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Year 3 Surgery > Breast Surgery > Flashcards

Breast Surgery Flashcards

1
Q

Wha is the Breast Triple Assessment?

Suggest 2 critertia for referral by GP

A

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
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2
Q

Outline the Breast Triple Assessment stages

A
  • History (PC, RFs, FHx, Dx, PMHx, Sx etc) + Exam
  • Imaging
  • Biopsy
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3
Q

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)

A

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
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4
Q

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)

A

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
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5
Q

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
A

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
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6
Q

What is a common way to categorise types of Breast Pain

A
  • Cyclical (most common)
  • Non-cylical
  • Extra Mammary (E.g Chest wall/ Shoulder pain)
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7
Q

Outline Cyclical Breast Pain

A
  • 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
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8
Q

Outline Non-Cyclical Breast Pain

A

33% of Breast pain cases

Can be caused by Medications, e.g;

  • Hormonal contraceptives
  • Anti-depressants (Sertraline)
  • Anti-psychotics (Haloperidol)
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9
Q

What features do you ask about in a pt with Mastalgia

A

Lumps, Skin changes, Discharge, Fevers
Assosciation with menstrual cycle
Pregnancies, Breast-feeding

Dx, PMHx, Fx

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10
Q

Outline Investigations for Breast pain

A

Mastalgia alone does not qualify for Imaging

All pts within reproductive age should have a Pregnancy test

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11
Q

Outline Breast pain managment

Most cases are Idiopathic

A

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

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12
Q

What is Galactorrhoea

A

Copious, Bilateral, Multi-ductal, Milky discharge not assosciated with Pregnancy or Lactation

(Includes Milk production 6-12mths after pregnancy and cessation of breast-feeding)

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13
Q

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

A

Both increases PRL secretion

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14
Q

Hyperprolactinaemia is the most commn cause of Galactorrhoea

List causes of Hyper-PRL

A
  • 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
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15
Q

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

A

These patients can often safely be reassured and observed

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16
Q

What features do you ask about in a pt with Galactorrhoea

Important to confirm True Galactorrhoea

A

Lumps, Mastalgia, LMP

Features of Endocrine disease
Neurological symptoms (Headache, Vision changes)

Dx very important

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17
Q

Outline Investigations for Galactorrhoea

A

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

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18
Q

Outline Galactorrhoea management

A

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

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19
Q

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

A
  • DCIS, Ductal Carcinoma In Situ

- LCIS, Lobular Carcinoma In Situ

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20
Q

DCIS is themost common non-invasive breast malignancy. It represents 20% of all diagnosed breast cancers

Describe it and its Prognosis

A

Malignancy of Ductal tissue of beast, contained within the BM

Left untreated, 20-30% will develop invasive disease

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21
Q

Outline Investigations for/ Diagosis of DCIS

A

Often detected during screening;

  • Appears as Microcalcifications on Mammography
  • Either Localised OR Wide-spread

This is confirmed on Biopsy

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22
Q

List the Subtypes of DCIS and compare their most likely apperance on Mammography

(Most lesions are mixed)

A

Comedo- Microcalcifications
Cribriform- Multi-focal
Micropapillary- Multi-focal
Solid- Multi-focal

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23
Q

Outline DCIS Management

A

Localised DCIS;

  • Complete wide excision
  • Ensure surroundng tissue of all magins have no residual disease

Cases of Widespread or Multifocal DCIS;
- Usually, Complete Mastectomy

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24
Q

Describe LCIS

Compare it to DCIS

A

Malignancy of the Secretory lobules of the breast, contained within BM

Compared to DCIS, LCIS is;

  • Rarer
  • More at risk of developing Invasive malignancy
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25
Q

Outline Diagnosis of LCIS

A

Usually diagnosed;

  • Before Menopause (>90%)
  • Incidentally during Biopsy
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26
Q

Outline LCIS Managment

A

Low grade LCIS;
- Monitoring rather than Excision

If pt has BRCA1/2 genes;
- Consider Bilateral Prophylactic Mastectomy

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27
Q

How do Breast Carcinomas-in-situ usually present?

A

Usually Asymptomatic, found incidentally/ by screening

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28
Q

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

A
  • IDC, Invasive Ductal Carcinoma (75-85%)
  • ILC, Invasive Lobular Carcinoma (10%)

Others (5%)
- E.g Medullar or Colloid Carcinoma

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29
Q

Why is the division of Breast carcinomas into Ductal and Lobular WRONG?

Why is it still used as a classification

A

Almost all breast carcinomas arise in the Terminal Duct Lobular Unit

The 2 subtypes behave differently

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30
Q

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?

A

Further subtypes of IDCs;

  • Tubular*
  • Cribriform*
  • Papillary*
  • Mucinous/ Colloid
  • Medullary
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31
Q

ILCs are;

  • The 2nd most comon type of breast cancer (10% of all invasive cancers)
  • More common in older women

Describe them

A

Characterised by diffuse/ stromal pattern of spread, that makes detection harder (hence by diagnosis, tumors are quite large)

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32
Q

List RFs for Invasive Breast Cancer

Similar to Breast Carcinomas In-Situ

A

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
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33
Q

List examples of High exposure to unopposed Oestrogen

A
  • Early menarche
  • Late menopause
  • No children
  • Oral contraceptive
  • 1st pregnancy after 30y/o
  • HRT use
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34
Q

How can Invasive Breast Cancer present

Can be Symptomatic or Asymptomatic

A
  • Breast pain, Breast lump
  • Palpable axilla lump
  • Asymmetry, Skin changes (Paget’s, Dimpling)
  • Swelling (all or part of breast)
  • Nipples: Retraction, Abnormal discharge
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35
Q

Outline Investigations for Invasive Breast Cancer

Managment is Extensive+Variable

A

Gold standard: Triple Assessment

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36
Q

Which factors affect the Prognosis of Invasive Breast Cancer

A
  • Nodal status (most important)
  • Size
  • Grade
  • Vascular Invasion
  • Receptor status (all malignancies should be checked for ER, PR and HER2 status, influencing treatment)
37
Q

Name the system widely used to stage Primary Breast Cancer Prognosis

A

Nottingham Prognostic Index (NPI)

38
Q

Outline the UK Breast Screening Programme

A

Women 50-70 to have a Mammogram every 3yrs

39
Q

What is Paget’s Disease of the Nipple

A

When is involvement of the epidermis by malignant ductal carcinoma cells

40
Q

How does Paget’s disease present

A
  • 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
41
Q

List ddx of Paget’s

A

Dermatitis or Eczema

Paget’s: Always affects Nipple, sometimes Areola
(Eczema: Only involves Areola)

42
Q

Outline Investigations for Paget’s Disease

A

Biopsy to confirm, entire nipple may be removed for histology exam

Breast+Axilla exam (strong link to cancer)

May need Mammograms, USS, MRI Breast

43
Q

Outline Management of Paget’s Disease

A

1st line: Surgical

  • Type depends on how advanced underlying cancer is
  • IN ALL CASES, Nipple+Areola removed

Radiotherapy may be needed if underlying malignancy

44
Q

List 4 examples of Inflammatory Breast Disease

A

Mastitis
Breast Cysts

Mammary Duct Ectasia
Fat Necrosis

45
Q

What is Mastitis?

Whats the most common cause?

A

Inflammation of breast tissue (Acute/ Chronic)

Infection- Typically S. aureus, but can be Granulomatous

46
Q

Mastitis can be classed by Lactation status

Outline this

A

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
47
Q

How does Mastitis present?

A
  • Tenderness, Swelling, Erythrema
  • Over area of infection

Lactational Mastitis: Usually Peripheral
Non-L Mastitis: Usually Central

48
Q

Outline Mastitis Management

A

Systemic Abx, Simple Analgesia

In Lactational Mastitis;
- Continued milk drainage/ feedig

If Persistent/ Multiple areas of infection;
- Consider Dopamine agonists to cessate breastfeeding

49
Q

What is a Breast Abscess?

Most commonly develops from Acute Mastitis

A

Collection of pus within breast, lined with granulation tissue

50
Q

How may a Breast Abscess present

A
  • Tender Fluctuant + Erythrematous masses
  • May be a Punctum
  • Fever, lethargy
51
Q

Outline Investigations and Management for a Breast Abscess

A

Can be confirmed via USS

Intial phase;

  • Often fully reversible
  • Empirical Abx + US-guided needle aspiration

Advanced;
- Incision + Drainage under LA

52
Q

List a complication of Drainage of a non-lactational breast abscess

How are these managed, and what is the prognosis?

A

Formation of a Mammary Duct Fistula (between Skin and Subareolar breast duct)

  • Fistulectomy + Abx
  • Can often recur
53
Q

What is a Breast Cyst
How do they form?

(Cysts make up 15% of palpabe breast mass cases)

A
  • Epithelial lined fluid-flled cavities

- When lobules become distended due to blockage, usually in Peri-menopaual age groups

54
Q

How may a Breast Cyst present?

A
  • Singular/ Multiple lumps
  • Uni- or Bi-lateral

On Palpation;

  • Distinct smooth massess
  • May be Tender
55
Q

Outline Investigations for Breast Cysts

A

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
56
Q

Outline Management of Breast Cysts

A

Once diagnosed, usually self-resolve

Larger cysts;
- Can be aspirated for Aesthetics/ Pt reassurance

57
Q

List complications of Breast Cysts

2% of pts have an unrelated Carcinoma at presentation

A
  • 2-3x greater risk of breast cancer in future

- Fibroadenosis (fibrocytic changes) which can mask malignancy

58
Q

How can most cases of breast Fibroadenosis be managed

A

Analgesia

Any cyclical pain: High dose Danazol or GLA (Gamolenic acid)

59
Q

What is Mammary Duct Ectasia?

Common in Peri-menopausal women, 40% of women have significant duct dilation by 70

A

Dilation + Shortening of major lactiferous ducts

60
Q

How may Mammary Duct Ectasia present?

A
  • Green/ Yellow Nipple discharge
  • Palpable mass
  • Nipple retraction (often slit-like)

(Any blood stained discharge requires Triple Assessment)

61
Q

Outline Investigations for Mammary Duct Ectasia

A

Mammography;
- Dilated Calcified ducts w/o any features of malignancy

On Biopsy;
- Mass contains multiple plasma cells on Histology (AKA ‘Plasma Cell Mastitis’)

62
Q

Outline Mammary Duct Ectasia Management

A

Conservatively, unless radiology can’t exclude cancer

Unremitting nipple discharg;
- Duct excision

63
Q

What is Fat Necrosis? (AKA Traumatic fat necrosis)

What can cause it?

A
  • Ischaemic necrosis of fat lobules

Acute inflammatory response in breast;

  • Blunt trauma to breast (40% in cases)
  • Previous Surgery/ Radiology (60%)
64
Q

How may Fat Necrosis present?

A

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

65
Q

Outline Investigations for Fat Necrosis of the breast

A

+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

66
Q

Outline Fat Necrosis Management

A

Self-limiting

Only need Analgesia + Reassurance

67
Q

What is Gynaecomastia?
How common is it?

(1% of cases-> Breast cancer)

A

Males develop breast tissue, due to imbalanced Oestrogen and Androgen activity

At least 33% of men experienc it in their lifetime
(Usually fully reversible)

68
Q

Compare the 2 types of Gynaecomastia

A

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

69
Q

List 4 mechanisms of Pathological Gynaecomastia

Changes in Oestrogen:Androgen activity ratio

A

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

70
Q

How may Gynaecomastia present?

A

O/E;

  • Rubbery/ Firm mass
  • Starts from under nipple, spreads outwards over breast region
71
Q

Outline Investigation + Results for Gynaecomastia

A

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

72
Q

Outline Gynecomastia Management

Depends on Cause+Phase

A

Most cases, Reassurance is all that’s needed

Tamoxifen: To alleviate symptoms, esp Tenderness

Later Fibrosis stages: Surgery, if medical treatments failed

73
Q

List types of Benign Breast Tumours

A 
Fibroadenoma (most common)
Ductal Adenoma
Intraductal Papilloma
Lipoma
Phyllodes Tumours
74
Q

Fibroadenomas usually occur in women of reproductive age

Describe them
How do they present O/E

A

Proliferations of Stromal+Epithelial tissue of Duct Lobules

Most are <5cm in diameter
Can be Multiple+Bilateral

O/E;
- Highly mobile, Well-defined, Rubbery

75
Q

Outline the prognosis of Fibroadenomas

List the main indications for potential excision

A

Very low malignant potential
Can be left alone with follow-ups over a 2yr period

Diameter >3cm or Pt preference

76
Q

Describe Ductal Adenomas

A

Benign Glandular tumour
Usually in Older Females

Lesions are Nodular, Can mimic Malignancy
(So most cases undergo Triple Assessment)

77
Q

Describe Intraductal Papillomas

How may they present?

A

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

78
Q

How are Intraductal Papillomas investigated?
How are they managed?

(Breast cancer risk only increased with Multi-ductal papillomas)

A

Can appear similar to Ductal Carcinomas on Imaging, so usually need Biopsy

Some cases may be excised, most treated with Microdochectomy

79
Q

Describe Lipomas, their prognosis and treatment

A

Soft, Mobile adiopose tumour
Low malignant potential

Usually only removed if;

  • Significantly enlarging
  • Compressive symptoms
  • Aesthetic issues
80
Q

What are Phyllodes Tumours?

Describe them

A

Rare Fibroepithelial tumours, made of Epithelial+Stromal Tissu

Large, Grow rapidly and occur in Older people

81
Q

Outline Phyllodes Tumour Investigation, Management and Prognosis

(Phyllodes means ‘Leaf’, due to characteristic leaf-like fibrous tissue projections on microscopy)

A

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
82
Q

How may Benign Breast Tumours present?

Investigation+Management: Triple assessment, Reassurance+Routine check-ups. Excised if can’t exclude malignancy

A

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)

83
Q

What’s the main Ddx for Gynaecomastia

A

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)

84
Q

Niipple retraction is often benign

Compare the usual causes of Slit-like and Circumferential

A

Slit-like: Duct Ectasia

Circumferential: Carcinoma

85
Q

How would Fibrocystic change present

What condition could this be associated with

A

Painful thickening, rather than a lump

Associated with Breast Cysts

86
Q

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)

A

Connect tissue around chest muscle to under the skin of the breast

Sagging/ drooping

Puckering/ Dimpling

87
Q

Outline process of Peau d’orange development?

A

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

88
Q

List some potential causes of Peau d’orange

A

Breast cancer (most common)
Mastitis, Pregnancy
Thyroid disease, Heart Failure, Clots

Year 3 Surgery (7 decks)

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