Breast Surgery Flashcards
Breast cancer epidemiology?
Affects 1/10 women
20,000 cases/yr in UK
Commonest cause of cancer death in females 15-54.
What is the aetiology/risk factors of breast cancer?
Family Hx Oestrogen Exposure Proliferative breast disease with atypia Previous Ca breast First child >35 yrs Obesity
What in the family history is relevant for Breast Cancer?
10% Ca breast is familial
- One 1st degree relative = 2x risk
Inherited in an AD dominant fashion. One parent hsa a 50% chance of passing it to child.
5% assoc with BRCA 1(17q) –> 80% breast Ca, 40% + ov Ca.
BRCA2 –> 80% breast ca.
What can increase oestrogen exposure and contribute to breast cancer?
Early menarche, late menopause
HRT, OCP
First child >35
Obesity
What is the pathology of Breast Cancer types?
DCIS/LCIS Invasive Ductal Carcinoma Phyllodes Tumour Invasive lobular Medullary Colloid/mucinous Inflammatory Papillary
What is DCIS/LCIS
Ductal or Lobular carcinoma in situ.
- Non-invasive pre-malignant condition
- Microcalcification on mammography
- 10x increased risk of invasive carcinoma.
- Comedo necrosis if a feature of high nuclear grade ductal carcinoma.
What is the most common breast cancer?
Invasive Ductal Carcinoma
Can also have invasive lobular carcinoma
What is a phyllodes tumour?
Stromal tumour
Large, non-tender mobile lump
Other types of breast tumours?
Invasive lobular
Medullary
Colloid/mucinous - 2/3% of breast cancer. Have a grey, gelatinous surface.
Inflammatory = Progressive, erythema and oedema of the breast in absence signs of infection such as fever, discharge or elevated WCC. Elevated Ca 15-3
Papillary
What is the spread of breast cancer?
Direct extension –> Muscle and/or skin
Lymph –> p’eau d’orange + arm oedema
Blood
- Bones: Bone pain, #, increased Ca
- Lungs: dyspnoea, pleural effusion
- Liver: abdo pain, hepatic impairment
- Brain: headache, seizures
What is the screening for breast cancer?
NHS breast screening programme - expanded to include women aged 47-73.
Offer a mammogram every 3 years.
- Conduct craniocaudal and oblique views
- Decreased breast ca deaths by 25%
- 10% false negative rates.
If a person only has one first degree or second-degree relative with breast cancer they do not need to be referred except if what is present?
Age of diagnosis <40 Bilateral breast cancer Male breast cancer Ovarian cancer Jewish Sarcoma in younger than 45 Glioma or children adrenal cortical carcinomas Paternal history of breast cancer
Presentation of breast cancer?
Lump: commonest presentation of Ca breast
- Usually painless
- 50% in upper outer quadrant
- ± axillary nodes
Skin changes
- Paget: persistent eczema
- Peau d’orange
Nipple
- Discharge
- Inversion
Mets
- Pathological fracture
- SOB
- Abdominal pain
- Seizures
May present through screening
What is the triple assessment?
Any breast lump - Hx and clinical examination - Radiology <35yrs: US >35yrs: US + mammography
Pathology - Solid lump: tru-cut core biopsy - Cystic lump: FNAC (green/18G needle) Offer reassurance if clear fluid Send cytology if bloody fluid
Core biopsy residual mass
Core biopsy if +ve cytology.
NICE referral for breast lump guidelines?
Refer for 2WW for :
- age 30 and over with unexplained breast lump with or without pain or
- age 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern
Other investigations for breast cancer?
Bloods: FBC, LFts, ESR, Bone profile.
Imaging: CXR, Liver US, CT scan, Breast MRI, Bone scan and PET-CT.
May need wire-guided excision biopsy
What is the 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.
What is the TNM staging
Tis = CIS T1 = <2cm no skin fixation T2 = 2-5cm, skin fixation T3 = 5-10cm, ulceration + pectoral fixation T4 = >10cm, chest wall extension, skin involved
T4a = invades chest wall T4b = Invades skin T4c = invades chest wall and skin T4d = inflammatory
N1: mobile nodes
N2: fixed nodes
What are the principles of management of breast cancer?
Manage in MDT with an individual approach.
Oncologist Breast surgeon Breastcare nurse Radiologist Histopathologist
Try to enrol patient in a trial
Factors: age, fitness, wishes, clinical stage
1-2: surgical
3-4: chemo and palliation.
Management of breast cancer? Surgery
Vast majority will have surgery.
Prior to surgery - presence or absence of axillary lymphadenopathy determines management.
No axillary lymphadenopathy = US axillary. If positive then have sentinel node biopsy.
Those with lymphadenopathy - axillary node clearance is indicated. May lead to arm lymphedema + functional arm impairment.
Aim = gain local control
Two options
- WLE + radiotherapy (80% treated like this)
- Mastectomy
Mastectomy is for:
- Typically large tumours >4cm
- Multifocal or central tumours
- Nipple involvement
- DCIS >4cm
- Pt choice
Same survival, WLE has increased recurrence rates.
Reconstruction always an option. Uses latissimus dorsi myocutaneous flap and subpectoral implants. Can use a TRAM or DIEP flaps.
What is a sentinel node biopsy?
SN = first node that a section of breast drains to
If clinically -ve axillary LNs, no need for further dissection. if SN is clear.
Give blue dye into tumour.
Visual inspection @ surgery to ID SN
SN removed and sent for frozen section
If node +ve –> Axillary clearance or radiotherapy.
What are the surgical complications of breast surgery?
Haematoma Seroma Frozen shoulder Long-thoracic nerve palsy Lymphoedema
what is the Nottingham prognostic index?
- Predicts survival and risk of relapse
- Guides appropriate adjuvant systemic therapy
+ hist grade + nodal status
(0.2 x tumour size) + histo grade + nodal status.
(1-3). (more than 3 = 3 points).
> 5.4 = 50% 5 yr survival. 2-2.4 = 93% 5 yr survival.
What is radiotherapy used for in breast cancer?
Routine for Post-Wide Local Excision: decreased local recurrence
Whole breast radiotherapy that treats the ipsilateral side.
Post mastectomy: only if high risk of local recurrence (T3-T4) . Large poorly differentiated node +ve. Need more positive lymphnodes.
Axillary: node +ve disease
Palliation: bone pain.
What is chemotherapy used for in breast cancer?
Pre-menopausal,
node +ve,
high grade or
recurrent tumours.
Ie Mastectomy with axillary clearance and ID ca = Chemo.
Neo-adjuvant chemo improves survival in large tumours. This shrinks tumour before surgery to allow breast soncering surgery rather than mastectomy.
6 x FEC, 5-FU, Epirubicin, Cyclophosphamide.
FEC-D for Node +ve
FEC for node -ve
Trastuzumab (anti-Her2) is used if Her2+ve (cardiac toxicity SE). Herceptin.
What is endocrine therapy used for?
- Used in ER or PR +ve disease. Decreased recurrence, increased survival.
- 5yr of adjuvant therapy.
Tamoxifen
- SERM: antagonist @ breast, agonist @ uterus. SE= menopausal symptoms , endometrial cancer, VTE.
Anastrazole - POST MENOPAUSAL WOMEN
- Aromatase inhibitor –> decreased oestrogen
- Better than tamoxifen if post-menopausal. SE: menopausal symptoms.
If pre-menopausal and ER+ve may consider ovarian ablation or GnRH analgoues.
Treating Advanced Disease in breast cancer?
- Tamoxifen if ER+ve
- Chemo for relapse
- Her2+ve tumours may respond to trastuzumab. - Herceptin
Cannot be used in patients with a history of heart disorders.
Supportive
- Bone pain: DXT, bisphosphonate, analgesiea
- Brain: occasional surgery, DXT, steroids, AEDs,
- Lymphoedema: decongestion, compression.
What is reconstruction and how is it done?
Offered either at primary surgery or as a delayed procedure.
Implants: silastic or saline inflatable
Lat dorsi myocutaneous flap
- Pedicled flap: Skin, fat, muscle and blood supple.
- Supplied by thoracodorsa A via subscapular A
- Usually used with an implant.
Transverse rectus abdominal flap
- gold standard
- Pedicled
- Or free: attached to internal thoracic A
- No implant necessary
- CI if poor circulation: smokers, obese,
- Risk of abdo hernia
What are the congenital breast disease?
Amastia: complete absence of breast and nipple
Hypoplasia more common: some asymmetry normal
Accessory nipple
- Can occur anywhere along milk line
- Presents in 1%.
What can cause gynaecomastia?
Hormone secretiing tumours: Sex-cord testicular cancer
- Chronic liver disease: hypogonadism + decreased E2 metabolism.
- Drugs: spironolactone, digoxin, cimetidine.
What is mastalgia?
Cyclical Mastalgia
- 35yrs
- Pre-menstrual pain
- relieved by menstruation
- Commonly in upper outer quadrants bilaterally.
Non-cyclical
- 45yrs around
- Severe lancing breast pain (often left)
- May be associated with back pain
What is the management of mastalgia?
Reassurance + good bra for most 1st line: EPO OCP Topical NSAIDS Bromocriptine Danazol Tamoxifen
What are the inflammatory breast diseases?
Acute Mastitis
Fat Necrosis
Duct Ectasia
Periductal Mastitis
What is acute mastitis?
Usually lactating
- Painful red breast. Mat be an abscess (lump near nipple).
- Tell mothers to continue to breastfeed.
Give fluclox alone in early stages if there are systemic features, despite effective milk removal.
Fluclox for 10 days.
What is fat necrosis?
Pbese women with large breast.
Associated with previous trauma.
Painless, palpable, non-mobile mass. Then develop into a irregular breast lump.
May calcify simulated Ca.
Manage with analgesia
What is duct ectasia?
Duct Dilatation - Post-menopausal symptoms. 50-60yrs. Common in smokers.
Slit-like nipple, often bilateral ± peri-areolar mass.
Thick white OR green discharge.
May be calcified on mammography.
Need to distinguish from Ca
Surgical duct excision if mass present or discharge troublesome. Close f/up.
What is periductal mastitis?
Smokers, 30yrs.
Painful, erythematous sub-areolar mass. Associated with inverted nipple ± purulent discharge.
May –> Abscess or discharging fistula.
Manage with broad-spectrum antibiotics.
What are the benign epithelial lesions of the breast?
Benign mammary dysplasia
Cystic disease - produce a radiolucent halo sign. If symptomatic they should be aspirated.
Duct papilloma
What is a benign mammary dysplasia?
30-50yrs
Pre-menstrual breast nodularity and pain. Often in upper outer quadrant - tender ‘lumpy-bumpy’ breast.
Aberrations of normal development
- Fibroadenosis, cyst formation epitheliosis, papillomatosis.
Manage with triple assessment. Reassurance, analgesia, good bra ± evening primrose oil.
Danazol may occasionally be used.
What is cystic breast disease?
Peri-menopausal >40.
Distinct, fluctuant round mass, often painful.
Aspiration: green-brown fluid.
Persistence or blood –> triple assessment.
What is a duct papilloma?
40-50yrs
Common cause of bloody discharge. Not usually palpable.
Triple assessment + excise to reduce risk of Ca.
What are the stromal tumours?
Fibroadenoma
Phyllodes Tumour
What is a fibroadenoma?
<35yrs
Rare post-menopause
Increased in blacks.
Commonest benign tumour
Painless, mobile, rubbery mass
Often multiple and bilateral.
Popcorn calcification.
Offer reassurance + f/up if <2.5cm.
Shell-out surgically if
- >2.5cm, FH of breast ca or Patient choice.
What is a phyllodes tumour?
50s +
Large, fast growing mass. Mobile, non-tender. Epithelial and connective tissue elements.
Offer WLE.
What is DCIS?
- Presents with microcalcifications on mammogram.
- Rarely associated with symptoms.
- Lump, discharge, eczematous change = Paget’s disease.
–> Ca @ 1%/yr (10x increased risk) in ipsilateral breast.
Manage with WLE + radiotherapy.
Extensive or multifocal ==> Mastectomy + reconstruction + SNB.
Paget’s disease of the nipple
Unilateral, scaly, erythematous, itchy
+/- palpable mass (invasive carcinoma).
Can be a weeping, crusty lesion.
Usually underlying invasive or DCIS breast cancer. Mostly invasive.
Mastectomy + radio ± chemo/endo.
LCIS condition?
Incidental biopsy findings (no calcifications)
- Often bileral (20-40%)
Young women
increased risk Ca (10x in both breast)
Bilateral prophylactic mastectomy or close watching with mammographic screening.
Mondor’s disease of the breast?
Localised thrombophlebitis of the breast vein.
Sclerosing adenosis (radial scars and complex sclerosing lesions)
Present as breast lump or breast pain
Causes mammographic changes which may mimic carcinoma.
Cause distortion of distal lobular unit without hyperplasia.
Lesions should be biopsied, excision is not mandatory.
Causes of nipple discharge?
- Physiological
- Galactorrhoea
- Hyperprolactinaemia
- Mammary duct ectasia - menopausal women, discharge typically thick and green. Most common in smokers.
- Carcinoma - blood stained, may be underlying mass or axillary lymphadenopathy.
- Intraductal papilloma - Commoner in younger patients. May cause blood stained discharge. No palpable lump.
Implant rupture?
Snowstorm sign on US of axillary lymph nodes indicates extracapsular breast implant rupture.
Silicone that leaks into the lymphatic system.
