Breast Surgery Flashcards
epidemiology of breast ca?
Commonest cause of cancer death in females 15-54
Second commonest cause of cancer deaths overall
presentation of breast ca??
Lump: commonest presentation
usually painless, 50% in upper outer quadrant, +/- axillary nodes
skin changes:
Pagets: persistent eczema
Peau d’orange
Nipple:
discharge, inversion
Mets:
pathological #, SOB, abdo pain, seizures
most common site to find breast ca lump?
upper outer quadrant
Triple assessment of any breast lump?
- Hx and clinical examination
- Radiology:
<35 yrs: US
>35 yrs: US + mammography
- Pathology:
solid lump: core biopsy
Cystic lump: FNA
Ix of breast ca?
Triple assessment:
Hx + clinical examination, US/ mammogram, FNA/ core biopsy
Bloods: FBC, LFTs, ESR, bone profile
Imaging for staging: CT scan
Clinical staging of breast cancer?
Stage 1: confined to breast, mobile, no LNs
Stage 2: Stage 1 + nodes in ipsilateral axilla
Stage 3: Stage 2 + fixation to muscle (not chest wall)
LNs matted and fixed, large skin involvement
Stage 4: Complete fixation to chest wall + mets
TNM Staging of Breast Ca?
T1 <2cm
T2 2-5cm
T3 5+cm
T4a invades chest wall
T4b invades skin (includes ulceration or oedema)
T4c invades chest wall and skin
T4d inflammatory breast cancer.
N1: mobile nodes
N2: fixed nodes
What is amastia?
complete absence of breast and nipple
accessory nipples occur where?
anywhere along the milk line

causes of gynaecomastia?
occurs in 30% of boys at puberty: oestrogen/ testosterone imbalance
hormone secreting tumours e.g. sex-cord testicular
Chronic liver disease: hypogonadism + decreased E2 metabolism
Drugs: spironolactone, digoxin, cimetidine
presentation of acute mastitis?
assoc w lactating mother
painful, red breast
may -> abscess
mx of acute mastitis?
lactating mothers: conservative, express milk + analgesia
flucloxacillin
fluclox + incision and drainage if fluctuant abscess
presentation of fat necrosis?
assoc w previous trauma
painless, palpable, non mobile mass
may calcify simulating Ca
mx of fat necrosis?
analgesia
no follow up necessary
duct ectasia presentation?
slit like nipple
often bilateral +/- peri-areolar mass
thick white/ green discharge
may be calcified on mammography
mx of duct ectasia?
need to distinguish from Ca
surgical duct excision if mass present or discharge troublesome
close follow up
periductal mastitits presentation?
painful, erythematous sub-areolar mass
assoc w inverted nipple +/- purulent discharge
may -> abcess of discharging fistula
assoc w smoking

mx of periductal mastitis?
broad spectrum abx
presentation of intraductal papilloma?
common cause of bloody discharge
not usually palpable

mx of intraductal papilloma?
triple assessment
excise due to increased risk of ca
features of fibrocystic disease?
premenstrual breast nodularity (lumpiness) and pain
often in upper outer quadrant
lumps in fibrocystic breasts tend to fluctuate in size throughout the month

mx of fibrocystic disease?
triple assessment
reassurance
analgesia
good bra
evening primrose oil
danazol may occasionally be used
presentation of fibroadenoma?
< 35 yo
rare post menopause
commonest benign tumour
painless, mobile, rubbery mass
often multiple and bilateral
Popcorn calcification
mx of fibroadenoma?
Reassurance + f/up if <2.5cm
Shell-out surgically if
- >2.5cm
- FH of breast Ca
- Pt. choice
large fast growing mass
in breast
mobile, non-tender
epithelial and connective tissue elements
dx?
Phyllodes tumour
tx: wide local excision
Presents as Microcalcification on mammogram
Rarely assoc. with symptoms:
- lump
- discharge
- eczematous change = Paget’s disease
→ Ca @ 1%/yr (10x ↑ risk) in ipsilateral breast
Ductal Carcinoma in situ
mx of Ductal carcinoma in situ?
wide local excision + radiotx
extensive or multifocal -> mastectomy + reconstruction + sentinel node biopsy
Pagets Disease of nipple
presentation?
unilateral, scaly, erythematous, itchy
+/- palpable mass (invasive ca)
mx of Paget’s Disease of Nipple?
Usually underlying invasive or DCIS breast cancer.
Mastectomy + radio ± chemo/endo
Presentation of lobar calcification in situ?
Incidental biopsy finding (no calcification)
Often bilat (20-40%)
Young women
↑ risk Ca risk (x10) in both breasts
Mx of Lobar carcinoma in situ?
Bilateral prophylactic mastectomy or close watching w mammographic screening
MDT involved in Breast Ca tx?
Oncologist
Breast surgeon
Specialist Nurse
radiologist
histopathologist
Plastics
what is duct ectasia?
dilatation and shortening of the terminal breast ducts within 3cm of the nipple.
indications for surgical removal of fibroadenoma?
> 3cm
causing discomfort
pt request
when to refer pt for suspected breast cancer?
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if they are:
- aged 30 and over and have an unexplained breast lump with or without pain or
- aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern
fibrocystic disease aka?
fibroadenosis
or benign mammary dysplasia
what is inflammatory breast cancer?
progressive, erythema and oedema of the breast in the absence signs of infection such as fever, discharge or elevated WCC and CRP
+ raised CA 15-3
IBC is a rare but rapidly progressive form of breast cancer caused by obstruction of lymph drainage causing erythema and oedema. It is usually a primary cancer and is managed with neo-adjuvant chemotherapy first-line, followed by total mastectomy +/- radiotherapy.
assessment of LN in breast ca?
Gold standard: Sentinel Node Biopsy
SN= first node that a section of breast drains to
minimises the morbidity of an axillary dissection
If node +ve -> axillary clearance or radiotx
main operations of breast reconstruction surgery?
latissimus dorsi myocutaneous flap
sub pectoral implants: silastic or saline inflatable
transverse rectus abdominis myocutaneous flap
surgical options for breast cancer?
Mastectomy
Wide local excision

indications for mastectomy?
> 4cm typically large tumours
multifocal or central tumours
large lesion in small breast
pt choice
nipple involvement
what is the Nottingham Prognostic Index?
Predicts survival and risk of relapse of breast ca
Calculation of NPI:
Tumour Size x 0.2 + Lymph node score + Grade score

what drug is used in Her2 +ve breast ca?
Trastuzumab (anti-Her2)
Radiotherapy in breast ca?
indications
post-wide local excision: decrease local recurrence
post-mastectomy: only if high risk of local recurrence
axillary node +ve disease
palliation: bone pain
Mx of oestrogen receptor +ve breast ca?
Tamoxifen
- selective ER modulator: antagonist @ breast, agonist @ uterus
- for pre or perimenopausal women
Anastrazole
aromatase inhibitor -> decrease oestrogen
for post menopausal women
Supportive mx of bone pain in br ca?
Radiotx
bisphosphonates
analgesia
supportive mx of lymphoedema from br ca?
decongestion and compression
supportive mx of brain mets from br ca?
surgery/ radio tx
steroids
anti epileptic drugs
Breast Cancer Screening?
all women are offered breast cancer screening with mammography every 3 years between the ages of 50 and 70 years.
what are the breast cancer markers?
CA 15-3
CA 27.29
CEA
Ix of Pagets disease of the nipple?
find underlying ca
punch biopsy, mammography and ultrasound of the breast.
1st line mx for breast ca?
Surgery!!
An exception may be a very frail, elderly lady with metastatic disease who may be better managed with hormonal therapy.
when is trastuzumab contraindicated?
SE: cardiac toxicity
Trastuzumab cannot be used in patients with a history of heart disorders.
fibroadenoma > 4cm ix?
A size of greater than 4cm attracts a recommendation for core biopsy to exclude a phyllodes tumour.
soft, fluctuant swellings on breast examination
‘halo appearance’ on mammography
breast cyst
what chemotx is used for node+ve cancer?
FEC-D chemotherapy
what chemotx is used for node-ve breast cancer?
FEC chemotherapy
5-FU, Epirubicin, Cyclophosphamide
BRCA1/2 auto dom or recessive?
autosomal dominant
mx of breast cyst?
Cysts should be aspirated, those which are blood stained or persistently refill should be biopsied or excised
most common type of breast ca?
invasive ductal carcinoma (no special type)
mx of duct papilloma?
Microdochectomy
mx of post menopausal ER+ve women?
aromatase inhibitor
e.g. anastrazole
In post menopausal women oestrogens are produced by the peripheral aromatization of androgens and aromatase inhibitors are therefore the most popular agent in this age group.