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CP3 Surgery > Breast > Flashcards

Breast Flashcards

1
Q

Describe the areas of the breast

A

4 quadrants: upper inner, upper outer

Lower inner, lower outer

Tail of spence

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2
Q

What makes up the nipple?

A

Smooth muscle fibres

Areola: glands of Montgomery

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3
Q

How many lobules are there in the mammary glands?

A

15-20

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4
Q

What is the blood supply of the breast?

A

Medially: internal mammary

Laterally: superficial thoracic

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5
Q

What is the lymphatic drainage of the breast?

A

Axillary lymph nodes (75%)

Intermal mammary lymph nodes: 20%

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6
Q

What are the different types of benign breast lumps?

A 
Fibroadenosis / fibrocystic change
Fibroadenoma
Cysts
Fat necrosis 
Phylloides tumour
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7
Q

What is the most common cause of benign breast lump?

A

Fibroadenosis / Fibrocystic change

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8
Q

What is the presentation of fibroadenosis?

A

Cyclical breast pain, localised fibrosis
inflammation
cyst formation

Present between menarche and the menopause with ‘lumpy breasts’ and cyclical pain

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9
Q

What is the treatment of fibroadenosis?

A

Reassurance, anti-inflammatories, topical evening primrose oil or hormone manipulation

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10
Q

What is a fibroadenoma?

A

benign, non-tender, mobile breast limp

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11
Q

Who gets fibroadenoma?

A

Women 25-35

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12
Q

What is the presentation of fibroadenoma?

A

Painless (or very localised pain)

Highly mobile, firm and smooth lump. Sometimes referred to as ‘breast mice’

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13
Q

What is the rule of 1/3 in fibroadenoma?

A

1/3 regress
1/3 remain the same
1/3 get bigger

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14
Q

What is the management of fibroadenoma?

A

Reassurance - low malignant potential

if >3cm, surgical excision

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15
Q

What is a breast adenoma?

A

Benign glandular tumour in the older population

Benign, but can send for triple assessment in unsure cases

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16
Q

What is a breast cyst?

A

Cavity lined by flattened epithelium derived from the ductal unit, filled with watery fluid

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17
Q

What is the presentation of a breast cyst?

A

Perimenopausal women - round, symmetrical lumps, occasionally with pain

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18
Q

What is the management of breast cysts?

A

Drained with USS guidance, and if the fluid is suspicious e.g. blood stained, they should be sent away for cytology

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19
Q

What is the cause of fat necrosis?

A

trauma to breast

Clinically can mimic neoplastic disease

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20
Q

What is a phyllodes tumours?

A

Rapidly growing benign tumour of the stroma

smooth, hard lumps

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21
Q

What is the risk of carcinoma of the breast?

A

1 in 8
Incidence increases with age, with 5% related to an identifiable genetic abnormality (BRCA1/2)
40% = detected on screening

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22
Q

What is the morphology of most breast carcinoma?

A

invasive adenocarcinoma

90% are invasive ductal carcinoma and 5% are invasive lobular carcinoma

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23
Q

What are the two categories of breast carcinoma with regard to oestrogen?

A

Oestrogen receptor (ER) positive or negative

ER positive carcinomas offer a better prognosis

24
Q

What other hormone receptors are there for breast carcinoma?

A

HER-2 and progesterone receptors are also therapeutic targets

25
Q

What is Paget’s disease of the nipple?

A

Spread of intra-ductal carcinoma of the breast, leading to eczematous changes around the nipple.

Any eczematous rash on the breast should thus raise suspicion

26
Q

How can breast carcinoma spread?

A

Local - onto the overlying skin / into the pectoral muscles to cause deep fixation of the tumour

Lymphatic - can prevent lymphatic drainage: peau d’orange
nodes in axilla / clavicle

Vascular: distal dissemination is most common to the bone (pathological fractures and hypercalcaemia)
lung
ovary (krunkenberg)

27
Q

What is the presentation of a malignant breast tumour?

A 
Lumps
Abnormal discharge / retration
asymmetry
mastalgia 
skin changes
28
Q

What are the risk factors for carcinoma of the breast?

A 
Genetic: PH, FH, BRCA positive (25%)
Environmental: 75% 
early menarche/late menopause
Nulliparity (or late age of first child)
Not breast feeding 
HRT
Obesity

Smoking is also a risk factor

29
Q

How are breast lumps investigated?

A

Triple assessment:
clinical examination
Breast imaging (USS + mammogram if >35)
Cytology: FNAC if cystic, core biopsy if solid

30
Q

Why is mammography less sensitive in women under the age of 35?

A

Breast tissue is much more dense

31
Q

What is the apprarance of a breast carcinoma on mammography?

A

Spiculated mass lesion with associated micro calcification

32
Q

What are core biopsies better than FNAC?

A

FNAC cannot distinguish between in-situ and invasive cancers, whereas core biopsies preserve the tissue architecture so invasion can be determined along with grading

33
Q

How are tumours staged?

A

TNM:
T1 <2cm, T2 2-5cm T3 >5cm T4: fixed to chest wall or peau d’orange

N0 = no nodes, N1 = mobile ipsilateral nodes, N2 = fixed nodes

M0= no distant mets 
M1 = distant mets
34
Q

What investigations are done if mets are suspected?

A

Liver USS
CXR
Bone scan

35
Q

What are the surgical options for breast tumours

A

WLE

Simple mastectomy

36
Q

When is WLE performed

A

solitary lesion, peripheral tumour, small lesion in large breast, DCIS <4cm

Margins checked to ensure they are clear of disease

37
Q

What is simple mastectomy perfomed?

A

Large tumours (or small breasts), central location of the tumour, or late presentation with complications

DCIS >4cm

38
Q

How are the regional lymph nodes managed following carcinoma?

A

Sentinel node biopsy
Dye injected into / around the tumour bulk to identify the first 1/2 nodes that drain the tumour, which are removed and analysed histologically

If negative, it can be assumed there is no nodal involvement

If positive, full axillary clearance is required (20% risk of lymphedema

39
Q

What further treatments are given fro breast carcinoma?

A

Adjuvant radiotherapy

If there is nodal disease / high grade therapy - chemotherapy is considered

hormone therapy

Breast reconstruction

40
Q

What chemotherapy is given?

A

Anthracyclines
cyclophosphamide
methotrexate

41
Q

What hormonal treatments are given for breast carcinoma?

A

If ER / HER +ve:
Tamoxifen if pre/perimenopausal

Aromatase inhibitors (e.g. letrazole, atomising, exemestone) if post menopausal, to stop peripheral oestrogen production

Herceptin (traztuzumab) if HER2 positive (25%)
always combined with chemotherapy

42
Q

What are the factors affecting prognosis in breast cancer?

A

Tumour size, nodal status, grade, ER/PR status and vascular invasion

43
Q

What is the ‘Nottingham Prognostic Index’?

A

Widely used tool to assess survival and risk of relapse, helping to select appropriate adjuvant therapy

44
Q

What does NPI entail?

A

(tumour size x 0.2) + histological grade + nodal status

Tumour size: measured in cm
Grade of differentiation is scored form 1-3 by the histologists

Nodal status is also scored from 1-3
No nodes = 1
1-3 nodes = 2
>3 nodes = 3

45
Q

What are the 10 year survival rates according to NPI?

A 
<2.4 = 95% 
2.4-3.4 = 85% 
3.4-4.4 = 70% 
4.4-5.4 = 50% 
>5.4= 20%
46
Q

When might nipple discharge occur?

A

Clear = physiological
Milky discharge = pregnancy or hyperprolactinaemia
Green = physiological (duct ectasia) or due to fibroadenotic cyst

47
Q

What is the initial management of blood stained discharge?

A

referral to breast

microductectomy will be performed for analysis

48
Q

What is Mastitis?

A

Infection of the ducts beneath the nipple
more common in smoking / nipple piercings

Can also get when breastfeeding (lactational)

49
Q

What is mastalgia?

A

Breast pain

either cyclical or non-cyclical

50
Q

What is the treatment of mastalgia?

A

Evening primrose oil

Tamoxifen / danazol used for cyclical pain

51
Q

What is duct ectasia?

A

Duct ectasia is a dilatation and shortening of the terminal breast ducts within 3cm of the nipple

52
Q

What is the presentation of duct ectasia?

A

typically presents with nipple retraction and occasionally creamy nipple discharge

53
Q

What is the mangement of duct ectasia?

A

troublesome nipple discharge may be treated by microdochectomy (if young) or total duct excision (if older).

54
Q

What is intraductal papilloma?

A

Growth of papilloma in a single duct
Usually presents with clear or blood stained discharge originating from a single duct
No increase in risk of malignancy

55
Q

SUMMARY: what are the different types of breast carcinomas?

A

Invasive ductal carcinoma. (most common type of breast cancer)

To complicate matters further this has recently been renamed ‘No Special Type (NST)’. In contrast, lobular carcinoma and other rarer types of breast cancer are classified as ‘Special Type’

Invasive lobular carcinoma
Ductal carcinoma-in-situ (DCIS)
Lobular carcinoma-in-situ (LCIS)

56
Q

What are the criteria for referral for breast cancer?

A

aged 30 and over and have an unexplained breast lump with or without pain or
aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern

with skin changes that suggest breast cancer or
aged 30 and over with an unexplained lump in the axilla

57
Q

What are the complications of breast surgery?

A

Long thoracic nerve injury (presents with winging of the scapula)
Intercostobrachial nerve injury
Cellulitis
Seroma

Lymphedema

CP3 Surgery (12 decks)

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