Breast Surgery Flashcards
define breast triple assessment
Women (and men) can be referred to this ‘one stop’ clinic by their GP if they have signs or symptoms that meet the breast cancer “2 week wait” referral criteria, or if there has been a suspicious finding on their routine breast cancer screening mammography.
what are the main types of imaging used for the breast?
Mammography involves compression views of the breast across two views (oblique and craniocaudal), allowing for the detection mass lesions or microcalcifications.
Ultrasound scanning is more useful in women <35 years and in men, due to the density of the breast tissue in identifying anomalies. This form of imaging is also routinely used during core biopsie
when is MRI used?
lobular breast cancers
how is a biopsy used?
differentiation between invasive and invasive in situ
grading and staging
how is the triple assessment used?
at each stage of assessment - suspicicion for malignancy graded
Examination Score Imaging Score Histology Score
P1 – Normal M1 / U1 – Normal B1 – Normal
P2 – Benign M2 / U2 – Benign B2 – Benign
P3 – Uncertain/likely benignM3 / U3 – Uncertain/likely benign B3 – Uncertain, probably benign
P4 – Suspicious of malignancy M4 / U4 – Suspicious of malignancy B4 – Suspicious of malignancy
P5 – Malignant M5 / U5 – Malignant B5 – Malignant
define lactation
copious, bilateral, multi-ductal, milky discharge, not associated with pregnancy or lactation
how is lactated controlled?
prolactin release produced and secreted from anterior pituitary
dopamine inhibits prolactin release
TRH and oestrogen stimulate the release
what are the most common cause of hyperprolactinaemia?
Idiopathic, occurring in around 40% cases
Pituitary Adenoma, whereby benign tumours of the pituitary gland can secrete excessive prolactin hormone, often termed prolactinomas
Drug-Induced, with medications such as SSRIs, anti-psychotics, or H2-antagonists all stimulating prolactin release
Neurological, whereby neurogenic pathways are activated to inhibit dopamine levels, such as varicella zoster infection or spinal cord injury
Hypothyroidism, as elevated thyrotropin-releasing hormone can also stimulate prolactin related.
Cushing’s disease, Acromegaly, and Addison’s disease have also been associated with the condition.
Renal failure or liver failure
Damage to the pituitary stalk, leading to reduced dopamine inhibition to the pituitary, from surgical resection, multiple sclerosis, sarcoidosis, or tuberculosis
what is the causes of normoprolactinaemic galactorrhoea?
idiopathic
what are the clinical fx of galactorrhoea?
must be differentiated from alternative nipple discharge
any other sx - reast lumps, mastalgia, and their last menstrual period, to assess for potential underlying causes or an alternative diagnosis. Ask about features of endocrine disease and for neurological symptoms (headaches, visual disturbances
drug HX - contraception, OTC, recreational drug use
breast exam usually unremarkable
any visual images - compressive pituitary masses or features of hypothyroidism
which investigations are required for galactorrhoea?
exclude pregnancy
serum prolactin levels
complete thyroid functions, LFTS, renal function tests
endocrine tests - IGF-1, ACTH
MRI test with contrast if pituitary tumour is suspected
how is galactorrhoea managed?
dopamine agonist therapy - caberoline
neurosurgery - trans-phenoidal surgery
bilateral total duct excision
why might men have mastalgia?
gynaecomastia
what are the types of mastalgia?
cyclical pain, which is defined as pain associated with the menstrual cycle. Typically, cyclical pain affects both breasts, beginning a few days before the beginning of menstruation and subsiding at the end. It is caused by hormonal changes, therefore most cases come in those actively menstruating or using HRT.
Around a third of mastalgia is non-cyclical pain is unrelated to the menstrual cycle. It can be caused by medication, including hormonal contraceptives, anti-depressants (such as sertraline), or antipsychotic drugs (such as haloperidol). Other causes of breast pain can be extramammary pain, such as chest wall pain or shoulder pain.
what other sx should be asked in relation to mastalgia?
lumps, skin changes, fevers, or discharge, as well as association with menstrual cycle. Ensure to as about drug history, breast-feeding, pregnancies, previous medical history, and family history.
which investigations are required for mastalgia?
Breast pain in isolation with no other relevant features on history or examination is not an indication for imaging. All patients within reproductive age should have a pregnancy test
how is mastalgia managed?
underyling cause treated
reassurance and pain control
cyclical - better fitting bra or soft support at night
non cyclical pain not usually respond to analgesia
refferal to specialist - danazol - anti gonadotrophin agent
define mastitis
inflammation of the breast tissue, both acute or chronic. By far the most common cause is from infection, typically through S. Aureus, but can occasionally be granulomatous
how can mastitis be classified?
Lactational mastitis (more common) is seen in up to a third of breastfeeding women; it usually presents during the first 3 months of breastfeeding or during weaning
It is associated with cracked nipples and milk stasis (often caused by poor feeding technique), and is more common with the first child
Non-lactational mastitis (less common) can also occur, especially in women with other conditions such as duct ectasia, as a peri-ductal mastitis
Tobacco smoking is an important risk factor, causing damage to the sub-areolar duct walls and predisposing to bacterial infection
what are the clinical fx for mastitis?
h tenderness, swelling or induration, and erythema
how is mastitis managed?
abx and analgesia
if lactational - continue milk drainage or feeding
use dopamine agonist
define breast abscess
collection of pus within the breast lined with granulation tissue, most commonly developing from acute mastitis.
They present with tender fluctuant and erythematous masses, with a puncutum potentially present. Associated systemic symptoms include fever and lethargy. A suspected abscess can be confirmed via an ultrasound scan
define breast cysts
epithelial lined fluid-filled cavities, which form when lobules become distended due to blockage, usually in the perimenopausal
what are the clinical fx of breast cysts?
singularly or with multiple lumps
distinct smooth masses
which investigations are required for breast cysts?
halo shape on mammogram
definitively diagnosed with USS
aspirated - if fluid is free not cancer
how are breast cysts managed?
no management required
larger cysts can be aspirated
what are the complications of breast cysts?
carcinoma at presentation (2%) or at greater risk in future
may develop fibroadenosis caused by multiple small cysts and fibrotic areas
analgesia
cyclical pain - high dose gamolenic acid
define mammary duct ectasia
dilation and shortening of the major lactiferous ducts. It is a common presentation in peri-menopausal women, with 40% of women having significant duct dilatation by 70yrs
what are the clinical fx of duct ectasia?
green/yellow discharge
palpable mass
nipple retraction
what if discharge is blood?
triple assessment
which investigations are required for duct ecstasia?
mammogram - dilated calcified ducts
multiple plasma cells on histology
how is duct ecstasia managed?
conservatively
unremitting nipple discharge can be treated with duct excision
define fat necrosis
cute inflammatory response in the breast, leading to ischaemic necrosis of fat lobules.
what are the causes of fat necrosis?
It is often referred to as traumatic fat necrosis due to its association with trauma, however blunt trauma to the breast is only implicated in 40% cases, with previous surgical or radiological intervention making up the remaining proportion
what are the clinical fx of fat necrosis?
usually asx or as lump
can present with fluid discharge, skin dimpling, pain and nipple inversion.
The acute inflammatory response can persist, causing a chronic fibrotic change (Fig. 3) that can subsequently develop into a solid irregular lump
which investigations are required for fat necrosis?
positive trauma history and/or hyperechoic mass on USS
