Breast Surgery Flashcards
Give 5 causes of Gynaecomastia.
Physiological: Puberty Ectopic tumour secretion: Prolactinoma Androgen deficiency diseases: Kallman/Klinefelter Testicular failure: Mumps Liver disease Haemodialysis Hyperthyroidism Drugs: Spironolactone; Cimetidine; Cannabis; Digoxin; Oestrogens; GnRH agonists; Finasteride
How would you conduct a breast examination?
Introduction: Name + DOB
Explain procedure: examination of breast tissue for lumps and bumps
Obtain consent
Chaperone
Allow patient to get undressed
Ask about pain/discharge/point to areas
Inspection: normal; hand behind head
Signs: Asymmetry; Scars; Cosmetic augmentation; Tethering/Puckering/ Nipple discharge/ Skin colour/ Pea d’orange/ Paget’s disease of the nipple
Palpation: Clock face technique, moving outward/inward between breast
Cover: 4 quadrants; subareolar area; Tail of Spence; Axilla
Assess Lymph nodes
Closure
Explain next steps
What is Peau d’Orange?
Irregular patch of skin due to blocked lymphatic drainage causing superficial oedema and thickening like the peel of an orange
A patient presents with an erythematous, scaly rash on the nipple. The rash is itchy, inflamed. The rash is localised to the nipple and areola.
What is your diagnosis?
A. Eczema
B. Psoriasis
C. Paget’s disease of the nipple
D. Lichen Planus
C
What investigations would you conduct in a patient with Paget’s disease of the nipple?
Triple assessment: Clinical examination + Mammography/US + Biopsy (punch)
When assessing breast pain, what should you ask regarding the pain?
SOCRATES
When assessing breast pain, what should you ask regarding the pain?
Mnemonic: SOCRATES
Site
Onset
Character
Radiation
Associated changes: Positions; Activities; Relation to cycle (Cyclical vs Non-Cyclical)
Time
Exacerbating
Severity
What are the clinical features of cyclical breast pain?
Bilateral and generalised
Heaviness
Aching
How can you manage breast pain?
Supportive: Establish cause; Breast pain diary; Avoid caffeine; Apply heat
+
Medical: NSAIDs; Hormonal Tx (e.g. Tamoxifen)
How should a breast lump be investigated?
Triple assessment: Clinical assessment + Imaging + Histology
What are the clinical features of a breast lump which may make you suspicious of breast cancer?
Hard Irregular Fixed/tethered Painless Nipple retraction Skin dimpling/oedema (peau d'Orange)
What are the NICE guidelines for a 2 week wait referral for suspected breast cancer?
> 30 years with unexplained lump; Unexplained lump in axilla
> 50 years with unilateral nipple changes
Skin changes suggestive of breast cancer
A fibroadenoma is a tumour of which breast tissue?
Stromal/Epithelial breast duct tissue
What are the clinical features of a fibroadenoma?
<3cm Smooth Mobile Discrete Firm Painless
Do Fibroadenomas increase your risk of developing breast cancer?
No. However, complex fibroadenomas and positive family history of breast cancer may indicate higher risk
A woman presents with multiple hardened areas in her breast with some areas of softer lumps. There is some mastalgia. Additionally she notices changes in the size of her breast. All these symptoms are peri-menstrual in nature, occurring in the first 10 days then subsiding after.
What is your diagnosis?
Fibrocystic breast changes
How do you manage fibrocystic breast changes?
Supportive: Breast support; NSAIDs; Avoid caffeine; Apply heat to area
±
Medical: Tamoxifen
What age do breast cysts tend to present at?
30-50 - perimenopausal
What are the clinical features of breast cysts?
Smooth
Well-circumscribed
Mobile
Possibly fluctuant
How can breast cyst be managed?
Confirm diagnosis
Supportive: Watch and wait; Aspiration
What are the clinical features of fat necrosis in the breast?
Firm Irregular Fixed Skin changes Hx of trauma/surgery/radiotherapy
How do you differentiate between fat necrosis and breast cancer?
US/Mammogram
Histology (core biopsy or FNA)
What are the clinical features of a lipoma?
Soft
Painless
Mobile
Do not cause skin changes
A 32 year old woman has noticed small lumps around the nipple. There are no skin changes. O/E you notice firm, mobile, painless lumps which are beneath the areola. She has no other PMHx but recently stopped breastfeeding.
What is your diagnosis?
Galactocoele
What proportion of Phyllodes tumour are malignant?
25% or 25% borderline too
What is a Phyllodes tumour?
Tumour of breast stroma
How is a Phyllodes tumour managed?
Surgery: Wide excision
± Malignant/Metastatic
Medical: Chemotherapy
Which organ produces Prolactin?
Anterior Pituitary Gland (Pars posterior)
Which neurotransmitter blocks prolactin secretion?
Dopamine (DA)
Which medications can be used to treat Galactorrhoea?
DA agonists: Cabergoline; Bromocriptine
What are the causes of Galactorrhoea?
Post-partum
Idiopathic hyperPL
Ectopic secretion - Prolactinoma
Endocrine disorders: Hypothyroidism; PCOS
Medication: Antipyschotics
What are the consequences of Hyperprolactinaemia?
PL inhibits GnRH thus affects the HPG axis.
Gynaecomastia
Reduced libido
ED
Menstrual irregularities (amenorrhoea)
Which form of Multiple Endocrine Neoplasia may result in a prolactinoma?
List the other features of this form.
MEN Type 1
3Ps
Pituitary adenoma + Pancreatic tumour + Parathyroid hyperplasia
How are prolactiomas classified?
Based on size
MicroPLoma <10mm
MacroPLoma >10mm
Which conditions may cause discharge from the breast?
Milk discharge:
- Idiopathic
- Prolactinoma
- Endocrine disorders
- Dopamine antagonists
Non-milk discharge:
- Infection
- Duct papilloma
- Mammary gland ectasia
What investigations would you conduct in a patient with galactorrhoea?
FBC
U+Es
LFTs
TFTs
Sex hormones: GnRH; T; PL
What is the management for galactorrhoea?
Tx cause
+
Medical: Cabergoline
± Pituitary adenoma >10mm
Surgery: Trans-sphenoidal pituitary adenectomy
Which patient group does mammary duct ectasia occur in most commonly?
Perimenopausal women
Smoking is the biggest RF
What are the clinical features of mammary duct ectasia?
Nipple discharge
Tenderness or pain
Nipple retraction or inversion
A breast lump (pressure on the lump may produce nipple dischar
How is mammary duct ectasia managed?
Supportive: Reassurance cancer is excluded; manage mastalgia; ABX if infection
±
Surgery: Surgical excision (microdochectomy)
Which cell type causes an intraductal papilloma?
Overgrowth of epithelial cells
What are the clinical features of an intraductal papilloma?
Nipple discharge (clear or blood-stained)
Tenderness or pain
A palpable lump
How is a diagnosis of Intraductal Papilloma made?
Clinical assessment (history and examination)
Imaging (ultrasound, mammography and MRI)
Histology (usually by core biopsy or vacuum-assisted biopsy)
Ductography may show papilloma (‘filling defect’)
How is an intraductal papilloma managed?
Surgery: Surgical excision
How may lactational mastitis present?
Breast pain and tenderness (unilateral) Erythema in a focal area of breast tissue Local warmth and inflammation Nipple discharge Fever
How is Lactational mastitis managed?
Supportive: Continue breastfeeding; breast massage; heat packs; warm; simple analgesia
± Bacterial Infection
Medical: Flucloxacillin
± Fundal Infection
Medical: Fluconazole
What is the management in Candida of the nipple when breast feeding?
Medical: Miconazole
Both mother and child receives Tx
Which bacteria may cause a breast abscess?
S aureus
Streptococcus
Enterobacteriacae
Enterococci
How may a breast abscess present?
Nipple changes Purulent nipple discharge (pus from the nipple) Localised pain Tenderness Warmth Erythema (redness) Hardening of the skin or breast tissue Swelling: fluctuant, tender lump within the breast
Signs of infection
How can a breast abscess be categorised?
Lactational (blockage of duct) vs Non-lactational (infection)
A concerned mother asks if she should continue to breastfeed when they have a breast abscess?
They should regularly express breast milk if feeding is too painful, then resume feeding when possible. This is not harmful to the baby and is important in helping resolve the mastitis or abscess.
Give 5 RFs for Breast cancer.
Female sex Smoking Increased oestrogen exposure Alcohol Obesity More dense breast tissue FHx Breast Cancer BRCA1/BRCA2 gene mutation White ethnicity Nulliparity Early menarche and late menopause COCP HRT
A concerned teenager asks about her risk of breast cancer when taking the pill. What do you tell her?
Risk increases slightly, risk returns to normal 10 years after being on the pill
Which genes are related to breast cancer?
Where are they found?
What diseases are they associated with?
BRCA1 (Chromosome 17)
- Breast cancer 80%
- Ovarian cancer 40%
BRCA2 (Chromosome 13)
- Breast cancer 70%
- Ovarian cancer 25%
How is Breast Cancer categorised?
Location: Ductal or Lobular
What are the features of a DCIS?
Pre-cancerous/cancerous epithelial duct tissues Localised to single area Potential to spread Potential to become invasive (30%) Good prognosis if fully excised
What are the features of a IBC-NST?
NST
Duct cells
80% of invasive breast cancer fall into this category
Can be seen on mammograms
What are the majority of invasive breast cancers classified as?
Invasive ductal carcinomas
Which type of breast cancer may not be visible on mammograms?
Invasive Lobular Carcinomas
How is IDC graded?
Grade 1 = well
Grade 2 = moderately
Grade 3 = poorly differentiated
which form of breast cancer is also known as lobular neoplasia?
Lobular carcinoma in situa (LCIS)
What are the four molecular subtypes of breast cancer?
These are based on gene expression.
Luminal A
Luminal B
Basal
HER2
What does NHS Breast Cancer screening comprise of?
50-71 years old
Mammogram - reported by consultant radiologist as:
- Satisfactory (no radiological evidence of breast cancer)
- Abnormal (further investigation needed)
- Unclear (results or imaging inadequate)
How does the presence of breast implants, alter the examination of breast tissue by Mammography?
Can make it difficult to visualise the breast tissue thus use the Eklund technique
What are the clinical features of breast cancer?
Lump: Hard, irregular, fixed (tethered)
Breast pain
Skin changes
Nipple changes: discharge/inversion/dilated veins
Signs of metastasis: bone pain; liver features; lung feature; brain features
What does the one-stop breast clinic comprise of?
Triple assessment:
Hx + CEx
Imaging
Histopathology
Which investigations may be conducted in suspected breast cancer?
FBC
U+E
LFT
Bone profile
USS Mammography -> Breast tomosynthesis MRI Breast CX CT-CAP CT-Brain Bone scan PET/CT
Receptor testing
Gene testing (patients under 50) FNA of lymph nodes
How is breast cancer managed?
MDT decision
Surgical: Wide local excision or mastectomy + SLNB
+ Breast reconstruction
+ Radiotherapy
+ Chemotherapy: FEC regime
± Biologics
- Herceptin (Trastuzumab): HER2
± Endocrine therapy
- Tamoxifen (SERM)
- Anastrazole (Aromatase-i)
What is the first line drug used in breast cancer of post-menopausal women at medium/high risk of disease recurrence?
Anastrazole
What are the side effects of anastrazole?
Menopausal symptoms
OP
MSK Pain
Why would Anastrazole be ineffective in pre-menopausal women?
Anastrazole stops peripheral conversion of androgens to oestrogens however in younger women, production is largely by the ovaries
How long does endocrine therapy in breast cancer last?
Commenced after any adjuvant chemotherapy
Standard course is 5 years
How can ovarian function be suppressed in premenopausal women that are ER positive?
GnRH analogue (Gorserelin)
Laparoscopic oophorectomy
What is the 5 year survival of women diagnosed with breast cancer?
85%
How is lymphoedema managed?
Supportive: Manual lymphatic drainage; compression bandages; exercises; weight loss; good skin care
What is the MOA of Tamoxifen?
SERM thus blocks oestrogen receptors in breast tissue and stimulates oestrogen receptors in uterus and bone - prevents OP but increases risk of endometrial cancer
What is the MOA of Anastrazole?
Anastrozole is an Aromatase inhibitor which reduces the peripheral conversion of testosterone to oestrogens.
Used in postmenopausal women
What are the options for reconstructive surgery?
Immediate reconstruction vs Delayed reconstruction
Partial reconstruction (flap or fat tissue) Reduction and reshaping
Implants vs Flap reconstructions
Flap reconstructions:
- Lat Dorsi Flap
- TRAM flap
- DIEP Flap
Flaps may be peddled (original blood supply and moving tissue under the skin to a new location) or free flap (cutting tissue away and transplanting)
