Breast Mushkies

Question 1

Breast exam components?

Answer 1

1. Inspection
2. Palpation
3. Completion

Question 2

Breast inspection?

Answer 2

1. Positions x 4 = hands by sides, leaning forwards, behind head, pressing hips
2. Shape = asymmetry, masses
3. Skin = scars, radiotherapy tattoos, eczema, erythema, peau d’orange
4. Nipple = inversion, discharge, discoloration, destruction
5. Peripheral = axillae, arm, abdomen (DIEP), back (lat dorsi flap harvest)

Question 3

Breast palpation?

Answer 3

1. Breast
2. Axillae
3. Supraclavicular and cervical nodes
4. Lateral chest wall

Question 4

Breast exam completion?

Answer 4

1. Palpate/percuss spine for tenderness, masses
2. Examine abdomen for hepatomegaly
3. Percuss and auscultate lungs

Question 5

Axillary lymph nodes?

Answer 5

1. Apical
2. Anterior
3. Posterior
4. Medial Lateral

Question 6

Breast scars?

Answer 6

1. Periareolar

2. Submammary

Question 7

Breast lump Ix?

Answer 7

Triple assessment

1. History and Examination
   2a. <35 years old = US
   2b. >35 years old = US + mammogram
2. Solid lump = Tru-Cut biopsy, Cystic lump = FNAC

Question 8

Breast Ca RFs?

Answer 8

BOOBYS

1. Bleeding = early menarche <13, late menopause >55
2. Oestrogen = OCP, HRT
3. Other breast disease = Ca, DCIS, atypia
4. Breast feeding = protective
5. Young’un = first child >35 y/o
6. Sister = FHx

Question 9

Classification of breast disease?

Answer 9

Benign or Malignant

Question 10

Malignant breast disease?

Answer 10

1. Ductal carcinoma NOS = 70%
2. Lobular carcinoma = 20%
3. Phylloides tumours
4. Other = mucinous, medullary, papillary

Question 11

Benign Breast disease?

Answer 11

1. Stromal = fibroadenomas
2. Epithelial = fibroadenosis, cysts, papillomas
3. Inflammatory = mastitis, abscess, fat necrosis, duct ectasia

Question 12

Commonest single breast lumps?

Answer 12

1. Fibroadenoma
2. Cyst
3. Fat necrosis
4. Cancer

Question 13

Features of a malignant breast lump?

Answer 13

1. Irregular, nodular surface
2. Poorly defined edge
3. Hard/scirrhous consistency
4. Painless
5. Fixation to skin or chest wall
6. Nipple involvement

Question 14

4 indications for mastectomy?

Answer 14

1. Multifocal tumour
2. Central tumour
3. Large lesion in small breast
4. DCIS > 4cm
5. Pt choice

Question 15

4 indications for wide local excision?

Answer 15

1. Solitary lesion
2. Peripheral tumour
3. Small lesion in large breast
4. DCIS < 4cm
5. Pt choice

Question 16

Drain removal post breast op features?

Answer 16

1. Typically 2 drains = axilla and site of surgery
2. Left for 3-5 days or until draining <50ml/d
3. Pts can go home with drains and district nurse support

Question 17

2 types of breast reconstruction?

Answer 17

1. Implant reconstruction

2. Myocutaneous flap reconstruction

Question 18

Implant reconstruction features?

Answer 18

1. Rounder shape than normal breast
2. Breast usually lies higher
3. Becker implant may have palpable SC filling port in the axilla

Question 19

Implant reconstruction advantages?

Answer 19

Simpler technique, can be primary or delayed

Question 20

Implant reconstruction disadvantages?

Answer 20

1. Cosmetic result not as good
2. Requires plenty of available skin
3. Lies higher than other breast
4. Late complications = capsular contracture, implant leakage, infection requiring removal

Question 21

Myocutaneous flap features?

Answer 21

1. Scars extend over back or abdominal wall
2. Recess on back where lat dorsi has been removed
3. Ask pt to lift head off bed when lying supine to see recess in the rectus muscle

Question 22

Myocutaneous flaps advantages?

Answer 22

1. Useful when little remaining skin.muscle
2. Good cosmetic result
3. Primary or delayed

Question 23

Myocutaneous flaps disadvantages?

Answer 23

1. Increased blood loss
2. Increased op times and complications
3. Use of rectus impossible if pt has had abdo surgery
4. Late complications = flap necrosis and infection

Question 24

Types of myocutaneous flap?

Answer 24

1. Lat dorsi flap = often augmented w/ an implant
2. TRAM flap = transverse rectus abdominis myocutaneous, risk of abdominal hernia, C/I if poor circulation, no implant necessary and combined tummy tuck
3. DIEP flap = deep inferior epigastric perforator, may not be possible if small perforators

Question 25

Gynaecomastia examination?

Answer 25

1. Inspection = unilateral/bilateral breast swelling
2. Palpation = must feel glandular tissue to differentiate from pseudo
3. Completion

Question 26

Completion of gynaecomastia exam?

Answer 26

1. Look for cause = external genitalia, thyroid, CLD, visual fields
2. History
3. Prescription and recreational drugs

Question 27

Causes of gynaecomastia?

Answer 27

3Ps

1. Physiological
2. Pathological
3. Potions

Question 28

Physiological gynaecomastia?

Answer 28

Usually resolves by adulthood

Question 29

Pathological gynaecomastia?

Answer 29

1. Decreased androgen production

2. Increased oestrogen production

Question 30

Causes of reduced androgen production?

Answer 30

1. Hyperprolactinaemia
2. Renal failure
3. Testicular = atrophy, orchitis, torsion, Klinefelters

Question 31

Causes of increased oestrogen production?

Answer 31

1. Increased production = sex cord stromal tumours, lung Ca

2. Increased peripheral aromatisation = CLD, thyrotoxicosis

Question 32

Potions that cause gynaecomastia?

Answer 32

1. Recreational = Marijuana, Diazepam, Anabolic Steroids

2. Prescription

Question 33

Prescription drugs that cause gynaecomastia?

Answer 33

1. Spironolactone
2. Digoxin
3. Captopril
4. Verapamil
5. Ranitidine

Question 34

Gynaecomastia Ix?

Answer 34

1. Testicular Ca = AFP, bHCG
2. Hypogonadism = testosterone and LH
3. Prolactinoma = PRL
4. TFTs

Question 35

Gynaecomastia suggestive of Ca Fx?

Answer 35

1. Older age
2. FHx
3. Unilateral
4. Firm or hard nodules w/in breast tissue
5. Axillary LNs