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Surgery > Breast surgery > Flashcards

Breast surgery Flashcards

1
Q

what would a lump suggestive of breast cancer be like

A

hard
irregular
painless
fixed
tethered to skin/chest wall
nipple retraction
skin dimpling/oedema=> peau d’orange

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2
Q

when put woemn on 2ww

A

unexplained breast lump 30 and over
unilateral nipple changes 50 and over

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3
Q

unexplained brst lump undeer 30s how refer

A

non urgent referal

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4
Q

breast lump:
painless
smooth
mobile
round
well defined
firm

A

fibroadenoma

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5
Q

whats fibroadnenoma

A

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

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6
Q

lumpiness breast thats painful and gets 10 days before period and then gets better

A

fibrocytic breast changes

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7
Q

whats fibrocytic breast changes

A

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

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8
Q

how to mangage fibrocytic breast changes

A

exclude cancer - imaging, clinical, histology
manage the cyclic breast pain = mastalgia =
supportive bra
NSAIDs
avoid caffeine
heat on area
hormonal by specialsit- tamoxifen/ danaxol

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9
Q

most common type of breast lum,p

A

breast cycst

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10
Q

breast lum,p:
mobile
well circumbised
smooth
painful

A

breast cycst

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11
Q

whats breast cysts like

A

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

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12
Q

treatment brest cysts

A

exclude cancer
aspiration if in pain
- may need culutre fluid

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13
Q

painless
firm
irregular
fixed
may have skin nsimpling and nipple inversion
differentials

A

fat necrosis lum,p
breast cancer

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14
Q

whats fat necrosis breast lump

A

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

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15
Q

treat fat necorisis breast lump

A

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

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16
Q

breast lump:
soft
painless

mobile
no skin changes

A

lipoma

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17
Q

whats a lipoma

A

benign tumour of fat
can occur anywhere in body

soft
painless
mobile
no skin hcnaees

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18
Q

mangement lipoma

A

conservcative can resolve by self
can remove

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19
Q

lady just stopped breast feeding
firm
mpbile
oainless breast lump

A

galactocele

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20
Q

whats a galactocele

A

bengin
women lactating - often after stopping breastfeeding
lactiferous duct blocked
firm
mobile
painless
usually just below areola

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21
Q

treat galactocele

A

can drain
may need abx if infected

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22
Q

phyllodes tumour

A

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

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23
Q

casues of gynaecomastia 5 main broad casues

A

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

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24
Q

what can casues high oestrogen leading to gynaemcosmastia

A

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

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25
Q

what two cancers can casue gynaecomastia

A

testicular cancer- leydig cell tumour
small cell lung cancer

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26
Q

what can casue low testosterone casuing gynaecomastia

A

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

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27
Q

what infection can casue orchitits

A

mumps

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28
Q

whats medications/drugs can casue gynaecomastia

A

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

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29
Q

how do antipsycoitcs can casue gynaecomastia

A

dopamine antagoist

block dopamine prodcution

dopamine inhibits prolactin

but less dopamine so prolactin increases

prolactin stiulats glandular breast tissue development

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30
Q

what hormones can be abnomrla that can casue gynaecomastia

A

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

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31
Q

if male has gynaecomastia what other examination may you want to do

A

testicular examination

assess for signs of liver disease

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32
Q

how to asses for gynaecomastia

A

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

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33
Q

pt sweating
tachycardia
weight loss
gynaecomastia

casue

A

hyperthroidism

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34
Q

investigfations gynaecomastia

A

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

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35
Q

imaging may want to do for gynaecomastia

A

us - diagnose
mammorgram- if ?cancer
biopsy if ?cancer
cxr- ?lung cancer
testicualr us- ?cancer

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36
Q

whats most common form breast pain - cyclical or non cyclical pain

A

cyclical pain

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37
Q

whats cyclical breast pain

A

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

38
Q

s and s of cyclical breast pain

A

bilateral
generalsied
heviness
aching

39
Q

whats non cyclical breast pain

A

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

40
Q

how to diangose breast pain

A

diary can help if cyclical diagnose
exclude breast cancer- do history and examination
check for signs infection- mastitis
do preg test

41
Q

management of cyclical breast pai

A

supportive bra
reasure
warm
NSAIDS
avoid caffeine
hormonal treatment by speciclaist - tamoxifen danazol

42
Q

whats galactorrhea

A

breast milk production no associated with pregnacy/breast feeding

43
Q

where prolactin produced

A

anterior pituitary

44
Q

whats action of dopamine

A

block prolactin

45
Q

whe and how does breast milk production occur during pregnacy and what stimulates and inhibits the prodcution

A

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

46
Q

casue of galactorrhea

A

normally due to high prolactin levels = hyperprolactinameia

47
Q

casyes of hyperprolactinameia - galactorhea

A

prolactinomas - pituitary glad tumour
endocrine disorders- hypothryoidism, PCOS
meds- dopamine antagonsits eg. antipsycotics

48
Q

s and s of gallactorhea

A

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

49
Q

what gene can prolactinomas be assocaited with

A

MEN1

50
Q

macroprolactinomas are larger than 10mm.
what sympotms can they have other than hyperprolactinameia

A

headaches
bitemporal heminanopia

51
Q

patient has symptoms of hyperprolactinameia -
WHAT OTHER EXAMINATION DO YOU NEED TO DO

A

asses visual fields as prolactinoma can press on optic chaism

52
Q

investigations for galactorrhea

A

LFT
TFT
U AND E
preg test
serum prolactin
MRI if suspect pit tumour
visual field examiantion

53
Q

manage galactorrhea

A

treat casue
dopamin agonst can help- bromocriptine, cabergoline

transpshenoidal removal pit tumour

54
Q

what differentiasl are there for galactorhea- non milk discharge

A

mammary duct ectasia
duct papilloma
pus from breast abscess

55
Q

whats mammary duct ectasia

A

benign
dilation of laege ducts in breast.
inflammation leads to intermittent discharge from nipple

56
Q

presentation of mammary duct ectasia

A

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

57
Q

whatsa big risk factor for mammary duct ectasia

A

smoking

58
Q

how to diagnose mammary duct ectasia

A

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

59
Q

mammary duct ectasia see what on ammorgram

A

microcalcification

60
Q

managment mammary duct ectasia

A

may resovle by self
reassurance
symptomatic managemnt of mastalgia- warm, supportive bra, nsaids
antibiotics if infection
surgical excision of duct if bad - microdochetomy

61
Q

whats intraductal papilloma

A

warty lesion that grown within the ducts in the breast

62
Q

cause of intraductal papilloma

A

proliferation of epithelial cells
bengin
can be associated with atypical hyperplasia/ breast cancer!

63
Q

presentation of intraductal papilloma

A

nipple discharge- clear/ blood stained
tnederness/ oain
palpable lump

64
Q

diangosis of intradcutal papilloma

A

triple assesment for breast cancer ecxclusion

ductography- contrast into abnormal duct- see filling defect

65
Q

management of intraductal papilloma

A

surgical excision
examine it once removed for atypical signs that may not be seen on biopsy

66
Q

whats lactational mastitis

A

inflammation of breast tisue
common complication of breast feeding
can occur with or without an infection

67
Q

cause sof lactational mastitis

A

obstruction

infection

68
Q

whast most common infection casuse of lactational mastitis

A

staphylcoccus aureus

69
Q

presentation lactational mastitis

A

woman breast feeding
nippled discahrge
nreast tenderness/pain uilateral
eythema in focal area
local warmth and inflammation
fever - suspect cause is infection

70
Q

complciation of lactational mastitis

A

breast abscess

71
Q

management of lactational mastitis

A

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

72
Q

whats casue of candidal infection of nipple

A

often after course of antibiotics
cracks in nipple can lead to recurrent mastitis
associated with oral thrush/candidal nappy rash in baby

73
Q

presentation of candidal infection of nipple

A

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

74
Q

managment of candical nippleinfection

A

treat mum and infant as otherwise keep comin bacl

mum- topical miconazole 2% after breast feeding each time

baby- oral miconazole gel / nystatin

75
Q

whast breast abscess

A

collection of pus in area of breast.
can be lactational or non lactational

76
Q

cause of breast abscess

A

usually due to bacterial infection
mastitis infection may precede abscess

77
Q

what bacteria responsible for breast bascess

A

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

78
Q

presentation of breast abscess

A

acute usually
swollen
fluctuant - fluid move in lump
tender lump

symptom s of infection:
fever
fatigue
muscle aches
sepsis- tachycardia, tachypnoea, conducsion

79
Q

symptoms mastitis with infection

A

nipple changes
hardening of skin / breast tissue
localised apin
warmth
tenderness
erythema
swllinh

80
Q

managemtn of non lactational mastitis

A

braad spectrum antibiotics-
co-amoxiclav
erythromycin/ clarithromycin + metronidazole

treat casue eg. candidal infection/excema
analgeisa

81
Q

managment of breast abscess

A

antibiotics
ultrasound - confrim diagnosis
draiangae- needle aspiration. incision and drainage
microscopy, culture and sensntives of drained fluid
refer surgucal team

82
Q

risk factors breast abscess/ masittis

A

smoking
damage to nipple- nipple excema , candidal infection, nipple piercing
breast disease eg. cancer that blocks drainage of breast so predispose to infection

83
Q

breast abscess/ mastitis should women keep breast feeding?

A

yes
even if infected
if too painful breast feed then express milk

84
Q

risk facrtors breast cancer

A

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

85
Q

BRCA1 faulty gene increase risk of what
BRCA2 fulty gene increase risk of what

A

BRCA1 on CHR17
increase risk breat, ovarian cancer. increase risk of prostte and bowel cancer

BRCA2 increase risk breast and ovarian cancer
chr 13

86
Q

whens screening for breast cancer

A

age 50-70 every 3 yr mammogram

87
Q

presentation breast cancer

A

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

88
Q

types of breast cancer

A

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

89
Q

who are high risk patients of rbeast cancer

A

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

90
Q

investigations for breast cancer

A

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

91
Q

where can breast cancer metasise to

A

ay where!
so can have primary breast cancer for any thing

most common:
liver, lungs
bones, brain

92
Q

person had breast cancer surgery. what need think about when taking blood/cannula

A

dont take from side of the surgery as may have lyphoedema - so this side be more prone to infection

Surgery (7 decks)

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