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eMRCS questions > Breast surgery > Flashcards

Breast surgery Flashcards

1
Q

Ix of breast

A

USG- <35
Mammo >35

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2
Q

Arterial supple of breast

A
  • Internal mammary (thoracic) artery
  • External mammary artery (laterally)
  • Anterior intercostal arteries
  • Thoraco-acromial artery
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3
Q

Which muscles do the breasts lie on

A
  1. Pectoralis major
  2. Serratus anterior
  3. External oblique
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4
Q

Radial scar features

A

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

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5
Q

Radial scar tx

A

Lesions should be biopsied, excision is not mandatory

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6
Q

Fat necrosis features

A

Up to 40% cases usually have a traumatic aetiology
* Physical features usually mimic carcinoma

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7
Q

Fat necrosis tx

A

Imaging and core biopsy

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8
Q

Intraductal papilloma features

A

Growth of papilloma in a single duct
* Usually presents with clear or blood stained discharge originating from a single duct

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9
Q

Excessive milk cause

A

Pituitary tumour

  • Microadenomas <1cm in diameter
  • Macroadenomas >1cm in diameter
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10
Q

Features of fibroadenoma

A

Smooth; Fram; Mobile; Round mass

Can fluctuate size with menstrual cycle

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11
Q

Phyllode tumour pathology and features

A

● 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

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12
Q

Tx of phyllodes tumour

A

WLE
<5cm- 2cm margin
>5cm- 5cm margin

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13
Q

Duct ectasia features

A

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

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14
Q

Types of ductal carcinoma in situ

A

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

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15
Q

Tx of DCIS

A

This is done with breast conserving surgery (wide local excision) or (in cases of widespread or multifocal DCIS) with mastectomy.

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16
Q

LCIS features

A

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.

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17
Q

LCIS mx

A

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.

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18
Q

Invasive lobular carcinoma features

A

Only bilateral carcinoma

Multifocal lesions

Worst prognosis- pleomorphic

Bull eye pattern- pathology

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19
Q

Invasive ductal carcinoma features

A

● Large irregular surface - hard consistency

White necrotic area Branching micro
- calcificaation Stellate lesion(+)

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20
Q

Which subtype of DCIS has recurrence after surgery

A

Only comedo

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21
Q

FNAC vs Core / True-cut Biopsy

A

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

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22
Q

When to do mastectomy vs WLE

A

Mastectomy
Multifocal tumour
Central
Large lesion in small breast
DCIS >4cm

WLE
Solitary
Peripheral tumour
Small lesion in large breast
DCIS <4cm

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23
Q

SE of axillary node clearance

A

Lymphoedema, increased risk of cellulitis and
frozen shoulder.

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24
Q

Complications of breast surgery

A
  • 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.
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25
Q

Axillary LN clearance levels

A

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)

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26
Q

When is hormonal therapy used

A

ER & PR (+)ve patient cases to downstage

Or older who refuse surgery

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27
Q

Types of hormonal therapy

A

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
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28
Q

When can tamoxifen not be used

A

History of thrombosis

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29
Q

What to use if patient has ER- tumour

A

In these cases (+)ve C-erb B2 (HER2/neu) suggests TRASTUZUMAB (Herceptin) may be effective

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30
Q

When is chemotherapy used

A

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
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31
Q

When is Neo adjuvant chemo used

A
  • Young pt. with high grade ca specially if >3cm
  • To down-stage the tumors with an aim to provide breast conserving surgery
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32
Q

Tx of periductal mastitis in postmenopausal

A

Anaerobic bacteria cause so tx would be metronidazole.

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33
Q

Most important prognostic factor for breast cancer

A

Nodal status

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34
Q

Firbocystic disease

A

Cyclical mastalgia
Pain 2 weeks leading to period then settles with menstruation
Bilateral

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35
Q

Tietze Syndrome

A

Chest pain
Costchondral swelling of upper ribs attaching to sternum
Pain can spread to arms or shoulders

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36
Q

Duct ectasia tx

A

Reassure

If older and persistent discharge - total duct excision

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37
Q

Tx of duct papiloma

A

Microdochectomy

38
Q

Pagets vs eczema of nipple

A

Pagets- affect nipple first then areola area

Eczema- affects areola

39
Q

Inflammatory carcinoma of breast features

A

Aggressive
Mets early
Tx resistant

In pregnancy or lactation

Mistaken for mastitis- red hot

40
Q

Screening of breast cancer

A

Mammography
50-70 every 3 years

Strong FH - can be offered screening from 47

41
Q

Reconstruction options

A

Lat dorsi myocutaneous flap and subpectoral implants

42
Q

Tamoxifen cancer risks

A

Endometrial

43
Q

When to use aromatase inhibitors

A

When tamoxifen no longer effective

44
Q

Post mastectomy with skin flap- large fluctuant mass under neath, Dx?

A

Seroma
Very common post breast surgery

Straw coloured fluid
Tx with drainage

45
Q

Radical vs simple mastectomy

A

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

46
Q

Tx of 1.5cm malignant lesion in upper outer breast with no evidence of LN spread

A

WLE and node biopsy

47
Q

Tx of 2.5 lesion in centre of breast with FNA of LN showing mets

A

Simple mastectomy and axillary LN clearance

48
Q

Histology shows lobular carcinoma present at 3 of resection margins, mx?

A

Mastectomy

Lobular- often multifocal

49
Q

When is radiotherapy used

A

If breast conserving surgery used- e.g WLE

To breast alone

50
Q

When is each medical therapy used

A

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

51
Q

Nottingham prognostic score

A

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%

52
Q

Mucinous tumour features

A

Grey gelatinous surface
Soft

53
Q

Young female found to have BRCA1 mutation, what is the survailence

A

Annual MRI

54
Q

Drugs causing gynaeocmastia

A

Digoxin
Isoinazid
Spiro
Cimetidne
Oestrogen

55
Q

Most common cause of painless lump in postmenopausal woman

A

Invasive Ductal carcinoma

56
Q

Woman with lump with hx of implants ix

A

USS first

Non conclusive MRI

If implants related problems- MRI

57
Q

Halo sign on mammography

A

Breast cyst

58
Q

Breast cancer with lymphocytic infiltration

A

Medullary

59
Q

When endo vs radio vs chemo is used

A

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

60
Q

What does nipple retraction/dimpling indicate

A

tumour infiltration of the breast ducts and ligaments respectively

61
Q

Which artery is damaged in level 3 nodal clearance

A

Thoracoacromial

62
Q

Most sensitive imaging for breast cancer

A

MRI

63
Q

Indications of breast MRI

A
  1. Lobular carcinomaQ: Difficult to detect and measure by conventional method because of multifocal and infiltrating growth pattern
  2. Staging of primary breast cancerQ
  3. Occult primary tumour with malignant axillary lymphadenopathy and normal mammogram and breast USGQ
  4. Screen younger women with high familial risk of breast cancerQ
  5. Assessing the integrity of breast implantQ
64
Q

Micro vs macrocalcifications breast

A

Macro- bening
Micro- tumour

65
Q

Malignant signs on mammography

A

Ill defined margin
Irregular stellate
Spiculatede
Comet tail
Wide Halo

Microcalcifications

66
Q

Popcorn calcifications

A

Fibroadenoma

67
Q

BRCA 1 vs 2

A

1
13
Poor differentiation
HR negative

2
13
HR positivitie

68
Q

Hereditary breast cancer

A

BRCA PALNCH

PJS
Li Fraumeni
Atacia tel
Cowden
HNPCC

69
Q

Features of medullary breast cancer

A

Soft
rapid increase in size
Dense lymphocytes
Sheet like growth

70
Q

TNM staging breast cancer

A

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

71
Q

Risk factor for male Breast cancer

A

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
72
Q

Stromal cells on FNA of phyllodes vs FA

A

Polyclonal/mono on FA
Always Monoclonal on Phyllodes

Phyllodes- higher activity

73
Q

What ligaments run from deep layer of superficial fasciae to dermis in breast

A

Suspensory ligaments of Cooper

74
Q

Prevalence of breast cancer in women in the UK

A

12.5%

75
Q

When is a Sentinel lymph nodes biopsy performed

A

If mammographic mass, palpable mass or mastectomy

76
Q

Top 2 causes of mastalgia

A

Cyclical- 2w leading up to menstruation
then settles with

2nd- trigger point in pec major

77
Q

Types of free flap for breast reconstruction

A

TDAP (thoracodorsal)

TRAM (rectus abdo)

DIEP (inferior epi)

IGAP (inferior gluteal)

TUG (upper gracilis)

78
Q

Timings of free flap and radio

A

Should be done before
As radio will make attachment hard

79
Q

What does screening involve

A

Mammography of cranial-caudal and lateral oblique view

Double read by 2 trained personal

No examiantion

80
Q

% of phyllodes that malignantly transform

A

25%

81
Q

BMI and breast cancer

A

Post menopausal obesity linked with breast cancer

82
Q

RF for breast cancer

A

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

83
Q

Lymphoma rate after axillary dissection

A

20%

84
Q

BRCA chance of developing breast cancer by 50

A

50%

85
Q

Area where breast lesions are most commonly found

A

Upper outer quadrant

86
Q

Incision for entering axilla

A

Retract pec major medially to expose pec minor (lies underneath) and clavipectorla fascia

Incise the fascia at edge of pec minor

87
Q

When to send breast milk cultures

A

Masitits severe or recurrent
Hospital infection likely
Severe pain

88
Q

Lump associated with oral contraception

A

Cyst formation

89
Q

Tamoxifen SE post menopausal

A

Bleeding as agonist in endometrium

90
Q

Young woman with BCRA1 + with lump ix

A

MRI

91
Q
A

eMRCS questions (45 decks)

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