Breast Surgery Flashcards
Common Breast Condiitons Breast Examination Referal and Diagnostic Pathways Breast Cancer covered more in cancer care block
1
Q
Name some common presenting complaints of the breast
A
Pain Lump/lumps Nipple changes Asymmetry Gynaecomastia
2
Q
How may breast pain present?
A
Cyclic pattern
Unilateral or bilateral
3
Q
How common is breast pain?
A
Very common, the most common breast complaint
4
Q
What changes can nipples undergo?
A
Retraction
Skin changes
Discharge
5
Q
Name the benign breast lump causes
A
Fibrocystic changes
Fibroadenomas
Cysts
Lipomas
6
Q
What is the peak age for fibroadenomas?
A
20-24 (decrease in incidence over time)
7
Q
What is the peak age for fibrocystic changes?
A
40-50
8
Q
What is the peak age for cysts?
A
50-55
9
Q
What is the pattern of incidence of breast cancer?
A
It increases with age exponentially
10
Q
What % of premenopausal women get fibrocystic breast changes?
A
20%
11
Q
What is the relationship between fibrocystic changes and cancer?
A
No increased risk of cancer, but a cyst can mask a cancer
12
Q
How common is a fibroadenoma?
A
Most common benign breast tumour
13
Q
How should a fibroadenoma be managed?
A
Excision if growing
14
Q
What are fibroadenomas also known as?
A
Breast mouse
15
Q
What is the relationship between fibroadenomas and cancer?
A
No increased risk but can be confused with a cancer (Phylloides tumour)
16
Q
How are breast cysts managed?
A
Aspiration if large cysts
17
Q
How are benign and malignant conditions of the breast differentiated?
A
Triple assessment - Clinical examination and hx, imaging, and histology/cytology
18
Q
What group of people are at risk of low grade infection behind the nipple?
A
Smokers
19
Q
What are fibrocystic changes usually due to?
A
Hormone changes during the normal cycles
20
Q
How can discomfort due to hormone cycles be helped? Is this commonly done?
A
Using hormones to help regulate cycles
Rarely requires treatment, but can help relieve symptoms
21
Q
What is the relationship between breast cycts and cancer?
A
No increased risk of cancer, but could be a sign of cancer presence
22
Q
What is duct ectasia?
A
Inflammation of a mammary duct due to blockage
23
Q
What kind of symptoms can duct ectasia cause?
A
Green-yellow discharge from the nipple
Tenderness
Nipple retraction
Lump
24
Q
What complication of duct ectasia may occur?
A
Fistula formation
inflammation -> abscess -> fistula with periareolar skin
25
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
26
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
27
How frequently are women called for screening?
Every 3 years
28
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
```
29
What are the clinical elements to the triple diagnosis?
(Hx) Inspection and palpation
30
What are the radiological elements to the triple assessment?
Mammograms
USS
MRI
31
What are the pathological elements to the triple diagnosis?
Fine needle aspiration cytology
Core biopsy
VACB
Excisional biopsy
32
What does VACB stand for?
Vacuum assisted breast core biopsy
33
Where anatomically are the breasts located?
Anterior thoracic wall, in the pectoral region
34
What is the main glandular structure in female breast tissue?
Mammary glands
35
What are the mammary glands involved in?
Lactation
36
Where is the lateral border of breast tissue?
Mid-axillary line
37
Where are the superior and inferior borders of the breast tissue?
2nd and 6th intercostal cartilages
38
How many regions are there in a breast?
2
39
Name the regions of the breast
Circular body
| Axillary tail
40
What is the nipple composed of mostly?
Smooth muscle fibres
41
What is the area surrounding the nipple called?
Areola(e)
42
What glands are present in the areolae?
Sebaceous glands
43
What is the purpose of the glands of the areolae?
Secrete an oily protective lubricant
44
Within the breast tissue, what are th emammary glands surrounded by?
Connective tissue stroma
45
What are the structures within a mammary gland?
Ducts and secretory lobules (15-20)
46
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
47
What are the 2 main components of the connective tissue strome?
Fatty and fibrous tissue
48
What is important about the fibrous stroma of the breast?
It condenses to form the Cooper ligaments
49
What do the Cooper ligaments do?
- Attach the breast to the dermis and pectoral fascia
| - Separate the secretory lobules of the breast
50
What is the retormammary space?
A layer of loose connective tissue between the breast and pectoral fascia
51
What can the retromammary spce be used in?
Reconstructive plastc surgery
52
How is arterial supply to the breast divided?
By medial and lateral aspect supply
53
What artery supplies the medial aspect of the breast?
Internal thoracic artery
54
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)
55
Which 3 groups of lymph nodes drain the breast tissue?
Axillary nodes
Parasternal nodes
Posterior intercostal nodes
56
Which set of nodes recieve the majority of breast lymphatic drainage?
Axillary
57
What innervation does the breast receive?
Sensory and autonomic nerve fibres
58
What nerves carry these fibres?
Anterior and lateral cutaneous branches of 4th to 6th intercostal nerves
59
What regulates the secretion of milk?
Prolactin secretion from the anterior pituitary
60
What are the steps of a breast examination?
- Introduction and informed consent
- Inspection
- Palpation
- Axilla
- Lymph nodes
- Complete examination
61
Who should be present for a breast examination?
The pt, the examiner, and a chaperone.
62
What should you ask the patient before begining?
Is there any pain? If so, where?
| Where do they feel the lump?
63
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.
64
What are we looking for on inspection?
Asymmetry, swelling, masses, skin changes, nipple changes
65
What scars may be visible on breasts?
Lumpectomy sars
Mastectomy scars
Breast augmentation surgery scars
66
What 3 positions should the arm be in for general inspection?
Arms by side
Hands on hips and push inwards
Hands behind/above head
67
What 3 things can cuase nipple retraction?
- Congenital
- Underlying tumour
- Duct ectasia
68
What can the pt do to exacerbate any skin dimpling?
Lean forwards (with hands above head)
69
What does skin dimpling/puckering suggest?
Underlying mass
70
Which breast should be palpated first?
The normal/asymptomatic one
71
How should the pt be positioned for palpation?
Leaning back on bed at 45 degrees
72
Which part of the hand should you use?
The flat of your fingers to compress the breast tissue
73
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)
74
Don't forget to palpate the....
Axillary tail!
75
What do you do if a pt has reported nipple discharge?
Ask the pt to squeeze the nipple to demonstrate the discharge
76
What does infective discharge look like?
Yellow/green
77
What does a bloody discharge suggest?
Malignancy e.g. papilloma
78
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
79
How do you report the size/shape of a breast lump?
- Approx. dimensions of the lump
| - Shape of the mass (spherical,elongated, irregular)
80
How do you report the consistency of a breast lump?
Smooth, firm, stony, rubbery
81
What else should you report with a lump?
- Overlying skin changes
- Mobility
- Fluctuance (a cyst can be squishy)
82
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.
83
Which other lymph nodes should be palpated?
Cervical, supraclavicular, infraclavicular, and parasternal
84
After completing examination, what further assessments can be suggested?
USS
Mammography
Biopsy
85
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
86
What % of all breast cancers are mucinous carcinomas?
2-3%
87
What TNM stage is inflammatory breast cancer?
T4d
88
What is T1 staging?
<2cm
89
What is T2 staging?
2-5cm
90
What is T3 staging?
5cm +
91
What is T4a staging?
Invasion of chest wall
92
What is T4b staging?
Invasion of the skin (inc. ulceration or oedema)
93
What is T4c staging?
Invasion of chest wall and skin
94
What is the most common type of breast cancer?
Invasive ductal carcinoma
95
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.
96
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.
97
What is the most likely diagnosis in a pt under 30 with a non-tender, discrete, and mobile lump?
Fibroadenoma
98
What is first line advice for managing mastitis?
Advise to continue breast feeding if possible.
99
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.
