Breast Surgery Flashcards
1
Q
Embryological origin of the epithelial lining of the ducts and acini
A
Ectoderm
2
Q
Embryological origin of the supporting tissue (stroma)
A
Mesenchyme
3
Q
When is the mammary ridge developed
A
5 weeks
4
Q
Where are the milk lines situated
A
Stretch from axilla to the groin
5
Q
At what age is the breast bud formed
A
10
6
Q
When does nipple development occur
A
12
7
Q
Which ribs does the breast span
A
2nd to 6th
8
Q
Which muscles does the breast cover
A
- Medial 2/3rd = Pec major
- Lateral 1/3rd = Serratus anterior
9
Q
Outline the structure of the breast
A
- Composed of 15-20 lobules
- Lobules drain into lactiferous ducts
- Lactiferous ducts drain into lactiferous sinuses which store milk
- Lactiferous ducts feed excretory sinuses
10
Q
What type of epithelium lines the lobule ducts
A
Columnar/cuboidal epithelium
11
Q
What type of epithelium lines the excretory ducts
A
Squamous epithelium
12
Q
What connects the breast to the deep fascia of the chest wall
A
Suspensory ligaments of Cooper
13
Q
Which rib space does the nipple align with
A
4th
14
Q
Outline the blood supply to the lateral breast
A
Lateral thoracic and Thoracoacromial arteries (branches of the axillary artery)
15
Q
Outline the blood supply to the medial breast
A
Perforating branches of intercostal spaces 1-4 (branches of the IMA)
16
Q
Outline the venous drainage of the lateral breast
A
Thoracoacromial vein -> lateral thoracic vein -> axillary vein
17
Q
Outline the venous drainage of the medial breast
A
Internal thoracic vein -> subclavian vein
18
Q
Via which route does breast cancer spread to the thoracic vertebrae and ribs
A
Haematogenous via posterior intercostal veins that communicate with the vertebral venous plexus
19
Q
Describe the cutaneous innervation of the breast
A
Cutaneous branches of intercostal nerves T4-6
20
Q
Outline the lymphatic drainage of the breast
A
- 75-97% via axillary nodes
- 25% to internal mammary nodes through 2nd-4th intercostal spaces
21
Q
Outline the connection between right and left breast lymphatics
A
There is anastomosis across the midline and down the abdominal wall
22
Q
How are Axillary lymph nodes classified in axillary node clearance
A
- Level 1 = lateral to pec minor
- Level 2 = posterior to pec minor
- Level 3 = medial to pec minor
23
Q
Which structures drain into the anterior (pectoral) nodes
A
Anterior upper trunk and breast
24
Q
Which structures drain into the posterior (subscapular) nodes
A
Posterior upper trunk and axillary tail
25
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
26
What stimulates the growth and development of breast tissue during puberty
Oestrogens
27
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
28
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
29
How does lactation occur
When prolactin release is no longer inhibited by oestrogen
30
What is released from the breast during the first 2-4 days post-partum
Colostrum - high in protein and IgA
31
What causes milk ejection
Oxytocin - released in response to suckling
32
What happens to the breast tissue during menopause
Regression of breast tissue and replacement with fat and fibrosis
33
What imaging modality is used in the triple assessment
- <35 = USS
| - >35 = Mammography
34
What imaging modality is preferable in those with implants presenting with a lump
- <35 = USS
| - >35 = Mammography
35
What imaging modality is preferred for assessing issues with breast implants
MRI
36
What imaging modality is preferred for screening young patients with a family history of breast Ca
MRI
37
What does C1 mean on cytology assessment
Insufficient cells for diagnosis
38
What letter denotes core biopsy in the triple assessment
B
39
What does B5a indicate
DCIS
40
What does B5b indicate
Invasive carcinoma
41
What is the gold standard method of histological assessment
Core biopsy
42
When is punch biopsy indicated
For suspicious skin lesion on breast or areola
43
Describe the cyclical variation in fibrocystic breast disease
Symptoms peak at the end of the luteal phase (just before menstruation)
44
Outline the histological changes seen in fibrocystic breast disease
- Stromal fibrosis adenosis (increase in glandular tissue)
- Cyst formation
- Papillomatosis
- Epithelial hyperplasia
45
Symptoms of fibrocystic breast disease
- Nodular breast tissue (cobblestone texture)
- Discrete tender lumps
- Cyclical breast pain
- Breast cysts
46
Management of fibrocystic breast disease
- Reassurance
- Analgesia
- Aspiration of cysts
- COCP
47
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
48
Management of breast cysts
- Aspirate
- If clear fluid = discard
- If blood-stained = biopsy
49
From where do fibroadenomas develop
Whole lobule
50
Clinical features of fibroadenoma
- Mobile, firm breast lump
- 1-5cm
- 7% bilateral
- 7% recurrent after excision
51
What constitutes a 'giant' fibroadenoma
>5cm
52
Describe the structure of a fibroadenoma
Growth of glandular and cystic tissue within a network of fibrous stroma, enclosed by capsule
53
Why must core biopsy be performed in fibroadenoma
Cannot be distinguished from Phyllodes tumour on cytology alone
54
Outline the indications for surgical excision of fibroadenoma
- >3cm
- Patient request
- Diagnostic difficulties
55
Management of Phyllodes tumour
Wide local excision (axillary surgery is NOT indicated)
56
Clinical features of Fat necrosis
- Lump
- Skin dimpling and retraction
- Associated with trauma
57
How does fat necrosis appear on mammography
Focal calcification and scarring
58
Outline the management of fat necrosis
- Must be imaged and biopsied
| - Can be excised if diagnostic uncertainty
59
Clinical features of sclerosing adenosis (radial scars)
- Breast lump or pain
- Mammographic changes mimic carcinoma
- Distortion of distal lobular unit, without hyperplasia
60
How do blocked Montgomery's tubercles present
Periareolar lump (caused by blockage of the sebaceous glands of the areolar)
61
Clinical features of Mondor's disease
- Thrombophlebitis of subcutaneous vein
| - Presents as tender skin dimpling with palpable indurate cord
62
Treatment of Mondor's disease
NSAIDs
63
Management of Galactocele
Aspirated to dryness
64
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
65
Paget's Vs Eczema differences
- Paget's is typicaly unilateral
- Eczema does NOT affect the nipple
- Paget's spares areola
66
Investigating Paget's disease
- Bilateral mammograms
- Punch biopsy
- Biopsy of underlying lesion
67
Clinical features of mammary duct ectasia
- Older women
- Smokers
- Green nipple discharge
- Occasional nipple retraction
68
How may troublesome duct ectasia be managed
Hadfield's procedure (total duct excision)
69
Clinical features of duct papilloma
- Usually within 2-3cm of nipple
- Benign polyp of ductal epithelium
- Blood-stained discharge
70
List the abnormal features of nipple discharge
- Single duct
- Frankly blood-stained
- RBCs on cytology
- Papilloma on USS
71
How should cases of nipple discharge with concerning features be managed
Microdochectomy (diagnostic procedure)
72
What is the most common cause of blood-stained discharge in younger women
Intraductal papilloma
73
Most common cause of mastitis neonatorum
- Staph aureus
| - E. coli
74
Most common cause of lactational/puerperal mastitis
Staph aureus
75
How should mastitis neonatorum be managed
Antibiotics (rarely needs drainage)
76
How should lactational/puerperal mastitis be managed
- Antibiotics
- Continue breast feeding
- Simple analgesia/cold compress
77
How should lactational abscesses be managed
- Aspiration under USS
- Saline and LA irrigation
- Repeat every 2-3 days
78
Clinical features of periareolar mastitis
- 90% smokers
- Periareolar inflammation
- Yellow discharge
- Nipple retraction
79
Outline the management of periareolar mastitis
1. Antibiotics
2. Needle aspiration
3. Subareolar duct excision if recurrent (risks mammary duct fistula)
80
Lifetime risk of breast cancer
1 in 8
81
List the typical pathological changes seen in conjunction with invasive breast cancer
1. Nuclear pleomorphism
2. Coarse chromatin
3. Angiogenesis
4. Invasion of the basement membrane
5. Dystrophic calcification
6. Abnormal mitosis
7. Vascular invasion
8. Lymph node metastasis
82
What is comedo necrosis and what does it indicate
- Large cells with pleomorphic nuclei and luminal necrosis
| - DCIS
83
Outline the management of DCIS
- WLE if <4cm
- Mastectomy if >4cm
- Consider adjuvant radiotherapy if high grade or large
84
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
85
Histological features of invasive lobular carcinoma
- Indian file pattern
| - Bullseye pattern
86
Management of inflammatory breast cancer
1. Primary chemotherapy
| 2. Mastectomy with axillary clearance
87
What tumour features are amenable to wide local excision
- Solitary lesion
- Peripheral tumour
- Small lesion in large breast
- DCIS <4cm
- Patient choice
88
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
89
What treatment must follow breast-conserving surgery
Adjuvant radiotherapy
90
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)
91
List the common complications of simple mastectomy
- Haematoma
- Seroma
- Psychological trauma
- Disease recurrence
92
What nerve is at risk during sentinel node biopsy
Intercostobrachial nerve (causing numbness of the inner arm)
93
List the intraoperative hazards in axillary node clearance
- Axillary vein
- Thoracodorsal trunk
- Long thoracic nerve
- Thoracoacromial artery (in level 3 dissection)
94
What type of genes are BRCA genes
DNA-mistmatch repair genes
95
On which chromosome is BRCA 1 found
Long-arm of chromosome 17
96
Which cancers is BRCA 1 associated with
- Female breast cancer
- Ovarian cancer
- Prostate cancer
- Colon cancer
97
What is the lifetime incidence of developing breast cancer in a BRCA -1 carrier
70%
98
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
99
On which chromosome is BRCA 2 found
Long-arm of chromosome 13
100
Which cancers is BRCA 2 associated with
- Male and female breast cancer
| - Ovarian cancer
101
What are the typical features of breast cancers in those with BRCA-2 mutation
- Less well defined
| - More commonly lobular
102
What is the lifetime risk of developing breast cancer in a BRCA-2 carrier
55%
103
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
104
How does breast cancer risk correlate with oestrogen exposure
Raised incidence with greater lifetime oestrogen exposure
105
What score is used to predict prognosis in breast cancer
Nottingham prognostic index
106
Outline the components of the Nottingham prognostic index
(0.2 x tumour size (cm)) + tumour grade + lymph node status
107
What is the single most important prognostic factor
Lymph node status
108
How many sentinel nodes are there
1-7
109
How are the sentinel nodes identified
By combination of 2 techniques:
1. Technetium-99 detected by gamma probe
2. Blue patent V dye
110
What score quantifies the number of ER-positive cells
Allred score
111
What system is used to stage breast cancer
Bloom-Richardson model
112
Who are invited to breast screening and how often
All women aged 50-70 (+/- 3 years) every 3 years
113
Outline the basic hormonal adjuvant options for ER+ve breast cancer treatement
- Premenopausal = Tamoxifen
| - Post-menopausal = Aromatase inhibtor e.g. Letrozole
114
How long should Tamoxifen be given and why is this limited
- 5 years
| - Evidence of increased risk of endometrial cancer when given for longer
115
What is the function of aromatase
Converts circulating androgens to oestrogen in the peripheral fatty tussues
116
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
117
What is the clinic follow-up duration in breast cancer patients
2 years
118
What is the typical site of autologous tissue used on oncoplastic breast reconstruction
Pedicled extended latissimus dorsi flap
119
What is the capsular contracture rate for implant-based reconstructions
75%
120
What is the most frequent site of breast metastases
Bones
121
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
122
What drugs can be used for the treatment of gynaecomastia
- Danazol
| - Tamoxifen
123
What condition is linked with breast chemotherapy
Secondary AML
124
In whom does lobular carcinoma typically occur in
Premenopausal women
125
List the typical features of lobular carcinoma
- Typically has no clinical features
- Often bilateral
- Can be missed on mammogram
- Can be multifocal
126
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
