Breast Surgery Flashcards
1
Q
Lactational Mastitis
what is it
A
inflammation of breast tissue
common complication of breast feeding
2
Q
Lactational Mastitis
causes of mastitis
A
- obstruction in ducts and accumulation of milk
- infection (Staph aureus)
3
Q
Lactational Mastitis
how may obstruction be prevented
A
Regularly expressing breast milk
4
Q
Lactational Mastitis
presentation
A
- Breast pain and tenderness (unilateral)
- Erythema in a focal area of breast tissue
- Local warmth and inflammation
- Nipple discharge
- Fever
5
Q
Lactational Mastitis
mnx when caused by blockage of ducts
A
conservative:
- continued breastfeeding, expressing milk
- breast massage
- heat packs, warm showers
- simple analgesia
6
Q
Lactational Mastitis
mnx if infection suspected or conservative doesn’t work
A
- flucloxacillin
- erythromycin if allergic
- sample of milk sent for C&S
- Fluconazole if suspected candidal infection
- continue breastfeeding
7
Q
Lactational Mastitis
rare complication of mastitis
A
breast abscess
may need surgical incision and drainage
8
Q
Lactational Mastitis
why may candidal infection cause recurrent mastitis
A
it causes cracked skin on the nipple that creates an entrance for infection.
9
Q
Lactational Mastitis
if there is candida of the nipple, what may the infant get
A
oral thrush and candidal nappy rash
10
Q
Lactational Mastitis
presentation of candida of the nipple
A
- Sore nipples bilaterally, particularly after feeding
- Nipple tenderness and itching
- Cracked, flaky or shiny areola
- baby: white patches in mouth and tongue, or candidal nappy rash
11
Q
Lactational Mastitis
mnx of candida of the nipple
A
- Topical miconazole 2% to the nipple after each breastfeed
- baby: PO miconazole gel or nystatin
12
Q
Breast Pain (Mastalgia)
types
A
cyclical
non cyclical
13
Q
Breast Pain (Mastalgia)
what may non-cyclical breast pain be caused by
A
- Medications (e.g., hormonal contraceptive medications)
- Infection (e.g., mastitis)
- Pregnancy
no originating from breast:
- costochondritis
- shingles, post-herpetic neuralgia
14
Q
Breast Pain (Mastalgia)
3 things to exclude when presenting with breast pain
A
- cancer
- infection
- pregnancy
15
Q
Breast Pain (Mastalgia)
what can help diagnose cyclical breast pain
A
a breast pain diary
16
Q
Breast Pain (Mastalgia)
mnx of cyclical breast pain
A
- supprotive bra
- NSAIDs
- avoid caffeine
- heat
- Hormonal treatments (e.g., danazol and tamoxifen) under specialist guidance
17
Q
Breast Cancer
what does triple assessment involve
A
- clinical assessment (hx + exam)
- imaging (US or mammography)
- histology (fine needle aspiration or core biopsy)
18
Q
Breast Cancer
clinical features which may suggest its breast cancer
A
- hard, irregular, painless or fixed in place lumps
- lump tethered to skin or chest wall
- nipple retraction
- skin dimpling or oedema (peau d’orange)
19
Q
Breast Cancer
when should you do a 2 week wait referral
A
- unexplained breast lump in patients ≥ 30
- unilateral nipple changes in patients ≥50 (discharge, retraction or other changes)
- unexplained lump in the axilla in patients ≥ 30
- skin changes suggestive of breast cancer
20
Q
Breast Cancer
when should you consider a non-urgent referral
A
unexplained breast lumps in patients <30
21
Q
Fibroadenoma
what are they
A
benign tumours of stromal/epithelial breast duct tissue
‘breast mouse’
22
Q
Fibroadenoma
what age group are they common in
A
20 - 40
23
Q
Fibroadenoma
what do they respond to
A
the female hormones (oestrogen and progesterone)
24
Q
Fibroadenoma
examination findings
A
- painless
- smooth
- round
- well circumscribed
- firm
- mobile
- usually up to 3cm
25
Fibroadenoma
are they associated with an increased risk of developing breast cancer
no
26
Fibrocystic Breast Changes
what are they
generalised lumpiness to the breast
27
Fibrocystic Breast Changes
when do these changes fluctuate
with the menstral cycle
28
Fibrocystic Breast Changes
when do symptoms occur in the the menstrual cycle
prior to menstruating (within 10 days) and resolve once menstruation begins
29
Fibrocystic Breast Changes
symptoms
different areas of the breast, or both breasts, with:
- Lumpiness
- Breast pain or tenderness (mastalgia)
- Fluctuation of breast size
30
Fibrocystic Breast Changes
options to manage cyclical breast pain
- supportive bra
- NSAIDs
- avoid caffeine
- apply heat
- hormonal trx (e.g., danazol and tamoxifen) under specialist guidance
31
what are the most common cause of breast lumps
breast cysts
32
Breast Cysts
do they increase risk of breast cancer
it may slightly
33
Breast Cysts
examination findings
Smooth
Well-circumscribed
Mobile
Possibly fluctuant
34
Breast Cysts
affected by menstrual period?
may fluctuate in size over the menstrual cycle.
35
Fat necrosis
what is it
a benign lump formed by localised degeneration and scarring of fat tissue in the breast
36
Fat necrosis
what is it commonly triggered by
- localised trauma
- radiotherapy
- surgery
37
Fat necrosis
how do the triggers cause fibrosis and necrosis of fat tissue
inflammatory reaction
38
Fat necrosis
does it increase the risk of breast cancer
no
39
Fat necrosis
examination findings
- painless
- firm
- irregular
- fixed in local structures
- may be skin dimpling or nipple inversion
40
Fat necrosis
what may US or mammogram show
similar appearance to breast cancer.
41
Fat necrosis
what may be required to confirm the dx and exclude breast cancer
histology (by fine needle aspiration or core biopsy)
42
Fat necrosis
mnx
- conservative, resolved spontaneously with time
| - surgical excision may be used if required for sx
43
Lipoma
what are they
benign tumours of fat (adipose) tissue
44
Lipoma
examination findings
- soft
- painless
- mobile
- do not cause skin changes
45
Lipoma
trx
treated conservatively with reassurance. Alternatively, they can be surgically removed.
46
Galactocele
what are they
breast milk filled cysts that occur when the lactiferous duct is blocked, preventing the gland from draining milk
47
Galactocele
who do they commonly occur in
lactating women who have stopped breastfeeding
48
Galactocele
presentation
firm, mobile, painless lump, usually beneath the areola.
49
Galactocele
trx
resolve without any treatment. It is possible to drain them with a needle.
Rarely, they can become infected and require antibiotics.
50
Phyllodes tumour
what are they
rare tumours of the connective tissue (stroma) of the breast, occurring most often between ages 40 and 50
51
Phyllodes tumour
features
- large
| - fast growing
52
Phyllodes tumour
types
benign (~50%), borderline (~25%) or malignant (~25%)
53
Phyllodes tumour
trx
surgical removal of the tumour and wide excision
chemo if malignant
54
Gynaecomastia
what is it
enlargement of the glandular breast tissue in males
55
Gynaecomastia
which hormones stimulate glandular breast tissue development
oestrogen and prolactin
56
Gynaecomastia
why can antipsychotic medication cause gynaecomastia
they are dopamine antagonists
dopamine inhibits prolactin
less dopamine = more prolactin = gynaecomastia and galactorrhea
57
Gynaecomastia
why can there be gynaecomastia in adolescents
proportionally higher oestrogen levels around puberty
58
Gynaecomastia
causes (conditions that increase oestrogen)
- obesity (aromatase converts androgens to oestrogen)
- testicular cancer (oestrogen secretion from Leydig cell tumour)
- liver cirrhosis + liver failure
- hyperthyroidism
- hCG secreting tumour (e.g. small cell lung cancer)
59
man presenting with gynaecomastia. what additional examination should be performed
testicular examination for leydig cell tumour
Also, examine for signs of liver failure and hyperthyroidism.
60
Gynaecomastia
causes (conditions that reduce testosterone)
- testosterone deficiency in older age
- hypothalamus or pituitary conditions that reduce LH + FSH (tumour, radio, surgery)
- Klinefelter syndrome (XXY sex chromosomes)
- orchitis (infection of testicles with mumps)
- testicular damage
61
Gynaecomastia
drug causes
- Anabolic steroids (raise oestrogen levels)
- Antipsychotics (increase prolactin levels)
- Digoxin (stimulates oestrogen receptors)
- Spironolactone (inhibits testosterone production and blocks testosterone receptors)
- Gonadotrophin-releasing hormone (GnRH) agonists (e.g., goserelin used to treat prostate cancer)
- Opiates (e.g., illicit heroin use)
- Marijuana
- Alcohol
62
Gynaecomastia
difference between gynaecomastia and breast enlargement due to obesity (pseudogynaecomastia) on palpation
gynaecomastia: firm tissue behind the areolas
obese: tissue soft and more evenly distributed
63
Gynaecomastia
key points to cover in hx
- age of onset, duration , change over time
- sexual dysfunction (indicates low testosterone)
- breast lumps or skin changes (breast cancer)
- testicular lumps or sx of hyperthyroidism
- medications
- anabolic steroids, illicit drugs or alcohol
64
Gynaecomastia
key points to cover in examination
- true gynaecomastia vs adipose tissue
- unilateral or bilateral (palpable lumps, skin changes or lymphadenopathy)
- BMI
- testicular exam
- reduced hair (testosterone deficiency)
- liver disease (jaundice, hepatomegaly, spider naevi, ascites)
- hyperthyroidism (sweating, tachycardia, weight loss)
65
Gynaecomastia
inx for simple gynaecomastia in an otherwise healthy adolescent
watchful waiting
66
Gynaecomastia
inx for unexplained rapid-onset gynaecomastia in a 30 year old male with no apparent cause
bloods and imaging
67
Gynaecomastia
trx in problematic causes (e.g. pain or psychological distress)
- tamoxifen (reduces oestrogen in breast tissue)
| - surgery
68
Galactorrhoea
what is it
breast milk production not associated with pregnancy or breastfeeding
69
Galactorrhoea
what is breast milk produced in response to
prolactin
70
Galactorrhoea
what produces prolactin
anterior pituitary gland
breast and prostate also produce it
71
Galactorrhoea
what blocks the secretion of prolactin
dopamine
so dopamine antagonists (i.e., antipsychotic medications) can result in raised prolactin and galactorrhea
72
Galactorrhoea
what can suppress prolactin secretion
Dopamine agonists (e.g., bromocriptine or cabergoline)
73
Galactorrhoea
when may milk production start in pregnancy
2nd or 3rd trimester
74
Galactorrhoea
in pregnancy, what inhibits the secretion of prolactin
Oestrogen and progesterone
75
Galactorrhoea
in pregnancy, what stimulates breast milk excretion
oxytocin
76
Galactorrhoea
what stimulates full milk production shortly after birth
response to oxytocin release and a rapid drop in oestrogen and progesterone
77
Galactorrhoea
what is usually the cause
hyperprolactinaemia
78
Galactorrhoea
key causes of hyperprolactinaemia
- idiopathic
- prolactinomas
- endocrine: hypothyroidism, PCOS
- meds: dopamine antagonists e.g. antipsychotics
79
Galactorrhoea
what does prolactin suppress and therefore cause
GnRH by the hypothalamus
leading to reduced LH and FSH release
80
Galactorrhoea
what does hyperprolactinaemia present with (due to reduced LH and FSH)
- amenorrhoea
- reduced libido
- erectile dysfunction
- gynaecomastia
81
Galactorrhoea
what are prolactinomas
tumours of the pituitary gland that secrete excessive prolactin
82
Galactorrhoea
what condition may prolactinomas be associated with
multiple endocrine neoplasia (MEN) type 1
an autosomal dominant genetic condition
83
Galactorrhoea
what are microprolactinomas
<10mm
84
Galactorrhoea
what are macroprolactinomas
>10mm
85
Galactorrhoea
what adverse effects can macroadenomas have relating to their size
- Headaches
| - Bitemporal hemianopia
86
Galactorrhoea
why is there bitemporal hemianopia in prolactinomas
- optic chiasm sits just above pituitary gland
- the optic chiasm is where the optic nerves cross over
- Only the nerves fibres containing the signal from the outer visual fields cross over,
- fibres from the inner visual fields continue on the same side
- pituitary tumour of sufficient size will press on the optic chiasm
- outer visual fields in both eyes (the inner visual fields are spared
87
Galactorrhoea
what conditions can cause nipple discharge that is not breast milk
- mammary duct ectasia
- duct papilloma
- pus from a breast abscess
88
Galactorrhoea
initial investigations
PREGNANCY TEST
- Serum prolactin
- U&Es
- LFTs
- TFTs
89
Galactorrhoea
diagnostic inx for pituitary tumour
MRI scan
90
Galactorrhoea
what can be used to trx the sx of hyperprolactinaemia
Dopamine agonists (e.g., bromocriptine or cabergoline)
91
Galactorrhoea
what is the definitive treatment of hyperprolactinaemia secondary to a prolactinoma.
Trans-sphenoidal surgical removal of the pituitary tumour
92
Mammary Duct Ectasia
what is it
a benign condition where there is dilation of the large ducts in the breasts
ectasia = dilatation
93
Mammary Duct Ectasia
what does inflammation of the ducts lead to
intermittent white, grey or green discharge from the nipple
94
Mammary Duct Ectasia
who does it occur most frequently in
perimenopausal women
95
Mammary Duct Ectasia
what is a significant RF
smoking
96
Mammary Duct Ectasia
- presentation
- nipple discharge
- tenderness or pain
- nipple retraction or inversion
- breast lump (pressure may produce nipple discharge)
97
Mammary Duct Ectasia
what is the initial priority when investigating
exclude breast cancer
98
Mammary Duct Ectasia
what inx to exclude breast cancer
triple assessment:
- clinical assessment (hx + exam)
- imaging (US, mammography, MRI)
- histology (fine needle aspiration or core biopsy)
99
Mammary Duct Ectasia
what is a key finding on a mammogram
microcalcifications
| but not specific to mammary duct ectasia
100
Mammary Duct Ectasia
other inx that may be performed (apart from triple assessment)
- ductography
- nipple discharge cytology
- ductoscopy
101
Mammary Duct Ectasia
what is ductography
contrast is injected into an abnormal duct, and mammograms are performed to visualise the duct
102
Mammary Duct Ectasia
what is nipple discharge cytology
examining the cells in a sample of the nipple discharge
103
Mammary Duct Ectasia
what is ductoscopy
inserting a tiny endoscope (camera) into the duct
104
Mammary Duct Ectasia
mnx
- may resolve
- reassurance after excluding cancer
- mnx of mastalgia: supportive bra, warm compresses
- abx if infection
105
Mammary Duct Ectasia
what may be required in problematic cases
surgical excision
106
Intraductal Papilloma
what is it
a warty lesion that grows within one of the ducts in the breast.
the result of proliferation of epithelial cells
107
Intraductal Papilloma
are they cancerous
the are benign tumours
but can be associated with atypical hyperplasia or breast cancer.
108
Intraductal Papilloma
what age do most occur in
35-55y
109
Intraductal Papilloma
presentation
- Nipple discharge (clear or blood-stained)
- Tenderness or pain
- A palpable lump
110
Intraductal Papilloma
inx
- triple assessment (clinical, imaging, histology)
| - ductography
111
Intraductal Papilloma
what will it show on ductography
The papilloma will be seen as an area that does not fill with contrast (a “filling defect”).
112
Intraductal Papilloma
mnx
- complete surgical excision
| - tissue is examined for atypical hyperplasia or cancer that may not have been picked up on the biopsy
113
Breast Abscess
what is it
a collection of pus within an area of the breast, usually caused by a bacterial infection.
114
Breast Abscess
what types are there
Lactational abscess (associated with breastfeeding)
Non-lactational abscess (unrelated to breastfeeding)
115
Breast Abscess
what does pus contain
dead white blood cells of the immune system and other waste from the fight against the infection
116
Breast Abscess
how does an abscess form
When pus becomes trapped in a specific area and cannot drain
117
Breast Abscess
what may precede the development of an abscess
Mastitis caused by infection
118
Breast Abscess
what is a key RF for infective mastitis and breast abscesses
smoking
119
Breast Abscess
what can predispose the woman to infection
Damage to the nipple (e.g., nipple eczema, candidal infection or piercings) provides bacteria entry
underlying breast disease (e.g., cancer) can affect the drainage of the breast
120
Breast Abscess
what is the most common causative bacteria
1. staph aureus
strep, enterococcal, anaerobics
121
Breast Abscess
what are penicillins effective against
gram positive bac
- staph aureus
- strep
- enterococcal
122
Breast Abscess
what is co-amoxiclav and metronidazole effective against
anaerobes
123
Breast Abscess
onset
acute (within a few days)
124
Breast Abscess
how does Mastitis with infection in the breast tissue presents with
- Nipple changes
- Purulent nipple discharge (pus from the nipple)
- Localised pain
- Tenderness
- Warmth
- Erythema (redness)
- Hardening of the skin or breast tissue
- Swelling
125
Breast Abscess
what is the key feature that suggests a breast abscess
a swollen, fluctuant, tender lump within the breast
126
Breast Abscess
what does fluctuance refer to
being able to move fluid around within the lump using pressure during palpation
127
Breast Abscess
examination findings of infection without an abscess
hardness of the tissue, forming a lump
but it will not be fluctuant as it is not filled with fluid.
128
Breast Abscess
dx of mastitis or a breast abscess
clinical with hx + exam
129
Breast Abscess
mnx of lactational mastitis (caused by blockage of the ducts)
- conservative
- continue breastfeeding
- heat packs
- warm showers
- analgesia
- flucloxacillin if infection suspected
130
Breast Abscess
mnx of non-lactational mastitis
- Analgesia
- Antibiotics
- Treatment for the underlying cause (e.g., eczema or candidal infection)
131
Breast Abscess
what abx for non-lactational mastitis
broad spectrum
- co-amoxiclav
or
- erythromycin/clarithromycin + metronidazole
132
Breast Abscess
mnx
- refer to on-call surgical team
- abx
- drainage (needle aspiration or surgical incision + drainage)
- MC&S
133
Breast Abscess
should women continue breastfeeding
yes
134
what is the most common form of cancer in the UK
breast cancer
Around 1 in 8 women will develop breast cancer in their lifetime.
135
Breast Cancer
RFs
- female
- increased oestrogen exposure (earlier onset of periods + later menopause)
- more glandular tissue
- obesity
- smoking
- FH (1st degree relative)
- COCP, HRT
136
Breast Cancer
what happens to the risk 10 years after stopping the COCP
risk returns to normal
137
Breast Cancer
what is BRCA
BReast CAncer gene
tumour suppressor genes `
138
Breast Cancer
where is the BRCA1 gene located
Ch17
139
Breast Cancer
in patients with a faulty BRCA1 gene, what will patients' risk of cancers be
- 70% will develop breast cancer by 80y
- 50% will develop ovarian cancer
- increased risk of bowel + prostate cancer
140
Breast Cancer
where is the BRCA2 gene located
Ch13
141
Breast Cancer
in patients with a faulty BRCA2 gene, what will patients' risk of cancers be
- 60% will develop breast cancer by 80y
| - 20% will develop ovarian cancer
142
Breast Cancer
what are the other rarer genetic abnormalities associated with breast cancer
TP53 and PTEN genes
143
Breast Cancer
what are the more common types
- Ductal Carcinoma In Situ (DCIS)
- Lobular Carcinoma In Situ (LCIS)
- Invasive Ductal Carcinoma – NST
- Invasive Lobular Carcinomas (ILC)
- Inflammatory Breast Cancer
- Paget’s Disease of the Nipple
144
Breast Cancer
DCIS: what is it
Pre-cancerous or cancerous epithelial cells of the breast ducts
145
Breast Cancer
DCIS: is it localised to a single area
yes but potential to spread locally over years
146
Breast Cancer
DCIS: when is it often picked up
by mammogram screening
147
Breast Cancer
DCIS: can it become invasive breast cancer
30% potential
148
Breast Cancer
DCIS: prognosis
Good prognosis if fully excised and adjuvant treatment is used
149
Breast Cancer
LCIS: what is it
A pre-cancerous condition occurring typically in pre-menopausal women
150
Breast Cancer
LCIS: how is it usually picked up
diagnosed incidentally on a breast biopsy
Usually asymptomatic and undetectable on a mammogram
151
Breast Cancer
LCIS: is there a risk of invasive breast cancer in the future
yes around 30%
152
Breast Cancer
LCIS: how is it often managed
close monitoring (e.g. 6 monthly examination and yearly mammograms)
153
Breast Cancer
Invasive Ductal Carcinoma (NST): what is it
NST: no special/specific type, where it is not more specifically classified e.g. medullary or mucinous
154
Breast Cancer
Invasive Ductal Carcinoma (NST): where does it originate
in cells from the breast ducts
155
Breast Cancer
Invasive Ductal Carcinoma (NST): is it invasive
80% of invasive breast cancers fall into this category
156
Breast Cancer
Invasive Ductal Carcinoma (NST): can it be seen on mammograms
yes
157
Breast Cancer
Invasive Lobular Carcinoma (ILC): where does it originate
in cells from the breast lobules
158
Breast Cancer
Invasive Lobular Carcinoma (ILC): is it invasive
Around 10% of invasive breast cancers
159
Breast Cancer
Invasive Lobular Carcinoma (ILC):is it visible on mammograms
not always visible
160
Breast Cancer
Inflammatory Breast Cancer: what % of breast cancers
1-3%
161
Breast Cancer
Inflammatory Breast Cancer: what does it present similarly to
breast abscess or mastitis
162
Breast Cancer
Inflammatory Breast Cancer: presentation
Swollen, warm, tender breast with pitting skin (peau d’orange)
163
Breast Cancer
Inflammatory Breast Cancer:does it respond to abx
no
164
Breast Cancer
Inflammatory Breast Cancer: prognosis
Worse prognosis than other breast cancers
165
Breast Cancer
Paget’s Disease of the Nipple: what does it look like
- eczema of the nipple/areolar
166
Breast Cancer
Paget’s Disease of the Nipple: presentation
Erythematous, scaly rash
167
Breast Cancer
Paget’s Disease of the Nipple: what may it represent
DCIS or invasive breast cancer
168
Breast Cancer
Paget’s Disease of the Nipple: what does it indicate
breast cancer involving the nipple
169
Breast Cancer
Paget’s Disease of the Nipple: mnx
Requires biopsy, staging and treatment, as with any other invasive breast cancer
170
Breast Cancer
name some rarer types of breast cancer
- Medullary breast cancer
- Mucinous breast cancer
- Tubular breast cancer
- Multiple others
171
Breast Cancer
who is screening offered to
mammogram every 3 years to women aged 50 – 70 years
172
Breast Cancer
which patients are at high-risk
- 1st degree relative w/ breast cancer <40y
- 1st degree male relative w/ breast cancer
- 1st degree relative w/ bilateral breast cancer. first diagnosed <50y
- Two 1st degree relatives w/ breast cancer
173
Breast Cancer
what do patients require before genetic tests
genetic counselling and pre-test counselling
174
Breast Cancer
who is annual mammograms offered to
women with increased risk
potentially starting from aged 30
175
Breast Cancer
what chemoprevention may be offered for women at high risk
- tamoxifen if premenopausal
| - anastrozole if postmenopausal (except w/ severe osteoporosis)
176
Breast Cancer
what is an option for a small number of high risk women
Risk-reducing bilateral mastectomy or bilateral oophorectomy
177
Breast Cancer
clinical features
- Lumps that are hard, irregular, painless or fixed in place
- Lumps may be tethered to the skin or the chest wall
- Nipple retraction
- Skin dimpling or oedema (peau d’orange)
- Lymphadenopathy, particularly in the axilla
178
Breast Cancer
NICE recommend a 2 week wait referral for suspected breast cancer for...
- an unexplained lump in in pts aged ≥30
| - unilateral nipple changes in pts aged ≥50 (discharge, retraction or other changes)
179
Breast Cancer
NICE recommend considering a 2 week wait referral for...
- an unexplained lump in the axilla in pts aged ≥30
| - skin changes suggestive of breast cancer
180
Breast Cancer
NICE suggest considering a non-urgent referral for...
unexplained breast lumps in patients <30y
181
Breast Cancer
what does a triple diagnostic assessment comprise of
1. Clinical assessment (history and examination)
2. Imaging (ultrasound or mammography)
3. Biopsy (fine needle aspiration or core biopsy)
182
Breast Cancer
when may US be used for imaging and why
assess lumps in women <30y
because they have more dense breasts with more glandular tissue
helpful in distinguishing solid lumps (e.g., fibroadenoma or cancer) from cystic (fluid-filled) lumps
183
Breast Cancer
who are mammograms used in
generally more effective in older women. They can pick up calcifications missed by ultrasound.
184
Breast Cancer
when may MRI scans be used
- For screening in women at higher risk of developing breast cancer (e.g., strong family history)
- To further assess the size and features of a tumour
185
Breast Cancer
what is involved in a lymph node assessment
US of the axilla
US-guided biopsy of any abnormal nodes
A sentinel lymph node biopsy may be used during breast cancer surgery where the initial US does not show any abnormal nodes
186
Breast Cancer
what happens in sentinel lymph node biopsy
- isotope contrast and a blue dye injected into tumour area
- it travels through the lymphatics to the 1st lymph node (the sentinel node)
- shows up blue on the isotope scanner
- biopsy of this node performed
- if cancer cells found, lymph node removed
187
Breast Cancer
what are the 3 types of breast cancer receptors
Oestrogen receptors (ER)
Progesterone receptors (PR)
Human epidermal growth factor (HER2)
188
Breast Cancer
what is triple-negative breast cancer
the breast cancer cells do not express any of these three receptors.
worst prognosis because it limits trx options
189
Breast Cancer
what does gene expression profiling involve
assessing which genes are present within the breast cancer on a histology sample
helps predict the probability that the breast cancer will reoccur as a distal metastasis within 10y
190
Breast Cancer
NICE recommend gene expression profiling for whom
women with early breast cancers that are ER positive but HER2 and lymph node negative.
It helps guide whether to give additional chemotherapy.
191
Breast Cancer
notable locations that breast cancer metastase to
2 L and 2 B
liver
lungs
bones
brain
but can spread anywhere
192
Breast Cancer
which 2 cancers can spread practically anywhere
melanoma and breast cancer
193
Breast Cancer
inx for staging
- triple assessment
- Lymph node assessment + biopsy
- MRI of breast and axilla
- Liver US for liver metastasis
- CT of thorax, abdo + pelvis for metastasis
- Isotope bone scan for bony metastasis
194
Breast Cancer
which system is used to stage breast cancer
TNM system
This grades the tumour (T), nodes (N) and metastasis (M).
195
Breast Cancer
what are the options for tumour removal
- Breast-conserving surgery (e.g. wide local excision), usually coupled with radiotherapy
- Mastectomy (removal of the whole breast), potentially with immediate or delayed breast reconstruction
196
Breast Cancer
what is offered to pts where cancer cells are found in the nodes
axillary clearance (removal of axillary lymph nodes)
197
Breast Cancer
what does axillary clearance increase the risk of and why
chronic lymphoedema
due to impaired lymphatic drainage
198
Breast Cancer
non-surgical trx for chronic lymphedema
- Massage techniques to manually drain the lymphatic system (manual lymphatic drainage)
- Compression bandages
- Specific lymphoedema exercises to improve lymph drainage
- Weight loss if overweight
- Good skin care
199
Breast Cancer
why should you avoid taking blood or putting a cannula in the arm on the side of previous breast cancer removal surgery
higher risk of complications and infection due to the impaired lymphatic drainage on that side.
200
Breast Cancer
when is radiotherapy usually used
in patients with breast-conserving surgery to reduce the risk of recurrence
201
Breast Cancer
common side effects of radiotherapy
- General fatigue from the radiation
- Local skin and tissue irritation and swelling
- Fibrosis of breast tissue
- Shrinking of breast tissue
- Long term skin colour changes (usually darker)
202
Breast Cancer
when is chemo used
1 in 3 scenarios:
- Neoadjuvant therapy: shrink tumour before surgery
- Adjuvant chemotherapy: after surgery to reduce recurrence
- Trx of metastatic or recurrent breast cancer
203
Breast Cancer
trx for oestrogen-receptor positive breast cancer in premenopausal women
tamoxifen
204
Breast Cancer
what is tamoxifen
a selective oestrogen receptor modulator (SERM)
blocks oestrogen receptors in breast tissue, and stimulates oestrogen receptors in the uterus and bones
helps prevent osteoporosis, but it does increase the risk of endometrial cancer.
205
Breast Cancer
trx for oestrogen-receptor positive breast cancer in postmenopausal women
Aromatase inhibitors
| e.g., letrozole, anastrozole or exemestane
206
Breast Cancer
what are aromatase inhibitors
blocking the creation of oestrogen in fat tissue
because aromatase is an enzyme found in fat (adipose) tissue that converts androgens to oestrogen
207
Breast Cancer
how long is tamoxifen or an aromatase inhibitor given for
5-10y
208
Breast Cancer
what are the other options for women with oestrogen-receptor positive breast cancer
- Fulvestrant (selective oestrogen receptor downregulator)
- GnRH agonists (e.g., goserelin or leuprorelin)
- Ovarian surgery
209
Breast Cancer
what trx can be used for HER2 positive breast cancer
Trastuzumab (Herceptin)
and/or Pertuzumab (Perjeta)
or Neratinib (Nerlynx)
210
Breast Cancer
what are Trastuzumab (Herceptin)
and Pertuzumab (Perjeta)
monoclonal antibodies that target the HER2 receptor
211
Breast Cancer
what is Neratinib (Nerlynx)
a tyrosine kinase inhibitor, reducing the growth of breast cancer
212
Breast Cancer
if patients have been treated for breast cancer, how do you follow them up
surveillance mammograms yearly for 5 years
213
Breast Cancer
what are the 2 options for reconstructive surgery following a mastectomy
Immediate reconstruction, done at the time of the mastectomy
Delayed reconstruction, which can be delayed for months or years after the initial mastectomy
214
Breast Cancer
After breast-conserving surgery. what reconstructive surgery may be given
- Partial reconstruction (using a flap or fat tissue to fill the gap)
- Reduction and reshaping (removing tissue and reshaping both breasts to match)
215
Breast Cancer
what are the options for reconstructing the breast after mastectomy
Breast implants (inserting a synthetic implant)
Flap reconstruction (using tissue from another part of the body to reconstruct the breast)
216
Breast Cancer
what are the long term problems with implants
hardening, leakage and shape change.
217
Breast Cancer
what are the different flap options
- Latissimus Dorsi Flap
- Transverse Rectus Abdominis Flap (TRAM Flap)
- Deep Inferior Epigastric Perforator Flap (DIEP Flap)
218
Breast Cancer
what is a pedicled flap
keeping the original blood supply and moving the tissue under the skin to a new location
219
Breast Cancer
what is a free flap
cutting the tissue away completely and transplanting it to a new location.
220
what is a well documented side effect of Trastuzumab ( Herceptin)
cardiotoxicity resulting in heart failure
221
microcalcifications on mammogram
cells do not extend past the basement membrane into the myo-epithelial layer on core needle biopsy
what is it
DCIS
222
what is the difference between cytology and histology
histology: studying tissues under a microscope
cytology: studying cells under a microscope
223
what is the difference between fine needle aspiration and core needle biopsy
core needle biopsy: for histology
fine needle aspiration: for cytology
224
25y female presents with swelling of her nipple on her right breast. There is a bloody discharge from the nipple and the nipple is inverted. Just laterally to the areola there is a sinus discharging pus. smoker
what is it
Periductal mastitis
The mammary duct fistula is a feature associated with periductal mastitis. This condition occurs when the ducts behind the nipple become infected.
225
what should all patients be offered with wide local excision
radiotherapy
