Breast Surgery Flashcards
how is breast cancer diagnosed / excluded?
triple assessment
- clinical assessment
- imaging (USS, mammography)
- histology (FNA, core biopsy)
presentation of breast cancer?
- new breast lump
- nipple retraction / discharge
- skin dimpling / oedema (peau d’orange)
describe characteristics of a breast cancer lump
- hard
- irregular
- painless
- fixed in place
- tethered to skin
2WW criteria for breast cancer?
- unexplained breast lump in pts 30+
- unilateral nipple discharge / retraction in pts 50+
describe the characteristics of a fibroadenoma
- small (<3cm in diameter)
- smooth
- round with well-defined borders
- firm
- mobile
- “breast mouse”
is a fibroadenoma worrying?
- no
- no risk of going on to develop cancer
features of fibrocystic breast changes?
- can be uni- or bilateral
- lumpiness
- mastalgia (pain and tenderness)
- fluctuating breast size
- fluctuate with menstrual cycle
- regress with menopause
management of fibrocystic breast changes?
exclude breast cancer then reduce mastalgia:
- supportive bra
- NSAIDs (ibuprofen)
- avoid caffeine
- apply heat to area
- hormonal treatment
hormonal treatment options for mastalgia?
- danazol
- tamoxifen
what is the most common type of breast lump?
breast cysts
which age demographic is most affected by breast cysts?
- women aged 30-50
- particularly in perimenopausal period
features of a breast cyst?
- smooth
- well-circumscribed
- mobile
- may be fluctuant
- may be painful
- changes with menstrual cycle
management of a breast cyst?
- exclude breast cancer
- aspirate to resolve pain
- surgical excision
is a breast cyst worrying?
- yes
- slightly increased risk of developing breast cancer
is fat necrosis worrying?
- no
- no increased risk of developing breast cancer
features of the lump in fat necrosis?
- painless
- firm
- irregular
- fixed to local structures
- skin dimpling
- nipple retraction
how is fat necrosis differentiated from breast cancer?
- look the same on imaging
- therefore need to do histology:
- FNA / core biopsy
management of fat necrosis?
- exclude breast cancer
- conservative (most resolve spontaneously
- surgical excision if symptomatic
what is a lipoma?
a benign fat tumour
findings on examination of a lipoma?
- soft
- painless
- mobile
- NO associated skin changes
management of a lipoma?
conservative
what is a galactocoele?
milk-filled cyst blocking the lactiferous duct
when do women typically develop galactocoeles?
- when lactating
- typically when they’ve just stopped breastfeeding
features of a galactocoele?
- firm
- mobile
- painless
- subareolar region
management of a galactocoele?
- conservative
- can be drained by needle
- ABx if infected
key complication of galactocoele?
can become infected
which demographic is typically affected by phyllodes tumours?
women aged 40-50
is a phyllodes tumour worrying?
- yes
- 50% are benign
- 25% are borderline
- 25% are malignant
management of a phyllodes tumour?
- surgical removal (can still recur despite this)
- chemotherapy if it has metastasised
how can mastalgia be classified?
- cyclical
- non-cyclical
features of cyclical breast pain?
- comes on in first 2 weeks of cycle (luteal phase), then settles
- bilateral, generalised pain
- heaviness
- aching
- associated with other signs of premenstrual syndrome
signs of premenstrual syndrome?
- cyclical breast pain
- low mood
- bloating
- fatigue
- headaches
causes of non-cyclical breast pain? (hint: think local and non-local)
- any local breast pathology
- drugs (HRT, contraceptives)
- pregnancy
- infection (mastitis, costochondritis)
- skin (shingles, post-herpetic neuralgia)
management of cyclical breast pain?
- supportive bra use
- NSAIDs (oral or topical)
- avoid caffeine
- heat packs
- hormones under a specialist (danazol, tamoxifen)
is male breast enlargement common? which age groups could be affected?
- yes!
- common in neonates, teens and 50s
pathophysiology of gynaecomastia?
- imbalance between circulating oestrogens (increase) and androgens (decrease)
- could also be due to high prolactin
causes of gynaecomastia due to increased oestrogen?
- obesity
- testicular Ca (leydig cell tumour)
- liver cirrhosis / failure
- hyperthyroidism
- hCG-secreting tumour (e.g. SCLC)
causes of gynaecomastia due to decreased testosterone?
- age-related deficiency
- hypothalamus / pituitary tumours or damage (e.g. post-radio, post-surgery)
- klinefelter syndrome (XXY)
- orchitis
- testicular damage (e.g. due to trauma / torsion)
illicit and prescribed drug causes of gynaecomastia?
- anabolic steroids
- antipsychotics
- digoxin
- spironolactone
- opiates
- marijuana
- alcohol
investigations for gynaecomastia?
- LFTs
- testosterone (low)
- oestrogen (high)
- sex hormone binding globulin
- prolactin (high)
- LH, FSH
- AFP, b-HCG (markers of testicular Ca)
- genetic karyotyping (klinefelter syndrome)
imaging for gynaecomastia?
- USS breast
- mammogram + biopsy (if Ca suspected)
- USS testicles (Ca)
- CXR (lung Ca)
management of gynaecomastia?
- treat underlying cause (e.g. stop drug)
- tamoxifen for pain
- surgery
define galactorrhoea
breast milk production not relating to pregnancy or breastfeeding
which hormone triggers the production of breast milk?
prolactin
how does dopamine affect prolactin levels?
DA suppresses prolactin release
in pregnancy, when does breast milk production begin?
- in 2nd and 3rd trimester
- it’s normal to leak a little at this point too
what is galactorrhoea?
breast milk production which is not associated with pregnancy or breastfeeding
where is prolactin produced?
anterior pituitary
which hormones inhibit prolactin release?
- oestrogen
- progesterone
what is the role of oxytocin?
to stimulate breast milk excretion
how can the causes of hyperprolactinaemia be split?
- idiopathic
- tumours (prolactinomas)
- endocrine problems
- drugs
endocrine (non-tumour) causes of hyperprolactinaema?
- hypothyroidism
- PCOS
drug causes of hyperprolactinaemia?
DA antagonists (antipsychotics)
presentation of hyperprolactinaemia?
- galactorrhoea
- amenorrhoea
- low libido
- ED in men
- gynaecomastia in men
- headaches / vision changes if caused by a pituitary tumour
which hereditary condition could predispose someone to prolactinomas?
multiple endocrine neoplasia type 1 (MEN1)
mode of inheritance of MEN1?
autosomal dominant