Breast surgery Flashcards
what is the most common breast cancer?
invasive ductal - NST
what is pagets disease of the nipple?
it is eczematoid changes of the nipple that indicates an underlying malignancy
what is the pathophysiology of inflammatory breast cancer?
cancerous cells block the lymph drainage
what are the risk factors for breast cancer?
BRCA1/2, first degree relative, nulliparity, early menarche, late menopause, COCP, previous surgery, PMHx, p53 mutations, not breast feeding, radiation, obesity
what is the referral criteria for breast cancer?
> 30 with unexplained lump with or without pain, >50 with nipple changes, consider if skin changes or axillary lump >30
what is the breast cancer screening programme?
50-70 every 3 years, >70 make own appointments
refer if >1 relative and age <40, bilateral, male, ovarian, jewish, sarcoma, glioma, complicated, paternal history, screen early if increased risk
what is the presentation of breast cancer?
thickening, lump, change in size or shape of breast, dimpling, inflammation, nipple retraction, discharge, peeling, pitting, crusting
how is breast cancer investigated and managed?
ix: H&E, mammogram, U/S, biopsy, CT/MRI, SLNB
mx: surgery - mastectomy or WLE (solitary, small, peripheral, DCIS<4cm), radiotherapy, hormonal therapy, biologics, chemo
summarise breast abscess?
it can be lactational or non-lactational - cannot drain and therefore collection of WBC and pus. Can be infective. The risk factors are smoking, damage to nipple, underlying breast disease, caused by S Aureus etc. Presents with nipple discharge (purulent), localised pain, tenderness, warmth, erythema, hardening, swelling, fluctuant, fatigue, fever, sx sepsis
mx: lactational: massage, breast feed, express, analgesia, heat, abx
non: analgesia, ABx: co-amox or macrolide, treat cause
abscess: refer, ABx, U/s, I&D or aspiration, M,C&S of fluid
what are the differentials for breast lumps?
fibrocystic disease (mastalgia, cyclical, lumps), breast cancer, fibroadenoma (painless, smooth, round, firm, mobile), phyllodes tumour (connective tissue, large, fast growing), lipoma (soft, painless, mobile), fat necrosis (painless, firm, irregular), galactocele (after stopping breast feeding, firm, mobile, under areola), cysts
what is gynaecomastia?
it is enlargement of the breast tissue in males, that is caused by imbalance between oestrogen and testosterone, increased prolactin, hyperthyroidism, drugs, hypothalamus or pituitary conditions, increased oestrogen, idiopathic, physiological, and decreased testosterone
how is gynaecomastia investigated and managed?
ix: bloods - FBC, U&Es, LFTs, TFT, testosterone, SHBG, E2, prolactin, LH, FSH, bhCG, AFP
karyotyping
USS, mammogram, biopsy, testicular US, CXR
mx: conservative, stop causative drug, tamoxifen, surgery
what is galactorrhoea?
it is breast milk that is not due to pregnancy or breast feeding - in response to prolactin
can be caused by increased prolactin, endocrine disorders, drugs
how does galactorrhoea present?
milk, menstrual cycle irregularities, decreased libido, ED, gynaecomastia
what can non milk discharge be?
mammary duct ectasia, duct papilloma, abscess
how does prolactinoma present?
associated with MEN, micro or macro, headache, bitemporal hemianopia
how is galactorrhoea investigated and managed?
ix: serum prolactin, PT, U&Es, LFTs, TFTs, MRI
mx: underlying cause, dopamine agonists, transsphenoidal surgical removal
summarise breast pain?
can be cyclical or non-cyclical. It is not a symptom of breast cancer.
cyclical: hormones: 2w prior to and stops during menstruation. other sx of premenstrual syndrome: low mood, bloating, fatigue, headaches, usually bilateral, generalised and heaviness/aching
non-cyclical: 40-50y, localised: medications, infection, pregnancy, chest wall, skin
ix: diary, r/o cancer, infection, pregnancy
mx: conservative, supportive bra, NSAIDs, warmth, avoid caffeine, hormonal e.g. tamoxifen
what is lactational mastitis?
it is inflammation of the breast tissue during breast feeding, with or without infection usually due to obstruction (accumulation of milk) or infection (S Aureus)
how does lactational mastitis present?
breast pain and tenderness, erythema of focal area, local warmth, inflammation, fever, nipple discharge
how is lactational mastitis managed?
conservative - express, massage, heat, analgesia
flucloxacillin or erythromycin, M,C&S
I&D for abscess
treat candida
what is a complication of the management of lactational mastitis?
after abx can get candida infection - recurrent and associated with oral or nappy rash
sore bilateral nipples, tenderness, itching, soreness, cracked, flaky, shiny areola, oral or nappy rash in baby
topical miconazole 2% to each nipple after each feed
baby: miconazole gel or nystatin
what is mammary duct ectasia?
it is dilatation of large ducts in the breast due to inflammation usually in smokers and periomenopause
how does mammary duct ectasia present?
nipple discharge, tenderness, pain, nipple retraction or inversion, lump
how is mammary duct ectasia investigated and managed?
ix: H&E, triple assessment, ductograhy, ductoscopy, discharge cytology
mx: conservative, r/o cancer and reassure, symptomatic with warmth, analgesia, supportive bra, ABx, excision of duct
what is intraductal papilloma?
it is a warty lesion in a duct of the breast due to proliferation of epithelial cells - benign but can be associated with breast cancer or atypical hyperplasia
how does intraductal papilloma present?
35-55y, asymptomatic, clear, blood stained discharge, tenderness, pain, lump
how is intraductal papilloma investigated and treated?
ix: H&E, triple assessment, ductography
mx: surgical excision, look at tissue for hyperplasia or cancer
