Breast surgery Flashcards
what would a lump suggestive of breast cancer be like
hard
irregular
painless
fixed
tethered to skin/chest wall
nipple retraction
skin dimpling/oedema=> peau d’orange
when put woemn on 2ww
unexplained breast lump 30 and over
unilateral nipple changes 50 and over
unexplained brst lump undeer 30s how refer
non urgent referal
breast lump:
painless
smooth
mobile
round
well defined
firm
fibroadenoma
whats fibroadnenoma
common benign tumour of stromal/ epithelilal breast duct tissue
typicall small and mobile- like mouse
common in younger women 20-40s snd regress after menopause
non cancerous
firm
small normally under 3cm diameter
painless
round
smooth
well defined(well circumbsised)
mobile - free to move under skin and above chest wall
lumpiness breast thats painful and gets 10 days before period and then gets better
fibrocytic breast changes
whats fibrocytic breast changes
stoma. ducts. lobules reposnd to oestrogen and progresterone - can become fibrous (irregular and hard) and cystic- fluid filled
bengin
fluctuate with mentrural cycle- usulaly reosve with menopause
often occur propr to mensutration (within 10 days and resolve once start)
lumpiness
breast tenderness/ breast pain
fluctation breast size
how to mangage fibrocytic breast changes
exclude cancer - imaging, clinical, histology
manage the cyclic breast pain = mastalgia =
supportive bra
NSAIDs
avoid caffeine
heat on area
hormonal by specialsit- tamoxifen/ danaxol
most common type of breast lum,p
breast cycst
breast lum,p:
mobile
well circumbised
smooth
painful
breast cycst
whats breast cysts like
bengin
smooth
well circumbsied
can vary in size
can be red and inflammed if infected
30-50 and perimenopause
can increase risk of breast cancer
treatment brest cysts
exclude cancer
aspiration if in pain
- may need culutre fluid
painless
firm
irregular
fixed
may have skin nsimpling and nipple inversion
differentials
fat necrosis lum,p
breast cancer
whats fat necrosis breast lump
benign
formed by localised degenration and scarring of fat tissue
casues:
loclaised trauma
radiothepray
surgery
infalmmation rxn
= all causing fibrosis and necroisis
o/e
painless
irregular
firm
fixed
can have skin simpling/nipple inversion
treat fat necorisis breast lump
us and mammogram may look like breast ancer
hsitology ay be needd to exclude breast cancer
once kow not cancer then conservative treamtnent/ can resolve spontaenously, can have surgically excised
breast lump:
soft
painless
mobile
no skin changes
lipoma
whats a lipoma
benign tumour of fat
can occur anywhere in body
soft
painless
mobile
no skin hcnaees
mangement lipoma
conservcative can resolve by self
can remove
lady just stopped breast feeding
firm
mpbile
oainless breast lump
galactocele
whats a galactocele
bengin
women lactating - often after stopping breastfeeding
lactiferous duct blocked
firm
mobile
painless
usually just below areola
treat galactocele
can drain
may need abx if infected
phyllodes tumour
rare tumour of connective tissue of bresat
large and fast growing
ca be benging, bordeline, malignant
can metatisise
treat=
removal and surround tossue removal
can recur
may need chemo
casues of gynaecomastia 5 main broad casues
normally due to hormonal imblaance bwtween oestrogen and androgens- testosterone
high oestrogen
low testosterone
medications/ drugs
idiopathic
physiological in adolescnets as oestrogen higher but resovles
what can casues high oestrogen leading to gynaemcosmastia
obesity- aromatase convert androgen to oestrogen
testicular cancer - oestrogen secretion from leydig cell yumour
liver cirrhoisis liver failure
hyperthryoidsim
hCG secreting tumour - small cell lung cancer
what two cancers can casue gynaecomastia
testicular cancer- leydig cell tumour
small cell lung cancer
what can casue low testosterone casuing gynaecomastia
testosterone deficicency in older age
kleinfelter syndrome XXY
hypothalamus/pituitary condition that dec FSH and LH eh. tumour, srugery, radiotherpay
orchittis - casue eg mumps
testicular damage- torsion/trauma
what infection can casue orchitits
mumps
whats medications/drugs can casue gynaecomastia
spirinolactone - iinhibit tesoterone prodcutions and block testosterone receptors
digoxin- stimulate oestrogen r
anabolic steroids- increase oestrogen
opiates- heorin use
weed
alcohol
antipsycotics- dopamine antagonist–> increase [rolactin
how do antipsycoitcs can casue gynaecomastia
dopamine antagoist
block dopamine prodcution
dopamine inhibits prolactin
but less dopamine so prolactin increases
prolactin stiulats glandular breast tissue development
what hormones can be abnomrla that can casue gynaecomastia
testosterone / androgens= inhhibiorry effect on breast tissue developmebt
oestrogen - stimulate breast tissue development
prolactin - - stimulate glandular breast tissue development
dopamine antagonsit - block dopamine so increase prolactin cus dopamine hibits prolactin
if male has gynaecomastia what other examination may you want to do
testicular examination
assess for signs of liver disease
how to asses for gynaecomastia
cehck its not adipose tissue- adipose be soft and even
glandular be firm tissue behind arelolar
ask age, duration changes
anabolic steroids, drug use, alchol
any sex dysfucntion- may show if low testosteone
exclude breast cancer - lum,ps?
testicualr lumps?
meds on
uni or bilateral
lumps, lymphadenopathy bmi
testicualr examination
signs of low testosterone- less pubic hair
signs liver disease
signs hyperthryoidsim
pt sweating
tachycardia
weight loss
gynaecomastia
casue
hyperthroidism
investigfations gynaecomastia
if teenage ok check and wull resolve
in unexpalined rapid onset check
u and e
lft
tft
testosterone
sex hormone binding globulin
oestrogen
prolactin
beta hCG and alpha feto protein- tessticualr cancer tumour markers
genetic karyotype
LH AND FSH
imaging may want to do for gynaecomastia
us - diagnose
mammorgram- if ?cancer
biopsy if ?cancer
cxr- ?lung cancer
testicualr us- ?cancer
whats most common form breast pain - cyclical or non cyclical pain
cyclical pain
whats cyclical breast pain
more common
related to hormonal fluctuations
pain normally worse 2 weeks before menstruatation (luteal phase) then settles during period
may have pther symptoms of prementrual syndrome- low mood, fatigue, bloating, headaches
s and s of cyclical breast pain
bilateral
generalsied
heviness
aching
whats non cyclical breast pain
more common women 40-50
more localised
often no cause
may originate from other palce- chest wall- costochondritits
- skin- shingles/ post herpetic neuralgia
casues:
meds- HRT
infection -mastitis
pregnacy
how to diangose breast pain
diary can help if cyclical diagnose
exclude breast cancer- do history and examination
check for signs infection- mastitis
do preg test
management of cyclical breast pai
supportive bra
reasure
warm
NSAIDS
avoid caffeine
hormonal treatment by speciclaist - tamoxifen danazol
whats galactorrhea
breast milk production no associated with pregnacy/breast feeding
where prolactin produced
anterior pituitary
whats action of dopamine
block prolactin
whe and how does breast milk production occur during pregnacy and what stimulates and inhibits the prodcution
production starts 2/3 rd trimester - small amounts can get leakage
oestrgoen and progesterone inhibits prolactin secretion
oxytocin stimulates milk excretion
milk prudction stops once breast feeding stops
casue of galactorrhea
normally due to high prolactin levels = hyperprolactinameia
casyes of hyperprolactinameia - galactorhea
prolactinomas - pituitary glad tumour
endocrine disorders- hypothryoidism, PCOS
meds- dopamine antagonsits eg. antipsycotics
s and s of gallactorhea
prolactin supresses GnRH and so also then get low FSH and LH
so hyperprolactinameia also presents with:
menstrual irregularities esp amenorrhea
reduced libido
erectile dysfucntion in men
gyanecomastia in men
what gene can prolactinomas be assocaited with
MEN1
macroprolactinomas are larger than 10mm.
what sympotms can they have other than hyperprolactinameia
headaches
bitemporal heminanopia
patient has symptoms of hyperprolactinameia -
WHAT OTHER EXAMINATION DO YOU NEED TO DO
asses visual fields as prolactinoma can press on optic chaism
investigations for galactorrhea
LFT
TFT
U AND E
preg test
serum prolactin
MRI if suspect pit tumour
visual field examiantion
manage galactorrhea
treat casue
dopamin agonst can help- bromocriptine, cabergoline
transpshenoidal removal pit tumour
what differentiasl are there for galactorhea- non milk discharge
mammary duct ectasia
duct papilloma
pus from breast abscess
whats mammary duct ectasia
benign
dilation of laege ducts in breast.
inflammation leads to intermittent discharge from nipple
presentation of mammary duct ectasia
nipple discharge- white, grey, green
tenderness/ pain
nipple retraction/ inversion
breast lump may be present - if press on it discharge may come out nipple
more frequent in perimenopasual women
whatsa big risk factor for mammary duct ectasia
smoking
how to diagnose mammary duct ectasia
eclude breast cancer- triple assesment- clinical, imaging, histology
microcalcification of mammogram - not specific to this though
may use:
ductography= contrast and mammorgram
nipple discharge cytology
ductoscpy
mammary duct ectasia see what on ammorgram
microcalcification
managment mammary duct ectasia
may resovle by self
reassurance
symptomatic managemnt of mastalgia- warm, supportive bra, nsaids
antibiotics if infection
surgical excision of duct if bad - microdochetomy
whats intraductal papilloma
warty lesion that grown within the ducts in the breast
cause of intraductal papilloma
proliferation of epithelial cells
bengin
can be associated with atypical hyperplasia/ breast cancer!
presentation of intraductal papilloma
nipple discharge- clear/ blood stained
tnederness/ oain
palpable lump
diangosis of intradcutal papilloma
triple assesment for breast cancer ecxclusion
ductography- contrast into abnormal duct- see filling defect
management of intraductal papilloma
surgical excision
examine it once removed for atypical signs that may not be seen on biopsy
whats lactational mastitis
inflammation of breast tisue
common complication of breast feeding
can occur with or without an infection
cause sof lactational mastitis
obstruction
infection
whast most common infection casuse of lactational mastitis
staphylcoccus aureus
presentation lactational mastitis
woman breast feeding
nippled discahrge
nreast tenderness/pain uilateral
eythema in focal area
local warmth and inflammation
fever - suspect cause is infection
complciation of lactational mastitis
breast abscess
management of lactational mastitis
if casue is a blockage- conservcative management - continue breast feeding, breast massage, warmth, simple anaglesia
if conservative not working or suspect infection is the casue -
antibiotics- flucloxacillin or erythromycin if penacillin allergic
sample milk for culture and sensitivities
fluconazole can be used if casue is candidal infection
continue breast feeding - wont harm baby and will help clear infection
whats casue of candidal infection of nipple
often after course of antibiotics
cracks in nipple can lead to recurrent mastitis
associated with oral thrush/candidal nappy rash in baby
presentation of candidal infection of nipple
sore nipples - bilaterally especialy sore after breast feeding
nipple tnederness and itching
cracked, flaky, shiny areola
baby may have cancdical nappy rash or white spots in mouth/tongue
managment of candical nippleinfection
treat mum and infant as otherwise keep comin bacl
mum- topical miconazole 2% after breast feeding each time
baby- oral miconazole gel / nystatin
whast breast abscess
collection of pus in area of breast.
can be lactational or non lactational
cause of breast abscess
usually due to bacterial infection
mastitis infection may precede abscess
what bacteria responsible for breast bascess
staphylcoccus aureau! most common
enterococcus species
streptococcal speicies
= these are gram positive so penicillins simple ones will work- flucloxacillin/amoxicillin
anaerobic bactiera -
bacteroides species
anerobic streptococci
= use broader penicillin- co- amoxicclin/ metronidazole
presentation of breast abscess
acute usually
swollen
fluctuant - fluid move in lump
tender lump
symptom s of infection:
fever
fatigue
muscle aches
sepsis- tachycardia, tachypnoea, conducsion
symptoms mastitis with infection
nipple changes
hardening of skin / breast tissue
localised apin
warmth
tenderness
erythema
swllinh
managemtn of non lactational mastitis
braad spectrum antibiotics-
co-amoxiclav
erythromycin/ clarithromycin + metronidazole
treat casue eg. candidal infection/excema
analgeisa
managment of breast abscess
antibiotics
ultrasound - confrim diagnosis
draiangae- needle aspiration. incision and drainage
microscopy, culture and sensntives of drained fluid
refer surgucal team
risk factors breast abscess/ masittis
smoking
damage to nipple- nipple excema , candidal infection, nipple piercing
breast disease eg. cancer that blocks drainage of breast so predispose to infection
breast abscess/ mastitis should women keep breast feeding?
yes
even if infected
if too painful breast feed then express milk
risk facrtors breast cancer
female
smoking
obesitiy
faulty BRCA 1, BRCA2 gene
fam hist - first degree relative
COCP- small increase risk. once not been on it for 10 years risk normal
HRT - oestrogen combined
increase of oestrogen exposure- early periods, late menopasue
high dense breast tissue- glandular
BRCA1 faulty gene increase risk of what
BRCA2 fulty gene increase risk of what
BRCA1 on CHR17
increase risk breat, ovarian cancer. increase risk of prostte and bowel cancer
BRCA2 increase risk breast and ovarian cancer
chr 13
whens screening for breast cancer
age 50-70 every 3 yr mammogram
presentation breast cancer
hard, fixed, irregular, painoess lump
tethered to skin/chest wall
nipple retraction
peau d’orange - oedema casue swelling so dimples of pores
lymphodenopathy- esp axiall
types of breast cancer
DCIS - pre cancerous. cancerous of brest ducts
localised
potetial to become invasve
good prognosisi
lobular carcinoma in situ
- precancerous in perimenopasual women
asymptomatic
undetecatble on mammorgran
close monitring
NST- invasive ductal carcinoma
breaast ducts 80% of breast cancers
can see on mammorgramn
invasive lobular carcinoma
10% of breast cancer s
breast lobules
not alwasy seen on mamorgram
pagets disease of nipple
- look like exzema of nipple / areola
erythematous, itcht, scaly rash
breast cancer involve nipple
inflammatory breast cancer 1-3%
like abscess/mastitis
swollen, warm, tneder breast, peau d’orange
doesnt repsond to antibiotics
who are high risk patients of rbeast cancer
frist degree relative with it under 40
got male first degree relative with brst cancer
got 2 first degree relatives with it
for goirst degree relative with bilateral cancer first diangosied under 50
may offer oophectory, mastectomy
chemorpevention
investigations for breast cancer
triple asssesment
clincal, imaging, biospy
us for women under 30
mammorgram women older - see calcifications not seen on us
mri - screen women at high risk and stage , see size, feature of the cancer
lymph node asssesment - us of axialla, us guided biopsy of nodes, sentinel node biospy during the srugery
where can breast cancer metasise to
ay where!
so can have primary breast cancer for any thing
most common:
liver, lungs
bones, brain
person had breast cancer surgery. what need think about when taking blood/cannula
dont take from side of the surgery as may have lyphoedema - so this side be more prone to infection
