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MBBS Surgery > Breast > Flashcards

Breast Flashcards

1
Q

Mastectomy define
Muscles underlying
Lymph nodes levels

A

Removal of the entire breast

Pectoralis major then the pectoralis minor

Level 1 (low) -lateral to pectoralis minor
Level 2 middle - deep to pectoralis minor 
Level 3 (High) - medial to pectoralis minor
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2
Q

Complications when removing the lymph nodes to the axilla during mastectomy

A

Long thoracic nerve supplying the serratus anterior - winging of scapular

Thoracodorsal never supplying lattisimus dorsi

Intercostobrachial nerve supplies sensation to the upper aspect of the arm

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3
Q

Benign vs malignant breast condition ( name them)

A 
Benign: 
Fibrocystic change
Cyst
Fibroadenoma
Duct ectasia

Malignant
Paget disease
Phylloidea tumor
Carcinoma

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4
Q

Marker vs precursor for breast ca…

A

LCIS is a marker

DCIS is a precursor

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5
Q

Why is cardiac Hx is important in a px with suspected breast ca

A

Because many side effects of chemotherapy and immunotherapy is cardiotoxic

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6
Q

Peau d’orange , what is it

A

Invasion of turmoil to the lymphatics to the skin is locally advance breast ca

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7
Q

Radiological investigations for breast ca

A

Uss

Mammogram (if >40 years)

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8
Q

Uss in breast lump shows / tells you as a dr what ?

A

Whether the lump is solid or cystic

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9
Q

Which 2 views is a mammogram done

A

Mediolateral oblique ( the muscle pectoralis major is seen)

Craniocaudal

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10
Q

BIRADS (breast imaging reporting and data systems)

A 
0- investigations inadequate 
1- normal
2- benign 
3- suspicious, prob benign 
4- suspicious, prob malignant 
5- highly suspicious for malignancy 
6- known biopsy with proven malignancy
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11
Q

On mammogram findings for suggestive of breast ca

A

Stellate lesions with micro calcification

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12
Q

Screening for breast ca includes

A

A monthly breast self exam
An annual clinical breast examination by your dr
An annual breast mammogram every year from the age of 40

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13
Q

Percent of persons with normal mammogram with an abnormal clinical exam

A

10%

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14
Q

Regarding breast lump , multifocality vs multicentricity

A

Multifocality: the presence of two or more foci of cancer within the same quadrant of the same breast

Multicentricity: the presence of two or more foci if cancer indifferent quadrants if the same breast

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15
Q

Fine needle aspiration procedure

FNAC tells what about a lesion

A

Attach needle to syringe.
Enter lump using needle, move the needle up and down to get certain amount of cells in the needle
Spray needle content on slide

Determines whether the lesion is benign or malignant

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16
Q

Core biopsy determines what about a lesion

A

Invasive
Pathological type ( ductile vs lobular)
Grade
IHC (ER, PR, Her2)

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17
Q

Classifications of invasive ductal carcinoma

A 
Tubular
Cribriform
Papillary 
Mutinous
Medullary

Tubular, cribriform and mucinous are well differentiate and have a better prognosis

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18
Q

What is stereotactic breast biopsy which uses mammogram

And it’s advantages

A

A specific type of breast imaging that uses low dose X-ray - to help locate a breast lump or abnormally and remove a tissue sample for examination under a microscope

Less invasive than surgical biopsy
Leaves little to no scarring
An excellent way to evaluate calcium deposits if tiny masses that are not visible under ultrasound

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19
Q

Fibroadenoma, clinical features and Mx

A

Clinical features : young female , size varies with hormonal change , well defined , bosselated, firm and mobile

Mx : if patient desires - lumpectomy
:If surgery not contemplated- triple assessment to R/O malignancy (USS, FNAC)
:if large - lumpectomy to ensure not phylloidea tumor

20
Q

Simple breast cyst , clinical features and Mx

A

Clinical features : perimenopausal, cyclical mastalgia;sometimes painful, well define, smooth surface, tender mass

Mx: confirm on USS
: If asymptomatic- reassure
:if symptomatic-Aspirate- if fluid straw colored and lump disappears then reassure
-if anything else but straw colored (eg bloody) or lump persists then cytology and excise lump

21
Q

Breast discharges : bloody, green, clear, milk, pus - what’s your differentials for each …

A

Bloody: intraductal papilloma (most common) , then carcinoma

Green, cheesy: duct ectasia

Clear: fibrocystic change

Milk: galactocele, prolactinema

Pus: breast abscess

22
Q

Intraductal papilloma Mx

A

MMG/USS the underlying mass

- Microdochectomy (excision if a lactiferous duct)

23
Q

Breast abscess presentation and Mx

A

Tender , red , fluctuate mass in postpartum

  • aspirate, antibiotics (S.Aureus)
  • if this fails then I&D
24
Q

Mastalgia clinical features and Mx

A

Cyclical vs non cyclical?
Cyclical usually due to fibrocystic change - presents with pain,mass and discharge

Conservative Mx

  • discontinue caffeine and fatty foods
  • support bras

Vitamin E
Evening primrose oil
Danazol
Bromocriptine

25
Q

Breast cancer , once dx is made in FNAC, core biopsy, open biopsy then staging the patient … what is the clinical stage for breast cancer

A 
T(tumor size)
T1 <2 cm
T2 2-5 cm
T3 >5cm 
T4 fixed 
N(lymph nodes )
N0 no palpable nodes
N1 mobile axillary
N2 fixed axillary
N3 internal mammary or supraclavicular nodes

M (Metastasis)
Liver, lung, bone,brain

26
Q

Investigations for stages breast cancer

A

LFT
CXR
US or CT scan of liver, bone scan for advanced disease
CT Brain only if symptomatic

27
Q

Preop staging

  • operable breast cancer, stage and what’s your Mx
  • locally advance , stage and Mx

Metastatic, stage and Mx

A

Operable breast cancer : T1-3, N0-1
-surgery first then adjuvant treatment

Locally advance : T4, N2-3
-Adjuvant treatment first (neoadjuvant) then surgery

Metastatic: M1
-palliative therapy

28
Q

What are the 2 Options of breast surgery

A

Breast ablation (mastectomy)

Breast conservation surgery

29
Q

Breast conservation surgery

A

Tumor removed with 1 cm margin

Must be accompanied by adjuvant radiotherapy to the remaining breast

30
Q

Criteria to help choose between breast conservation and mastectomy

A

Patient Choice

Multifocality

Tumors size

Tumor location

Pregnancy -2nd trimester ( if u are pregnant you cannot have RT therefore no breast conservation)

Connective tissue disorder - others who can’t have RT are those with scleroderma or SLE

Lack of access to RT

31
Q

Surgery to axillary .. why remove axillary nodes?

A

It is the only means if staging the axilla

Best prognostic factor

Determines need for adjuvant therapy

Regional control (improves QoL)
-metastasis in axillary LNs
Lymphedema
Invasion of brachial plexus
Invasion of axillary a/v
32
Q

What is Axillary clearance and it’s complications

A

The removal of all axillary lymph nodes

Complications:
Brachial plexus injury
Long thoracic nerve
Thoracodorsal 
Intercostobrachial

Lymphedema can progress to an angiosarcoma known as steward treves syndrome

33
Q

Breast reconstruction options

A

Implants

Latissimus dorsi flap

Transverse rectus abdominis myocutaneous flap
(TRAM)

34
Q

Sentinel lymph node biopsy procedure

A

General anesthesia is used to put patient to sleep

Inject around the tumor with methylene blue or radioactive dye

Make a small incision in the axilla and find the lymph node that drains it first

Take the node out

Send it to the frozen section for testing

35
Q

Who gets chemotherapy? Side effect and base types (3)

St Gallen’s criteria

A

Any patient with potential for metastasis will benefit from chemotherapy

Side effect - cardio toxicity

Bases- cyclophosphamide, adriamycin ( usually) , 5FU

Criteria (any 1 of the 7 present given they should get )

1 Age <35
2 Tumor size >2cm 
3 Grade (High) 
4 LN +ve
5 Lymphovascular Invasion 
6 HR -ve
7 Her 2u +ve
36
Q

Who gets hormonotherapy?

Postmenopausal vs premenopausal

A

For HR +ve patients only

Post men - aromatase inhibitors ( drug of choice), tamoxifen

Pre men- tamoxifen( drug of choice ) , GnRH, Ovarectomy

37
Q

Aromatase and tamoxifen side effects in post menopausal women

A

Aromatase inhibitors(superior) : osteoporosis, pathological fractures - always do DEXA (bone density) scan , commence on biphosphonates

Tamoxifen: endometrial cancer, DVT, PE, infertility

38
Q

Hormonotherapy side effects in pre menopausal women

A

Tamoxifen (superior) : but not if patient desires a family

GnRH : expensive - if patient desires a family

Ovarectomy: patient in 40s, Ovarectomy converts to postmenopausal, start AI

39
Q

Immunotherapy for breast cancer , targets, used if ____ +ve, side effect

A

Targets the HER 2u receptors (human epidermal growth factor )

Used if Her 2u +ve

Side effect : Cardiotoxicity

40
Q

Paget disease vs eczema of the breast - presentation

A

Paget- erosion starts in the nipple and progresses to the areola

Eczema - erosions begins in the areola and progresses to the nipple ..

41
Q

Paget disease , what is it and tx

A

Erosion, erythema of nipple, it is in situ carcinoma of nipple

Tx - wide local excision ( ie breast conservation) of the nipple-areola complex followed by adjuvant RT

42
Q

Phylloidea Tumor,- typed of tumor, also known as, mistaken for , derived from and Tx

A

Giant fibroadenomas my be mistaken for a phyllodes tumor

It is also known as cystosarcoma

It is sarcoma

Derives from mesenchyma

Tx: mastectomy if big ; WLE if small

43
Q

Indications for further investigations using an MRI in breast investigations

A
  • Multicentricity in a dense breast
  • if patient has implants
  • screening tool if patient has a mutation in Barca
44
Q

So sacromas spread to the lymph nodes

A

No

45
Q

Presenting complaints when taking a breast history

A

Mass - how detected , change in size , associated pain

Discharge- bloody, spontaneous, single duct

Mastalgia - cyclical vs non cyclical

Skin changes - scaling, erythema of nipple then areola ( paget disease) or - scaling , erythema of areola then nipple (eczema)

46
Q

Risk factors for breast cancer

A

Controllable

  • weight
  • exercise
  • diet
  • smoking
  • never breast fed
  • HRT
  • late child bearing
  • Nulliparious

Uncontrollable

  • age
  • family hx
  • early Menarche
  • late Menopause
  • Radiation heredity
  • Genetics
47
Q

What do want to know in medical and surgical history for breast cancer

A

Medical - cardiac

Surgical

  • hysterectomy ( because certain form of the endocrine therapy can cause endometrial carcinoma)
  • ovarectomy ( renders the patient automatically postmenopausal , this is important as the endocrine treatment of postmenopausal is different to that of premenopausal breast cancer)

MBBS Surgery (11 decks)

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