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Zero to Finals Decks > Breast Surgery > Flashcards

Breast Surgery Flashcards

1
Q

how is breast cancer diagnosed / excluded?

A

triple assessment

  • clinical assessment
  • imaging (USS, mammography)
  • histology (FNA, core biopsy)
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2
Q

presentation of breast cancer?

A
  • new breast lump
  • nipple retraction / discharge
  • skin dimpling / oedema (peau d’orange)
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3
Q

describe characteristics of a breast cancer lump

A
  • hard
  • irregular
  • painless
  • fixed in place
  • tethered to skin
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4
Q

2WW criteria for breast cancer?

A
  • unexplained breast lump in pts 30+

- unilateral nipple discharge / retraction in pts 50+

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5
Q

describe the characteristics of a fibroadenoma

A
  • small (<3cm in diameter)
  • smooth
  • round with well-defined borders
  • firm
  • mobile
  • “breast mouse”
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6
Q

is a fibroadenoma worrying?

A
  • no

- no risk of going on to develop cancer

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7
Q

features of fibrocystic breast changes?

A
  • can be uni- or bilateral
  • lumpiness
  • mastalgia (pain and tenderness)
  • fluctuating breast size
  • fluctuate with menstrual cycle
  • regress with menopause
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8
Q

management of fibrocystic breast changes?

A

exclude breast cancer then reduce mastalgia:

  • supportive bra
  • NSAIDs (ibuprofen)
  • avoid caffeine
  • apply heat to area
  • hormonal treatment
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9
Q

hormonal treatment options for mastalgia?

A
  • danazol

- tamoxifen

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10
Q

what is the most common type of breast lump?

A

breast cysts

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11
Q

which age demographic is most affected by breast cysts?

A
  • women aged 30-50

- particularly in perimenopausal period

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12
Q

features of a breast cyst?

A
  • smooth
  • well-circumscribed
  • mobile
  • may be fluctuant
  • may be painful
  • changes with menstrual cycle
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13
Q

management of a breast cyst?

A
  • exclude breast cancer
  • aspirate to resolve pain
  • surgical excision
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14
Q

is a breast cyst worrying?

A
  • yes

- slightly increased risk of developing breast cancer

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15
Q

is fat necrosis worrying?

A
  • no

- no increased risk of developing breast cancer

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16
Q

features of the lump in fat necrosis?

A
  • painless
  • firm
  • irregular
  • fixed to local structures
  • skin dimpling
  • nipple retraction
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17
Q

how is fat necrosis differentiated from breast cancer?

A
  • look the same on imaging
  • therefore need to do histology:
  • FNA / core biopsy
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18
Q

management of fat necrosis?

A
  • exclude breast cancer
  • conservative (most resolve spontaneously
  • surgical excision if symptomatic
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19
Q

what is a lipoma?

A

a benign fat tumour

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20
Q

findings on examination of a lipoma?

A
  • soft
  • painless
  • mobile
  • NO associated skin changes
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21
Q

management of a lipoma?

A

conservative

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22
Q

what is a galactocoele?

A

milk-filled cyst blocking the lactiferous duct

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23
Q

when do women typically develop galactocoeles?

A
  • when lactating

- typically when they’ve just stopped breastfeeding

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24
Q

features of a galactocoele?

A
  • firm
  • mobile
  • painless
  • subareolar region
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25
Q

management of a galactocoele?

A
  • conservative
  • can be drained by needle
  • ABx if infected
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26
Q

key complication of galactocoele?

A

can become infected

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27
Q

which demographic is typically affected by phyllodes tumours?

A

women aged 40-50

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28
Q

is a phyllodes tumour worrying?

A
  • yes
  • 50% are benign
  • 25% are borderline
  • 25% are malignant
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29
Q

management of a phyllodes tumour?

A
  • surgical removal (can still recur despite this)

- chemotherapy if it has metastasised

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30
Q

how can mastalgia be classified?

A
  • cyclical

- non-cyclical

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31
Q

features of cyclical breast pain?

A
  • comes on in first 2 weeks of cycle (luteal phase), then settles
  • bilateral, generalised pain
  • heaviness
  • aching
  • associated with other signs of premenstrual syndrome
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32
Q

signs of premenstrual syndrome?

A
  • cyclical breast pain
  • low mood
  • bloating
  • fatigue
  • headaches
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33
Q

causes of non-cyclical breast pain? (hint: think local and non-local)

A
  • any local breast pathology
  • drugs (HRT, contraceptives)
  • pregnancy
  • infection (mastitis, costochondritis)
  • skin (shingles, post-herpetic neuralgia)
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34
Q

management of cyclical breast pain?

A
  • supportive bra use
  • NSAIDs (oral or topical)
  • avoid caffeine
  • heat packs
  • hormones under a specialist (danazol, tamoxifen)
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35
Q

is male breast enlargement common? which age groups could be affected?

A
  • yes!

- common in neonates, teens and 50s

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36
Q

pathophysiology of gynaecomastia?

A
  • imbalance between circulating oestrogens (increase) and androgens (decrease)
  • could also be due to high prolactin
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37
Q

causes of gynaecomastia due to increased oestrogen?

A
  • obesity
  • testicular Ca (leydig cell tumour)
  • liver cirrhosis / failure
  • hyperthyroidism
  • hCG-secreting tumour (e.g. SCLC)
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38
Q

causes of gynaecomastia due to decreased testosterone?

A
  • 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)
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39
Q

illicit and prescribed drug causes of gynaecomastia?

A
  • anabolic steroids
  • antipsychotics
  • digoxin
  • spironolactone
  • opiates
  • marijuana
  • alcohol
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40
Q

investigations for gynaecomastia?

A
  • LFTs
  • testosterone (low)
  • oestrogen (high)
  • sex hormone binding globulin
  • prolactin (high)
  • LH, FSH
  • AFP, b-HCG (markers of testicular Ca)
  • genetic karyotyping (klinefelter syndrome)
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41
Q

imaging for gynaecomastia?

A
  • USS breast
  • mammogram + biopsy (if Ca suspected)
  • USS testicles (Ca)
  • CXR (lung Ca)
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42
Q

management of gynaecomastia?

A
  • treat underlying cause (e.g. stop drug)
  • tamoxifen for pain
  • surgery
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43
Q

define galactorrhoea

A

breast milk production not relating to pregnancy or breastfeeding

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44
Q

which hormone triggers the production of breast milk?

A

prolactin

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45
Q

how does dopamine affect prolactin levels?

A

DA suppresses prolactin release

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46
Q

in pregnancy, when does breast milk production begin?

A
  • in 2nd and 3rd trimester

- it’s normal to leak a little at this point too

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47
Q

what is galactorrhoea?

A

breast milk production which is not associated with pregnancy or breastfeeding

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48
Q

where is prolactin produced?

A

anterior pituitary

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49
Q

which hormones inhibit prolactin release?

A
  • oestrogen

- progesterone

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50
Q

what is the role of oxytocin?

A

to stimulate breast milk excretion

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51
Q

how can the causes of hyperprolactinaemia be split?

A
  • idiopathic
  • tumours (prolactinomas)
  • endocrine problems
  • drugs
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52
Q

endocrine (non-tumour) causes of hyperprolactinaema?

A
  • hypothyroidism

- PCOS

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53
Q

drug causes of hyperprolactinaemia?

A

DA antagonists (antipsychotics)

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54
Q

presentation of hyperprolactinaemia?

A
  • galactorrhoea
  • amenorrhoea
  • low libido
  • ED in men
  • gynaecomastia in men
  • headaches / vision changes if caused by a pituitary tumour
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55
Q

which hereditary condition could predispose someone to prolactinomas?

A

multiple endocrine neoplasia type 1 (MEN1)

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56
Q

mode of inheritance of MEN1?

A

autosomal dominant

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57
Q

how big is a macroprolactinoma? how might this affect vision?

A
  • > 10mm

- bitemporal hemianopia

58
Q

causes of non-milk breast discharge?

A
  • mammary duct ectasia
  • duct papilloma
  • breast abscess (gives pus)
59
Q

investigations for galactorrhoea?

A
  • pregnancy test! essential
  • serum prolactin
  • UEs
  • LFTs
  • TFTs
60
Q

how is a prolactinoma diagnosed?

A

clinical picture plus MRI head

61
Q

management of galactorrhoea?

A
  • treat underlying cause
  • DA agonists (bromocriptine, cabergoline)
  • trans-sphenoidal removal of pituitary tumour
62
Q

describe mammary duct ectasia

A
  • benign enlargement of breast ducts

- causes intermittent discharge

63
Q

key risk factor for mammary duct ectasia?

A

smoking

64
Q

which demographic is likely to be affected by mammary duct ectasia?

A

perimenopausal women

65
Q

presentation of mammary duct ectasia?

A
  • nipple discharge (can be white, green or grey)
  • tenderness
  • pain
  • nipple retraction
  • nipple inversion
  • breast lump
66
Q

key characteristic of the breast lump in mammary duct ectasia?

A

pressing on the lump produces discharge

67
Q

how is mammary duct ectasia diagnosed?

A

can be found incidentally on mammogram

  • Hx and examination
  • imaging
  • histology (FNA, core biopsy)
68
Q

imaging used to diagnose mammary duct ectasia?

A
  • USS
  • mammography
  • MRI
69
Q

findings on mammography in mammary duct ectasia?

A

microcalcifications

70
Q

management of mammary duct ectasia?

A
  • conservative
  • symptomatic relief (supportive bra, warm compresses)
  • ABx if infected
  • surgical excision of affected duct is last line
71
Q

what is an intraductal papilloma?

A

warty, benign tumour growing in a breast duct

72
Q

typical demographic affected by intraductal papillomas?

A

women aged 35-55

73
Q

presentation of intraductal papilloma?

A
  • often asymptomatic, picked up incidentally on mammogram / USS
  • nipple discharge (clear or blood stained)
  • tenderness
  • pain
  • palpable lump
74
Q

how is intraductal papilloma diagnosed?

A

triple assessment:

  • Hx and examination
  • imaging
  • histology (core biopsy, vacuum-assisted biopsy)

can use ductography

75
Q

finding on ductography in intraductal papilloma?

A
  • “filling defect”

- the papilloma won’t fill with contrast but the rest of the breast will

76
Q

management of intraductal papilloma?

A
  • complete surgical excision

- examine the removed tissue for atypical hyperplasia / Ca

77
Q

is there any risk of an intraductal papilloma becoming malignant?

A

although they’re benign, they’re associated with hyperplasia / Ca

78
Q

what is mastitis?

A
  • inflammation of breast tissue

- common complication of breastfeeding

79
Q

how can mastitis be prevented?

A

regularly expressing breast milk (this stops any obstruction to the duct flow)

80
Q

commonest infective cause of mastitis?

A

staph aureus

81
Q

presentation of mastitis?

A
  • unilateral breast pain and tenderness
  • localised erythema
  • local warmth and inflammation
  • nipple discharge
  • fever
82
Q

management of mastitis caused by an obstruction?

A
  • conservative
  • continue breastfeeding and expressing milk
  • breast massage
  • heat packs
  • warm showers
  • analgesia
83
Q

management of mastitis caused by infection?

A
  • 1st line = flucloxacillin

- fluconazole if fungal cause suspected

84
Q

key complication of mastitis?

A

breast abscess

85
Q

management of a breast abscess?

A

incision and drainage

86
Q

what might a Hx of recurrent mastitis suggest?

A

candida of the nipple

87
Q

associated infections in infant when mother has nipple candida?

A
  • oral thrush

- candidal nappy rash

88
Q

presentation of candida of the nipple?

A
  • bilateral sore nipples
  • worse after breastfeeding
  • tenderness
  • itchiness
  • changes to areola
  • symptoms in baby (white patches in mouth or on genitals)
89
Q

what areolar changes might be seen in candida of the nipple?

A

it may be:

  • cracked
  • flaky
  • shiny
90
Q

management of candida of the nipple?

A
  • 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
91
Q

how can breast abscesses be classified?

A
  • lactational

- non-lactational

92
Q

key RFs for breast abscess development?

A
  • smoking
  • damage to the nipple (eczema, candida infection, piercing)
  • underlying breast disease
93
Q

commonest causative organism of breast abscesses?

A

staph aureus

94
Q

presentation of breast abscess?

A
  • 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
95
Q

features of the breast lump palpated in breast abscess?

A

fluctuant and tender

96
Q

examples of systemic signs of infection that may be seen in breast abscess?

A
  • muscle aches
  • fatigue
  • fever
  • signs of sepsis (high HR, high RR, confusion)
97
Q

management of lactational mastitis?

A
  • conservative
  • continue breastfeeding and expressing milk
  • breast massage
  • fluclox / eryth / clarith if infection suspected / symptoms not improving
98
Q

management of non-lactational mastitis?

A
  • analgesia
  • ABx
  • treat underlying cause (eczema, candida infection)
99
Q

which ABx can be offered in non-lactational mastitis?

A

need to be broad-spec to cover anaerobes:

  • co-amox
  • erythromycin / clarithromycin + netronidazole
100
Q

management of breast abscess?

A
  • refer to surgery
  • ABs
  • USS breast
  • drainage (needle aspiration or surgical incision and drainage)
  • MCS of drained fluid
101
Q

advice for women who are breastfeeding with mastitis +/- breast abscess?

A
  • continue breastfeeding
  • if this is too painful, try to regularly express breast milk
  • there’s no harm to baby here
102
Q

what is the most common form of cancer in the UK?

A

breast Ca

103
Q

RFs for breast Ca?

A
  • female sex
  • increased oestrogen exposure (early periods, late menopause)
  • obesity
  • smoking
  • FHx (1st deg relatives)
104
Q

does the COCP affect breast Ca risk? for how long?

A
  • yes, it slightly increases it

- this goes away 10 years after stopping the pill

105
Q

does HRT affect breast Ca risk?

A
  • yes

- worse with combined HRT

106
Q

which chromosome holds the BRCA1 gene?

A

17

107
Q

which chromosome holds the BRCA2 gene?

A

13

108
Q

which cancers are associated with the BRCA1 gene?

A
  • breast Ca
  • ovarian Ca
  • bowel Ca
  • prostate Ca
109
Q

which cancers are associated with the BRCA2 gene?

A
  • breast Ca

- ovarian Ca

110
Q

give some examples of types of breast Ca

A
  • ductal carcinoma in situ (DCIS)
  • lobular carcinoma in situ (LCIS)
  • invasive ductal carcinoma
  • invasive lobular carcinoma
  • inflammatory breast Ca
111
Q

how does inflammatory breast cancer present?

A
  • similarly to mastitis / breast abscess
  • swollen, warm, tender breast
  • pitting skin (peau d’orange)
112
Q

presentation of paget’s disease of the nipple?

A
  • erythematous, scaly rash

- looks like eczema on nipple

113
Q

what could paget’s disease of the nipple be a sign of?

A
  • DCIS

- invasive breast Ca

114
Q

which type of breast Ca is most likely to metastasise?

A

invasive breast Ca

115
Q

how is breast Ca screened for in the UK?

A

all women aged 50-70 are offered a mammogram every 3 years

116
Q

which pts are screened more regularly for breast Ca (due to higher risk)?

A
  • 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
117
Q

chemoprevention for pts at high risk of breast Ca?

A
  • tamoxifen if premenopausal

- anastrozole if postmenopausal

118
Q

surgical intervention to prevent breast Ca in high-risk pts?

A

bilateral mastectomy

119
Q

presentation of breast Ca?

A
  • lump
  • nipple retraction / discharge
  • skin dimpling (peau d’orange)
  • lymphadenopathy (esp in axilla)
120
Q

describe the lump in breast Ca

A
  • hard
  • irregular
  • painless
  • fixed in place
  • tethered to skin / chest wall
121
Q

2WW criteria for suspected breast Ca?

A
  • unexplained breast lump in pt aged >30

- unilateral nipple changes in pt aged >50

122
Q

components of the triple diagnostic assessment of breast Ca?

A
  • Hx and examination
  • imaging (USS, mammography)
  • biopsy (FNA, core biopsy)
123
Q

how do you choose between USS and mammography in suspected breast Ca?

A
  • USS better for lump assessment in younger women

- mammography better in older women

124
Q

how are lymph nodes assessed in breast Ca pts?

A
  • USS axilla

- biopsy of any abnormal nodes

125
Q

what are the 3 types of breast Ca cell receptor?

A
  • oestrogen receptor (ER)
  • progesterone receptor (PR)
  • human epidermal growth factor (HER2)
126
Q

what is triple -ve breast Ca? prognosis of this?

A
  • where there are none of the 3 cell receptors present

- worst prognosis because there’s nothing to target with the treatment

127
Q

breast Ca is likely to metastasise to which 4 sites?

A
  • lungs
  • liver
  • bones
  • brain
128
Q

how is breast Ca staged?

A

using TNM system and the following:

  • LN assessment, biopsy
  • MRI breast and axilla
  • liver USS (mets)
  • CT TAP (mets)
  • isotope bone scan (bony mets)
129
Q

surgical management of breast Ca?

A
  • breast-conserving surgery (paired with radiotherapy)
  • mastectomy
  • axillary LN clearance
130
Q

key complication of axillary LN clearance?

A

chronic lymphoedema (impaired lymph drainage)

131
Q

presentation of chronic lymphoedema?

A

area affected gets really swollen

132
Q

non-surgical management of chronic lymphoedema?

A
  • manual lymphatic drainage (by massaging the area)
  • compression bandages
  • weight loss
  • good skin care
133
Q

how can chronic lymphoedema be prevented?

A

don’t take blood on the same side as where someone has had axillary LN clearance

134
Q

common SEs of radiotherapy?

A
  • fatigue
  • skin irritation, swelling
  • breast tissue fibrosis, shrinking
  • skin colour changes (gets darker)
135
Q

what are the 3 ways chemotherapy can be used in breast Ca treatment?

A
  • as a neoadjuvant (to shrink the tumour before surgery)
  • as an adjuvant (post-surgery to reduce recurrence)
  • as treatment of mets / recurrent cases
136
Q

drug offered to premenopausal women with ER+ breast Ca?

A

tamoxifen

137
Q

drugs offered to postmenopausal women with ER+ breast Ca?

A

aromatase inhibitors:

  • letrozole
  • anastrozole
  • exemestane
138
Q

complication of tamoxifen therapy?

A

endometrial Ca!

139
Q

how long is hormone therapy used in breast Ca?

A

5 - 10 years

140
Q

which drugs can be used in the treatment of HER2+ breast Ca?

A
  • trastuzumab (herceptin)
  • pertuzumab (perjeta)
  • neratinib (nerlynx)

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