Breast Surgery Flashcards
Common Breast Condiitons Breast Examination Referal and Diagnostic Pathways Breast Cancer covered more in cancer care block
Name some common presenting complaints of the breast
Pain Lump/lumps Nipple changes Asymmetry Gynaecomastia
How may breast pain present?
Cyclic pattern
Unilateral or bilateral
How common is breast pain?
Very common, the most common breast complaint
What changes can nipples undergo?
Retraction
Skin changes
Discharge
Name the benign breast lump causes
Fibrocystic changes
Fibroadenomas
Cysts
Lipomas
What is the peak age for fibroadenomas?
20-24 (decrease in incidence over time)
What is the peak age for fibrocystic changes?
40-50
What is the peak age for cysts?
50-55
What is the pattern of incidence of breast cancer?
It increases with age exponentially
What % of premenopausal women get fibrocystic breast changes?
20%
What is the relationship between fibrocystic changes and cancer?
No increased risk of cancer, but a cyst can mask a cancer
How common is a fibroadenoma?
Most common benign breast tumour
How should a fibroadenoma be managed?
Excision if growing
What are fibroadenomas also known as?
Breast mouse
What is the relationship between fibroadenomas and cancer?
No increased risk but can be confused with a cancer (Phylloides tumour)
How are breast cysts managed?
Aspiration if large cysts
How are benign and malignant conditions of the breast differentiated?
Triple assessment - Clinical examination and hx, imaging, and histology/cytology
What group of people are at risk of low grade infection behind the nipple?
Smokers
What are fibrocystic changes usually due to?
Hormone changes during the normal cycles
How can discomfort due to hormone cycles be helped? Is this commonly done?
Using hormones to help regulate cycles
Rarely requires treatment, but can help relieve symptoms
What is the relationship between breast cycts and cancer?
No increased risk of cancer, but could be a sign of cancer presence
What is duct ectasia?
Inflammation of a mammary duct due to blockage
What kind of symptoms can duct ectasia cause?
Green-yellow discharge from the nipple
Tenderness
Nipple retraction
Lump
What complication of duct ectasia may occur?
Fistula formation
inflammation -> abscess -> fistula with periareolar skin
Why is breast cancer such a biiiig ol’ topic? Give me some stats.
Most common cancer in women in UK - affects 1 in 8 women.
Over 48,000 cases per year and around 10,000 deaths per year
Who is the UK breast cancer screening programme aimed at?
Women aged 47-73
Other specific programmes for more high risk groups eg familial BRCA mutations
How frequently are women called for screening?
Every 3 years
What are the common signs and symptoms of breast malignancy?
Lump or breast thickening Discharge Bleeding Size/contour of breast changes Colour/appearance of areola Redness/pitting of skin
What are the clinical elements to the triple diagnosis?
(Hx) Inspection and palpation
What are the radiological elements to the triple assessment?
Mammograms
USS
MRI
What are the pathological elements to the triple diagnosis?
Fine needle aspiration cytology
Core biopsy
VACB
Excisional biopsy
What does VACB stand for?
Vacuum assisted breast core biopsy
Where anatomically are the breasts located?
Anterior thoracic wall, in the pectoral region
What is the main glandular structure in female breast tissue?
Mammary glands
What are the mammary glands involved in?
Lactation
Where is the lateral border of breast tissue?
Mid-axillary line
Where are the superior and inferior borders of the breast tissue?
2nd and 6th intercostal cartilages
How many regions are there in a breast?
2
Name the regions of the breast
Circular body
Axillary tail
What is the nipple composed of mostly?
Smooth muscle fibres
What is the area surrounding the nipple called?
Areola(e)
What glands are present in the areolae?
Sebaceous glands
What is the purpose of the glands of the areolae?
Secrete an oily protective lubricant
Within the breast tissue, what are th emammary glands surrounded by?
Connective tissue stroma
What are the structures within a mammary gland?
Ducts and secretory lobules (15-20)
How do these structures converge on the nipple?
Many alveoli drain into one duct, many ducts converge at the nipple like spokes of a wheel
What are the 2 main components of the connective tissue strome?
Fatty and fibrous tissue
What is important about the fibrous stroma of the breast?
It condenses to form the Cooper ligaments
What do the Cooper ligaments do?
- Attach the breast to the dermis and pectoral fascia
- Separate the secretory lobules of the breast
What is the retormammary space?
A layer of loose connective tissue between the breast and pectoral fascia
What can the retromammary spce be used in?
Reconstructive plastc surgery
How is arterial supply to the breast divided?
By medial and lateral aspect supply
What artery supplies the medial aspect of the breast?
Internal thoracic artery
What arterys supplies the lateral aspect of the breast? (4)
Mammary branch (of AIA)
Lateral mammary branches (of PIA)
Lateral thoracic and thoracoacromial branches (axillary artery)
Which 3 groups of lymph nodes drain the breast tissue?
Axillary nodes
Parasternal nodes
Posterior intercostal nodes
Which set of nodes recieve the majority of breast lymphatic drainage?
Axillary
What innervation does the breast receive?
Sensory and autonomic nerve fibres
What nerves carry these fibres?
Anterior and lateral cutaneous branches of 4th to 6th intercostal nerves
What regulates the secretion of milk?
Prolactin secretion from the anterior pituitary
What are the steps of a breast examination?
- Introduction and informed consent
- Inspection
- Palpation
- Axilla
- Lymph nodes
- Complete examination
Who should be present for a breast examination?
The pt, the examiner, and a chaperone.
What should you ask the patient before begining?
Is there any pain? If so, where?
Where do they feel the lump?
For general inspection, how should the patient be positioned?
Ask the patient to sit upright, ideally on the side of the bed.
Inspect with arms in 3 different positions.
What are we looking for on inspection?
Asymmetry, swelling, masses, skin changes, nipple changes
What scars may be visible on breasts?
Lumpectomy sars
Mastectomy scars
Breast augmentation surgery scars
What 3 positions should the arm be in for general inspection?
Arms by side
Hands on hips and push inwards
Hands behind/above head
What 3 things can cuase nipple retraction?
- Congenital
- Underlying tumour
- Duct ectasia
What can the pt do to exacerbate any skin dimpling?
Lean forwards (with hands above head)
What does skin dimpling/puckering suggest?
Underlying mass
Which breast should be palpated first?
The normal/asymptomatic one
How should the pt be positioned for palpation?
Leaning back on bed at 45 degrees
Which part of the hand should you use?
The flat of your fingers to compress the breast tissue
I mean its completely up to you, but what are some of the ways you can systematically palpate the breast?
- Clock face method (examine each “hour” of the breast)
- Spiral method (start at nipple and work out)
Don’t forget to palpate the….
Axillary tail!
What do you do if a pt has reported nipple discharge?
Ask the pt to squeeze the nipple to demonstrate the discharge
What does infective discharge look like?
Yellow/green
What does a bloody discharge suggest?
Malignancy e.g. papilloma
How do you report the position of a breast lump?
- Which quadrant it lies in/which hour of the clock
- How far it is from the nipple
How do you report the size/shape of a breast lump?
- Approx. dimensions of the lump
- Shape of the mass (spherical,elongated, irregular)
How do you report the consistency of a breast lump?
Smooth, firm, stony, rubbery
What else should you report with a lump?
- Overlying skin changes
- Mobility
- Fluctuance (a cyst can be squishy)
What is the best way to examine the axilla?
Supporting the pts arm so they relax their muscles, palpate with the other hand.
Note any lymphadenopathy.
Which other lymph nodes should be palpated?
Cervical, supraclavicular, infraclavicular, and parasternal
After completing examination, what further assessments can be suggested?
USS
Mammography
Biopsy
If a pt present with an erythematous rash originating in the nipple, and then it spreads to the surrounding areolar area. What do we suspect?
Paget’s disease of the nipple
What % of all breast cancers are mucinous carcinomas?
2-3%
What TNM stage is inflammatory breast cancer?
T4d
What is T1 staging?
<2cm
What is T2 staging?
2-5cm
What is T3 staging?
5cm +
What is T4a staging?
Invasion of chest wall
What is T4b staging?
Invasion of the skin (inc. ulceration or oedema)
What is T4c staging?
Invasion of chest wall and skin
What is the most common type of breast cancer?
Invasive ductal carcinoma
What features of a breast cancer would indicate that mastectomy is the most appropriate surgical option?
- Multifocal tumour
- Central tumour
- Large lesion in a small breast
- Over 4cm
Most importantly though, its down to the pts choice.
What features of a breast cancer would indicate that wide local excision is the most appropriate surgical option?
- Solitary lesion
- Peripheral tumour
- Small lesion in large breast
- Under 4cm
Most importantly though, its down to the pts choice.
What is the most likely diagnosis in a pt under 30 with a non-tender, discrete, and mobile lump?
Fibroadenoma
What is first line advice for managing mastitis?
Advise to continue breast feeding if possible.
When would abx be prescribed in mastitis?
If systemic symptoms are present, or a fissure present, or if symtpoms persist despite 12 hours of effective milk removal.
