Breast Surgery Flashcards
Most of the breast is _______ tissue. The _____ surrounds the nipple. Behind the nipple are the ______, which lead into the _______ where breast milk is produced. Milk is secreted through the ducts and out of openings on the nipple
Most of the breast is adipose (fatty) tissue. The areola surrounds the nipple. Behind the nipple are the ducts, which lead into the lobules, where breast milk is produced. Milk is secreted through the ducts and out of openings on the nipple
Explain the triple assessment of a breast lump to exclude or diagnose cancer?
- Clinical assessment (history and examination)
- Imaging (ultrasound or mammography)
- Histology (fine needle aspiration or core biopsy)
Clinical features that may suggest breast cancer are:
- 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)
The NICE guidelines (updated January 2021) recommend a two week wait referral for suspected breast cancer for:
- An unexplained breast lump in patients aged 30 or above
- Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes)
The NICE guidelines recommend also considering a two week wait referral for breast cancer for:
An unexplained lump in the axilla in patients aged 30 or above
Skin changes suggestive of breast cancer
The NICE guidelines suggest considering non-urgent referral for…..
unexplained breast lumps in patients under 30 years.
What is Fibroadenoma
Fibroadenomas are common benign tumours of stromal/epithelial breast duct tissue. They are typically small and mobile within the breast tissue. They are sometimes called a “breast mouse”, as they move around within the breast tissue.
Who is fibroadenoma seen in?
They are more common in younger women, aged between 20 and 40 years.
On examination, fibroadenomas are:
- Painless
- Smooth
- Round
- Well circumscribed (well-defined borders)
- Firm
- Mobile (moves freely under the skin and above the chest wall)
- Usually up to 3cm diameter
Are Fibroadenomas cancerous
No
However
Complex fibroadenomas and a positive family history of breast cancer may indicate a higher risk.
Fibrocystic breast changes were previously called ________ _______ _______. However, fibrocystic breast changes, and generalised lumpiness to the breast, is considered a _________ of normal and not a disease
Fibrocystic breast changes were previously called fibrocystic breast disease. However, fibrocystic breast changes, and generalised lumpiness to the breast, is considered a variation of normal and not a disease
Fibrocystic Breast Changes are common in
women of menstruating ages
Fibrocystic Breast Changes
Symptoms often occur…
prior to menstruating (within 10 days) and resolve once menstruation begins. Symptoms usually improve or resolve after menopause.
Fibrocystic Breast Changes
Symptoms can affect different areas of the breast, or both breasts, with
- Lumpiness
- Breast pain or tenderness (mastalgia)
- Fluctuation of breast size
Management of fibrocystic breast changes is to exclude cancer and manage symptoms. Options to manage cyclical breast pain (mastalgia) include:
- Wearing a supportive bra
- Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen
- Avoiding caffeine is commonly recommended
- Applying heat to the area
- Hormonal treatments (e.g., danazol and tamoxifen) under specialist guidance
What are Breast Cysts
Breast cysts are benign, individual, fluid-filled lumps. They are the most common cause of breast lumps and occur most often between ages 30 and 50, more so in the perimenopausal period. They can be painful and may fluctuate in size over the menstrual cycle.
On examination, breast cysts are:
Smooth
Well-circumscribed
Mobile
Possibly fluctuant
Do Breasts cysts require further assessment?
Yes
Breasts cysts require further assessment to exclude cancer, with imaging and potentially aspiration or excision. Aspiration can resolve symptoms in patients with pain. Having a breast cyst may slightly increase the risk of breast cancer.
What is Fat necrosis
Fat necrosis causes a benign lump formed by localised degeneration and scarring of fat tissue in the breast. It may be associated with an oil cyst, containing liquid fat. Fat necrosis is commonly triggered by localised trauma, radiotherapy or surgery, with an inflammatory reaction resulting in fibrosis and necrosis (death) of the fat tissue. It does not increase the risk of breast cancer.
On examination, fat necrosis can be
- Painless
- Firm
- Irregular
- Fixed in local structures
- There may be skin dimpling or nipple inversion
Diagnosis of fat necrosis
Ultrasound or mammogram can show a similar appearance to breast cancer. Histology (by fine needle aspiration or core biopsy) may be required to confirm the diagnosis and exclude breast cancer.
fat necrosis management
usually treated conservatively. It may resolve spontaneously with time. Surgical excision may be used if required for symptoms.
What is Lipoma
Lipomas are benign tumours of fat (adipose) tissue. They can occur almost anywhere on the body where there is adipose tissue, including the breasts.
On examination, lipomas are typically:
Soft
Painless
Mobile
Do not cause skin changes
Management of lipoma
They are typically treated conservatively with reassurance. Alternatively, they can be surgically removed.
What are Galactocele
are they malignant or benign
Galactoceles occur in women that are lactating (producing breast milk), often after stopping breastfeeding. They are breast milk filled cysts that occur when the lactiferous duct is blocked, preventing the gland from draining milk. They present with a firm, mobile, painless lump, usually beneath the areola.
hey are benign and usually resolve without any treatment. It is possible to drain them with a needle. Rarely, they can become infected and require
What are Phyllodes tumours
Phyllodes tumours are rare tumours of the connective tissue (stroma) of the breast, occurring most often between ages 40 and 50. They are large and fast-growing. They can be benign (~50%), borderline (~25%) or malignant (~25%). Malignant phyllodes tumours can metastasise
leaf like
.
Treatment for Phyllodes tumour
Treatment involves surgical removal of the tumour and the surrounding tissue (“wide excision”). They can reoccur after removal.
Chemotherapy may be used in malignant or metastatic tumours.
Breast pain (mastalgia) is common. It can be:
Cyclical – occurring at specific times of the menstrual cycle
Non-cyclical – unrelated to the menstrual cycle
What is Cyclical Breast Pain
When does it occur
Cyclical breast pain is more common and is related to hormonal fluctuations during the menstrual cycle. The pain typically occurs during the two weeks before menstruation (the luteal phase) and settles during the menstrual period. There may be other symptoms of premenstrual syndrome, such as low mood, bloating, fatigue or headaches.
Cyclical Breast Pain
Symptoms are typically
Bilateral and generalised
Heaviness
Aching
Non-Cyclical Breast Pain
Who is common in?
What is it caused by?
Non-cyclical breast pain is more common in women aged 40 – 50 years. It is more likely to be localised than cyclical breast pain. Often no cause is found. However, it may be caused by:
- Medications (e.g., hormonal contraceptive medications)
- Infection (e.g., mastitis)
- Pregnancy
The pain may not originate in the breast but instead come from:
- The chest wall (e.g., costochondritis)
- The skin (e.g., shingles or post-herpetic neuralgia)
The three main things to exclude when someone presents with breast pain are:
- Cancer (perform a thorough history and examination)
- Infection (mastitis)
- Pregnancy (perform a pregnancy test)
A ____ ___ _____ can help diagnose cyclical breast pain.
A breast pain diary can help diagnose cyclical breast pain.
Management
Options to manage cyclical breast pain include:
- Wearing a supportive bra
- Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (oral or topical)
- Avoiding caffeine is commonly recommended
- Applying heat to the area
- Hormonal treatments (e.g., danazol and tamoxifen) under specialist guidance
What is Gynaecomastia
Gynaecomastia refers to the enlargement of the glandular breast tissue in males. Male breast enlargement is relatively common, particularly in adolescents and older men (aged over 50 years). It may also be present in newborns due to circulating maternal hormones, resolving as the maternal hormones are cleared.
Gynaecomastia can be caused by conditions that increase oestrogen like:
- Obesity (aromatase is an enzyme found in adipose tissue that converts androgens to oestrogen)
- Testicular cancer (oestrogen secretion from a Leydig cell tumour)
- Liver cirrhosis and liver failure
- Hyperthyroidism
- Human chorionic gonadotrophin (hCG) secreting tumour, notably small cell lung cancer
Gynaecomastia is generally caused by which two hormonal imbalance
oestrogen and androgens (e.g., testosterone)
with higher oestrogen and lower androgen levels
______ oestrogen stimulates breast development, whilst androgens have an _______ effect on breast development.
Raised oestrogen stimulates breast development, whilst androgens have an inhibitory effect on breast development.
aised ___________ (_________) can also cause gynaecomastia.
aised prolactin (hyperprolactinaemia) can also cause gynaecomastia.
What inhibits prolactin
dopamine
What can block dopamine
And what are the effects of prolaction as a result
Dopamine antagonists (e.g., antipsychotic medications) block dopamine production, which can allow prolactin levels to rise and cause gynaecomastia and galactorrhea (breast milk production).
It is worth remembering the link between gynaecomastia and _____ _____ ________ ________ About 2% of patients presenting with gynaecomastia have a ______ _____. An examination question might describe a patient presenting with gynaecomastia and ask what additional examination should be performed. The answer will be a testicular examination. Also, examine for signs of ________ _____ and _________
It is worth remembering the link between gynaecomastia and Leydig cell testicular tumours. About 2% of patients presenting with gynaecomastia have a testicular tumour. An examination question might describe a patient presenting with gynaecomastia and ask what additional examination should be performed. The answer will be a testicular examination. Also, examine for signs of liver failure and hyperthyroidism.
Gynaecomastia can be caused by conditions that reduce testosterone like:
- Testosterone deficiency in older age
- Hypothalamus or pituitary conditions that reduce LH and FSH levels (e.g., tumours, radiotherapy or surgery)
- Klinefelter syndrome (XXY sex chromosomes)
- Orchitis (inflammation of the testicles, e.g., infection with mumps)
- Testicular damage (e.g., secondary to trauma or torsion)
There is a long list of medications and drugs that can cause gynaecomastia
Name a few
- 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
Blood tests for gynaecomastia
- Renal profile (U&Es)
- Liver function tests (LFTs)
- Thyroid function tests (TFTs)
- Testosterone
- Sex hormone-binding globulin (SHBG)
- Oestrogen
- Prolactin (hyperprolactinaemia)
- Luteinising hormone (LH) and follicle-stimulating hormone (FSH)
- Alpha-fetoprotein and beta-hCG (testicular cancer)
- Genetic karyotyping (if Klinefelter’s syndrome is suspected)
Imaging for gynaecomastia?
- Breast ultrasound (may help assess the extent of gynaecomastia)
- Mammogram (if cancer is suspected)
- Biopsy (if cancer is suspected)
- Testicular ultrasound (if cancer is suspected)
- Chest x-ray (if lung cancer is suspected)
Management depends on the underlying cause. Gynaecomastia almost always resolves with time in adolescents. Stopping a causative drug (e.g., anabolic steroids or spironolactone) will usually resolve the symptoms. Patients may be referred to the specialist breast clinic where the cause is unclear or cancer is suspected.
Treatment options in problematic cases (e.g., pain or psychological distress) include:
- Tamoxifen (a selective oestrogen receptor modulator that reduces the effect of oestrogen on the breast tissue)
- Surgery
Galactorrhoea refers to_____ ______ production not associated with pregnancy or breastfeeding. Breast milk is produced in response to the hormone ______
Galactorrhoea refers to breast milk production not associated with pregnancy or breastfeeding. Breast milk is produced in response to the hormone prolactin.
Whati nhibits breast milk production
. Milk production may start in small amounts during the second or third trimester of pregnancy, and leaking can occur during that timeOestrogen and progesterone inhibit the secretion of prolactin. In pregnancy, higher levels of oestrogen and progesterone inhibit breast milk production.
_______ stimulates breast milk excretion. Full milk production starts shortly after birth in response to _______ release and a rapid drop in oestrogen and progesterone
Oxytocin stimulates breast milk excretion. Full milk production starts shortly after birth in response to oxytocin release and a rapid drop in oestrogen and progesterone
There is a long list of causes of hyperprolactinaemia, but the key causes to remember are:
- Idiopathic (no cause can be found)
- Prolactinomas (hormone-secreting pituitary tumours)
- Endocrine disorders, particularly hypothyroidism and polycystic ovarian syndrome
- Medications, particularly dopamine antagonists (i.e., antipsychotic medications)
Prolactin suppresses _______ _____ _________ by the hypothalamus, leading to reduced LH and FSH release. Therefore, hyperprolactinaemia can also present with:
Prolactin suppresses gonadotropin-releasing hormone (GnRH) by the hypothalamus, leading to reduced LH and FSH release. Therefore, hyperprolactinaemia can also present with:
- Menstrual irregularities, particularly amenorrhoea (absent periods)
- Reduced libido (low sex drive)
- Erectile dysfunction (in men)
- Gynaecomastia (in men)
What are Prolactinomas
Prolactinomas are tumours of the pituitary gland that secrete excessive prolactin. This may be associated with multiple endocrine neoplasia (MEN) type 1, an autosomal dominant genetic condition.
