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Imperial Medicine Year 3 > Breast Surgery > Flashcards

Breast Surgery Flashcards

1
Q

Breast cancer epidemiology?

A

Affects 1/10 women
20,000 cases/yr in UK
Commonest cause of cancer death in females 15-54.

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2
Q

What is the aetiology/risk factors of breast cancer?

A 
Family Hx
Oestrogen Exposure 
Proliferative breast disease with atypia
Previous Ca breast 
First child >35 yrs 
Obesity
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3
Q

What in the family history is relevant for Breast Cancer?

A

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.

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4
Q

What can increase oestrogen exposure and contribute to breast cancer?

A

Early menarche, late menopause
HRT, OCP
First child >35
Obesity

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5
Q

What is the pathology of Breast Cancer types?

A 
DCIS/LCIS
Invasive Ductal Carcinoma
Phyllodes Tumour
Invasive lobular
Medullary 
Colloid/mucinous
Inflammatory 
Papillary
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6
Q

What is DCIS/LCIS

A

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.
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7
Q

What is the most common breast cancer?

A

Invasive Ductal Carcinoma

Can also have invasive lobular carcinoma

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8
Q

What is a phyllodes tumour?

A

Stromal tumour

Large, non-tender mobile lump

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9
Q

Other types of breast tumours?

A

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

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10
Q

What is the spread of breast cancer?

A

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
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11
Q

What is the screening for breast cancer?

A

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.
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12
Q

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?

A 
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
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13
Q

Presentation of breast cancer?

A

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

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14
Q

What is the triple assessment?

A 
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.

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15
Q

NICE referral for breast lump guidelines?

A

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
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16
Q

Other investigations for breast cancer?

A

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

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17
Q

What is the 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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18
Q

What is the TNM staging

A 
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

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19
Q

What are the principles of management of breast cancer?

A

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.

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20
Q

Management of breast cancer? Surgery

A

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.

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21
Q

What is a sentinel node biopsy?

A

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.

22
Q

What are the surgical complications of breast surgery?

A 
Haematoma
Seroma
Frozen shoulder 
Long-thoracic nerve palsy 
Lymphoedema
23
Q

what is the Nottingham prognostic index?

A
  • 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.

24
Q

What is radiotherapy used for in breast cancer?

A

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.

25
Q

What is chemotherapy used for in breast cancer?

A

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.

26
Q

What is endocrine therapy used for?

A
  • 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.

27
Q

Treating Advanced Disease in breast cancer?

A
  • 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.
28
Q

What is reconstruction and how is it done?

A

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
29
Q

What are the congenital breast disease?

A

Amastia: complete absence of breast and nipple

Hypoplasia more common: some asymmetry normal

Accessory nipple

  • Can occur anywhere along milk line
  • Presents in 1%.
30
Q

What can cause gynaecomastia?

A

Hormone secretiing tumours: Sex-cord testicular cancer

  • Chronic liver disease: hypogonadism + decreased E2 metabolism.
  • Drugs: spironolactone, digoxin, cimetidine.
31
Q

What is mastalgia?

A

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
32
Q

What is the management of mastalgia?

A 
Reassurance + good bra for most
1st line: EPO 
OCP 
Topical NSAIDS 
Bromocriptine 
Danazol
Tamoxifen
33
Q

What are the inflammatory breast diseases?

A

Acute Mastitis
Fat Necrosis
Duct Ectasia
Periductal Mastitis

34
Q

What is acute mastitis?

A

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.

35
Q

What is fat necrosis?

A

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

36
Q

What is duct ectasia?

A

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.

37
Q

What is periductal mastitis?

A

Smokers, 30yrs.

Painful, erythematous sub-areolar mass. Associated with inverted nipple ± purulent discharge.

May –> Abscess or discharging fistula.

Manage with broad-spectrum antibiotics.

38
Q

What are the benign epithelial lesions of the breast?

A

Benign mammary dysplasia
Cystic disease - produce a radiolucent halo sign. If symptomatic they should be aspirated.
Duct papilloma

39
Q

What is a benign mammary dysplasia?

A

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.

40
Q

What is cystic breast disease?

A

Peri-menopausal >40.

Distinct, fluctuant round mass, often painful.

Aspiration: green-brown fluid.

Persistence or blood –> triple assessment.

41
Q

What is a duct papilloma?

A

40-50yrs

Common cause of bloody discharge. Not usually palpable.

Triple assessment + excise to reduce risk of Ca.

42
Q

What are the stromal tumours?

A

Fibroadenoma

Phyllodes Tumour

43
Q

What is a fibroadenoma?

A

<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.

44
Q

What is a phyllodes tumour?

A

50s +
Large, fast growing mass. Mobile, non-tender. Epithelial and connective tissue elements.

Offer WLE.

45
Q

What is DCIS?

A
  • 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.

46
Q

Paget’s disease of the nipple

A

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.

47
Q

LCIS condition?

A

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.

48
Q

Mondor’s disease of the breast?

A

Localised thrombophlebitis of the breast vein.

49
Q

Sclerosing adenosis (radial scars and complex sclerosing lesions)

A

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.

50
Q

Causes of nipple discharge?

A
  • 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.
51
Q

Implant rupture?

A

Snowstorm sign on US of axillary lymph nodes indicates extracapsular breast implant rupture.

Silicone that leaks into the lymphatic system.

Imperial Medicine Year 3 (35 decks)

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