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Junior Surgery > Breast And Hernias > Flashcards

Breast And Hernias Flashcards

1
Q

Breast lump differentials

A

Fibroadenoma
Cancer
Fat necrosis
Abscess
Cyst

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2
Q

3 hormonal factors that increase risk of breast cancer

A

Early menstruation
Late menopause
No children

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3
Q

Why does breastfeeding reduce risk of breast cancer

A

Matures breast cells making them less likely to be cancerous

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4
Q

What is herceptin

A

A form of targeted chemotherapy
Acts on the HER2 gene protein

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5
Q

What investigations are done in the 2WW breast cancer service triple assessment

A

Clinical examination
Breast imaging: US + mammogram if >35
Cytology: fine needle aspiration if cystic, core biopsy if solid

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6
Q

Aetiology and epidemiology of a fibroadenoma

A

Is the most common benign breast lump (50% of all biopsies)
Most common in ages 25-35
Likely hormonal cause but unknown

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7
Q

Pathophysiology of a fibroadenoma

A

Benign overgrowth of one lobule of the breast, usually solitary

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8
Q

Clinical features of fibroadenoma

A

Highly mobile, firm and smooth lumps that evade palpation
Usually painless or cause localised pain

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9
Q

Management of fibroadenoma

A

Generally dont require treatment
Removal may be indicated if >4cm

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10
Q

Prognosis for fibroadenoma

A

1/3 regress, 1/3 remain and 1/3 grow
Not usually an increased risk of breast cancer only if there is a strong FH

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11
Q

Clinical features of fibroadenosis / fibrocystic change

A

Lumpy breast and cyclical pain / swelling
Localised fibrosis, inflammation and cyst formation
Nodules in one / both breasts
Areas of thickened / firm tissue
Discrete cystic swellings

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12
Q

Management of fibroadenosis / fibrocystic change

A

Anti-inflammatories
Hormonal manipulation with the combined OC pill can help symptoms
Topical evening primrose oil

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13
Q

Pathophysiology of breast cysts

A

Fluid filled, round or ovoid masses from the terminal duct lobular unit
Can be associated with fibrocystic change or occur alone

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14
Q

Clinical features of breast cysts

A

Classically present in perimenopausal women as round symmetrical lumps
Acute enlargement can present with severe, localised pain

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15
Q

Management of breast cysts

A

Generally referred for triple assessment
Drained with US guidance
Fluid is sent to cytology to rule out malignancy
Symptomatic management

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16
Q

Other causes of benign breast lumps

A

Fat necrosis: occurs following trauma to the breast but can clinically mimic neoplastic disease

Phylloides tumour: rapidly growing benign tumours of the stroma

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17
Q

What is mastitis

A

Inflammation of the breast tissue
+/- infection

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18
Q

Pathophysiology of lactational mastitis

A

Poor milk drainage leads to engorgement of breast tissue due to prolonged stagnation of the breast milk, infection develops as breast milk contains bacteria

Most commonly staph aureus

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19
Q

Clinical features of mastitis

A

Breast pain
Swelling
Erythema
Fever
Malaise
Reactive axillary lymphadenopathy

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20
Q

Management of lactational mastitis

A

Oral abx and oral analgesia
Advise to continue breastfeeding through the sore breast first and express milk between feeds
Cold / warm compresses may provide symptomatic relief

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21
Q

What is non-lactational mastitis

A

Similar to lactational mastitis occasionally with purulent nipple discharge

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22
Q

What is a breast abscess

A

A localised collection of pus within breast tissue

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23
Q

Aetiology of breast abscesses

A

Develops when mastitis does not respond to abx treatment

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24
Q

Clinical features of breast abscess

A

Localised, painful inflammation of the breast
Associated fever and malaise
A fluctuating tender palpable mass is seen OE

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25
Q

Breast abscess management

A

US + needle drainage
Abx therapy

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26
Q

What is galactorrhoea

A

Physiologic nipple discharge unrelated to pregnancy of breastfeeding
Usually bilateral and white / clear

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27
Q

Red flag symptoms associated with nipple discharge

A

Unilateral, persistent and spontaneous discharge
- usually localised to a single duct
Blood stained
Any symptom suggestive of malignancy

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28
Q

Risk of breast cancer in UK

A

1 in 8 women

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29
Q

What ages are invited for NHS mammogram

A

50-71

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30
Q

Breast cancer risk factors

A

Genetic (5% are related to BRCA1/2)
Early menarche / late menopause
Nulliparity (or late age of first child)
Not breast feeding
HRT
Obesity
Smoking

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31
Q

Morphology of breast tumours

A

Most are invasive adenocarcinoma
90% are invasive ductal carcinoma
5% are invasive lobular carcinoma
5% are lobular / ductal in situ

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32
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

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33
Q

Where can breast cancer locally spread to

A
  • into overlying skin to produce tethering or nipple retraction
  • into pectoral muscles to cause deep fixation of the tumour
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34
Q

What causes the peau d’ orange appearance

A

When a breast cancer prevents lymphatic drainage

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35
Q

Consequences of vascular spread of breast cancer

A

Distal dissemination is most commonly to the bone
Presents with pathological fractures and hypercalcaemia
Other sites are the lung and ovary

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36
Q

Clinical presentation of breast cancer

A

Breast lump found on self examination or screening
- pathological nipple discharge
- Paget’s disease of the nipple
- nipple retraction
- peau d’ orange
- axillary / supraclavicular lymphadenopathy

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37
Q

TNM classification for breast cancer

A

T1 <2cm, T2: 2-5cm, T3 >5cm T4 = fixed to chest wall or peau d’ orange
N0= no nodes, N1= ipsilateral nodes, N2 = fixed nodes
M0= no distant metastases, M1= distant metastases

38
Q

Management of non metastatic breast cancer

A

Wide local excision - breast conserving that can be used providing the breast is of adequate size and the tumour is not central

Mastectomy - preferred for large tumours or small breasts, central location or late presentation
Breast reconstruction can be performed

Sentinel lymph node biopsy also performed

39
Q

How does a sentinel lymph node biopsy work

A

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

If positive, full axillary clearance is required and further investigations for metastases

40
Q

Chemotherapy / radiotherapy for breast cancer

A

Most breast surgery is combined with adjuvant radiotherapy for invasive disease
If there is nodal disease or high grade tumours, chemo is considered

41
Q

Treatment if a tumour is ER positive

A

Tamoxifen if pre / peri menopausal
Aromatase inhibitors if post menopausal to stop peripheral oestrogen production

42
Q

Treatment for a HER positive tumour

A

Herceptin if HER2 positive
Combined with chemo

43
Q

What is the Nottingham prognostic index

A

Assesses survival and risk of relapse helping to select appropriate adjuvant therapy

NPI = (tumour size cm x 0.2) + histological grade (1-3) + nodal status (1-3)

44
Q

Define hernia

A

The protrusion of an organ or part of an organ through a defect in the wall of the cavity containing it into an abnormal position

45
Q

Define reducible

A

The contents of the hernia can be completely replaced into the cavity

46
Q

Define obstructed (hernia)

A

Bowel contents cannot pass through the herniated bowel

47
Q

Define strangulated (hernia)

A

There is ischaemia of the contents of the hernia (due to obstructed venous return), which unless relieved will lead to gangrene and perforation

48
Q

Define incarcerated (hernia)

A

The contents of the hernial sac are stuck inside by adhesions

49
Q

Describe the anatomy of an inguinal hernia

A

The inguinal canal is formed by the relocation of the testes during foetal development
- it is about 4cm long and lies parallel and medial to the first part of the inguinal ligament
- deep inguinal ring is the entrance to the inguinal canal located 1cm superior to the mid point of the inguinal ligament

50
Q

What does the inguinal canal contain

A

3 arteries: testicular / ovarian artery, artery to vas deferens, cremasteric artery

3 nerves: genital branch of genitofemoral, ilioinguinal and sympathetic

Vas deferens, round ligament of the uterus, pampiniform plexus and testicular lymphatics

51
Q

3 fascial coverings of the inguinal canal

A

Internal spermatic fascia - from the transversalis fascia

Cremasteric fascia - from the internal oblique fascia

External spermatic fascia - from external oblique fascia

52
Q

What are the boundaries of the inguinal ligament (MALT)

A

2 muscles (superior wall): internal oblique, transversalis abdominus
2 aponeuroses (anterior wall): aponeuroses of internal and external oblique
2 ligaments (inferior wall): inguinal ligament, lacunar ligament
2 T’s (posterior wall): transversalis fascia, conjoint tendon

53
Q

What is an indirect inguinal hernia

A

The most common type of inguinal hernia, occurs in younger patients
The contents of the hernia pass through the inguinal canal due to a patent processus vaginalis
The hernia is covered by the processus vaginalis and all 3 fascial coverings
Exits superficial ring inside spermatic cord, frequently passing into the scrotum / labia majorus
Indirect hernias are more likely to strangulate than direct as the superficial ring is not dilated

54
Q

What is a direct inguinal hernia

A

Contents pass through a weakness of the anterior abdominal wall in the inguinal triangle
Make up about 1/3 of inguinal hernias and are covered by the peritoneum and transversalis fascia as they lie outside the inner coverings of the spermatic cord

They exit the superficial ring but lateral to the cord

55
Q

Risk factors for direct inguinal hernia

A

Things that increase intra-abdominal pressure eg chronic cough, heavy lifting, smoking, micturition / defecation

56
Q

How do you differentiate between indirect and direct inguinal hernias

A

Can only be done in surgery where the inferior epigastric arteries demarcate the median edge of the deep ring thus the indirect hernia will pass lateral and the direct hernia medial to these vessels

57
Q

What is an intraductal papilloma

A

A benign tumour that grows within the lactiferous duct
Usually no palpable lump
Presents with bloodstained nipple discharge

58
Q

What is mammary duct ectasia

A

A benign breast condition occurs when large breast ducts dilate
Discharge is often thick and green tinged

59
Q

Complication of axillary node clearance

A

Lymphoedema
Can cause functional arm impairment

60
Q

Why is complete axillary lymph node dissection not done in involvement of single lymph node

A

If less than 3 nodes are involved and the patient has had breast conserving surgery and adjuvant radiotherapy then no further management of axilla is needed

61
Q

When is FEC-D chemotherapy used

A

In patients with node positive breast cancer (multi-nodal involvement)

62
Q

Potential complication of aromatase inhibitors

A

Osteoporosis
AI’s reduce peripheral oestrogen synthesis
Increase bone loss - bone mineral density should be checked

63
Q

What course and abx is given in mastitis

A

Flucloxacillin 10-14 days

64
Q

Why is anastrozole only used in post menopausal women

A

It targets aromatase and reduces the conversion of androgens into oestrogens in peripheral tissues (the main source of oestrogen in post menopausal women as oppose to ovaries in pre-menopausal)

65
Q

Management for a woman <30 presenting with a breast lump that is not painful

A

Routine referral to breast clinic (not urgent)

66
Q

When is tamoxifen used as oppose to aromatase inhibitors

A

Tamoxifen is used in ER+ve women who are pre or peri menopausal
Aromatase inhibitors in post menopausal

67
Q

When is whole breast radiotherapy recommended

A

After a wide-local excision

68
Q

How does inflammatory breast cancer present

A

Progressive, erythema and oedema of the breast in the absence signs of infection eg fever, discharge or elevated WCC and CRP

69
Q

What is inflammatory breast cancer caused by

A

Obstruction of lymph drainage causing erythema and oedema

70
Q

Management of inflammatory breast cancer

A

Neo-adjuvant chemotherapy first line
Total mastectomy +/- radiotherapy

71
Q

What is the likely pathology of an irregular lump of the right breast associated with skin tethering
Malignancy been ruled out

A

Fat necrosis

72
Q

What is a femoral hernia

A

More common in women than men
Located in the femoral triangle

73
Q

Anatomy of the femoral hernia

A

Femoral triangle (inguinal ligament, medial border of sartorius, lateral border of adductor longus) contains the femoral nerve, artery and vein
Femoral canal lies at the medial extremity of the femoral sheath and is the site of the femoral hernia
Bowel exits abdominal cavity through femoral ring
As hernia enlarges it passes out of saphenous opening and into deep fascia

74
Q

Why is there a high risk of strangulation with femoral hernia

A

Femoral canal opening is relatively small with strong borders

75
Q

How do femoral hernias present

A

50% as a surgical emergency due to obstructed contents
50% as a globular lump below and lateral to the pubic tubercle

76
Q

Differentials for groin lump

A

Inguinal hernia
Lipoma
Femoral artery aneurysm
Saphenous ovarix
Lymph node

77
Q

What is a richter’s hernia

A

A hernia involving only one sidewall of the bowel and not the bowel lumen, can result in bowel strangulation and perforation without causing obstruction or any of its warning signs
More likely in femoral sac

78
Q

Management of groin hernia (5)

A
  1. Assess for signs of obstruction / strangulation (if present - urgent surgical intervention repair)
  2. Attempt to reduce the hernia to reduce chance of complications
  3. Patients with asymptomatic or minimally symptomatic inguinal hernias can be safely observed without a need to progress to operative management
  4. If it becomes symptomatic, laparoscopic day case indicated
  5. All patients with femoral hernia should be referred to surgical repair due to high complication rates
79
Q

What is a true umbilical hernia

A

Occur in 3% of live births due to a defect in the transversalis fascia at the umbilical ring
- incomplete closure of the umbilical cicatrix
- covered by skin
- asymptomatic, more prominent on coughing, reduce easily, rarely obstructed
- rarely need surgical management, 90% retract by age 2

80
Q

Who do true umbilical hernias most commonly affect

A

Black, male and premature babies

81
Q

What is a paraumbilical hernia

A

An acquired hernia just above / below umbilicus
- caused by raised IAP (obese, Middle Aged, multiparous women)
- present with a localised dragging pain and enlarging hernia over time
- mainly reducible but due to small neck they commonly strangulate - surgical intervention

82
Q

What is an incisional hernia

A

Make up 10% of hernias
1% of abdominal incisions are followed by a hernia

83
Q

Risk factors for incisional hernia

A

Pre op: old age, poor nutrition, sepsis, uraemia, jaundice, obesity, steroids

Operative: vertical incisions, knots that are too loose / too tight, drains

Post op: post operative ileus, coughing, obesity, wound infection

84
Q

Symptoms of incisional hernia

A

Bulge in the scar and local discomfort
Subacute bowel obstruction
Adhesions can develop so hernia becomes irreducible and chance of strangulation increases

85
Q

Management of incisional hernia

A

Surgical repair generally indicated, but contraindicated if the risk factors that caused the hernia remain

86
Q

What is an epigastric hernia

A

1 or more protrusions through the linea alba above the umbilicus usually containing only extra peritoneal fat
- 75% are asymptomatic but some are painful which is worse on exertion or after meals
- pain indicates strangulation - surgical intervention

87
Q

What is divarification of the Rectus muscle

A

Rectus muscles dont meet in the midline at the linea alba and thus split apart when the patient flexes the abdo muscles
Common in obese men, parous women and people with chronic IAP
No indication for surgical management

88
Q

Summarise the different treatments for different types of breast cancers

A

Radiotherapy - wide local excision or mastectomy + T3-T4 tumours with 4+ positive axillary nodes

Tamoxifen - pre and peri menopause when +ve for hormone receptors

Aromatase inhibitors - +ve for hormone receptors, post menopause

Trastuzumab (Herceptin) - HER2 positive

FEC-D chemo - axillary node disease

89
Q

Side effects of tamoxifen

A

Increased risk of endometrial cancer
Venous thromboembolism
Menopause symptoms

90
Q

Management of total duct ectasia

A

Total duct excision in older women if the condition is bothering them
Otherwise none

91
Q

Mode of action of aromatase inhibitors

A

Reducing peripheral synthesis of oestrogen

92
Q

How does inflammatory breast cancer present

A

Progressive
Erythema
Oedema
Absence of signs of infection, fever, discharge, elevated WCC and CRP

Junior Surgery (6 decks)

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