Breast Surgery Flashcards
Embryological origin of the epithelial lining of the ducts and acini
Ectoderm
Embryological origin of the supporting tissue (stroma)
Mesenchyme
When is the mammary ridge developed
5 weeks
Where are the milk lines situated
Stretch from axilla to the groin
At what age is the breast bud formed
10
When does nipple development occur
12
Which ribs does the breast span
2nd to 6th
Which muscles does the breast cover
- Medial 2/3rd = Pec major
- Lateral 1/3rd = Serratus anterior
Outline the structure of the breast
- Composed of 15-20 lobules
- Lobules drain into lactiferous ducts
- Lactiferous ducts drain into lactiferous sinuses which store milk
- Lactiferous ducts feed excretory sinuses
What type of epithelium lines the lobule ducts
Columnar/cuboidal epithelium
What type of epithelium lines the excretory ducts
Squamous epithelium
What connects the breast to the deep fascia of the chest wall
Suspensory ligaments of Cooper
Which rib space does the nipple align with
4th
Outline the blood supply to the lateral breast
Lateral thoracic and Thoracoacromial arteries (branches of the axillary artery)
Outline the blood supply to the medial breast
Perforating branches of intercostal spaces 1-4 (branches of the IMA)
Outline the venous drainage of the lateral breast
Thoracoacromial vein -> lateral thoracic vein -> axillary vein
Outline the venous drainage of the medial breast
Internal thoracic vein -> subclavian vein
Via which route does breast cancer spread to the thoracic vertebrae and ribs
Haematogenous via posterior intercostal veins that communicate with the vertebral venous plexus
Describe the cutaneous innervation of the breast
Cutaneous branches of intercostal nerves T4-6
Outline the lymphatic drainage of the breast
- 75-97% via axillary nodes
- 25% to internal mammary nodes through 2nd-4th intercostal spaces
Outline the connection between right and left breast lymphatics
There is anastomosis across the midline and down the abdominal wall
How are Axillary lymph nodes classified in axillary node clearance
- Level 1 = lateral to pec minor
- Level 2 = posterior to pec minor
- Level 3 = medial to pec minor
Which structures drain into the anterior (pectoral) nodes
Anterior upper trunk and breast
Which structures drain into the posterior (subscapular) nodes
Posterior upper trunk and axillary tail
Which structures drain into the apical (subclavicular) nodes
- Upper limb
- Anterior upper trunk and breast
- Posterior upper trunk and axillary tail
- Lateral, anterior, and posterior lymph nodes
What stimulates the growth and development of breast tissue during puberty
Oestrogens
Outline the changes that occur in the breast tissue during the menstrual cycle
- Follicular Phase = Oestrogen secreted from the Graafian follicle causes mammary duct proliferation and increase in stromal tissue
- Luteal Phase = rise in progesterone causes dilatation of the mammary ducts
- Menstruation = involution of breast tissue
What changes to the breast are seen during pregnancy
- Placental oestrogen causes proliferation and branching of the lobules and ductal system
- Further fat and stromal tissue are laid down
- Breast weight can double
- Nipple and areolar become more pigmented
How does lactation occur
When prolactin release is no longer inhibited by oestrogen
What is released from the breast during the first 2-4 days post-partum
Colostrum - high in protein and IgA
What causes milk ejection
Oxytocin - released in response to suckling
What happens to the breast tissue during menopause
Regression of breast tissue and replacement with fat and fibrosis
What imaging modality is used in the triple assessment
- <35 = USS
- >35 = Mammography
What imaging modality is preferable in those with implants presenting with a lump
- <35 = USS
- >35 = Mammography
What imaging modality is preferred for assessing issues with breast implants
MRI
What imaging modality is preferred for screening young patients with a family history of breast Ca
MRI
What does C1 mean on cytology assessment
Insufficient cells for diagnosis
What letter denotes core biopsy in the triple assessment
B
What does B5a indicate
DCIS
What does B5b indicate
Invasive carcinoma
What is the gold standard method of histological assessment
Core biopsy
When is punch biopsy indicated
For suspicious skin lesion on breast or areola
Describe the cyclical variation in fibrocystic breast disease
Symptoms peak at the end of the luteal phase (just before menstruation)
Outline the histological changes seen in fibrocystic breast disease
- Stromal fibrosis adenosis (increase in glandular tissue)
- Cyst formation
- Papillomatosis
- Epithelial hyperplasia
Symptoms of fibrocystic breast disease
- Nodular breast tissue (cobblestone texture)
- Discrete tender lumps
- Cyclical breast pain
- Breast cysts
Management of fibrocystic breast disease
- Reassurance
- Analgesia
- Aspiration of cysts
- COCP
Clinical features of breast cysts
- Palpable 1-5mm in diameter
- Often multiple
- Appear rapidly and diminish after menstruation
- Smooth and may be fluctuant
- Often tender
- May be blue-ish in colour
- Halo sign on USS
Management of breast cysts
- Aspirate
- If clear fluid = discard
- If blood-stained = biopsy
From where do fibroadenomas develop
Whole lobule
Clinical features of fibroadenoma
- Mobile, firm breast lump
- 1-5cm
- 7% bilateral
- 7% recurrent after excision
What constitutes a ‘giant’ fibroadenoma
> 5cm
Describe the structure of a fibroadenoma
Growth of glandular and cystic tissue within a network of fibrous stroma, enclosed by capsule
Why must core biopsy be performed in fibroadenoma
Cannot be distinguished from Phyllodes tumour on cytology alone
Outline the indications for surgical excision of fibroadenoma
- > 3cm
- Patient request
- Diagnostic difficulties
Management of Phyllodes tumour
Wide local excision (axillary surgery is NOT indicated)
Clinical features of Fat necrosis
- Lump
- Skin dimpling and retraction
- Associated with trauma
How does fat necrosis appear on mammography
Focal calcification and scarring
Outline the management of fat necrosis
- Must be imaged and biopsied
- Can be excised if diagnostic uncertainty
Clinical features of sclerosing adenosis (radial scars)
- Breast lump or pain
- Mammographic changes mimic carcinoma
- Distortion of distal lobular unit, without hyperplasia
How do blocked Montgomery’s tubercles present
Periareolar lump (caused by blockage of the sebaceous glands of the areolar)
Clinical features of Mondor’s disease
- Thrombophlebitis of subcutaneous vein
- Presents as tender skin dimpling with palpable indurate cord
Treatment of Mondor’s disease
NSAIDs
Management of Galactocele
Aspirated to dryness
Clinical features of Paget’s disease of the nipple
- Scaly, non-itchy nipple lesion
- May be point of bleeding, discharge is rare
- Can spread to areola
Paget’s Vs Eczema differences
- Paget’s is typicaly unilateral
- Eczema does NOT affect the nipple
- Paget’s spares areola
Investigating Paget’s disease
- Bilateral mammograms
- Punch biopsy
- Biopsy of underlying lesion
Clinical features of mammary duct ectasia
- Older women
- Smokers
- Green nipple discharge
- Occasional nipple retraction
How may troublesome duct ectasia be managed
Hadfield’s procedure (total duct excision)
Clinical features of duct papilloma
- Usually within 2-3cm of nipple
- Benign polyp of ductal epithelium
- Blood-stained discharge
List the abnormal features of nipple discharge
- Single duct
- Frankly blood-stained
- RBCs on cytology
- Papilloma on USS
How should cases of nipple discharge with concerning features be managed
Microdochectomy (diagnostic procedure)
What is the most common cause of blood-stained discharge in younger women
Intraductal papilloma
Most common cause of mastitis neonatorum
- Staph aureus
- E. coli
Most common cause of lactational/puerperal mastitis
Staph aureus
How should mastitis neonatorum be managed
Antibiotics (rarely needs drainage)
How should lactational/puerperal mastitis be managed
- Antibiotics
- Continue breast feeding
- Simple analgesia/cold compress
How should lactational abscesses be managed
- Aspiration under USS
- Saline and LA irrigation
- Repeat every 2-3 days
Clinical features of periareolar mastitis
- 90% smokers
- Periareolar inflammation
- Yellow discharge
- Nipple retraction
Outline the management of periareolar mastitis
- Antibiotics
- Needle aspiration
- Subareolar duct excision if recurrent (risks mammary duct fistula)
Lifetime risk of breast cancer
1 in 8
List the typical pathological changes seen in conjunction with invasive breast cancer
- Nuclear pleomorphism
- Coarse chromatin
- Angiogenesis
- Invasion of the basement membrane
- Dystrophic calcification
- Abnormal mitosis
- Vascular invasion
- Lymph node metastasis
What is comedo necrosis and what does it indicate
- Large cells with pleomorphic nuclei and luminal necrosis
- DCIS
Outline the management of DCIS
- WLE if <4cm
- Mastectomy if >4cm
- Consider adjuvant radiotherapy if high grade or large
Lobular carcinoma in situ is a marker of risk for what
- 30% risk of synchronous breast cancer if radiological abnormality
- Metachronous breast cancer if no radiological abnormality
Histological features of invasive lobular carcinoma
- Indian file pattern
- Bullseye pattern
Management of inflammatory breast cancer
- Primary chemotherapy
2. Mastectomy with axillary clearance
What tumour features are amenable to wide local excision
- Solitary lesion
- Peripheral tumour
- Small lesion in large breast
- DCIS <4cm
- Patient choice
What tumour features are amenable to mastectomy
- Multifocal tumour
- DCIS >4cm
- Patient choice
- Patient who cannot receive adjuvant radiotherapy
- Local recurrence after previous breast conserving surgery
What treatment must follow breast-conserving surgery
Adjuvant radiotherapy
What are the necessary resection margins in breast-conserving surgery
- 1mm for invasive disease
- 2mm for DCIS
(A cuff of 1cm surrounding tissue is aimed for on excision)
List the common complications of simple mastectomy
- Haematoma
- Seroma
- Psychological trauma
- Disease recurrence
What nerve is at risk during sentinel node biopsy
Intercostobrachial nerve (causing numbness of the inner arm)
List the intraoperative hazards in axillary node clearance
- Axillary vein
- Thoracodorsal trunk
- Long thoracic nerve
- Thoracoacromial artery (in level 3 dissection)
What type of genes are BRCA genes
DNA-mistmatch repair genes
On which chromosome is BRCA 1 found
Long-arm of chromosome 17
Which cancers is BRCA 1 associated with
- Female breast cancer
- Ovarian cancer
- Prostate cancer
- Colon cancer
What is the lifetime incidence of developing breast cancer in a BRCA -1 carrier
70%
What are the typical features of breast cancers in those with BRCA-1 mutation
- High-grade
- Usually ER and PR negative
- Well-circumscribed or round appearance
On which chromosome is BRCA 2 found
Long-arm of chromosome 13
Which cancers is BRCA 2 associated with
- Male and female breast cancer
- Ovarian cancer
What are the typical features of breast cancers in those with BRCA-2 mutation
- Less well defined
- More commonly lobular
What is the lifetime risk of developing breast cancer in a BRCA-2 carrier
55%
What are the adaptations to the breast screening programme for those with moderate and severe genetic risk of breast cancer
- Annual examination and mammogram from 35
(Earlier if known family cases <35) - Those with dense breast tissue or <35 will have MRI
How does breast cancer risk correlate with oestrogen exposure
Raised incidence with greater lifetime oestrogen exposure
What score is used to predict prognosis in breast cancer
Nottingham prognostic index
Outline the components of the Nottingham prognostic index
(0.2 x tumour size (cm)) + tumour grade + lymph node status
What is the single most important prognostic factor
Lymph node status
How many sentinel nodes are there
1-7
How are the sentinel nodes identified
By combination of 2 techniques:
- Technetium-99 detected by gamma probe
- Blue patent V dye
What score quantifies the number of ER-positive cells
Allred score
What system is used to stage breast cancer
Bloom-Richardson model
Who are invited to breast screening and how often
All women aged 50-70 (+/- 3 years) every 3 years
Outline the basic hormonal adjuvant options for ER+ve breast cancer treatement
- Premenopausal = Tamoxifen
- Post-menopausal = Aromatase inhibtor e.g. Letrozole
How long should Tamoxifen be given and why is this limited
- 5 years
- Evidence of increased risk of endometrial cancer when given for longer
What is the function of aromatase
Converts circulating androgens to oestrogen in the peripheral fatty tussues
In whom is chest wall radiotherapy given
- Grade 3 cancers that are multifocal or near to skin/muscle
- Larger cancers >4cm
- Presence of lymphovascular invasion
- 3 or more positive nodes
What is the clinic follow-up duration in breast cancer patients
2 years
What is the typical site of autologous tissue used on oncoplastic breast reconstruction
Pedicled extended latissimus dorsi flap
What is the capsular contracture rate for implant-based reconstructions
75%
What is the most frequent site of breast metastases
Bones
What drugs can cause Gynaecomastia
- ACE-i
- Calcium channel blockers
- Spironolactone
- Digoxin
- Amiodarone
- Anti-androgens
- H-2 receptor antagonists
- PPI
- TCAs
- Phenothiozines
- Methyldopa
- Diazepam
- Steroids
- Finasteride
- Metoclopramide
What drugs can be used for the treatment of gynaecomastia
- Danazol
- Tamoxifen
What condition is linked with breast chemotherapy
Secondary AML
In whom does lobular carcinoma typically occur in
Premenopausal women
List the typical features of lobular carcinoma
- Typically has no clinical features
- Often bilateral
- Can be missed on mammogram
- Can be multifocal
Why does Actinomyocosis occur and what are the typical features
- Spread of infection from the lung through the chest wall
- Usually presents with hard lump beneath the nipple
- Abscess formation with pus containing sulphur granules
