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
how big is a macroprolactinoma? how might this affect vision?
- > 10mm
- bitemporal hemianopia
causes of non-milk breast discharge?
- mammary duct ectasia
- duct papilloma
- breast abscess (gives pus)
investigations for galactorrhoea?
- pregnancy test! essential
- serum prolactin
- UEs
- LFTs
- TFTs
how is a prolactinoma diagnosed?
clinical picture plus MRI head
management of galactorrhoea?
- treat underlying cause
- DA agonists (bromocriptine, cabergoline)
- trans-sphenoidal removal of pituitary tumour
describe mammary duct ectasia
- benign enlargement of breast ducts
- causes intermittent discharge
key risk factor for mammary duct ectasia?
smoking
which demographic is likely to be affected by mammary duct ectasia?
perimenopausal women
presentation of mammary duct ectasia?
- nipple discharge (can be white, green or grey)
- tenderness
- pain
- nipple retraction
- nipple inversion
- breast lump
key characteristic of the breast lump in mammary duct ectasia?
pressing on the lump produces discharge
how is mammary duct ectasia diagnosed?
can be found incidentally on mammogram
- Hx and examination
- imaging
- histology (FNA, core biopsy)
imaging used to diagnose mammary duct ectasia?
- USS
- mammography
- MRI
findings on mammography in mammary duct ectasia?
microcalcifications
management of mammary duct ectasia?
- conservative
- symptomatic relief (supportive bra, warm compresses)
- ABx if infected
- surgical excision of affected duct is last line
what is an intraductal papilloma?
warty, benign tumour growing in a breast duct
typical demographic affected by intraductal papillomas?
women aged 35-55
presentation of intraductal papilloma?
- often asymptomatic, picked up incidentally on mammogram / USS
- nipple discharge (clear or blood stained)
- tenderness
- pain
- palpable lump
how is intraductal papilloma diagnosed?
triple assessment:
- Hx and examination
- imaging
- histology (core biopsy, vacuum-assisted biopsy)
can use ductography
finding on ductography in intraductal papilloma?
- “filling defect”
- the papilloma won’t fill with contrast but the rest of the breast will
management of intraductal papilloma?
- complete surgical excision
- examine the removed tissue for atypical hyperplasia / Ca
is there any risk of an intraductal papilloma becoming malignant?
although they’re benign, they’re associated with hyperplasia / Ca
what is mastitis?
- inflammation of breast tissue
- common complication of breastfeeding
how can mastitis be prevented?
regularly expressing breast milk (this stops any obstruction to the duct flow)
commonest infective cause of mastitis?
staph aureus
presentation of mastitis?
- unilateral breast pain and tenderness
- localised erythema
- local warmth and inflammation
- nipple discharge
- fever
management of mastitis caused by an obstruction?
- conservative
- continue breastfeeding and expressing milk
- breast massage
- heat packs
- warm showers
- analgesia
management of mastitis caused by infection?
- 1st line = flucloxacillin
- fluconazole if fungal cause suspected
key complication of mastitis?
breast abscess
management of a breast abscess?
incision and drainage
what might a Hx of recurrent mastitis suggest?
candida of the nipple
associated infections in infant when mother has nipple candida?
- oral thrush
- candidal nappy rash
presentation of candida of the nipple?
- bilateral sore nipples
- worse after breastfeeding
- tenderness
- itchiness
- changes to areola
- symptoms in baby (white patches in mouth or on genitals)
what areolar changes might be seen in candida of the nipple?
it may be:
- cracked
- flaky
- shiny
management of candida of the nipple?
- both mum and baby must be treated or they’ll keep reinfecting each other
- TOP miconazole 2% to nipple after each feed
- PO miconazole / nystatin for baby
how can breast abscesses be classified?
- lactational
- non-lactational
key RFs for breast abscess development?
- smoking
- damage to the nipple (eczema, candida infection, piercing)
- underlying breast disease
commonest causative organism of breast abscesses?
staph aureus
presentation of breast abscess?
- acute onset within a few days
- nipple changes
- purulent discharge
- localised pain and tenderness
- warmth and redness
- hardening of skin
- swelling
- lump
- signs of infection
features of the breast lump palpated in breast abscess?
fluctuant and tender
examples of systemic signs of infection that may be seen in breast abscess?
- muscle aches
- fatigue
- fever
- signs of sepsis (high HR, high RR, confusion)
management of lactational mastitis?
- conservative
- continue breastfeeding and expressing milk
- breast massage
- fluclox / eryth / clarith if infection suspected / symptoms not improving
management of non-lactational mastitis?
- analgesia
- ABx
- treat underlying cause (eczema, candida infection)
which ABx can be offered in non-lactational mastitis?
need to be broad-spec to cover anaerobes:
- co-amox
- erythromycin / clarithromycin + netronidazole
management of breast abscess?
- refer to surgery
- ABs
- USS breast
- drainage (needle aspiration or surgical incision and drainage)
- MCS of drained fluid
advice for women who are breastfeeding with mastitis +/- breast abscess?
- continue breastfeeding
- if this is too painful, try to regularly express breast milk
- there’s no harm to baby here
what is the most common form of cancer in the UK?
breast Ca
RFs for breast Ca?
- female sex
- increased oestrogen exposure (early periods, late menopause)
- obesity
- smoking
- FHx (1st deg relatives)
does the COCP affect breast Ca risk? for how long?
- yes, it slightly increases it
- this goes away 10 years after stopping the pill
does HRT affect breast Ca risk?
- yes
- worse with combined HRT
which chromosome holds the BRCA1 gene?
17
which chromosome holds the BRCA2 gene?
13
which cancers are associated with the BRCA1 gene?
- breast Ca
- ovarian Ca
- bowel Ca
- prostate Ca
which cancers are associated with the BRCA2 gene?
- breast Ca
- ovarian Ca
give some examples of types of breast Ca
- ductal carcinoma in situ (DCIS)
- lobular carcinoma in situ (LCIS)
- invasive ductal carcinoma
- invasive lobular carcinoma
- inflammatory breast Ca
how does inflammatory breast cancer present?
- similarly to mastitis / breast abscess
- swollen, warm, tender breast
- pitting skin (peau d’orange)
presentation of paget’s disease of the nipple?
- erythematous, scaly rash
- looks like eczema on nipple
what could paget’s disease of the nipple be a sign of?
- DCIS
- invasive breast Ca
which type of breast Ca is most likely to metastasise?
invasive breast Ca
how is breast Ca screened for in the UK?
all women aged 50-70 are offered a mammogram every 3 years
which pts are screened more regularly for breast Ca (due to higher risk)?
- 1st deg relative with breast Ca under 40
- 1st deg male relative affected
- 1st deg relative with bilateral breast Ca
- two 1st deg relatives affected
chemoprevention for pts at high risk of breast Ca?
- tamoxifen if premenopausal
- anastrozole if postmenopausal
surgical intervention to prevent breast Ca in high-risk pts?
bilateral mastectomy
presentation of breast Ca?
- lump
- nipple retraction / discharge
- skin dimpling (peau d’orange)
- lymphadenopathy (esp in axilla)
describe the lump in breast Ca
- hard
- irregular
- painless
- fixed in place
- tethered to skin / chest wall
2WW criteria for suspected breast Ca?
- unexplained breast lump in pt aged >30
- unilateral nipple changes in pt aged >50
components of the triple diagnostic assessment of breast Ca?
- Hx and examination
- imaging (USS, mammography)
- biopsy (FNA, core biopsy)
how do you choose between USS and mammography in suspected breast Ca?
- USS better for lump assessment in younger women
- mammography better in older women
how are lymph nodes assessed in breast Ca pts?
- USS axilla
- biopsy of any abnormal nodes
what are the 3 types of breast Ca cell receptor?
- oestrogen receptor (ER)
- progesterone receptor (PR)
- human epidermal growth factor (HER2)
what is triple -ve breast Ca? prognosis of this?
- where there are none of the 3 cell receptors present
- worst prognosis because there’s nothing to target with the treatment
breast Ca is likely to metastasise to which 4 sites?
- lungs
- liver
- bones
- brain
how is breast Ca staged?
using TNM system and the following:
- LN assessment, biopsy
- MRI breast and axilla
- liver USS (mets)
- CT TAP (mets)
- isotope bone scan (bony mets)
surgical management of breast Ca?
- breast-conserving surgery (paired with radiotherapy)
- mastectomy
- axillary LN clearance
key complication of axillary LN clearance?
chronic lymphoedema (impaired lymph drainage)
presentation of chronic lymphoedema?
area affected gets really swollen
non-surgical management of chronic lymphoedema?
- manual lymphatic drainage (by massaging the area)
- compression bandages
- weight loss
- good skin care
how can chronic lymphoedema be prevented?
don’t take blood on the same side as where someone has had axillary LN clearance
common SEs of radiotherapy?
- fatigue
- skin irritation, swelling
- breast tissue fibrosis, shrinking
- skin colour changes (gets darker)
what are the 3 ways chemotherapy can be used in breast Ca treatment?
- as a neoadjuvant (to shrink the tumour before surgery)
- as an adjuvant (post-surgery to reduce recurrence)
- as treatment of mets / recurrent cases
drug offered to premenopausal women with ER+ breast Ca?
tamoxifen
drugs offered to postmenopausal women with ER+ breast Ca?
aromatase inhibitors:
- letrozole
- anastrozole
- exemestane
complication of tamoxifen therapy?
endometrial Ca!
how long is hormone therapy used in breast Ca?
5 - 10 years
which drugs can be used in the treatment of HER2+ breast Ca?
- trastuzumab (herceptin)
- pertuzumab (perjeta)
- neratinib (nerlynx)
