Breast surg Flashcards
What are the major blood supplies to the breast
lateral thoracic artery - arising from axillary artery
internal thoracic artery - arising from subclavian
What are the minor blood supplies to the breast
Posterior Intercostal arteries from aorta
Thoracoacromial artery from axillary art
What are the venous drainage routes of the breast
Cirumferential areolar venous plexus
- Internal thoracic vein
- Axillary vein
- Posterior intercostal vein
What are the lymphatic drainage routes of the breast
There are three major routes:
axillary, transpectoral and internal mammary
but goes through areolar complex first before being distributed to axillary. if axillary is blocked it tends to go to parasternal LNs which include internal mammary glands and posterior intercostal nodes etc
75% axillary
25% parasternal lymphnodes
What is triple assessment
Diagnosis of breast Ca
1. clinical exam
2. radiological assessment
- mammogram in the cranio-caudal view and mediolateral oblique view sometimes cone views if high suspicion
- ultrasound for those less than 35yo can differentiate solid from cystic lesions
3. cytological assessment
FNAC - but cannot distinguish Ca insitu and invasive Ca
BReast biopsy (ie trucut/ core) has superior diagnostic power but both have 90% sensitivity and specificity
In terms of benign epithelial neoplasm what are the different categories (there are 3)
BEN is now called ANDI - aberration of normal development and involution
1.Non-proliferative - No increased risk of CA
Common fibrocystic changes (cyst and ductal ectasia, simple fibroadenoma, nonsclerosing adenosis, mild hyperplasia)
Benign tumors (phylloides tumor, giant adenoma, adenomyoepithelioma)
Metaplasia (squamous and apocrine)
Diabetic mastopathy
2.Proliferative w/o atypia - 1.5 - 2x relative risk of CA Ductal hyperplasia
Papilloma/ Papillomatosis
Radial scar
Sclerosing adenosis
3.Proliferative with atypia - 4 - 5x relative risk of CA Atypical ductal hyperplasia (ADH)
Atypical lobular hyperplasia
Family history is regarded as a CA risk factor, independent of histological finding. In patient with ADH and positive family history, the relative risk of CA is 8 – 10 x
young female
well encapsulated, mobile, firm mass, smooth and painless
size fluctuates when breast feeding/ preg
fibroadenoma
hyperplasia of single lobule
40yo female leaf like tumour tissue irregular bosselated surface and deep cleft shiny skin mobile
phylloides tumour
surgically resect it by BCS
can reoccur in 20-30%
very rarely metastasis to LN - 1%
“presents with discharge”
can be creamy/ bloody
nipple retraction and inversion
ductal ectasia creamy secretion and preiductal mastitis several ducts tx with microdochetomy plastics for nipple inversion
bloody nipple discharge
ductal papilloma
arises from epithelium of duct in the nipple
single duct
increased risk of malignancy 1.5-2x due to proliferative changes
tx microdochetomy
What causes mastitis
usually local staph infection - in lactating females
can be systemic infection TB but uncommon
in non lactational mastitis duct ectasia is a cause of mastitis - add metronidazole due to anaerobes
How do you treat cyclic mastalgia
it is hormone related so tx centres around that
gamolenic acid
danazol
bromocriptine
tamoxifen
incidence and RF for breast Ca
1 in 24 females in HK 1 in 12 in UK RF: - exposure to female sex hormones - early menarche late menopause late or no pregnancy BREAST FEEDING IS PROTECTIVE
HRT/ COCP slightly increases risk
FHx
genotype
What are gene mutations associated with Breast Ca
BRCA 1 and 2
HER2
Describe invasive carcinoma of the breast
mostly adenocarcinoma
arises from terminal lobular ductal unit
- Invasive ductal Ca
- 75%
hard lesion, associated with intraductal carcinoma (DCIS)
common mets to LN, bone, brain, liver and lung
2. invasive lobular Ca 5-10% ill-defined thickening lesion single file arrangement around ducts or lobules multicentric lesions usually mets to LN
3.
Malignant features on examination
Skin tethering irregular surfaces nipple retraction lump fixed to muscle skin ulcers peau d'orange (po dorange) cancer en cuirasse - tumour infiltrates into skin of the chest pagets disease of nipple - eczema like dry nipple
What are the contraindications for breast conservative surgery
multifocal disease extensive microcalcification intraductal carcinoma if they have CI to radiotherapy - preg, collagen disorder large tumour >3cm with small breasts - breast to tumour ratio - for tumour>5cm no evidence to support
Relative CI
invasive lobular CA
old age
