Breast surgery

Question 1

Cyst

Answer 1

beningn, smooth, well circumscribed, mobile, possibly fluctuant,may be tender
30-60y, uncommon in post menopausal women
Fluctuates with menstrual cycle

Question 2

Fibroadenoma

Answer 2

Benign solid tumor
Smooth, firm, v mobile mass ‘ breast mouse’ ,rubbery, non tender
15-35y
May increase in size during pregnancy or with estrogen therapy

Question 3

Fibroadenosis (fibrocystic disease, benign mammary dysplasia)

Answer 3

Most common in middle-aged women
‘Lumpy’ breasts which may be painful. Symptoms may worsen prior to menstruation

Question 4

Phylloides Tumors

Answer 4

Large Rapidly growing periductal stromal cell neoplasm.
40-50y
One in four malignant

Question 5

Fat Necrosis

Answer 5

Firm , Tender, ill defined fixed lump, skin tethering
can look cancerous
May follow trivial or unnoticed trauma
Hyperechoic mass on USS ( bright, white)
More common in obese women with large breasts

Question 6

Mammary duct ectasia

Answer 6

ducts behind the nipple shorten and widen.
Sometimes a fluid is produced that can collect in the widened ducts.
Associated with smoking
Generally found in older women,Most common around the menopause
A palpable retroareolar mass, nipple discharge (often blood stained, green yellow too)
Mastalgia (non-cyclical) If ruptures may cause local inflammation, sometimes referred to as ‘plasma cell mastitis’
retraction can be present.

Question 7

Galactocele

Answer 7

Milk filled cyst from over distension of a lactiferous duct.
firm non tender mass
Commonly in upper quadrants beyond areola.

Question 8

Mastitis

Answer 8

Infection of breast tissue
Usually caused by Staph/Strep organisms
Most common in lactating female

Question 9

Mastitis management

Answer 9

continue breastfeeding.
‘if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection’. The first-line antibiotic is flucloxacillin for 10-14 days

Question 10

Abscess management

Answer 10

US incision and drainage and flucox

Question 11

Pathological causes
of gynaecosmastia

Answer 11

Lack of testosterone
Increased oestrogen (liver disease, hyperthyroidism, obesity, adrenal tumours)
Medication
EOH XS

Question 12

Intraductal Papilloma

Answer 12

post menopause
serous or bloody discharge from the nipple, no lump
Small (2-3mm) wart like lesion within a breast duct

Question 13

Breast cancer

Answer 13

hard, irregular lump. There may be associated nipple inversion or skin tethering

Question 14

Most common type of breast malignancy

Answer 14

Ductal Carcinoma In Situ
Pre-cancerous or cancerous epithelial cells of the breast ducts
Localised to a single area, within borders
Microcalcifications on mammogram

Question 15

Lobular Carcinoma In Situ (LCIS)

Answer 15

pre-menopausal women
Malignancy of secretory lobules
Rarer than ductal but increased risk of breast ca malignancy in future

Question 16

Inflammatory Breast Cancer

Answer 16

1-3% of breast cancers
Presents similarly to a breast abscess or mastitis
Swollen, warm, tender breast with pitting skin (peau d’orange)
bad prognosis
Worse prognosis than other breast cancers

Question 17

Paget’s Disease of the Nipple

Answer 17

Malignant disease of the nipple, Looks like eczema of the nipple and areola, Erythematous, scaly rash, reddening, thickening, flaking

Question 18

Breast abscess

Answer 18

More common in lactating women
Red, hot tender swelling

Question 19

Selective aromatase inhibitors

Answer 19

Blocks the conversion of androgens to oestrogen in peripheral Tissues (fat cells)
Only used in Post Menopausal women (can’t block oestrogen production by the ovaries).
important as aromatisation accounts for the majority of oestrogen production in postmenopausal women

Question 20

Aromatase inhibitors adverse effects

Answer 20

Osteoporosis development
hot flushes
arthralgia, myalgia
insomnia

Question 21

Tamoxifen

Answer 21

SERM which acts as an oestrogen receptor antagonist and partial agonist
used in the management of oestrogen receptor-positive breast cancer.
used in pre- and peri-menopausal women

Question 22

Tamoxifen complications/adverse effects

Answer 22

menstrual disturbance: vaginal bleeding, amenorrhoea
hot flushes,
nausea
VTE
endometrial cancer (due to its pro - oestrogenic effect on the uterus)

Question 23

herceptin (trastuzumab)

Answer 23

biological therapy
HER2 positive (HERceptin)
cannot be used in patients with a history of heart disorders

Question 24

Medication causes of gynaecomastia

Answer 24

digoxin, metronidazole spironolactone, chemo, anti-psychotics, anabolic steroids, finasteride

Question 25

BRACA inheritance

Answer 25

autosomal dominant

Question 26

Breast cancer risk factors

Answer 26

BRCA genes
1st degree relative premenopausal relative with breast cancer
Duration of oestrogen exposure
- nulliparity, 1st pregnancy > 30 yrs ,early menarche, late menopause, HRT ,not breastfeeding
ionising radiation
p53 gene mutations
obesity

Question 27

Breast screening

Answer 27

50-70 years
offered a mammogram every 3 years

Question 28

Wide local excision indications

Answer 28

<4cm in size
Small tumour in a large breast
Single lump
Every patient who have a wide local excision should be offered adjuvant radiotherapy

Question 29

Mastectomy indications

Answer 29

4cm or more
Large tumour in a small breast
Multiple tumours

Question 30

Triple assessment involves

Answer 30

History and clinical examination
Imaging
Pathology ( biopsies)

Question 31

Choice of imaging

Answer 31

Above 40 mammograms can be done
If <40 you will get ultrasound scan , density too much for mammogram
MRI if implants or lobular carcinoma