Breast Surgery

Question 1

Breast Cancer Epidemiology

Answer 1

• Incidence 35,000; Lifetime prevalence of 1 in 9; Incidence increase with age
• 1% of cases occur in men; 5% related to identifiable genetics (BRAC1/2, ATM)
• 60% present symptomatically, 40% through screening programmes

Question 2

Presentation of Breast Cancer

Answer 2

• Lump – Most common; painless unless Inflammatory carcinoma, Ill-defined borders with hard
texture and may either be immobile, tethered or fixed to chest wall (=generally not mobile)
• Nipple – May be prime site of disease (Bowen’s/Paget’s Disease) = Eczema like changes
o Might be inverted, destroyed, deviated or produce bloody discharge
• Skin changes – Dimpling, Puckering, Colour, Lymphoedema (Peau d’orange), Skin ulceration,
Fungation, Inflammatory changes
• Systemic – Weight loss/Anorexia, Bone pain, Jaundice, Pleural/Pericardial effusions, Anaemia

Question 3

Screening Programme

Answer 3

Women 50 – 70yrs; planning to extend to 47 –74yrs, Lateral and Oblique Mammograms
o Risk of false positive approximately 25% over 10yrs of screening; 10% of
invasive carcinoma not radiologically
detectable

Question 4

Investigation

Answer 4

• Triple Assessment – Clinical Examination +
Radiological Assessment + Tissue Diagnosis
o MRI for Lobular Carcinoma, Multifocal
disease, of for screening in younger
women with strong family history
• Tissue Diagnosis – Core Biopsy or Fine Needle
Aspiration Cytology (FNAC) ± Axillary nodes
o Core Biopsy can differentiate between
invasive vs Ductal Carcinoma In-Situ;
useful for determining Oestrogen
receptor status

• If cancer is found; Staging CT, US Liver, CXR, Bone scan, LFT, Serum Calcium and specific
investigations for another organ specific metastasis if suspected

Question 5

Staging: Tumour

Answer 5

Tis = DCIS
T1 = 2cm across or less
T2 = 2 – 5cm across
T3 = >5cm across
T4 = Spread to neighbouring

Question 6

Staging: Node

Answer 6

N0 = None in nearby nodes
N1 = Present but nodes not
stuck to other tissues
N2a = Stuck to each other
N3 = Clavicular/++ Nodes

Question 7

Staging:Metastasis

Answer 7

M0 = No metastasis
M1 = Spread to other parts of
the body

Question 8

Risk Factors

Answer 8

Age
Family History
Alcohol Use
Genetic factors – BRAC1/2, ATM, TP53
Sex Hormones in Post-Menopausal
Higher BMI in Post-Menopausal
Testosterone only in Pre-Menopausal
Oral Contraceptives
Hormone Replacement Therapy
Older age at first giving birth

Question 9

Protective Factors

Answer 9

Breastfeeding
Physical Activity
Higher BMI in Pre-Menopausal
Parity (ER/PR positive tumours)
Oophorectomy at <35yrs
Aspirin

Question 10

Medical Management

Answer 10

• Endocrine Management – Used if receptor positive tumour; Anti-Oestrogen preparations
(Pre-menopausal) and Aromatase inhibitors (Post-Menopausal), Herceptin if Her-2 positive
• Chemotherapy – Anthracycline, Cyclophosphamide, 5-Fluorouracil, Methotrexate; Offered to
patients with high risk features
• Medical therapy is palliative in metastatic disease; May include above + Radiotherapy to
reduce pain of bony metastasis/symptoms from cerebral/liver disease

Question 11

Wide Local Excision

Answer 11

Most common procedure; Breast conserving assuming appropriate size
and location; combined with local radiotherapy to residual breast to reduce risk of recurrence
o Also used for DCIS; High grade DCIS = +Radiotherapy; Axillary surgery not needed

Question 12

Sentinel Node Biopsy

Answer 12

Nearest node identified by radioactive tracer or dye; Axillary Node
sampling – Minimum of four node retrieved; inadequate for treatment
• If nodes are positive; Radiotherapy or Clearance (Increases the risk of Lymphoedema) needed

Question 13

Simple Mastectomy

Answer 13

Best local treatment for large tumours or with central location/late
presentation; used for multifocal tumours
o Adjuvant Radiotherapy rarely necessary; Reconstruction with Latissimus Dorsi,
Transverse Rectus Abdominis flap, Prosthetic implants

Question 14

Breast Lump in the Male Patient

Answer 14

• Most commonly benign; Gynaecomastia (typically painful), Lipoma or Cyst
• Red Flags are like female breast cancer; Nipple inversion, Discharge, Skin Changes,
Lymphadenopathy, Systemic symptoms
• Lumps should undergo Ultrasound ± Core biopsy, with FNA of LN if swollen

Question 15

Aetiology of Mastalgia

Answer 15

ΔΔ Breast Abscess, Mastitis, Fibrocystic disease, MSK pain, Pleural and Visceral pain (Angina,
ACS), Skin pathology etc

Question 16

Management of Mastalgia

Answer 16

• Mammography should be avoided due to pain; Ultrasound if necessary
• Analgesia – NSAIDs or Opioids if necessary
• Aspiration of abscess under local anaesthetic; I&D avoided especially if lactation abscess

Question 17

Fibroadenoma

Answer 17

Benign overgrowth of breast lobule; common <30yrs
o Firm, Painless, Mobile, Discrete lump (=Breast Mice)
o Conclusive diagnosis at ultrasound; Excision if indicated

Question 18

Cysts

Answer 18

Common >35yrs especially Perimenopausal
o Round, symmetrical and might be painful; Not fixed to surrounding tissue
o Treatment with repeated aspiration or hormonal manipulation for multiple recurrent
o Mammography to exclude associated tumour

Question 19

Fibrocystic Disease

Answer 19

Localised fibrosis, Inflammation, Cyst formation and Hormone driven
breast pain that typically occurs Pre-menopausal
o Typically presents with cyclical pain and swelling, lumpiness, multiple cysts
o Important to perform Triple assessment to rule out Carcinoma even if Δ as Fibrocystic
o Managed with anti-inflammatories (e.g. Evening primrose oil), COCP, Cyst aspiration

Question 20

Lactational Mastitis

Answer 20

Acute Staphylococcus infection of mammary ducts which may
degenerate into acute lactation abscess
o Oral Antibiotics or aspiration if abscess occurs; No need to stop lactating

Question 21

Mammary Duct Ectasia

Answer 21

Dilated, scarred, chronically inflamed subareolar mammary ducts;
Associated with smoking; Typically, around menopause
o Recurrent yellow-green nipple discharge, Recurrent abscesses
o Typically, mixed, anaerobic infections; Metronidazole and drainage of acute abscess

Question 22

Abscess

Answer 22

Hot swelling of Breast Segment; Antibiotics, Open Incision/Percutaneous Drainage

Question 23

Blood Stained Nipple Discharge

Answer 23

• Most frequently benign (97%);
• Pathological discharge mostly caused by Intraductal Papilloma (48%), Duct Ectasia (20-15%);
less frequently due to Ca Breast; (10-15%)