Breast and endocrine surgery

Question 1

OVERVIEW

i) what are the three main risk factors for developing breast cancer?
ii) at what age does like time risk jump up?
iii) what is the ratio of male:female?
iv) name four other things that increase risk of BC?

Answer 1

i) being caucasian, female and increased age
ii) after age 50 - 1 in 50 develop BC
iii) 1:200
iv) >30yrs in first pregnancy, <12yrs menarche, >55yrs at menopause, obese, nulliparous, HRT

Question 2

BREAST CANCER RISK

i) give two things that make you low risk
ii) give three things that make you moderate risk
iii) give three things that make you high risk

Answer 2

i) no familt history or one relative with BC >45yrs
ii) one first degree relative BC <40yrs, two first/second degree relatives with ovarian cancer at any age, bilateral BC <60yrs, first degree male relative with BC
iii) four relatives with BC or OC at any age (BRCA2 gene), askanazi jews, members of family with cancer syndromes

Question 3

GENETIC TESTING

i) who needs to be screened?
ii) what is the turn around testing time?

Answer 3

i) live affected relative screen first to identify mutation in family
ii) turn around 3-6 months

Question 4

HODGKINS DISEASE AND BREAST CANCER

i) what is the cumulative risk of women treated for HD in childhood? what does risk increase with?
ii) is there higher risk for women treated in childhood or adolescence?
iii) why does risk increase if women have had HD?

Answer 4

i) 15-33%
- risk increases as follow up time increases

ii) higher risk if women are treated in childhood
iii) increased risk due to radiotherapy treatment

Question 5

BREAST SCREENING

i) between which ages are women screened?
ii) how many breast cancers are detected per 10,000 women screened?
iii) what makes up the triple assessment? why is this done?

Answer 5

i) between 47 and 70yrs
ii) detect 40-50 cancers per 100,00 women screened

iii) triple assess - history/physical exam, imaging (screening) and tissue dx (if something is wrong)
- done because no investigation is 100% so do three to maximise effectiveness

Question 6

HISTORY/DESCRIPTION OF A LUMP

i) name three associated symptoms that may cause concern for BC?
ii) what must be excluded any time a lump is found in the breast
iii) what can be done to better visualise lumps?
iv) how should the contous of the breast look? what appearance of the skin is concerning?
v) which other areas must be examined (2) why?

Answer 6

i) pain, discharge, skin change
ii) cancer must be excluded
iii) move arms to different positions to vis lumps

iv) contours of the breast should be smooth
- skin pulling/tethering is concerning

v) must examine axilla/supraclavicular fossa as they contain LNs that drain the breast

Question 7

BC SYMPTOMS

i) what question is it important to ask in relation to release of nipple discharge? which one is more concerning?
ii) what nipple discharge appearance is most concerning? what is 50% of nipple discharge due to? what can be used to test it
iii) on palpation - which side do you start on?

Answer 7

i) does it come out on its own or does it need to be stimulated?
- on its own is more worrying

ii) bloody discharge is most concerning
- 50% of discharge is due to a polyp (benign)
- test on a urine dipstick

iii) start with asymptomatic side first

Question 8

IMAGING

i) over what age are mammograms done? what imaging technique is used under this age? why?
ii) what can make diagnosis of breast cancer more diffucult?
iii) can you do mammograms in men?
iv) which imaging technique is not used as a screening tool but is more targeted if there is suspicion of a problem?
v) what are the four things that a lump in the breast can be?

Answer 8

i) >40
- <40yrs do US as tissue too glandular for mammography

ii) being on HRT can make diagnosis more difficult
iii) yes
iv) US is not used a screening tool but to investigate a lump that is suspicious
v) abscess (infective), fibroadenoma (benign), cancer, cyst (pocket of fluid)

Question 9

PATHOLOGY OF BREAST CANCER

i) which cells is there proliferation of?
ii) what happens to the basement membrane?
iii) which cells are lost?
iv) what is pre cancerous BC called?
v) name four broad treatments

Answer 9

i) proliferation of epithelial cells
ii) loss of basement membrane
iii) loss of myoepithelial cells
iv) DCIS
v) surgery, radiotherapy, chemotherapy, endocrine therapy

Question 10

BREAST SURGERY

i) what % of patients have breast conserving surgery?
ii) do patients who have local excision or those who have radical masectomy have better survival?
iii) what five factors contribute to which surgery is done?
iv) name two muscles that reconstruction surgery can use?

Answer 10

i) 80% of patients have breast conserving surgery
ii) those who have quadrant excision have better survival than those who have radical masectomy
iii) size of tumour, size of breast, site of tumour, is it multifocal?, patient choice
iv) lat dorsi (lat dorsi flap) and transverse rectus abdominus (TRAM flap)

Question 11

THYROID CANCER

i) name three predisposing factors
ii) what is female to male ratio
iii) what % of thyroid nodules are malignant? in which group is risk of malignancy higher?
iv) what % of cold nodules are malignant

Answer 11

i) radiation to neck in childhood, exposure to enviro radiation, chronic lymphocytic thryoiditis, genetics (medullary)
ii) 2:1

iii) 5-10%
- hige risk of malignancy in men >60yrs

iv) 10%

Question 12

THYROID SURGERY

i) what surgical approach is used for a toxic nodule or for diagnosis on a dominant nodule?
ii) what approach is used for cancer, multinodular goitre or graves disease
iii) give four reasons for urgent referral

Answer 12

i) hemi thyroidectomy
ii) total thyroidectomy

iii) solitary thyroid nodules that are inc in size
- patients who have thyroid lump and family hx of thyroid cancer/irradiation
- thyroid lump in >65yrs
- cervical lymphadenopathy
- stridor (late presenting sign)

Question 13

PARATHYROIDS

i) where do they embryologically originate?
ii) what do they release and what does this cause?
iii) what are the clinical features of PT disease?

Answer 13

i) pharyngeal arch > 4th pharyngeal pouch
ii) release PTH which increases blood calcium levels

iii) bones, stones, abdominal groans and psychic moans
- weakness, tired, weight loss, muscle weak
- mental change, impaired conc, personality change
- abdo pain
- renal calculi and nephrocalcinosis
- cardiac arrhythmia and HT
- corneal calcification

Question 14

PARATHYROID SURGERY

i) what is used for pre op localisation?
ii) what type of surgery is done for excision of adenoma?
iii) can minimally invasive surgery be done?
iv) what can be measured intra operatively?

Answer 14

i) technetium sestamibi protein - labelled with technetium
ii) neck exploration
iii) yes - lapraroscopic / under local anaes
iv) PTH levels - measure pre op, on excition, 5 mins and 10 mins post excision

Question 15

BENIGN LUMPS

i) what three step process should be done to approach a lump? what is a limpoma? what is a phyllodes tumour? what may they mimic?
ii) what is the most common type? which age group of women does it mostly occur in? what two cell types are present and where do they form?
iii) which tissue do adenomas form from? which age group are they most common in? what can it mimic? which age do papillomas usually form? in which area?
iv) how does a benign lump feel? which type of highly mobile, well defiined and rubbery on palpation? what size are most benign lummps?
v) which benign lump may produce clear nipple discharge and present with a large mass? why should they be biopsied?
vi) what is mainstay of treatment? why may it be excised? which tumour type may be widely excised? why?

Answer 15

i) examine, image, biopsy
- Lipoma - benign adipose tissue with low malignant potential
- Phyllodes tumour - rare fibroepithelial tumour, hard to differentiate from fibroadenomas however 1/3 have malignant potential

ii) fibroadenoma > most common = women of reproductive age, stromal and epithelial tissue of duct lobules, ery low malignant potential

iii) Adenoma - benign glandular tumour occ in older female population
- nodular lesion that can mimic malignancy > triple assess
- Papilloma - usually occur in 40-50yrs in sub areolar area

iv) more mobile and smoother borders than malignant tumours
* multiple
- Fibroadenoma = highly mobile, well defined and rubbery on palpation
- most <5cm diameter

v) Papilloma - clear nipple discharge
* large can present with a mass
* biopsy as they can appear similar to ductal carcinoma on imaging

vi) mainstay = reassurance and routine check ups, may excise after triple assess if malignant potential
- fibroadenoma > low malig potential and can be left in situ with routine follow up / excise if >3cm or patient preference
- phyllodes tumour > widely excise (masectomy if tumour is large) > 1/3 have malignant potential

Question 16

MASTITIS/ABSCESS

i) what is mastitis? what is the most common cause? what are two classification by lactational status? which one is tobacco smoking a RF for? why?
ii) name four symptoms? which type commonly present in first three months of breastfeeding or during weening? how may a breast abscess appear? which imaging should be done?
iii) how should masitis be treated? (2) what can be given if there is persistent infection or it affects multiple areas? how should an abscess be treated?
iv) what is a breast abscess? name a complication and how it is managed?

Answer 16

i) mastitis = inflammation of breast tissue - acute or chronic
- most common cause is infection - S.aureus but can also be granulomatous
- can be classed by lactation status:
* lactational - seen in 1/3 breastfeeding women
* non lactational - occ in women with duct ectasia > RF is tobacco smoking > damages sub areolar duct walls > pre dis to bacterial infection

ii) tenderness, swellling, induration (hard) and erythema over area of infection
- lactational - presents in furst 3 months of bf or during weaning > cracked nipples and milk stasis
- breast abscess > tender erythematous masses with puncutum (point) > confirm via US

iii) treat masitis with Abx and Simple analgesics
- lactational > continued mulk drainage/feeding is recommended
- persistent infection/multiple areas > consider DA agonist eg cabergoline for cessation of breastfeeding
- abscess > prompt bx nd US guided needle aspiration (adv may req draining under local anaes)

iv) Breast abscess > collection of pus within lind granulation tissue (usually from acute mastitis)
- may form a mammary duct fistula > sx mx with flistulectomy and abx

Question 17

BREAST CYSTS

i) what are they? when do they form? which age group are they most common in? what % of palpable breast masses do they make up?
ii) how may they present? name two things felt on palpation?
iii) how do they look on mammography? what can they be definitively dx by? name ttwo things seen on aspiration that can be used to rule out cancer?
iv) what can be done is persistent or symptomatic? do they self resolve? what can be given if painful? name two things that can be given if cyclical pain (related to periods)
v) what % of patients will have carcinoma at px? is there an icnreased risk of BC in the future? name another complication?

Answer 17

i) epithelial lined fluid filled cavities
- form when lobules become distended due to blockage
* usually found in perimenopausal age group
* 15% of palpable breast masses

ii) can present singular or multiple in one or both breasts
* on palpation > distinct/smooth/may be tender

iii) halo shape on mammograhy (usually definitively dx on US)
* aspiration > if free of blood or lump dissapears = exclude cancer

iv) ersistent/symptomatic or undeterminable can be aspirated (freehand or US)
* usually require no further mx and self resolve
* appropriate analgesia if painful
*gamolenic acid or danazol if cyclical pain (linked to periods)

v) *2% of patients will have carcinoma at presentation (usually incidental and not relatd to th cyst)
* 2-3x increased risk of dev BC in the future
*fibroadenosis (multiple small cysts and fibrotic area)

Question 18

BREAST CANCER

i) where do almost all BC arise from? what is the most common type?
ii) what type makes up 10% of BC? which age group is this more common in? why is detection more difficult?
iii) what are the two biggest RF for BC? name four others? expsoure to which hormone can increase risk? what prognotic index is used for staging? what else can determine mort rates?
iv) name five symptoms a patient may present with? what is gold standard approach to dx? what is the most important prognostic factor?

Answer 18

i) *almost all BC arise in the terminal duct lobular unit
- invasive ductal carcinoma, invasive lobular carcinoma or other (medullary or colloid carcinoma)

ii) Invasive lobular carcinoma
* 10% of all BC
* more common in older women
* diffuse stromal pattern of spread that makes detection more difficult > usually large at dx

iii) Female, age are most significant RF (risk doubles every 10yrs until menopause)
* mutations in BRCA1/2, FH in first degree relative, previous benign disease, alcohol, obesity, developed countries
* exposure to unopposed oestrogen > early menarch, late menopause, nulliparous, COCP or HRT use
* nottingham prognostic index for clin pathol staging
* receptor status can also determine mortality rates > oestrogen, progesterone, human epidermal growth factor

iv) can present symptomatically or asymptomatically
* breast lump, assymetry, swelling, abnormal nipple discharg, nipple retraction, skin chng (dimpling), mastalgia, palpable mass in axilla
- gold standard dx is triple assessment 0 exam, imaging, histology, cytology
- nodal status is most important prognostic factor

Question 19

BREAST CANCER TREATMENT

i) when may breast conserving sx be done? how much is removed? when may masectomy be done? what does this involve?
ii) what is axillary sx often done alongside? give two indications?
iii) what is a senteniel node biopsy? what is axillary node clearance? name three complications of this?
iv) when may hormone tx be given? which patient group may get tamoxifen? how does this work? name two things it increases risk of?
v) name two aromatase inhibitors? what do they do? (2) who may be given immunotherapy? what does herceptin target? when is it given?

Answer 19

i) breast conserving - for localised operable disease > Wide local excision (tumour + 1cm margin of normal tissue)
- mastectomy - removes all tissue in affected breast and overlying skin > multifocal disease, high tumour:breast tissue, disease recurrence or patient choice

ii) Axillary sx - commonly done alongside WLE and masectomies to assess nodal status aand remove nodal disease

iii) senteniel node biopsy > remove first LNs in which tumour drains (inject a blue dye > identify)
- axillary node clearance > remove all nodes in axilla > complications = paraesthesiaa, sroma formation and lymphedema in upper limb

iv) Hormone tx > post op in malignant non metastatic disease
- tamoxifen in pre meno patients > blocks oes receptors (can increase risk of VTE and uterine carcinoma)

v) aromatase inhibitors eg anastrozolee, letrozole, exemstane > bind oes receeptors to inhibit further malignant growth, prev oes prod and converstion of androgens to oes in periph tissue
- Immunotherapy = cancers that express specific growth factor receptors
- HER2 positive > target with herceptin (MAB) as adjuvant or monotherapy if pt has haad ttwo chemo regimens for met BC