Breast Surgery Flashcards
Breast Cancer Epidemiology
- 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
Presentation of Breast Cancer
• 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
Screening Programme
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
Investigation
• 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
Staging: Tumour
Tis = DCIS T1 = 2cm across or less T2 = 2 – 5cm across T3 = >5cm across T4 = Spread to neighbouring
Staging: Node
N0 = None in nearby nodes N1 = Present but nodes not stuck to other tissues N2a = Stuck to each other N3 = Clavicular/++ Nodes
Staging:Metastasis
M0 = No metastasis
M1 = Spread to other parts of
the body
Risk Factors
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
Protective Factors
Breastfeeding Physical Activity Higher BMI in Pre-Menopausal Parity (ER/PR positive tumours) Oophorectomy at <35yrs Aspirin
Medical Management
• 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
Wide Local Excision
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
Sentinel Node Biopsy
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
Simple Mastectomy
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
Breast Lump in the Male Patient
• 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
Aetiology of Mastalgia
ΔΔ Breast Abscess, Mastitis, Fibrocystic disease, MSK pain, Pleural and Visceral pain (Angina,
ACS), Skin pathology etc
Management of Mastalgia
- 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
Fibroadenoma
Benign overgrowth of breast lobule; common <30yrs
o Firm, Painless, Mobile, Discrete lump (=Breast Mice)
o Conclusive diagnosis at ultrasound; Excision if indicated
Cysts
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
Fibrocystic Disease
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
Lactational Mastitis
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
Mammary Duct Ectasia
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
Abscess
Hot swelling of Breast Segment; Antibiotics, Open Incision/Percutaneous Drainage
Blood Stained Nipple Discharge
• Most frequently benign (97%);
• Pathological discharge mostly caused by Intraductal Papilloma (48%), Duct Ectasia (20-15%);
less frequently due to Ca Breast; (10-15%)
