Breast surgery Flashcards
Ix of breast
USG- <35
Mammo >35
Arterial supple of breast
- Internal mammary (thoracic) artery
- External mammary artery (laterally)
- Anterior intercostal arteries
- Thoraco-acromial artery
Which muscles do the breasts lie on
- Pectoralis major
- Serratus anterior
- External oblique
Radial scar features
Usually presents as a breast lump or breast pain
* Causes mammographic changes which may mimic carcinoma
* Cause distortion of the distal lobular unit, without hyperplasia
Radial scar tx
Lesions should be biopsied, excision is not mandatory
Fat necrosis features
Up to 40% cases usually have a traumatic aetiology
* Physical features usually mimic carcinoma
Fat necrosis tx
Imaging and core biopsy
Intraductal papilloma features
Growth of papilloma in a single duct
* Usually presents with clear or blood stained discharge originating from a single duct
Excessive milk cause
Pituitary tumour
- Microadenomas <1cm in diameter
- Macroadenomas >1cm in diameter
Features of fibroadenoma
Smooth; Fram; Mobile; Round mass
Can fluctuate size with menstrual cycle
Phyllode tumour pathology and features
● Both epith. + fibrous stromal elements
● Stroma shows hypercellularity; atypia; mitosis
Leaf like
Grows quickly
Ulceration
● Painless >3cm; Mobile
● Massive size - uneven bosselated surface
● Recent & rapid ↑size
Tx of phyllodes tumour
WLE
<5cm- 2cm margin
>5cm- 5cm margin
Duct ectasia features
Duct ectasia is the dilation and shortening of the major lactiferous ducts. It is a common presentation in peri-menopausal women, with 40% of women having significant duct dilatation by 70yrs.
● Nipple retraction; Tenderness(+)
● Mass under areola ± erythema
● Cheesy Green discharge; can be Brown
multiple plasma cells on histology
Types of ductal carcinoma in situ
Sub types include; comedo, cribriform, micropapillary and solid
Comdeo DCIS is most likely to form microcalcifications
Cribriform and micropapillary are most likely to be multifocal
Low grade- cribriform, papillary and micro
High- Solid and combeo
Tx of DCIS
This is done with breast conserving surgery (wide local excision) or (in cases of widespread or multifocal DCIS) with mastectomy.
LCIS features
Greater risk of developing an invasive breast malignancy.
Doesn’t show up on mammography well- no micro calcifications
No necrosis
LCIS is usually diagnosed before menopause, with only 10-20% of women diagnosed being post-menopausal.
LCIS mx
Low grade LCIS is usually treated by monitoring rather than excision.
When an invasive component is identified, it is less likely to be associated with axillary nodal metastasis than with DCIS.
Bilateral prophylactic mastectomy can be potentially indicated if individuals possess the BRCA1 or BRCA2 genes.
Invasive lobular carcinoma features
Only bilateral carcinoma
Multifocal lesions
Worst prognosis- pleomorphic
Bull eye pattern- pathology
Invasive ductal carcinoma features
● Large irregular surface - hard consistency
White necrotic area Branching micro
- calcificaation Stellate lesion(+)
Which subtype of DCIS has recurrence after surgery
Only comedo
FNAC vs Core / True-cut Biopsy
FNAC- shows cytology
If FNAC inconclusive or If features shows (e.g. hard mass, skin tethering present) carcinoma; in these cases, the
only appropriate Investigation is Core / True-cut Biopsy.
Biopsy- histology
A Positive core biopsy is mandatory before surgery
When to do mastectomy vs WLE
Mastectomy
Multifocal tumour
Central
Large lesion in small breast
DCIS >4cm
WLE
Solitary
Peripheral tumour
Small lesion in large breast
DCIS <4cm
SE of axillary node clearance
Lymphoedema, increased risk of cellulitis and
frozen shoulder.
Complications of breast surgery
- Long thoracic nerve injury: Occurs during the Axillary dissection and result in winging of the scapula.
- Intercostobrachial nerve injury: These nerves traverse the axilla. When they are divided (which they often
are) the patient will notice an area of parasthesia in the armpit. - Injury to the thoracodorsal trunk: This nerve and vessels supply Latissimus Dorsi. If they are damaged the
functional effects are not too serious, the greatest setback is that a latissimus dorsi flap cannot be used for
reconstruction purposes. - Infections: Cellulitis of the chest wall and arm may be a major problem if axillary nodal clearance is
undertaken. Infections may run a protracted course and require polytherapy for treatment.
*Lymphoedema: Usually complicates axillary node clearance or irradiation. Treatment is with manual lymphatic
drainage and compression sleeves.
- Seroma: This is an accumulation of fluid at the site of surgery. The fluid is usually straw coloured and may re- accumulate despite drainage. Most will resolve with time.
Axillary LN clearance levels
1- LN upto lat.border of P.Minor (removes nodes around Ax.V. superficial to PM & Ax tail)
2- All LN upto med.border of P.minor (nodes deep to PM)
3- All LN of axilla (requires division of P.minor) (upto apex of axilla)
When is hormonal therapy used
ER & PR (+)ve patient cases to downstage
Or older who refuse surgery
Types of hormonal therapy
3 types drug used- SERM(Selective Estrogen Receptor Modulator) , Aromatase inhibitor, LHRH agonist
- Tamoxifen – SERM . It binds with estrogen receptor and blocks estrogen action
-Anastrozole(ArimidexTM); Letrozole; Aminoglutethemide; Exemestane:- Aromatase inhibitor. They
block peripheral convertion of androgen to estrogen and also block intra-tumoral synthesis of estrogen- used in post menopausal women
- Goserelin(ZoladexTM): - LHRH agonist. Used incase of pre-menopausal ER(+) ve women
When can tamoxifen not be used
History of thrombosis
What to use if patient has ER- tumour
In these cases (+)ve C-erb B2 (HER2/neu) suggests TRASTUZUMAB (Herceptin) may be effective
When is chemotherapy used
Downstagign advanced lesions to facilitate surgery
Grade 3 lesions
Axillary nodal disease
- Young / pre-menopausal
- LN (+)ve & lymphoreticular invasion
- ER (-)ve
- Grade III pt.
- Large tumor
When is Neo adjuvant chemo used
- Young pt. with high grade ca specially if >3cm
- To down-stage the tumors with an aim to provide breast conserving surgery
Tx of periductal mastitis in postmenopausal
Anaerobic bacteria cause so tx would be metronidazole.
Most important prognostic factor for breast cancer
Nodal status
Firbocystic disease
Cyclical mastalgia
Pain 2 weeks leading to period then settles with menstruation
Bilateral
Tietze Syndrome
Chest pain
Costchondral swelling of upper ribs attaching to sternum
Pain can spread to arms or shoulders
Duct ectasia tx
Reassure
If older and persistent discharge - total duct excision
Tx of duct papiloma
Microdochectomy
Pagets vs eczema of nipple
Pagets- affect nipple first then areola area
Eczema- affects areola
Inflammatory carcinoma of breast features
Aggressive
Mets early
Tx resistant
In pregnancy or lactation
Mistaken for mastitis- red hot
Screening of breast cancer
Mammography
50-70 every 3 years
Strong FH - can be offered screening from 47
Reconstruction options
Lat dorsi myocutaneous flap and subpectoral implants
Tamoxifen cancer risks
Endometrial
When to use aromatase inhibitors
When tamoxifen no longer effective
Post mastectomy with skin flap- large fluctuant mass under neath, Dx?
Seroma
Very common post breast surgery
Straw coloured fluid
Tx with drainage
Radical vs simple mastectomy
A simple mastectomy (left) removes the breast tissue, nipple, areola and skin but not all the lymph nodes. A modified radical mastectomy (right) removes the entire breast — including the breast tissue, skin, areola and nipple — and most of the underarm (axillary) lymph nodes- rarely done anymore- maybe if spread to chest muscles
Tx of 1.5cm malignant lesion in upper outer breast with no evidence of LN spread
WLE and node biopsy
Tx of 2.5 lesion in centre of breast with FNA of LN showing mets
Simple mastectomy and axillary LN clearance
Histology shows lobular carcinoma present at 3 of resection margins, mx?
Mastectomy
Lobular- often multifocal
When is radiotherapy used
If breast conserving surgery used- e.g WLE
To breast alone
When is each medical therapy used
Pre menopausal - goserlein - LRH agonist
Women who are perimenopausal start on tamoxifen and switch at 3 years.
Post menopausal - managed by endocrine therapy alone- aromatase inhibitors
Nottingham prognostic score
Tumour size x 0.2 +LN score + grade score
5 year survival
2-2.4 93%
2.5-3.4 85%
3.5-5.4 70%
>5.4 50%
Mucinous tumour features
Grey gelatinous surface
Soft
Young female found to have BRCA1 mutation, what is the survailence
Annual MRI
Drugs causing gynaeocmastia
Digoxin
Isoinazid
Spiro
Cimetidne
Oestrogen
Most common cause of painless lump in postmenopausal woman
Invasive Ductal carcinoma
Woman with lump with hx of implants ix
USS first
Non conclusive MRI
If implants related problems- MRI
Halo sign on mammography
Breast cyst
Breast cancer with lymphocytic infiltration
Medullary
When endo vs radio vs chemo is used
Endocrine therapy
Oestrogen receptor positive tumours
Downstaging primary lesions
Definitive treatment in old, infirm patients
Irradiation
Wide local excision
Large lesion >4cm, high grade stage 3 or marked vascular invasion following mastectomy
Chemotherapy
Downstaging advanced lesions to facilitate breast conserving surgery
Patients with grade 3 lesions or axillary nodal disease
What does nipple retraction/dimpling indicate
tumour infiltration of the breast ducts and ligaments respectively
Which artery is damaged in level 3 nodal clearance
Thoracoacromial
Most sensitive imaging for breast cancer
MRI
Indications of breast MRI
- Lobular carcinomaQ: Difficult to detect and measure by conventional method because of multifocal and infiltrating growth pattern
- Staging of primary breast cancerQ
- Occult primary tumour with malignant axillary lymphadenopathy and normal mammogram and breast USGQ
- Screen younger women with high familial risk of breast cancerQ
- Assessing the integrity of breast implantQ
Micro vs macrocalcifications breast
Macro- bening
Micro- tumour
Malignant signs on mammography
Ill defined margin
Irregular stellate
Spiculatede
Comet tail
Wide Halo
Microcalcifications
Popcorn calcifications
Fibroadenoma
BRCA 1 vs 2
1
13
Poor differentiation
HR negative
2
13
HR positivitie
Hereditary breast cancer
BRCA PALNCH
PJS
Li Fraumeni
Atacia tel
Cowden
HNPCC
Features of medullary breast cancer
Soft
rapid increase in size
Dense lymphocytes
Sheet like growth
TNM staging breast cancer
T1 <2cm
2 2-5
3 >=5
4- chest wall
N1- 1-3 axillary
2- 4-9 axillary, or internal with no axillary
3- >10 axillary or internal mammary/infra/supraclavicular with axillary
Risk factor for male Breast cancer
Excess endogenous or exogenous estrogen (Testicular disease, infertility, obesity, cirrhosis)Q
* Radiation therapy, Klinefelter’s syndrome and testicular feminizing syndromesQ.
* BRCA2 mutationsQ
- Gynecomastia is not a risk factor for carcinoma male breast
Stromal cells on FNA of phyllodes vs FA
Polyclonal/mono on FA
Always Monoclonal on Phyllodes
Phyllodes- higher activity
What ligaments run from deep layer of superficial fasciae to dermis in breast
Suspensory ligaments of Cooper
Prevalence of breast cancer in women in the UK
12.5%
When is a Sentinel lymph nodes biopsy performed
If mammographic mass, palpable mass or mastectomy
Top 2 causes of mastalgia
Cyclical- 2w leading up to menstruation
then settles with
2nd- trigger point in pec major
Types of free flap for breast reconstruction
TDAP (thoracodorsal)
TRAM (rectus abdo)
DIEP (inferior epi)
IGAP (inferior gluteal)
TUG (upper gracilis)
Timings of free flap and radio
Should be done before
As radio will make attachment hard
What does screening involve
Mammography of cranial-caudal and lateral oblique view
Double read by 2 trained personal
No examiantion
% of phyllodes that malignantly transform
25%
BMI and breast cancer
Post menopausal obesity linked with breast cancer
RF for breast cancer
Increasing age
BRCA1/2
FH of breast or early ovarian
Ionising radiation <30
First preg after 35
Early menarch
Late meno
Alcohol consumption
Postmenopausal obesity
Prolonged HRT
Lymphoma rate after axillary dissection
20%
BRCA chance of developing breast cancer by 50
50%
Area where breast lesions are most commonly found
Upper outer quadrant
Incision for entering axilla
Retract pec major medially to expose pec minor (lies underneath) and clavipectorla fascia
Incise the fascia at edge of pec minor
When to send breast milk cultures
Masitits severe or recurrent
Hospital infection likely
Severe pain
Lump associated with oral contraception
Cyst formation
Tamoxifen SE post menopausal
Bleeding as agonist in endometrium
Young woman with BCRA1 + with lump ix
MRI
