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Surgery > Breast surgery > Flashcards

Breast surgery Flashcards

1
Q

Fibroadenoma

A

Most common benign breast growth. Women of reproductive age. Proliferations of stromal and epithelial tissue of the duct lobules
Highly mobile, well-defined, rubbery, usually <5cm. There may be multiple, may be bilateral.
Very low malignant potential. Can be left in situ with routine follow-ups. Indications for excision are >3cm or patient preference

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2
Q

Ductal adenomal

A

Benign glandular tumour. Older females. Nodular, can easily mimic malignancy so will usually undergo escalation for triple assessment

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3
Q

Benign breast diseases

A

Fibroadenoma, ductal adenoma, papilloma, lipoma, phyllodes tumour

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4
Q

Papilloma

A

Benign breast lesion usually in subareolar region, females 40-50, bloody/clear nipple discharge. May look similar to ductal carcinomas on imaging so usually needs biopsy. Some may be excised. Risk of cancer is only increased with multi-ductal papilloma and most are treated with microdochectomy

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5
Q

Lipoma

A

Soft and mobile benign adipose tumour
Otherwise asymptomatic
Low malignant potentiol
Only removed if they are enlarging significantly, or causing compression or aesthetic issues

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6
Q

Phyllodes tumour

A

Rare fibroepithelial tumour. Usually larger than other benign disease. occurs in older women. Comprised of both epithelial and stromal tissue. grow rapidly. Difficult to clinically and microscopically differentiate from fibroadenomas. One third have malignant potential. Most phyllode tumours are widely excised

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7
Q

Gynaecomastia

A 
Breast tissue development in males due to imbalance of oestrogen and androgen activity
Usually benign (cancer in 1%)
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8
Q

Causes of gynaecomastia

A

Physiological - adolescence due to delayed testosterone surge, or in elderly due to decreasing testosterone levels

Lack of tesosterone (Klinefelters, andorgen insensitivity, testicular atrophy, renal disease)

Increased oestrogen levels (liver disease, hyperthyroidism, obesity, adrenal tumours, some testicular tumours (Leydig)

Medications (digoxin, metronidazole, spironolactone, chemo, goserelin, antipsychs, anabolic steroids)

Idiopathic

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9
Q

Clinical features of gynaecomastia

A

Insidious onset
rubbery or firm mass (>2cm diam) that starts underneath the nipple and spreads outwards
Check for signs and symptoms of malignancy
Ask about associated symptoms and comorbidities
Check drug history

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10
Q

Investigations for gynaecomastia

A 
Only necessary if cause is unknown.
Triple assessment
LFTs, U+Es, hormone profile
LH high, test low = testicular failure
LH low, test low = increased oestrogen
LH high, test high = androgen resistance or gonadotrophin secreting malignancy
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11
Q

Management of gynaecomastia

A

Treat underlying cause
Reassurance
Tamoxifen may alleviate symptoms
Surgery may be necessary in later stages

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12
Q

Mastitis

A

Usually infective due to Staph aureus.
Clinical features - tenderness, swelling, induration, erythema
Management - antibiotics (flucloxacillin 10-14 days), simple analgesia
If lactational, continue milk drainage/feeding. If mastitis is persistent or theres multiple areas of infection, consider dopamine agonist (cabergoline) to cease breastfeeding to relieve symptoms

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13
Q

Lactational vs non-lactational mastitis

A

Lactional mastitis is more common - presents in first 3 months of breastfeeding. Cracked nipples and milk stasis, more common in first child.
Non-lactational may occur in women with other conditions such as duct ectasia, as a peri-ductal mastitis.More common in smokers

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14
Q

Breast abscess

A

Collection of pus within breast lined with granulation tissue
Complication of acute mastitis
Tender fluctuant and erythematous mass, with a punctum. fever and lethargy.
Confirmed via USS.
Empirical abx and US-guided aspiration. Advanced abscesses may require incision and drainage

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15
Q

Breast cysts

  • what is it
  • what population
  • clinical features
  • investigation findings
  • management
  • complications
A

Epithelial lined fluid-filled cavities which form when lobules become distended due to blockage.
Usually in perimenopause.
There may be one or multiple on one or both breasts
Palpation = distinct smooth masses, may be tender
Ix = halo shape on mammography, definitive diagnosis with USS. If ?malignancy, mass should be aspirated, and cancer can be excluded if fluid is free of blood or if lump disappears, otherwise send cystic fluid for cytology.
Mx - if cyst is diagnosed then no further management needed. Large cysts may be aspirated for aesthetic reasons.
Complications: 2-3x increased risk of developing breast cancer, some women develop fibroadenosis (fibrocystic change)

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16
Q

Mammary duct ectasia

A

Dilation and shortening of major lactiferous ducts
Common in perimenopause.
Green/yellow nipple discharge, palpable mass, nipple retraction
Ix = mammography (dilated calcified ducts). If biopsied, mass typically contains multiple plasma cells on histology
Mx = conservative unless malignancy cannot be excluded (-> excision)

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17
Q

Fat necrosis

A

Acute inflamm response in the breast, leading to ischaemic necrosis of fat lobules
Usually asymptomatic, may present as a lump
Ix= positive traumatic Hx and/or hyperechoic mass on USS
mx= analgesia and reassurance

18
Q

Ductal carcinoma in situ

  • what is it
  • how common
  • how many develop into invasive
  • subtypes
  • diagnosis
  • management
A

Most common type of non-invasive breast malignancy.
Malignancy of the ductal tissue, contained within the basement membrane.
20-30% develop into invasive malignancy.
Subtypes exist (comedo, cribiform, micropapillary, solic).
Detected during screening (localised/ widespread microcalcifications on mammography) which is then confirmed on biopsy
Mx= complete wide excision, or mastectomy.

19
Q

Lobular carcinoma in situ

  • what is it
  • how common
  • risk of becoming invasive
  • what population
  • diagnosis
  • management
A

Malignancy of the secretory lobules, contained within the basement membrane
Rarer than DCIS, but greater risk of developing into invasive malignancy.
Usually diagnosed before menopause.
Usually diagnosed as incidental finding during biopsy of the breast.
Mx - low grade can be monitored.
Prophylactic bilateral mastectomy may be offered if someone has BRCA1/BRCA2

20
Q

Invasive ductal carcinoma

  • how common
  • subtypes
A

Most common type of breast carcinoma

Further classified into tubular, cribiform, papillary, mucinous, or medullary.

21
Q

Invasive lobular carcinoma

  • how common
  • what population
  • how it look on imaging
  • diagnosis
A

Second most common type of breast cancer
More common in older women
Diffuse stromal pattern of spread, making detection more difficult.
By the time of diagnosis, tumours are often quite large

22
Q

Risk factors of invasive breast cancer

A

Female sex
Age (risk doubles every ten years until menopause)
Gene mutations (BRCA1, BRCA2 tumour suppressor genes)
FHx in a first degree relative
Previous benign disease
Obesity
Alcohol
Geographic variation
Exposure to unopposed oestrogen (early menarche, late menopause, nulliparous, first pregnancy after 30, OCP, HRT)

23
Q

Clinical features of breast cancer

A

Symptomatic or asymptomatic (detected via screening)
Breast lump, asymmetry, swelling, abnormal nipple discharge, nipple retraction, skin changes, mastalgia, palpable lump in axilla

24
Q

Investigations for breast cancer

A

Triple assessment - examination, imaging (mammogram/ USS), biopsy (histology or cytology)

25
Q

Prognosis

A

Most important prognostic factor is nodal status (number of axillary lymph nodes involved). Size, grade, and receptor status also influences prognosis.
Nottingham prognostic index.

(sizex0.2) + nodal status + grade

26
Q

Breast screening

A

Mammogram every 3 years between 50-70 years (47-73 being trialled)

27
Q

Paget’s disease of the nipple

  • how common
  • what is it
  • risk of malignancy
  • clinical features
  • DDx
  • Ix
  • Mx
A

Rare.
Roughening, reddening and slight ulceration of the nipple. Majority will have underlying neoplasm. Microscopically there is involvement of the epidermis by malignant ductal carcinoma cells.
Clinical presentation - itching or redness in the nipple/areola, flaking and thickening of the skin, painful and sensitive, flattened nipple, +/- yellow/bloody discharge.
DDx - dermatitis/eczema
Ix = biopsy of nipple (may remove entire nipple), triple assessment.
Mx - surgical removal of nipple and areola +/- radiotherapy

28
Q

Paget’s vs. eczema

A

Paget’s always affects the nipple and only affects the areola as a secondary event.
Eczema always only involves areola and spares the nipple.

29
Q

Surgical treatment for breast cancer

A

Breast conserving - suitable for localised disease and no evidence of metastasis. WLE is most common. 1cm margin of normal tissue needed.

Mastectomy - indicated in cases of multifocal disease, high tumour:breast ratio, disease recurrence, or patient choice

Axillary surgery (discussed in a different flash card)

30
Q

Axillary surgery

A

Commonly performed alongside WLE and mastectomies, in order to assess nodal status and remove nodal disease.

Sentinel node biopsy involves removing the first lymph node into which the tumour drains. The nodes are identified by injecting blue dye and radioisotope. Sentinel node is removed and sent for histology.

Axillary node clearance involves removing all nodes in the axilla and sending them for histology. May cause paraesthesia, seroma, and lymphoedema

31
Q

Indications for hormone treatments in breast cancer

A

Used as an adjuvant post-op in malignant non-metastatic disease to reduce risk of relapse.
May be used as the treatment in choice in elderly patients or those unfit for surgery.

32
Q

Types of hormone treatment

A

Tamoxifen - pre-menopausal. Selective oestrogen receptor modulatory (blocks oestrogen receptors). Increased risk of VTE, increased risk of uterine carcinoma (due to pro-oestrogen effect on uterus as it is a selective modulator)

Aromatse inhibitors (anastrazole) - post-menopausal. Bind to oestrogen receptors and inhibit further production, and blocks conversion of androgen to oestrogen in peripheral tissues.

Immunotherapy - herceptin (trastuzumab) is a monoclonal ab that targets HER-2 positive malignancies

33
Q

Oncoplastic management of breast cancer

A

Therapeutic mammoplasty - WLE with breast reduction technique. End result is a smaller uplifted breast with the nipple and areola preserved.

Latissimus dorsi flap formation - reconstruction of the removed breast (only suitable for small breasts due to limited muscle)

Transverse rectus abdominal muscle flap - uses the abdominal fat and muscle (reduces abdo fat but also reduces abdo strength).

Deep inferior epigastric perforator flap - uses tissue from abdo and its overlying skin to reconstruct breast. No muscle is used so abdo strength is usually maintained.

34
Q

Galactorrhoea is usually caused by hyperprolactinaemia. Causes of hyperprolactinaemia?

A 
Idiopathic
Pituitary adenoma
Drug-induced (SSRI, anti-psych, H2 antagonist)
Neurological
Hypothyroidism
Renal failure
Liver failure
Damage to pituitary stalk
35
Q

Prolactin secretion control

A

Dopamine is released by the hypothalamus to inhibit prolactin secretion.
Dopamine inhibitors therefore cause hyperprolactinaemia.

TRH and oestrogen acts to stimulate release of prolactin from pituitary

36
Q

Investigations for galactorrhoea

A

Exclude pregnancy
Serum prolactin levels
TFTs, LFTs, U+Es
Further endocrine tests may be indicated
MRI head with contrast if ?pituitary tumour
Breast imaging if palpable lumps/nodes are present

37
Q

Management of galactorrhoea

A

treat underlying cause
Pituitary tumour - dopamine agonist therapy (cabergoline, bromocriptine) and referral to neurosurgery for potential trans-sphenoidal surgery
Idiopathic normoprolactinaemic galactorrhoea usually resolves spontaneously
Bilateral total duct excision may be needed in severe cases

38
Q

Classification of mastalgia

A

Cyclical - pain associated with menstrual cycle, typically both breasts, beginning a few days before menses and subsides at the end

Non-cyclical - unrelated to menstrual cycle. May be caused by medication (eg. HRT, OCP), antidepressants, anti-psychs, or may be extramammary pain (eg, chest wall, shoulder)

39
Q

Investigations for mastalgia

A

Breast pain in isolation with no relevant history or examination is not an indication for imaging. All patients should have a pregnancy test.

40
Q

Management of mastalgia

A

first line is usually reassurance, wear a better fitting bra or soft-support bra during the night, oral ibuprofen or paracetamol or topical NSAIDs. (non-cyclical often doesnt respond to analgesia).
Idiopathic non-cyclical will often resolve spontaneously.
If first line is unsuccessful, refer to specialist (danazol which is an anti-gonadotrophin agent)

41
Q

The triple assessment

A

2-week-wait referral to a one-stop clinic

  1. history and examination
  2. Imaging- mammography, or USS if <35 due to density of breast tissue
  3. biopsy - core biopsy provides full histology. Fine needle aspiration may be needed in cysts to look at cytology

Surgery (9 decks)

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