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Surgery > Breast Surgery > Flashcards

Breast Surgery Flashcards

1
Q

epidemiology of breast ca?

A

Commonest cause of cancer death in females 15-54

Second commonest cause of cancer deaths overall

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2
Q

presentation of breast ca??

A

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

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3
Q

most common site to find breast ca lump?

A

upper outer quadrant

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4
Q

Triple assessment of any breast lump?

A
  1. Hx and clinical examination
  2. Radiology:

<35 yrs: US

>35 yrs: US + mammography

  1. Pathology:

solid lump: core biopsy

Cystic lump: FNA

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5
Q

Ix of breast ca?

A

Triple assessment:

Hx + clinical examination, US/ mammogram, FNA/ core biopsy

Bloods: FBC, LFTs, ESR, bone profile

Imaging for staging: CT scan

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6
Q

Clinical staging of breast cancer?

A

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

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7
Q

TNM Staging of Breast Ca?

A

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

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8
Q

What is amastia?

A

complete absence of breast and nipple

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9
Q

accessory nipples occur where?

A

anywhere along the milk line

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10
Q

causes of gynaecomastia?

A

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

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11
Q

presentation of acute mastitis?

A

assoc w lactating mother

painful, red breast

may -> abscess

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12
Q

mx of acute mastitis?

A

lactating mothers: conservative, express milk + analgesia

flucloxacillin

fluclox + incision and drainage if fluctuant abscess

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13
Q

presentation of fat necrosis?

A

assoc w previous trauma

painless, palpable, non mobile mass

may calcify simulating Ca

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14
Q

mx of fat necrosis?

A

analgesia

no follow up necessary

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15
Q

duct ectasia presentation?

A

slit like nipple

often bilateral +/- peri-areolar mass

thick white/ green discharge

may be calcified on mammography

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16
Q

mx of duct ectasia?

A

need to distinguish from Ca

surgical duct excision if mass present or discharge troublesome

close follow up

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17
Q

periductal mastitits presentation?

A

painful, erythematous sub-areolar mass

assoc w inverted nipple +/- purulent discharge

may -> abcess of discharging fistula

assoc w smoking

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18
Q

mx of periductal mastitis?

A

broad spectrum abx

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19
Q

presentation of intraductal papilloma?

A

common cause of bloody discharge

not usually palpable

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20
Q

mx of intraductal papilloma?

A

triple assessment

excise due to increased risk of ca

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21
Q

features of fibrocystic disease?

A

premenstrual breast nodularity (lumpiness) and pain

often in upper outer quadrant

lumps in fibrocystic breasts tend to fluctuate in size throughout the month

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22
Q

mx of fibrocystic disease?

A

triple assessment

reassurance

analgesia

good bra

evening primrose oil

danazol may occasionally be used

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23
Q

presentation of fibroadenoma?

A

< 35 yo

rare post menopause

commonest benign tumour

painless, mobile, rubbery mass

often multiple and bilateral

Popcorn calcification

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24
Q

mx of fibroadenoma?

A

Reassurance + f/up if <2.5cm

Shell-out surgically if

  • >2.5cm
  • FH of breast Ca
  • Pt. choice
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25
Q

large fast growing mass

in breast

mobile, non-tender

epithelial and connective tissue elements

dx?

A

Phyllodes tumour

tx: wide local excision

26
Q

Presents as Microcalcification on mammogram

Rarely assoc. with symptoms:

  • lump
  • discharge
  • eczematous change = Paget’s disease

→ Ca @ 1%/yr (10x ↑ risk) in ipsilateral breast

A

Ductal Carcinoma in situ

27
Q

mx of Ductal carcinoma in situ?

A

wide local excision + radiotx

extensive or multifocal -> mastectomy + reconstruction + sentinel node biopsy

28
Q

Pagets Disease of nipple

presentation?

A

unilateral, scaly, erythematous, itchy

+/- palpable mass (invasive ca)

29
Q

mx of Paget’s Disease of Nipple?

A

Usually underlying invasive or DCIS breast cancer.

Mastectomy + radio ± chemo/endo

30
Q

Presentation of lobar calcification in situ?

A

Incidental biopsy finding (no calcification)

Often bilat (20-40%)
Young women
↑ risk Ca risk (x10) in both breasts

31
Q

Mx of Lobar carcinoma in situ?

A

Bilateral prophylactic mastectomy or close watching w mammographic screening

32
Q

MDT involved in Breast Ca tx?

A

Oncologist

Breast surgeon

Specialist Nurse

radiologist

histopathologist

Plastics

33
Q

what is duct ectasia?

A

dilatation and shortening of the terminal breast ducts within 3cm of the nipple.

34
Q

indications for surgical removal of fibroadenoma?

A

> 3cm

causing discomfort

pt request

35
Q

when to refer pt for suspected breast cancer?

A

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
36
Q

fibrocystic disease aka?

A

fibroadenosis

or benign mammary dysplasia

37
Q

what is inflammatory breast cancer?

A

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.

38
Q

assessment of LN in breast ca?

A

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

39
Q

main operations of breast reconstruction surgery?

A

latissimus dorsi myocutaneous flap

sub pectoral implants: silastic or saline inflatable

transverse rectus abdominis myocutaneous flap

40
Q

surgical options for breast cancer?

A

Mastectomy

Wide local excision

41
Q

indications for mastectomy?

A

> 4cm typically large tumours

multifocal or central tumours

large lesion in small breast

pt choice

nipple involvement

42
Q

what is the Nottingham Prognostic Index?

A

Predicts survival and risk of relapse of breast ca

Calculation of NPI:

Tumour Size x 0.2 + Lymph node score + Grade score

43
Q

what drug is used in Her2 +ve breast ca?

A

Trastuzumab (anti-Her2)

44
Q

Radiotherapy in breast ca?

indications

A

post-wide local excision: decrease local recurrence

post-mastectomy: only if high risk of local recurrence

axillary node +ve disease

palliation: bone pain

45
Q

Mx of oestrogen receptor +ve breast ca?

A

Tamoxifen

  • selective ER modulator: antagonist @ breast, agonist @ uterus
  • for pre or perimenopausal women

Anastrazole

aromatase inhibitor -> decrease oestrogen

for post menopausal women

46
Q

Supportive mx of bone pain in br ca?

A

Radiotx

bisphosphonates

analgesia

47
Q

supportive mx of lymphoedema from br ca?

A

decongestion and compression

48
Q

supportive mx of brain mets from br ca?

A

surgery/ radio tx

steroids

anti epileptic drugs

49
Q

Breast Cancer Screening?

A

all women are offered breast cancer screening with mammography every 3 years between the ages of 50 and 70 years.

50
Q

what are the breast cancer markers?

A

CA 15-3

CA 27.29

CEA

51
Q

Ix of Pagets disease of the nipple?

A

find underlying ca

punch biopsy, mammography and ultrasound of the breast.

52
Q

1st line mx for breast ca?

A

Surgery!!

An exception may be a very frail, elderly lady with metastatic disease who may be better managed with hormonal therapy.

53
Q

when is trastuzumab contraindicated?

A

SE: cardiac toxicity

Trastuzumab cannot be used in patients with a history of heart disorders.

54
Q

fibroadenoma > 4cm ix?

A

A size of greater than 4cm attracts a recommendation for core biopsy to exclude a phyllodes tumour.

55
Q

soft, fluctuant swellings on breast examination

‘halo appearance’ on mammography

A

breast cyst

56
Q

what chemotx is used for node+ve cancer?

A

FEC-D chemotherapy

57
Q

what chemotx is used for node-ve breast cancer?

A

FEC chemotherapy

5-FU, Epirubicin, Cyclophosphamide

58
Q

BRCA1/2 auto dom or recessive?

A

autosomal dominant

59
Q

mx of breast cyst?

A

Cysts should be aspirated, those which are blood stained or persistently refill should be biopsied or excised

60
Q

most common type of breast ca?

A

invasive ductal carcinoma (no special type)

61
Q

mx of duct papilloma?

A

Microdochectomy

62
Q

mx of post menopausal ER+ve women?

A

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.

Surgery (17 decks)

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