Breast Surgery Flashcards
Wha is the Breast Triple Assessment?
Suggest 2 critertia for referral by GP
A hospital-based assessment clinic, allowing early+rapid detection of breast cancer
- Signs/symptoms that meet the breast cancer 2ww referral criteria
- Suspicious finding on routine screening
Outline the Breast Triple Assessment stages
- History (PC, RFs, FHx, Dx, PMHx, Sx etc) + Exam
- Imaging
- Biopsy
Outling the Imaging stage of the Breast Triple Assessment
(MRI can be useful in assessing lobular breast cancers + response to neoadjuvant therapy. Whilst it has high sensitivity, it has a low specificity)
Mammography (can be done w/ Contrast)
- Compression views of breast across 2 views
- Allows to detect Mass Lesions or Micro-calcifications
USS;
- More useful in Women <35 and Men (due to tissue density)
- Also routiney used during core biopsies
Outline the Biopsy/ Histoloy stage of the Breast Triple Assessment
(Required of any suspicious mass/ lesion presenting to the clinic, most commonly via core biopsy)
Core Biopsy;
- Provides histology, allowing differentiation between Invasive and In-situ Carcinoma
- Higher Sensitvity + Specifcity than FNA
FNA Biopsy; (Fine needle aspiration)
- Provides Cytology
- Used if Recurrent Cystic disease, to relieve symptoms
Malignancy suspicion is graded at each stage
Outline how an Overall Risk Index is created by Triple Assessment, to determine if;
- Benign/ Malignant
- Further intervention+biopsy needed
P= Examination Score, B= Histology score
Imaging (Mammography/ USS) Score= M/U
1= Normal 2= Benign 3= Uncertain/ Likely Benign 4= Suspicious of Malignancy 5= Malignant
What is a common way to categorise types of Breast Pain
- Cyclical (most common)
- Non-cylical
- Extra Mammary (E.g Chest wall/ Shoulder pain)
Outline Cyclical Breast Pain
- Pain assosciated with Menstrual cycle
- Begins few days before beginning and subsiding at end
- Typically, affects both breasts
- Mostly in those activlely Menstruating or using HRT
Outline Non-Cyclical Breast Pain
33% of Breast pain cases
Can be caused by Medications, e.g;
- Hormonal contraceptives
- Anti-depressants (Sertraline)
- Anti-psychotics (Haloperidol)
What features do you ask about in a pt with Mastalgia
Lumps, Skin changes, Discharge, Fevers
Assosciation with menstrual cycle
Pregnancies, Breast-feeding
Dx, PMHx, Fx
Outline Investigations for Breast pain
Mastalgia alone does not qualify for Imaging
All pts within reproductive age should have a Pregnancy test
Outline Breast pain managment
Most cases are Idiopathic
1st: Reassurance + Pain control;
- Better fitting or Soft support bra during night
- Oral Ibuprofen/ Paracetamol or Topical NSAIDs
2nd: Refer to specalist;
- Consider Danazol (Anti-Gonadotrophin agent)
- ADRs: Nausea, Dizziness, Weight gain
What is Galactorrhoea
Copious, Bilateral, Multi-ductal, Milky discharge not assosciated with Pregnancy or Lactation
(Includes Milk production 6-12mths after pregnancy and cessation of breast-feeding)
Dopamine acts to inhibit PRL secretion, which is the main hormone regulating Lactation
Outline the effects of TRH and Oestrogen on Prolactin secretion from Ant Pit gland
Both increases PRL secretion
Hyperprolactinaemia is the most commn cause of Galactorrhoea
List causes of Hyper-PRL
- Idiopathic: 40% of cases
- Pituitary Adenoma
- Drugs: SSRIs, Anti-psychotics, H2 Antagonists
- Neurological: Dopamine inhibited (VZ infection)
- HypoTism: Elevated TRH
- Renal/ Liver failure
- Pituitary Stalk damage: Reduced inhibition from Dopamine
Normoprolactinaemic galactorrhoea is less common and is typically idiopathic, the diagnosis only being made once all other causes of galactorrhoea have been excluded (i.e. normal blood markers and regular menstruation).
How are these pts treated
These patients can often safely be reassured and observed
What features do you ask about in a pt with Galactorrhoea
Important to confirm True Galactorrhoea
Lumps, Mastalgia, LMP
Features of Endocrine disease Neurological symptoms (Headache, Vision changes)
Dx very important
Outline Investigations for Galactorrhoea
Pregnancy test if reproductive age
- TFTs, LFTs, U&Es
- Serum PRL (>1000mU/L suggests Prolactinoma)
MRI w/ Contrast: If Pituitary tumour suspected
Breast imaging: Consider if Palpable Lumps/ L Nodes
Outline Galactorrhoea management
Confirmed Pituitary tumours;
- Dopamine Agonist therapy (Cabergoline, Bromocriptine)
- Potentially, Trans-Sphenoidal surgery
Idiopathic Normoprolactinaemic;
- Resolves on its own
- If persistent, can trial Dopamine agonist therapy
Troublesome Galactorrhoea + Medication intolerance;
- Bilateral Total Duct Excision
Carcinomas in situ are malignancies that contained within BM tissue. They are seen as pre-malignant condition, typically found on imaging and are asymptomatic
What are the 2 main types in Breast disease
- DCIS, Ductal Carcinoma In Situ
- LCIS, Lobular Carcinoma In Situ
DCIS is themost common non-invasive breast malignancy. It represents 20% of all diagnosed breast cancers
Describe it and its Prognosis
Malignancy of Ductal tissue of beast, contained within the BM
Left untreated, 20-30% will develop invasive disease
Outline Investigations for/ Diagosis of DCIS
Often detected during screening;
- Appears as Microcalcifications on Mammography
- Either Localised OR Wide-spread
This is confirmed on Biopsy
List the Subtypes of DCIS and compare their most likely apperance on Mammography
(Most lesions are mixed)
Comedo- Microcalcifications
Cribriform- Multi-focal
Micropapillary- Multi-focal
Solid- Multi-focal
Outline DCIS Management
Localised DCIS;
- Complete wide excision
- Ensure surroundng tissue of all magins have no residual disease
Cases of Widespread or Multifocal DCIS;
- Usually, Complete Mastectomy
Describe LCIS
Compare it to DCIS
Malignancy of the Secretory lobules of the breast, contained within BM
Compared to DCIS, LCIS is;
- Rarer
- More at risk of developing Invasive malignancy
Outline Diagnosis of LCIS
Usually diagnosed;
- Before Menopause (>90%)
- Incidentally during Biopsy
Outline LCIS Managment
Low grade LCIS;
- Monitoring rather than Excision
If pt has BRCA1/2 genes;
- Consider Bilateral Prophylactic Mastectomy
How do Breast Carcinomas-in-situ usually present?
Usually Asymptomatic, found incidentally/ by screening
Carcinoma of the breast is the most common cancer in the Western world and accounts for 20% of all cancers in women in the UK, with 1 in 10 women developing breast cancer in their lifetime
List the classes of Invasive Breast Carcinoma
- IDC, Invasive Ductal Carcinoma (75-85%)
- ILC, Invasive Lobular Carcinoma (10%)
Others (5%)
- E.g Medullar or Colloid Carcinoma
Why is the division of Breast carcinomas into Ductal and Lobular WRONG?
Why is it still used as a classification
Almost all breast carcinomas arise in the Terminal Duct Lobular Unit
The 2 subtypes behave differently
IDCs are the most common breast carcinomas (80% of all cases)
List their further classifications
Which 3 are Well-circumscribed and show the best Prognoses?
Further subtypes of IDCs;
- Tubular*
- Cribriform*
- Papillary*
- Mucinous/ Colloid
- Medullary
ILCs are;
- The 2nd most comon type of breast cancer (10% of all invasive cancers)
- More common in older women
Describe them
Characterised by diffuse/ stromal pattern of spread, that makes detection harder (hence by diagnosis, tumors are quite large)
List RFs for Invasive Breast Cancer
Similar to Breast Carcinomas In-Situ
2 Most significant RFs;
- Female sex
- Age (risk doubles every 10yrs until menopause)
- Gene mutations, Previous Benign disease
- Obesity, Alcohol, Geographic variation
- High exposure to unopposed Oestrogen
- Fx in 1st degree relative
List examples of High exposure to unopposed Oestrogen
- Early menarche
- Late menopause
- No children
- Oral contraceptive
- 1st pregnancy after 30y/o
- HRT use
How can Invasive Breast Cancer present
Can be Symptomatic or Asymptomatic
- Breast pain, Breast lump
- Palpable axilla lump
- Asymmetry, Skin changes (Paget’s, Dimpling)
- Swelling (all or part of breast)
- Nipples: Retraction, Abnormal discharge
Outline Investigations for Invasive Breast Cancer
Managment is Extensive+Variable
Gold standard: Triple Assessment
Which factors affect the Prognosis of Invasive Breast Cancer
- Nodal status (most important)
- Size
- Grade
- Vascular Invasion
- Receptor status (all malignancies should be checked for ER, PR and HER2 status, influencing treatment)
Name the system widely used to stage Primary Breast Cancer Prognosis
Nottingham Prognostic Index (NPI)
Outline the UK Breast Screening Programme
Women 50-70 to have a Mammogram every 3yrs
What is Paget’s Disease of the Nipple
When is involvement of the epidermis by malignant ductal carcinoma cells
How does Paget’s disease present
- Itching/ redness of Nipple and/or Areola
- Flaking + Thickened skin on/ around nipple
- Area often Painful+Sensitive
- Nipple may be Flattened w/ or w/o Yellow/ Bloody discharge
List ddx of Paget’s
Dermatitis or Eczema
Paget’s: Always affects Nipple, sometimes Areola
(Eczema: Only involves Areola)
Outline Investigations for Paget’s Disease
Biopsy to confirm, entire nipple may be removed for histology exam
Breast+Axilla exam (strong link to cancer)
May need Mammograms, USS, MRI Breast
Outline Management of Paget’s Disease
1st line: Surgical
- Type depends on how advanced underlying cancer is
- IN ALL CASES, Nipple+Areola removed
Radiotherapy may be needed if underlying malignancy
List 4 examples of Inflammatory Breast Disease
Mastitis
Breast Cysts
Mammary Duct Ectasia
Fat Necrosis
What is Mastitis?
Whats the most common cause?
Inflammation of breast tissue (Acute/ Chronic)
Infection- Typically S. aureus, but can be Granulomatous
Mastitis can be classed by Lactation status
Outline this
Lactational Mastitis;
- More common, in upto 33% of breastfeeders
- Usually during Weaning or 1st 3mths of Breastfeeding
- Assosciated with Cracked Nipples + Milk Stasis
- More common in 1st child
Non-lactational Mastitis;
- Especially in women with Duct Ectasia-> Peri-ductal Mastitis
- Tobacco smoking is a RF
How does Mastitis present?
- Tenderness, Swelling, Erythrema
- Over area of infection
Lactational Mastitis: Usually Peripheral
Non-L Mastitis: Usually Central
Outline Mastitis Management
Systemic Abx, Simple Analgesia
In Lactational Mastitis;
- Continued milk drainage/ feedig
If Persistent/ Multiple areas of infection;
- Consider Dopamine agonists to cessate breastfeeding
What is a Breast Abscess?
Most commonly develops from Acute Mastitis
Collection of pus within breast, lined with granulation tissue
How may a Breast Abscess present
- Tender Fluctuant + Erythrematous masses
- May be a Punctum
- Fever, lethargy
Outline Investigations and Management for a Breast Abscess
Can be confirmed via USS
Intial phase;
- Often fully reversible
- Empirical Abx + US-guided needle aspiration
Advanced;
- Incision + Drainage under LA
List a complication of Drainage of a non-lactational breast abscess
How are these managed, and what is the prognosis?
Formation of a Mammary Duct Fistula (between Skin and Subareolar breast duct)
- Fistulectomy + Abx
- Can often recur
What is a Breast Cyst
How do they form?
(Cysts make up 15% of palpabe breast mass cases)
- Epithelial lined fluid-flled cavities
- When lobules become distended due to blockage, usually in Peri-menopaual age groups
How may a Breast Cyst present?
- Singular/ Multiple lumps
- Uni- or Bi-lateral
On Palpation;
- Distinct smooth massess
- May be Tender
Outline Investigations for Breast Cysts
Mammography: Identified by “Halo’ shape
USS: Definitive diagnosis
Aspirated, freehand or US-guided;
- If Persisting/ Symptomatic/ Undeterminable
Cancer may be excluded if;
- fluid has no Blood or Lump dissappears
- Otherwise send fluid for Cytology
Outline Management of Breast Cysts
Once diagnosed, usually self-resolve
Larger cysts;
- Can be aspirated for Aesthetics/ Pt reassurance
List complications of Breast Cysts
2% of pts have an unrelated Carcinoma at presentation
- 2-3x greater risk of breast cancer in future
- Fibroadenosis (fibrocytic changes) which can mask malignancy
How can most cases of breast Fibroadenosis be managed
Analgesia
Any cyclical pain: High dose Danazol or GLA (Gamolenic acid)
What is Mammary Duct Ectasia?
Common in Peri-menopausal women, 40% of women have significant duct dilation by 70
Dilation + Shortening of major lactiferous ducts
How may Mammary Duct Ectasia present?
- Green/ Yellow Nipple discharge
- Palpable mass
- Nipple retraction (often slit-like)
(Any blood stained discharge requires Triple Assessment)
Outline Investigations for Mammary Duct Ectasia
Mammography;
- Dilated Calcified ducts w/o any features of malignancy
On Biopsy;
- Mass contains multiple plasma cells on Histology (AKA ‘Plasma Cell Mastitis’)
Outline Mammary Duct Ectasia Management
Conservatively, unless radiology can’t exclude cancer
Unremitting nipple discharg;
- Duct excision
What is Fat Necrosis? (AKA Traumatic fat necrosis)
What can cause it?
- Ischaemic necrosis of fat lobules
Acute inflammatory response in breast;
- Blunt trauma to breast (40% in cases)
- Previous Surgery/ Radiology (60%)
How may Fat Necrosis present?
Usually: Asymptomatic OR a Lump
Less commonly;
- Fluid discharge, Skin dimpling, Pain
- Nipple inversion
Acute inflammatory response can persist-> Chronic Fibrotic change that can-> Solid Irregular lump
Outline Investigations for Fat Necrosis of the breast
+ve traumatic history and/or Hyperechoic Mass on USS
Advanced Fibrotic lesions mimic Carcinoma;
- Mammogram: Calcified irregular speculated masses
Core biopsy often taken to rule out malignancy
Outline Fat Necrosis Management
Self-limiting
Only need Analgesia + Reassurance
What is Gynaecomastia?
How common is it?
(1% of cases-> Breast cancer)
Males develop breast tissue, due to imbalanced Oestrogen and Androgen activity
At least 33% of men experienc it in their lifetime
(Usually fully reversible)
Compare the 2 types of Gynaecomastia
Physiological;
- Mostly in teens, due to Delayed Testosterone surge relative to Oestrogen
- Less commonly, in Elderly due to decreasing Testosterone w/ increasing age
Pathological;
- Changes in Oestrogen:Androgen activity ratio
List 4 mechanisms of Pathological Gynaecomastia
Changes in Oestrogen:Androgen activity ratio
Idiopathic
Lack of Testosterone;
- Androgen insensitivity, Renal disease, Testicular atrophy, Klinefelter’s Syndrome
Increased Oestrogen;
- Liver disease, HyperTism, Obesity, Adrenal tumours, some Testicular tumours
Medication;
- Digoxin, Metronidazole, Spironolactone, Chemo-, Goserelin, Antipsychotics, Anabolic Steroids
How may Gynaecomastia present?
O/E;
- Rubbery/ Firm mass
- Starts from under nipple, spreads outwards over breast region
Outline Investigation + Results for Gynaecomastia
Testicular exam
Tests: Only if cause unknown;
- LFTs, U&Es, Hormone profile if these are normal
High LH, Low Testosterone= Testicular failure
Low LH, Low Testosterone= Increased Oestrogen
High LH, High Testosterone= Androgen resistance or Gonadotrophin-secreting malignancy
Outline Gynecomastia Management
Depends on Cause+Phase
Most cases, Reassurance is all that’s needed
Tamoxifen: To alleviate symptoms, esp Tenderness
Later Fibrosis stages: Surgery, if medical treatments failed
List types of Benign Breast Tumours
Fibroadenoma (most common) Ductal Adenoma Intraductal Papilloma Lipoma Phyllodes Tumours
Fibroadenomas usually occur in women of reproductive age
Describe them
How do they present O/E
Proliferations of Stromal+Epithelial tissue of Duct Lobules
Most are <5cm in diameter
Can be Multiple+Bilateral
O/E;
- Highly mobile, Well-defined, Rubbery
Outline the prognosis of Fibroadenomas
List the main indications for potential excision
Very low malignant potential
Can be left alone with follow-ups over a 2yr period
Diameter >3cm or Pt preference
Describe Ductal Adenomas
Benign Glandular tumour
Usually in Older Females
Lesions are Nodular, Can mimic Malignancy
(So most cases undergo Triple Assessment)
Describe Intraductal Papillomas
How may they present?
Usually in Females 40–50
Mostly in Subareolar region (Usually <1cm from Nipple)
Bloody/ Clear nipple discharge
Larger ones can present as a mass initially
How are Intraductal Papillomas investigated?
How are they managed?
(Breast cancer risk only increased with Multi-ductal papillomas)
Can appear similar to Ductal Carcinomas on Imaging, so usually need Biopsy
Some cases may be excised, most treated with Microdochectomy
Describe Lipomas, their prognosis and treatment
Soft, Mobile adiopose tumour
Low malignant potential
Usually only removed if;
- Significantly enlarging
- Compressive symptoms
- Aesthetic issues
What are Phyllodes Tumours?
Describe them
Rare Fibroepithelial tumours, made of Epithelial+Stromal Tissu
Large, Grow rapidly and occur in Older people
Outline Phyllodes Tumour Investigation, Management and Prognosis
(Phyllodes means ‘Leaf’, due to characteristic leaf-like fibrous tissue projections on microscopy)
Hard to differentiate from Fibroadenomas clinically and microscopically
Most Phyllodes Tumours;
- Widely Excised
- Mastectomy if Large lesion
- 33% of Phyllodes Tumours have malignant potential
- 10% recur after excision
How may Benign Breast Tumours present?
Investigation+Management: Triple assessment, Reassurance+Routine check-ups. Excised if can’t exclude malignancy
Variable, but generally;
- Mobile, Smooth borders
Can have Multiple Lumps
Pain/ Discomfort if they grow
(Malignant: Single lump, Craggy surfaces, Firm, Fixed to different tissue layers)
What’s the main Ddx for Gynaecomastia
Pseudogynaecomastia: Adipose in breast region, assosciated with being overweight
(Can be tested by pinching to see if there is an obvious disc of breast tissue present, however if not palpable then further imaging and/or histology may be required to definitively exclude)
Niipple retraction is often benign
Compare the usual causes of Slit-like and Circumferential
Slit-like: Duct Ectasia
Circumferential: Carcinoma
How would Fibrocystic change present
What condition could this be associated with
Painful thickening, rather than a lump
Associated with Breast Cysts
What are Cooper’s ligaments?
What can happen when they lengten/ loosen/ get damaged?
What can happen when they tighten/ constrict (due to cancer, fat atrophy or necrosis)
Connect tissue around chest muscle to under the skin of the breast
Sagging/ drooping
Puckering/ Dimpling
Outline process of Peau d’orange development?
Oedema in beast causes Epidermis to expand, but evenly spaced pores on skin holds down spots of skin
This looks like the skin of an orange
List some potential causes of Peau d’orange
Breast cancer (most common)
Mastitis, Pregnancy
Thyroid disease, Heart Failure, Clots
