ducts and is less than 2mm
USS features benign and malignant breast mass
Malignant = Taller than wide Irregular margins Multilobulated Micro Calcifications Hypoechoic/heterogenous Acoustic shadow Thick hyperechoic shadow
Benign= Wider than tall Minimal shadow Smooth lobulations Well circumscribed Hyperechoic Compressible
Mammogram malignant
Spiculation Mass Architectural distortion Skin changes Asymmetric Calcification
Grading of DCIS
nuclear pleiomorphism
nuclear size
What are the 6 principals of level 1 oncoplastic breast surgery
- Skin incision - wide enough to allow access for excision and reshaping. Always think of tension lines.
- Undermine skin
- Undermine nipple areolar complex
- Full thickness excision
- Reapproximation (mobilise breast)
- Deepitheliasation and reposition nipple
natural history of fibroadenoma
55% stay the same
35% smaller
10% get bigger
grading of DCIS
nuclear size and pleiomorphism
+ necrosis
bloomfield richardson grading breast cancer
1-3 tubular formation
1-3 mitoses
1-3 nuclear pleiomorphism
NPI + %10 year survival
<2.41 = 96% 5.41-6.4 = 50% >6.4 = 38%
TNM breast cancer
T1 <2cm
T2 2-5cm
T 3 >5cm
T4 invasion/IBC
N1 - 1-3 nodes
N2 - 4-9 nodes b - clinically positive internal mammary node
N3 - 10+ or supraclavicular nodes
Indications for breast MRI
Surveillance of high risk patients (BRCA, Li Fraumini, prior chest wall Rtx)
Breast cancer in women with very dense breast tissue
Occult malignancy in Paget’s or axillary mets
Pre reconstruction
locally advanced breast cancer
indications for frozen section
Immediate reconstruction
Neoadjuvant therapy
Negative FNA with an abnormal node radiologically/clinically
Considerations for SNLB after NAC
excise 2-3 nodes due to otherwise high false negative rates -
ok to do SNLB if clinically negative pre NAC otherwise should be doing a dissection
Gray area - low burdern of lymph node disease pre NAC which completely responds radiologically - could do a SLNB ensuring clipped node is taken and do a frozen section
