Breast Surgery

Question 1

What is the lymphatic drainage of the breast?

Answer 1

20% to internal mammary / parasternal lymph nodes, 80% to axillary lymph nodes (apical node > supraclavicular)

Question 2

What is the triple test for breast cancer?

Answer 2

History + examination
Imaging
Biopsy (FNA or core)
(then test for hormone receptor status, HER-2 status)

Question 3

What features on inspection are associated with breast cancer?

Answer 3

Peau d'orange (inflammatory carcinoma)
Dimpling
Nipple retraction
Tethering
Lump

Question 4

What type of imaging is appropriate in the investigation of a breast lump?

Answer 4

Mammogram if > 40

Ultrasound if < 40 or dense breast tissue

Question 5

What are the most common diagnoses of a breast lump in the following age groups?

(a) <35 years
(b) 35-50 years
(c) 50+ years

Answer 5

(a) Fibroadenoma, hormonal chances
(b) Fibrocystic change, breast cysts
(c) Cancer, fat necrosis, mammary duct ectasia (dilation)

Question 6

What can cause the following coloured nipple discharge?

(a) Milky
(b) Green
(c) Clear
(d) Blood

Answer 6

(a) Galactorrhoea, lactation
(b) Mammary duct ectasia
(c) Intraductal papilloma
(d) Malignancy, trauma, paget’s disease

Question 7

What is paget’s disease of the nipple?

Answer 7

Rare type of cancer involving nipple + areolar

Presents as eczema of nipple + areola with bloody discharge, burning sensation,nipple inversion +/- breast lump

Question 8

What adjuvent therapy is available for the treatment of breast cancer?

Answer 8

Tamoxifen: blocks oestrogen receptors in breast (ER+)
Aromatase Inhibitors: prevent conversion of androgens to oestrogen in peripheral tissues
Trastuzumab: monoclonal antibody (HER-2+)

Question 9

What is a fibroadenoma?

Answer 9

Benign hyperplasia in a single duct terminal unit (CT + glandular tissue), common in childbearing age

Question 10

What is mammary duct ectasia?

Answer 10

Stasis of colostrum blocks ducts causing dilation, common in postmenopausal women

Question 11

What is fibrocystic change?

Answer 11

‘Lumpy’ breasts due to hormonal changes, sometimes associated with tenderness, aching and pruritus (tend to peak before each period), common in childbearing age

Question 12

In what demographic do breast cysts most commonly occur?

Answer 12

35-50 years and women on HRT

Question 13

What are differentials for a painless breast lump?

Answer 13

Breast cancer (carcinoma)
Fibroadenoma
Fibrocystic change
Breast cyst
Lipoma

Question 14

What are differentials for a painful breast lump?

Answer 14

Mastitis
Breast abscess
Fat necrosis
Mammary duct ectasia
Breast cyst
Paget's disease
Inflammatory carcinoma