Breast Surgery Flashcards
risk factors breast cancer
FH BRCA1+2 Early menarche, late menopause • HRT, OCP (Million Women Study) • First child >35yrs • Obesity being old
breast feeding is protective
ductal carcinoma in situ, breast
DCIS/LCIS
• Non-invasive pre-malignant condition
• Microcalcification on mammography
• 10x ↑ risk of invasive Ca
invasive ductal carcinoma
Invasive Ductal Carcinoma
• Commonest: ~70% of cancers
• Feels hard (scirrhous)
other subtypes of breast ca aside from DCIS + invasive ductal
Other subtypes
• Invasive lobular: ~20% of cancers
- Medullary: affects younger pts, feels soft
- Colloid/mucinous: occur in elderly
- Inflammatory: pain, erythema, swelling, peau d’orange
- Papillary
Phyllodes Tumour =
• Stromal tumour
• Large, non-tender mobile lump
signs of breast cancer metastasis + key sites
Direct extension → muscle and/or skin • Lymph → p’eau d’orange + arm oedema • Blood → § Bones: bone pain, #, ↑Ca § Lungs: dyspnoea, pleural effusion § Liver: abdo pain, hepatic impairment § Brain: headache, seizures
breast cancer screening
- Every 3yrs from 47-73
- Craniocaudal and oblique views
- ↓ breast Ca deaths by 25%
- 10% false negative rate.
on examination presentation of breast cancer
Lump: commonest presentation of Ca breast § Usually painless § 50% in upper outer quadrant § ± axillary nodes • Skin changes § Paget’s: persistent eczema § Peau d’orange • Nipple § Discharge § Inversion • Mets § Pathological # § SOB § Abdominal pain § Seizures • May present through screening
ddx of breast cancer
- Cysts
- Fibroadenomas
- DCIS
- Duct ectasia
triple assessment of breast ca
Triple Assessment: any breast lump • Hx and Clinical Examination • Radiology § <35yrs: US § >35ys: US + mammography • Pathology § Solid lump: tru-cut core biopsy § Cystic lump: FNAC (green / 18G needle) - Reassure if clear fluid - Send cytology if bloody fluid - Core biopsy residual mass - Core biopsy if +ve cytology
other inv forbreast ca aside from triple assessment
Other Ix • Bloods § FBC, LFTs, ESR, bone profile • Imaging: help staging § CXR § Liver US § CT scan § Breast MRI: multifocal disease or ¯c implants § Bone scan and PET-CT • May need wire-guided excision biopsy
clinical staging breast cancer
Clinical Staging • 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
TNM Staging
• Tis (no palpable tumour): CIS
• T1: <2cm, no skin fixation
• T2: 2-5cm, skin fixation
• T3: 5-10cm, ulceration + pectoral fixation
• T4: >10cm, chest wall extension, skin involved
• N1: mobile nodes
• N2: fixed nodes
principles of managing breast ca
Manage in an MDT ¯c an individual approach § Oncologist § Breast surgeon § Breastcare nurse § Radiologist § Histopathologist • Try to enrol pts. in a trial • Factors: age, fitness, wishes, clinical stage § 1-2: surgical § 3-4: chemotherapy and palliation
breast ca surgery
Aim = gain local control • Two options § WLE + radiotherapy (80% treated like this) § Mastectomy - Typically large tumours >4cm - Multifocal or central tumours - Nipple involvement - Pt. choice - Not radical: no longer used • Same survival, but WLE has ↑ recurrence rates Sentinel Node Biopsy: gold standard
surgical complications shoulder surrg
• Haematoma, seroma • Frozen shoulder • Long-thoracic nerve palsy • Lymphoedema • Upper inner arm numbness § Intercostobrachial nerve injury
Nottingham prognostic index breast cancer
Predicts survival and risk of relapse
• Guides appropriate adjuvant systemic therapy
• (0.2 x tumour size) + histo grade + nodal status
§ Histo grade: Bloom-Richardson system (1-3)
radiotherapy in breast ca
Radiotherapy • Post-WLE: ↓ local recurrence • Post-mastectomy: only if high risk of local recurrence § Large, poorly differentiated, node +ve • Axillary: node +ve disease • Palliation: bone pain
chemotherapy breast ca
• Pre-menopausal, node +ve, high grade or recurrent
tumours.
• Neo-adjuvant chemo improves survival in large tumours
• 6 x FEC: 5-FU, Epirubicin, Cyclophosphamide
• Trastuzumab (anti-Her2) is used if Her2+ve
§ SE: cardiac toxicity
endocrine therapy breast ca
Endocrine Therapy
• Used in ER or PR +ve disease: ↓ recurrence, ↑ survival
• 5yrs of adjuvant therapy
• Tamoxifen
§ SERM: antagonist @ breast, agonist @ uterus
§ SE: menopausal symptoms, endometrial Ca
• Anastrazole / Letrozole
§ Aromatase inhibitor → ↓ oestrogen
§ Better cf. tamoxifen if post-men (ATAC trial)
§ SE: menopausal symptoms
• If pre-menopausal and ER+ve may consider ovarian
ablation or GnRH analogues (e.g. goserelin)
treating stage 3 or 4 breast ca
Treating Advanced Disease (Stage 3-4)
• Tamoxifen if ER+ve
• Chemo for relapse
• Her2 +ve tumours may respond to trastuzumab
upportive
• Bone pain: DXT, bisphosphonates, analgesia
• Brain: occasional surgery, DXT, steroids, AEDs
• Lymphoedema: decongestion, compression
breast reconstruction surgery
• Offered either at 1O surgery or as delayed procedure.
Implants: silastic or saline inflatable
Lat dorsi myocutaneous flap
• Pedicled flap: skin, fat, muscle and blood supply
• Supplied by thoracodorsal A. via subscapular A.
• Usually used ¯c an implant
Transverse rectus abdominis myocutaneous flap
• Gold-standard
• Pedicled (inf. epigastric A.)
• Or free: attached to internal thoracic A
• No implant necessary and combined tummy tuck
• CI if poor circulation: smoke
causes of gynaecomastia
Occurs in 30% of boys at puberty
• Hormone secreting tumours: e.g. sex-cord
testicular
• Chronic liver disease: hypogonadism + ↓E2
metabolism
• Drugs: spironolactone, digoxin, cimetidine
breast pain / mastalgia
Cyclical • ~35yrs • Pre-menstrual pain • Relieved by menstruation • Commonly in upper outer quadrants bilaterally
Non-cyclical
• ~45yrs
• Severe lancing breast pain
treating mastalgia
- Reassurance + good bra for most
- 1st line: Evening primrose oil (contains gamma-linoleic acid)
- OCP
- Topical NSAIDs (e.g. ibuprofen)
- Bromocriptine
- Danazol
- Tamoxifen
inflammatory breast disease
acute mastitis
fat necrosis
duct ectasia
periductal mastitis
acute mastitsi
Painful, red breast
May → Abscess (lump near nipple)
fluclox
+/- incision / drainage
fat necrosis of breast
Associated with previous trauma
Painless, palpable, non-mobile mass
May calcify simulating Ca
analgesia
duct ectasia, post menopausal
Slit-like nipple Often bilateral ± peri-areolar mass Thick white/green discharge May be calcified on mammography
inv to exclude ca with follow up
excise duct if probs
periductal mastitis
30s smoker
Painful, erythematous sub-areolar mass
Assoc. with inverted nipple ± purulent discharge
May → abscess or discharging fistula
broad spec abx
benign mammary dysplasia
Pre-menstrual breast nodularity and pain
Often in upper outer quadrant
- Tender “lumpy-bumpy” breasts
30-50 yrs old
reassure once triple assessed
cystic disease of breast
peri menopausal
Distinct, fluctuant round mass
Often painful
green brown fluid
if any blood do TA
duct papilloma
Common cause of bloody discharge
Not usually palpable
40s-50s
triple assess and excise as risky
fibroadenoma
<35 yrs Commonest benign tumour Painless, mobile, rubbery mass Often multiple and bilateral Popcorn calcification
remove if large or bothersome
PHyloides tumour
50+ years Large, fast growing mass Mobile, non-tender Epithelial and connective tissue element
wide local excision
check pics
ductal carcinoma in situ
Presents as Microcalcification on mammogram
Rarely assoc. with symptoms:
- lump
- discharge
- eczematous change = Paget’s disease
→ Ca @ 1%/yr (10x ↑ risk) in ipsilateral breast
Paget’s disease of breast
s Unilat, scaly, erythematous, itchy
+/- palpable mass (invasive carcinoma)
treat as malignant
lobular carcinoma in situ breast
Incidental biopsy finding (no calcification)
Often bilat (20-40%)
Young women
↑ risk Ca risk (x10) in both breasts
will likely need prophylactic double mastectomy
