Gen surgery Learning objectives: Flashcards

Question 1

Q

Questions from Lisa: Colorectal:

CRC RACGP guidelines: Screening: Who and when and what?

Answer

A

FOBT- every two years for patients of low risk- from ages 50-74 years

Question 2

Q

Risk stratification: CRC: Risk stratification based on family history:

What are important changes to managing and recommendations to CRC screening:

Answer

A

Actively consider commencing patients on low dose aspirin (level 1 evidence can reduce incidence and mortality in CRC

Question 3

Q

Screening flowchart based on Family history: read

What should be done for Low risk patients? Moderate risk patients? High risk patients?

Question 4

Q

Colorectal cancer identifying risk:

Who is at risk?

What should be done? How often?

(Low and medium risk)

Question 5

Q

CRC screening:

Who is at risk? What should be done? How often?

Question 6

Q

What is Familial adenomatous polyposis?

Define? What genes are associated with this condition

Question 7

Q

What is Peutz Jeghers syndrome?

What are the mutations that cause this?

What this conditions significance to CRC?

Question 8

Q

What are general principles in preventing complications udring the post-operative period? List 5

When is a post-operative fever most likely to occur?

Outline sequence of events for post-op complications:

Wind, Water, wound, walk, wonder drugs

Management of any of these causes of fever?

Answer

A

Frequent examinations of the patient, and their wound
Removal of surgical tubes as soon as possible (e.g urinary catheter) + surgiucal drains
Early mobilization
Monitoring fluid and electrolyte status
Analgesia, enough to adequate- enough to mobilize early -without too much pain

Post-op fever:

fever does not necessarily mean imply infection particularly in first 48 hours
Feveer may not be present of blunted if receiving chemo, glucocorticoids + other immunosuppressive drugs
Timing of fever may help identify cause:

Hours after surgery- POD# - Inflammatory reaction in response to physiological stress

Unlikely to be infectious unless necrotizing fascitis or other severe infection
reaction to blood products given in surgery
malignant hyperthermia

POD #1-2 days post op: (Wind) atelectasis- Most common cause day 1

atelectasis
early wound infection (especially clostridium, group A strep) - Feel for crepitus + look for dishwater drainagae
aspiration pneumonitis
Others: Acute adrenal insufficiency, thyroid storm, transfusion reactions

POD # Days 3-7: Likly infectious:

UTI
SSI
IV site infection (commonly staph aureus)
Septic thrombophelbitis
Leakage at bowel anastomosis (Presents with- tachycardia, hypotension, oligouria and abdominal pain)

POD # Days 8 plus:

INtra-abdominal abcesses
DVT/PE - (can occur anytime post op but most common in days 8-10)
Drug fever
Others: URTI, infected seroma/biloma/haemotoma/ C.difficle + endocarditis

Treatment: Resusitation then treat primary cause

Question 9

Q

Outline important aspects of wound care management:

Outline important aspects of management of surgical drains:

Answer

A

Wound Care post-op

- Can shower days 2-3 after epithelization
most dressing can be removed and left dry if dry
Steri strips/glue should be leaved for 2 weeks
examine wound if wet dressings, signs of infections (tachycardia, fever and pain)
Skin sutures and staples can be removed POD - 7-14 (exceptions- incisions across skin creases, closed under tension, or pt factors (elderly, immunosuppression, corticosteroid use)
negative pressure dressings consist of foam, and suction and promote granulation tissue (ideal for large grafted areas, or large non healing ulcers)

Drain management:

Placed at time of surgery to prevent acculumation and build up of fluid (blood, pus, serum, bile and urine)
Can be used to assess third spacing fluid accumulation post operatively
Should be inserted through its own wound, not surgical wound- to decrease risk of infection
Monitor output daily
drains should be removed once drainage is minimal (30ml < day/24hours)
Drains do not guarantee that the patient will not form a colleciton
Ridged drains can erode through structures and cause necrosis

Question 10

Q

What is A SSI?

What are common eitologies?

How are they classified? What are the infections risks associated with each? Give an example for each:

What are patient characteristics that effect SSIs: (list 6)

What are other external factors that effect SSIs?

Answer

A

S. Aureus, E.coli, Enterococcus spp, steptococcus spp, clostridium spp.

Patient characteristics:

age
DM
Steroids
immunosuppression
Smoking
obesity
Burns
Malnutrition
patient with other infections
traumatic wound
radiation to area
Chemotherapy

Other factors

Prolonged preoperative hospitilization
reduced blood flow through
Break in sterile fields
multiple antibiotics
hematoma/seroma
Foreign bodies (drains, sutures, grafts)
Skin preparation
hypoxemia
hypothermia

Question 11

Q

Prophylaxis for SSIs:

Answer

A

Preoperative antibiotics for most surgeries (cefazolin+/-)

Question 12

Q

Post-operative management- Immediate management post-op outline assessments:

What are common post operative care needs? And how are they managed: Read

List surgical complications associated with:

Diverticulitis:

Anastomosis?

Open AAA repair?

Appendicitis?

Choleycstitis?

Answer

A

Immediate management

Patients go to recovery area

Monitoring (depending on procedure)

Vitals - arterial line or not
Urine output & fluid balance - monitored after most significant procedures
Bloods - FBC, UECs (often re-checked)
Drains - monitored for volumes and content
Central line - CVP is monitored in those with poor cardiorespiratory reserve

Common post-operative care

Analgesia

Patient relief - usually opioids
Facilitates deep respiration to prevent atelectasis

Respiratory

Chest physiotherapy - deep breathing exercises & promoting removal of secretions
Benefit - prevent atelectasis & pneumonia

VTE prophylaxis

Started ~6 hours after operation once bleeding is excluded
Enoxaparin 40mg

Encourage early moving and feeds

Question 13

Q

Outline a pain assessment: Objective signs? Subjective scores?

What are consequences of poorly controlled pain?

Outline a stepwise approach to pain 1st non-pharm: list 4

For acute pain what universal system do you use?

Question 14

Q

MOA of paracetomol? Side effects?

NSAIDS MOA? Side effects list 4 (GRAB)

Opioids MOA? side effects? CNS? resp? CV? GI? Urinary?

Question 15

Q

What is PCA? (patient controlled analgesia)?

Use? How? Advantages? Disadvantages? Examples of doses?

Question 16

Q

List 5 common causes (sites) of causes of post-operative sepsis? 5cs?

Answer

A

Post-operative sepsis

Septic sources on surgical wards (5 Cs)

Chest infection
Cut - wound infection
Catheter - UTI
Collections - abscesses
Cannula & central line

Question 17

Q

Outline general principles in preventing complications in the post-operative period: List 6 - 3 marks

Answer

A

Continued next card:

Question 18

Q

Outline causes of post-op fever according to POD? (post operative date)

WHats is likely POD 1? 1-2? 3-7? and POD 8+?

Question 19

Q

List the 6 Ws of post-operative fever?

Question 20

Q

What are the different types of post-op bleeds?

Primary? Reactive? Secondary?

Outline an asssessment of haemorrhage (assessment)

DRSABCDE - Ix? Management?

Answer

A

Types of post-op bleeding

Primary

Intra-operative bleeding

Reactive

Within 24h of the operation
Cause - ligature that slips, missed vessel (intraoperative hypotension and vasoconstriction hides bleed)

Secondary

Erosion of a vessel due to spreading infection

Assessment of haemorrhagePrimary survey (DRSABCDE)

D - don PPE, check safe to approach

R - COWS

S - call MET call, notify surgeon

Haemorrhage control

A

Assess - check obstruction & patency, listen for stridor
Rx - suction, manoeuvres, LMA

B

Assess - SpO2, RR, cyanosis, trachea, chest expansion, percussion, auscultation
Ix - blood gas, CXR
Rx - 15L O2 non-rebreather

C

Assess - P, BP, CRT, temperature, JVP
Ix - bloods
Rx - IVCs, start fluids, blood products, IDC & UO

D

Assess - pupils, brief neurological

E

Assess - T, abdominal, top to toe

Ix

FBC - post-operative anemia is common and usually benign due to blood loss + IVF dilution; significant drop only suggests bleeding
G&H and cross-match
Coagulation

Question 21

Q

Wound Haemorrhage/haemotoma:

What are risk factors for this? (list 4)

Clinical features? (list 4)

Treatment?

Question 22

Q

Post-operative nausea and vommitting:

Incidence? Consequnces?

Causes of PONV? (list 6 important reversible causes)

What are risk factors influencing post-op Nausea and vommitting?

Answer

A

Post-operative nausea & vomiting (PONV)

Incidence

20-30% within first 24-48 hours after surgery

Consequences

Aspiration pneumonia
Electrolytes - hypokalemia, hyponatremia
Metabolic alkalosis
Suture dehiscence - rupture of wound along suture line
Bleeding
Incisional hernia

Cause of PONV

PONV - most common cause is related to the operation & above RFs & is benign

2 brainstem areas key in controlling vomiting

Vomiting centre - in medulla oblongata; controls and coordinates movements of vomiting; inputs from CTZ, GI tract & higher cortical structures (pain, sight, smell)
Chemoreceptor trigger zone (CTZ) - located outside of BBB, responds to stimuli in blood to trigger vomiting

Important reversible causes to rule out

Pain
Infection
Metabolic - uraemia, electrolyte disturbance, DKA
Post-op ileus or bowel obstruction
↑ICP
Medications

Risk factors influencing PONV

Patient factors - female, non-smoker, past PONV
Surgical factors - type (abdominal or pelvic, middle ear and eye, gynaecological), long duration
Anaesthetic - poor pain control, certain agents (opioids, volatile anaesthetic, NO), dehydration

Question 23

Q

Outline an assessment of Post-operative nausea and vommitting:

Consider all causes:

Hx, Assosicated symptoms? Pmhx, social, fh?

Examination?

Ix?

Management? Goals? DRSABCDE, non pharm? hydration? pharmacological?

Answer

A

Assessment of PONV

Consider above causes when assessing

HxHPC

Vomiting - onset, duration, appearance, haematemesis or coffee ground vomitus, volume, relation to eating & drinking, projectile

Surgery - indicaiton, details, complications, anaesthetic used

Associated symptoms (ROS)

Constitutional - pain, fever/chills
GI - bowel motions (passing stools and flatus), distention, anorexia
Urological - FUND
CNS - headache, drowsy, weakness
CV - chest pain, palpitations, syncope, SOB
Resp - cough, SOB, leg pain

PMHx

Medical history

Medication review - anaesthetic, analgesia, anti-emetics, regular medications)

Surgery - operation details and complications,

A&I

Social

Family Hx

Exam

Inspection - surroundings (vomit bag, IVC sites), airway protected, colour (pallor, jaundice), LOC (aspiration), expose fully, lying still or colicky pain

Vitals - P, RR, T, BP, O2, fluid balance (U/O, drain outputs, others), BSL

Peripheral - CRT, temp, skin turgor

Face - mucous membranes, sunken eyes

Chest & abdomen

Ix

Blood gas - severe vomiting for metabolic alkalosis

Bloods - FBC, UECs + CMP

Management

Goals - ↓patient discomfort, prevent aspiration, wound dehiscence & metabolic abnormalities

DRSABCDE

DRS

A&B - airway protected/aspiration

C - P, BP, assess hydration, IVC if severe

D - LOC (airway protection)

E - T, septic foci

Non-pharmacological

Reassurance - PONV common & usually doesn’t indicate a serious process; treatable with meds
Small meals
Shower
Hydrate and correct electrolytes
PO (small sips) or IV if dehydrated and can’t keep down
Correct electrolytes - abnormalities prolong ileus

Pharmacological

If PONV is severe or ileus is present give IV

Anti-emetics

Ondansetron*

Dose - 8mg subling PRN (standard post-op dose)
MoA - 5-HT3 antagonist in the chemoreceptor trigger zone (CTZ)
SEs - headache (common), diarrhoea, dizziness, QT prolongation

Prochlorperazine

MoA - D2 antagonist; potent anti-psychotic (mesolimbic) and anti-emetic effects (CTZ)
SEs - extrapyramidal, neuroleptic malignant syndrome

Metoclopramide

Use - weak anti-emetic not effective for post-operative PONV
MoA - D2 antagonist in the CTZ
SEs - extrapyramidal (akathisia, dystonia), hyperprolactinemia & galactorrhoea, headache
CI - Parkinson’s

Analgesia

Control of pain important to reduce PONV

Question 24

Q

Post-op delirum (or delirum in general)

List 6 causes: Think (IWATCHDEATH)

Outline assessment of pt with suspected delirium:

Primary survey, systems exam?

Ix?

Management?

Question 25

Q

Causes of post op fever:

Overview:

Timeline:

Wind, Water, Wound, Walk, What did we do?

Question 26

Q

Outline assessment of post op fever:

Hx, Exam, Ix, Management (Medical, supportive, ongoing investigations, safety net+closing)

Question 27

Q

What are common empirical antibiotics associated with surgery

E.g SSI/or cellulitis?

IV line?

Intarabdominal?

Urinary?

Respiratory?

What is a line infection? Causes? Ix? Management?

Question 28

Q

Respiratory complications of surgery:

DDX for post op dyspnoea? (Resp/Cv/Others) List 3 from each

What is post op atelectasis?

Incidence? Risk factors?

Clinical features: List 5

CXR finding? (list 4)

Management? - non-pharm/pharm

Question 29

Q

Post-op pneumonia:

List factors that can contribute to this?

RFs?

Clinical features?

Prevention?

Management HAP?

What is aspiration pneumonia? What are causes of this?

Airway obstruction post-op? Explain:

Question 30

Q

What is a seroma? Treatment?

Wound Dehiscence: Risk factors? Clinical features? Treatment?

Question 31

Q

PE

Clinical features: List 6 - When is it most common to occur after surgery

Treatment?

Pulmonary oedema: Types?

Clinical features? List 4

Treatment: (LMNOP)

Question 32

Q

Post-op cardiac complications:

DVT/PE

HTN

Arrhythmias

HF

Question 33

Q

Cardiac complications: Toronoto notes:

MI:

Risk factors?

Clinical features (when is it most likely to occur)

Question 34

Q

GUT complications post-op:

What are 3 conditions that can do this?

Post-op constipation: List common post-op causes:

Ix?

Management for uncomplicated constipation: - Non-pharm, NGT, Rx?

What are expected findings on AXR - for constipation:

Question 35

Q

Anatomotic leak:

What is it? define:

RFs (surgical) + (patient factors)

Patho:

Clinical features: List

Ix?

Management: Primary survey, active treatment depends on grade: Supportive management:

Question 36

Q

Paralytic ileus:

Overview:

RFs (patient factors) + Surgical factors

Clinical features: List 4

Signs: List 4

Ix?

Management: Correcting contributing factors:

Prevention: List 4 methods:

Question 37

Q

Gastric dilatation:

Causes? Clinical features? Rx?

Bowel adhesions:

Overview, causes? Clinical features:

Ix? Blood gas, Bloods, Imaging

Rx? Resus/active/supportive

Question 38

Q

Question 39

Q

Incisional Hernia:

What is it? Risk factors to occur (list 4) - 2 marks

Clinical features?

Examination findings: List 3

Ix?

Complications:

Management:

Question 40

Q

Post-op renal compications:

Post-op oliguria- What is the definintion?

Outline causes? (how do you classify)

Complications of this?

Management/assessment: DRSABCDE, HPC, DDX? PmHx? - How to assess urine output and fluid balance: Outline

Question 41

Q

Outline an assessment: Including, complete examination, Investigations and management of a patient with post-op oliguria:

12 marks:

Question 42

Q

Urinary retention:

List 5 causes:

Clinical features?

Assessment: outline:

Management:

+ oliguria+retention -toronto notesw:

Answer

A

Urinary retention

Causes

Common post-op causes

Blocked catheter - clot in urological surgery
Medications & anaesthetic agents - epidural, opioids
Uncontrolled pain
UTI
Constipation
Other causes see urinary retention

Clinical features

Anuria (or very little urine)
Sensation of needing to void
Suprapubic pain
Suprapubic mass - dull to percussion

Assessment

USS KUB & PVR* - bladder distention, obstruction, prostate, hydronephrosis
UECs - AKI

Management

Treat underlying cause
IDC –> SPA

UTI

Cause - catheterisation

Question 43

Q

Endocrine and metabolic complications post-op:

Hypoglycaemia:

List several causes of post-op hypoglycemia?

What is gastric dumping syndrome? (what is it a complication of?) How do you manage this?

Question 44

Q

Post-op hyperkalemia/hypokalemia:

Hyperkalaemia: Causes post op? (list 4- and catergories)

Clinical features?

Ix? Management?

Hypokalaemia: Causes post op? (REGS+3)

Clinical features? List 4:

ECG findings?

Question 45

Q

Post op complications:

Hyponatremia: Causes of Post-op (+RGES+3) (hypovolemia hyponatraemia, Euvolemic, Hypervolemic)

Management? Complications of hyponatremia? (explain- slow fluid resus)

When is hypocalcemia relevant post op? How is it monitored?

Question 46

Q

Wound complications:

Explain good basic wound management post op:

What are risk factors for poor wound healing? List 6

What are local factors? List 6: Systemic factors? (Pneumonic- DID NOT HEAL)

Question 47

Q

Post-op complications: Wound dehiscense:

Risk factors?

Clinical features?

When is infection likely to occur? and abcess?

How is it managed? Outline:

How do you prevent wound discense?

Question 48

Q

SSIs:

Risk factors? List 5 (patient factors vs surgical factors)

Clinical features? When? List 5 features

Ix?

Management?

Prevention strategies? List 4 Pre intra post op:

Question 49

Q

What is a keloid?

Patho? Explain to pt:

Risk factors? List 4

Clinical features? List 4

DDX? List 4

Management options? Explain

Question 50

Q

Outline general ADVICE for all patients before surgery: 4 marks

After surgery advice for all stages post op: Outline: (immediate, long term, practical, give, follow up)

Question 51

Q

Differential diagnosis: ACUTE abdomen:

What is an acute abdomen?

List 5 ddx from each quadrants (think in systems+locality)

Investigations for and acute abdomen list? And explain

What are the three types of peritonitis?

How can pain be localised based on symptoms?

Question 52

Q

Differential diagnosis of acute abdomen LUQ?

LLQ?

Common referred pain in abdomen?

Epigastric ddx? Diffuse pain abdomen ddx?

Suprapubic pain? ddx

Diffuse pain? ddx

tn

Question 53

Q

Differential diagnosis: Abdominal mass -list3 from each quadrant

Question 54

Q

Management of UGIB?

Managment LGIB?

Question 55

Q

List causes of GI bleeds - from mouth to anus- think all possible systems/causes:

E.g how to differentiate source of bleed: Tn

Question 56

Q

Learning objective:

Surgical oncology principles:

1) Screening
2) Assessement and diagnosis
3) Staging - (the importance of CT/PET)
4) MDT - (critical in oncology)
5) Palliation:

Breast screening australia? explain screening

National bowel screening program? Explain

National cervical screening program? Explain

Also

Screening in: Lung, prostate, skin cancers important

Answer

A

BreastScreen Australia

is a joint initiative of the Australian and state and territory governments and aims to reduce illness and death from breast cancer by detecting the disease early. Women over 40 can have a free mammogram every 2 years and we actively invite women aged 50 to 74 to screen

Why breast screening is important?

Your chances of getting breast cancer increase with age. 1 in 7 Australian women will develop breast cancer in their lifetime.
We aim to reduce illness and death from the disease. That’s why we try to screen as many eligible women as we can.
Between 1985–1989 and 2011–2015, 5-year relative survival rates from breast cancer improved from 75% to 94%

Bowel cancer is one of the most common cancers in Australia.

The National Bowel Cancer Screening Program reduces illness and death from bowel cancer by helping detect the early signs of the disease using a free, simple test that can be done at home

Why bowel screening is important

Bowel cancer often develops without any symptoms. The cancer can grow in the bowel for years before spreading to other parts of the body.
Very small amounts of blood can leak from these growths and pass into your faeces (poo). These tiny amounts of blood are not noticeable just by looking – that’s where screening comes in.
According to a 2017 study by Cancer Council Australia, screening for bowel cancer can reduce deaths from the disease by between 15% and 25%.
The bowel screening test is called an immunochemical faecal occult blood test (iFOBT). It can detect tiny amounts of blood in your poo that can be a sign of bowel cancer.

National cervical screening program:

The National Cervical Screening Program reduces illness and death from cervical cancer. Women and people with a cervix aged 25 to 74 years of age are invited to have a Cervical Screening Test every 5 years through their healthcare provider.
You play an important part in the program. By sharing your knowledge, you’ll increase understanding of, and participation in, the program.

You can:

tell patients about the benefits of cervical screening and their options for having a Cervical Screening Test
explain how the new test looks for human papillomavirus (HPV)
explain the difference between self-collected and clinician-collected samples
advise how and when the results are provided
remind them that after their first Cervical Screening Test, screening is every 5 years, if no HPV is found.
reassure them that it’s a straightforward process that is private and confidential.
Refer to our Healthcare provider toolkit. The information in the toolkit helps support you to learn about the National Cervical Screening Program, support patients before, during and after a screening appointment and tailor support to specific groups of people.

Question 57

Q

Pre-op general advice? Explain

What things need to be explained to all pts post any major surgery?

E.g Immediately post op? longer term? Practical? What needs to be given? Follow up?

Question 58

Q

Read TN:

DDx for different GI bleeds (based on anatomical location)

Question 59

Q

Read- Fluid management basics:

What is hartmans good for?

NSaline?

Dextros?

Question 60

Q

Crystalloids vs Colloids

Whats major differences in distribution?

Uses?

Replacing IV volume?

Benefits of each?

Limitations of each

Question 61

Q

Fluid management qs:

1) how do you calculate daily requirment- Give formula and example”

Rate of bolus infusions in resus?

In mild to severe hypotension?

When is bolus therapy indicated?

How do we assess a patients fluid status:for fluid deficit Outline assessment: 4 marks:

Question 62

Q

What are indicators for mainatenance fluids?List 5: (pt unable to eat or drink sufficiently)

What is the 4/2/1 rule? (maintenance)

What are pt gactors you need to consider for maintenance rate?

What are the different type of maintenance fluids? (what is the standards)

What about maintenance with electrolytes?

Question 63

Q

Outline reason for ongoing losses in patientss?

What do you need to assess for when assessing fluid loss? (use fluid balance sheet)

What are different types of fluid loss? (list 4)

What importance does time have in fluid replacement?

Question 64

Q

Fluid replacement and AKI:

Choice? Types? Considerations?

Answer 15

A

Breast examination

Lymph node examination
- Palpate lymph nodes

o Supraclavicular
o Infraclavicular
o Pectoral
o Subscapular
o Lateral
o Central
Feel for enlargement, tenderness, mobility and texture
2. Breast examination
Positions

o At rest
o Hands on hips
o Roll shoulders forward and back
o Arms on head, open and close hands above head
o If she has large breasts, get them to lift up their breast up so you can see the underside

Observe for

o Scarring
o Lumps
o Asymmetry of breasts or a visible lump 􀀁
o Localised discolouration of the skin 􀀁

o Nipples:

If a suspicious lump is present, inspect liver, lungs and spine.

Answer 16

A

Breast lesions can be Benign or Malignant;

When deciding to operate, consider indication (local, systemic symptoms, malignancy or cosmetic) against 1) associated risks due to comorbidities etc. and 2) whether the patient’s condition is better left alone.

¼ of women have a breast clinical referral in their life-time – very common
- 90% have clinical breast presentations benign
- Mostly minor aberrations of normal development (ANDI); consider managing their symptoms here
- Also consider however:
  - Could it be cancer?
  - Is there a risk of developing cancer? E.g. is this benign process a risk for malignancy

Reasons for presentation include:

Lump
Mastalgia: Breast pain is common in pre-menstrual women.
Nipple changes
- Discharge
- Retraction/distortion
- Eczema
Skin change
- Contour
- Colour
- Dimpling
Family history

BENIGN LESIONS

Benign breast lesions are inclusive of:

Fibrocystic disease: Painful breasts, with focal areas of nodularity or cysts in the upper outer quadrant:

Additional features
- Frequently bilateral
- Mobile
- Varies with the menstrual cycle
- Nipple discharge (straw-like, brown or green
Treatment:
- Evaluation of breast mass (US + mammogram) and reassuring the patient – triple assessment
- Analgesia (ibuprofen, ASSA)
- Severe symptoms (OCP, Danazol, bromocriptine)

Fibroadenoma (localised ANDI rather than a tumour)

Most common breast tumour in women <30. Comprised of fibroid and epithelial components.
Clinical features:
- Firm, discrete, rubbery nodule
- Well circumscribed, mobile
- Non-tender
- Hormone dependent
  - Undergo involution in peri-menopause – but can persist into old age, undergoing dystrophic calcification.
- Needle aspiration: No yield, unlike cysts.
Diagnosis:
- Triple assessment incl. core biopsy; US + FNA are insufficient to distinguish it from a Phyllodes tumour (biopsy is to confirm diagnosis)
Management:
- Generally conservative, w/ serial observation:
  - Review at 3 months after diagnosis (USS and Biopsy)
  - If stable, review again at 12 months:
    - If stable, D/C from clinic
    - If growth, refer for surgical opinion
- Consider excision if: (Consider lesion and patient factors)
  - Size >2-3cm and/or growing on serial US (q6mo x 2 years is the usual follow up) – as aforementioned point.
  - Triple test is discordant
  - If symptomatic
  - Patient request
  - Formed after age of 35
  - Patient preference
  - Features of core biopsy suggesting Phylodes tumour
Prognosis:
- Increased risk if atypical cells + Family Hx of Brest Cancer. Otherwise, doesn’t increase risk of breast cancer.
- Regress spontaneously in 85-90%
DDx:
- Phyllodes tumour: Malignant types are sarcomatous; however, most are low-grade, benign ones

Intraductal papilloma

Solitary intra-ductal benign polyp
Clinical features:
- May present as nipple discharge (most common cause of spontaneous, unilateral, bloody nipple discharge = pathologic discharge)
- Breast mass
- Nodule on U/S
Treatment: Surgical excision of involved duct to ensure no atypia (central ductal excision)
Prognosis: Can harbour areas of atypia, DCIS

Usual Ductal Hyperplasia (Proliferative subtype, fibrocystic disease)

Increased number of cells within the ductal space
Clinical features:
- Incidental finding on biopsy of mammographic abnormalities, or breast masses.
Action: Empirically none; but often if suspicious mass, will remove anyway.
Prognosis: Generally low risk; slightly increased if moderate or florid hyperplasia.

Sclerosing adenosis (continuation of the proliferative subtype, fibrocystic disease)

Lobular lesion with increased fibrous tissue, glandular cells
Clinical features: Mass (can mimic cancer) or mammographic abnormality
Treatment: Nil required – however, remove for safety and analysis anyway.
Prognosis: Low risk.
Can involve ducts (ductal hyperplasia with atypia) or lobules (lobular hyperplasia with atypia) i.e. continuation of proliferative lesions aforementioned.
Cells lose apical-basal orientation
Prognosis: Increased risk of breast cancer
Diagnosis: Core or excisional biopsy (Schimmer: Guide wire with wide excision)
Treatment: Complete resection, risk modification (avoid exogenous hormones) and close follow-up.
Fat necrosis: Uncommon, result of trauma (may be minor, positive history in only 50%) or after breast surgery (e.g. reduction)
- Clinical: Firm, ill-defined mass with skin, nipple retraction +/- tenderness
- Regresses spontaneously, but complete imaging + biopsy necessary to rule out malignancy
Granulomatous Mastitis
Diabetic fibrous mastopathy – T1 diabetic girl with scary breast lumps looking like cancer.
- Have to work up, to exclude cancer.
Mammary duct ectasia: Obstruction of subareolar duct leading to duct dilation, inflammation and fibrosis.
- Clinical features: May present with nipple discharge, bluish mass under nipple and local pain. RFs include:
  - Prior pregnancy, breastfeeding but not for extended period of time, multi-paraous women.
- Risk of secondary infection (abscess, mastitis)
- Resolves spontaneously within weeks, years – however, central duct excision is available.
Abscess: Lactational vs periductal/subareolar
- Clinical features: Unilateral, localised pain, tenderness, erythema, subareolar mass, with nipple discharge, inversion
  - Rule OUT inflammatory carcinoma
- Treatment: Initially broad spectrum antibiotics and incision and drainage, if persistent total duct excision.
  - If mass does not resolve, US to assess for presence of abscess, core biopsy to exclude cancer, consider MRI

So for lumps, consider benign causes, chronic mastitis (granulomatous, T1DM, fat necrosis), infections and malignancy + Other skin lump causes.

Aberrations of normal development, cyclical change and involution. Disease is reserved for severe disorders.

Answer 17

A

Breast Abscess

If tenderness and redness persist beyond 48 hours and an area of tense induration develops, then a breast abscess may have formed
Requires surgical drainage under general anaesthesia or aspiration with a large bore needle under local anaesthetic every second day (first option) until resolution, antibiotics, rest and complete emptying of the breast

Treatment

Surgical Drainage

Make an incision over the point of maximal tenderness, preferably in a dependent area of the breast. The surgical incision should be placed as far away from the areola and nipple as possible and the dressings kept clear of the areola to allow breastfeeding to continue. The incision needs to be placed in a radial orientation (like the spoke of a wheel) to minimise the risk of severing breast ducts or sensory nerves to the nipple.  
Use artery forceps to separate breast tissue to reach the pus.  
Take a swab for culture.  
Introduce a gloved finger to gently break down the  septa that separate the cavity into loculations
Insert a corrugated drainage tube into the cavity

Remove the tube two days after the operation.  
Change the dressings daily until the wound has healed. Continue antibiotics until resolution of the inflammation. Continue breastfeeding from both breasts but if breastfeeding is not possible because of the location of the incisions or drains, milk should be expressed from that breast.

Answer 18

A

Mastitis

Basically cellulitis of the interlobular connective tissue of the breast
Mostly restricted to lactating women, it is associated with a cracked nipple or poor milk drainage
Mastitis is a serious problem and requires early treatment

Aetiology

The infecting organism is usually Staphylococcus aureus
More rare: Escherichia coli
Candida albicans is common in breastfeeding women

Clinical features

A lump and then soreness (at first)  
A red tender area  possibly  
Fever, tiredness, muscle aches and pains

Treatment

à Breastfeeding from the affected side can continue as the infection is confined to interstitial breast tissue and doesn’t usually affect the milk supply.

Antibiotics: resolution without progression to an abscess will usually be prevented by antibiotics
- Flucloxacillin 500 mg (o) 6 hourly for 7–10 days, if severe = 2g
  or  
- Cephalexin 500 mg (o) 6 hourly for 7–10 days  
- For Candida albicans infection: fluconazole 200–400 mg (o) daily for 2–4 weeks
Therapeutic ultrasound (2 W/cm2 for 6 minutes) daily for 2–3 days  
Ibuprofen or paracetamol for pain

Answer 19

A

Breast health

Any breast problems?
Breast pain, changes, nipple discharge, lumps, areas of concern?
Past history of breast surgeries, biopsies or removal of lesions
Any breast augmentation or reduction?
Personal or family history of female cancers?
- Breast, ovarian, cervical, endometrial, vulvar?
History of mammography or breast imaging?
- If so when
- What was the result
Do you examine your own breasts?

Mastalgia

Could you be pregnant?
Is your period on time or overdue?
Is the pain in one or both breasts?
Do you have pain before your periods or all the time during your menstrual cycle?  
Do you have pain in your back or where your ribs join your chest bone?

Breast examination

1. Lymph node examination

Palpate lymph nodes
- Supraclavicular
- Infraclavicular
- Pectoral
- Subscapular
- Lateral
- Central
Feel for enlargement, tenderness, mobility and texture

2. Breast examination

Positions
- At rest
- Hands on hips
- Roll shoulders forward and back
- Arms on head, open and close hands above head
- If she has large breasts, get them to lift up their breast up so you can see the underside
Observe for
- Scarring
- Lumps
- Asymmetry of breasts or a visible lump  
- Localised discolouration of the skin  
- Nipples:
  - For retraction or ulceration  
  - For variations in the level (e.g. elevation on one  side)  
  - Or discharge (e.g. blood-stained, clear, yellow)  
- Skin attachment or tethering → dimpling of skin
  - Accentuate this sign by asking patient to raise her arms above her head)  
- Appearance of small nodules of growth  
- Visible veins (if unilateral they suggest a cancer)
- Peau d’orange due to dermal oedema  
If a suspicious lump is present, inspect liver, lungs and spine.

Red Flags

Hard irregular masses
Nipple inversion or discharge
Puckering: skin grows on top of the mass, there is indentation as they move
Paget’s disease: eczema around the nipple: underlying
Peau de orange: Poor prognosis

3. Breast palpation

Place arm overhead
- Assist with pillow placement, pillow under shoulder for large breasted women
Palpate the breast
- Light and deep pressure
  - Circular movements starting light and getting deeper
- Pay particular attention to the upper outer quadrant and tail of breast (50% of abnormalities are found)
  - Make sure to palpate all the way to the axilla: breast tissue still found here
Check the nipple
- Place a finger either side of the nipple and palpate with rocking motion
- Feel for masses under the nipple, and observe for nipple discharge

Findings

Lumps that are usually benign and require no immediate action are
- Tiny (<4 mm) nodules in subcutaneous tissue (usually in the areolar margin)
- Elongated ridges
- Usually bilateral and in the lower aspects of the breasts
- Rounded soft nodules (usually <6 mm) around the areolar margin  
A hard mass is suspicious of malignancy but cancer can be soft because of fat entrapment
The infra-mammary ridge, which is usually found in the heavier breast, is often nodular and firm to hard.  
Lumpiness (if present) is usually most marked in the upper outer quadrant.

Mastalgia (breast pain)

The typical age span for mastalgia is 30–50 years.  
The peak incidence is 35–45 years.  
There are four common clinical presentations:
- Diffuse, bilateral cyclical mastalgia  
- Diffuse, bilateral non-cyclical mastalgia  
- Unilateral diffuse non-cyclical mastalgia  
- Localised breast pain  
An underlying malignancy should be excluded.  
Less than 10% of breast cancers present with localised pain
- But don’t miss it

Clinical features

Usually heaviness, discomfort or pricking, stabbing in breast
Pain may radiate down the inner arm when the patient is carrying heavy objects or when the arm is in constant use

Types

Cyclical mastalgia

Commonest diffuse breast pain
Occurs in the later half of the menstrual cycle, especially in the premenstrual days, and subsides with the onset of menstruation
Has a hormonal basis, which may be an abnormality in prolactin secretion
The main underlying disorder is benign mammary dysplasia, also referred to as fibroadenosis, chronic mastitis, cystic hyperplasia or fibrocystic breast disease.

Non-cyclical mastalgia

Quite common and the cause is poorly understood
May be associated with duct ectasia and periductal mastitis

Differential Diagnosis

Most likely

Pregnancy
Cyclical mastalgia

Not to be missed

Neoplasia
Inflammatory breast cancer
Infection
- Mastitis
- Abscess
Myocardial ischaemia

Management

à After excluding diagnosis of cancer and other causes

Mild

Regular review
Proper brassiere support
Adjust oral contraception or HRT
Analgesia

Moderate

à as for mild plus

mefenamic acid 500 mg, three times daily  
vitamin B1 (thiamine) 100 mg daily, and  
vitamin B6 (pyridoxine) 100 mg daily  
consider ceasing OCP

Mastitis

Basically cellulitis of the interlobular connective tissue of the breast
Mostly restricted to lactating women, it is associated with a cracked nipple or poor milk drainage
Mastitis is a serious problem and requires early treatment

Aetiology

The infecting organism is usually Staphylococcus aureus
More rare: Escherichia coli
Candida albicans is common in breastfeeding women

Clinical features

A lump and then soreness (at first)  
A red tender area  possibly  
Fever, tiredness, muscle aches and pains

Treatment

à Breastfeeding from the affected side can continue as the infection is confined to interstitial breast tissue and doesn’t usually affect the milk supply.

Antibiotics: resolution without progression to an abscess will usually be prevented by antibiotics
- Flucloxacillin 500 mg (o) 6 hourly for 7–10 days, if severe = 2g
  or  
- Cephalexin 500 mg (o) 6 hourly for 7–10 days  
- For Candida albicans infection: fluconazole 200–400 mg (o) daily for 2–4 weeks
Therapeutic ultrasound (2 W/cm2 for 6 minutes) daily for 2–3 days  
Ibuprofen or paracetamol for pain

Answer 20

A

Breast Lumps

à Common

Many of the lumps are actually areas of thickening of normal breast tissue: mammary dysplasia
- The commonest lumps are those associated with mammary dysplasia (32%) 
- Common cause of cysts, especially in the premenopause phase.  
Many other lumps are due to mammary dysplasia with either fibrosis or cyst formation or a combination of the two producing a dominant (discrete) lump
Over 75% of isolated breast lumps prove to be benign but clinical identification of a malignant tumour can only definitely be made following aspiration biopsy or histological examination of the tumour 
The investigation of a new breast lump requires a very careful history and the triple assessment

Aetiology

Common

Mammary dysplasia
Fibroadenoma
Cancer
Cysts
Breast abscess/periareolar inflammation

Less common

Mammary duct ectasia
Duct papilloma
Lactation cysts (galactocoele)
Paget’s syndrome
Fat necrosis
Sarcoma
Lipoma

Clinical features

Lump (76%)  
Tenderness or pain (10%)  
Nipple changes (8%)  
Nipple discharge (2%)
Bloodstained:
- Intraduct papilloma (commonest)
- Intraduct carcinoma 
- Mammary dysplasia
Green–grey:
- Mammary dysplasia
- Mammary duct ectasia
Yellow: 
- Mammary dysplasia 
- Intraduct carcinoma (serous)
- Breast abscess (pus)
Milky white (galactorrhoea):
- Lactation cysts 
- Lactation 
- Hyperprolactinaemia
- Drugs (e.g. chlorpromazine)
Breast asymmetry or skin dimpling (4%)  
Periareolar inflammation

Investigations

Triple Assessment

Clinical assessment: History, examination
Imaging: mammography +/- ultrasound
Fine-needle aspiration +/- core biopsy

History

The history should include
- Family history of breast disease
- Patient’s past history, including trauma
- Previous breast pain
- Details about pregnancies
  - Complications of lactation such as mastitis, nipple problems and milk retention

Key questions

Have you had any previous problems with your breasts?  
Have you noticed any breast pain or discomfort?  
Do you have any problems such as increased swelling  or tenderness before your periods?  
Have you noticed lumpiness in your breasts before?  
Has the lumpy area been red or hot?  
Have you noticed any discharge from your nipple or  nipples?  
Has there been any change in your nipples?  
Does/did your mother or sisters or any close relatives  have any breast problems?

Lumps that require investigation and referral

Stony hard lump or area, regardless of size, history or position
New palpable lump in a postmenopausal woman
Persisting painless asymmetrical thickening
Enlarging mass: cyclic or non-cyclic
‘Slow to resolve’ or recurrent inflammation
Bloodstained or serous nipple discharge
Skin dimpling or retraction of nipple
New thickening or mass in the vicinity of a scar

Answer 21

A

Investigations

x-ray mammography

Mammography can be used as a screening procedure and as a diagnostic procedure
- It is currently the most effective screening tool for breast cancer
Positive signs of malignancy include an irregular infiltrating mass with focal spotty microcalcification.
Screening:
- established benefit for women over 50 years  
- possible benefit for women in their 40s  
- follow-up in those with breast cancer, as 6% develop in the opposite breast  
- localisation of the lesion for fine-needle aspiration and wide local excision

Ultrasound

This is mainly used to elucidate an area of breast density and is the best method of defining benign breast disease, especially with cystic changes
It is generally most useful in women less than 35 years old
Useful for
- Pregnant and lactating breast
- Differentiating between fluid-filled cysts and solid mass 
- palpable masses at periphery of breast tissue (not screened by mammography)
- For more accurate localisation of lump during fine- needle aspiration

Needle aspiration and biopsy techniques

Cyst aspiration  
Fine-needle aspiration biopsy: this is a very useful diagnostic test in solid lumps, and has an accuracy of 90–95% (better than mammography)  
Large needle (core needle) biopsy  
Incision biopsy

Fine needle aspiration of breast lump

This simple technique is very useful, especially if the lump is a cyst, and will have no adverse effects if the lump is not malignant
If it is, the needle biopsy will help with the preoperative cytological diagnosis

Answer 22

A

Lesion types

Non-proliferative lesions e.g. fibrocystic changes

Benign breast condition characterized by fibrous and cystic changes in the breast
Most common: breast cysts
Other lesions
- Papillary apocrine change
- Epithelial related calcifications
- Mild hyperplasia
No increased risk of breast cancer
Age 30-menopause
Clinical features
- Breast pain/swelling
  - Often bilateral
- Focal areas of nodularity/cysts
- Varies with menstruation cycle
- Nipple discharge
Treatment
- Evaluation of breast mass
- Analgesia
- Severe: OCP

Breast cysts

Common in women aged 40–50 years (perimenopausal)
Rare under 30 years 
Associated with mammary dysplasia
Tends to regress after the menopause
Has a 1 in 1000 incidence of cancer 
Usually lined by duct epithelium

Examination

Pain and tenderness variable 
Look for a discrete mass, firm, relatively mobile, that is rarely fluctuant.

Diagnosis

Mammography  
Ultrasound (investigation of choice)  
Cytology of aspirate

Proliferative lesions

Fibroadenoma

à Fibrous stroma surrounds duct-like epithelium and forms a benign tumour that is grossly smooth, white, and well circumscribed  

Most common breast tumour in women <30 years
Nodules: firm, rubbery, discrete, well-circumscribed, non-tender, mobile
Hormone dependent
Increased risk of breast cancer if complex

Clinical features

A discrete, asymptomatic lump  
Firm, smooth and mobile (the ‘breast mouse’)  
Usually rounded  
Usually in upper outer quadrant  
They double in size about every 12 months

Diagnosis

Core/excisional biopsy if confirmed about malignancy
U/S and FNA cannot differentiate Fibroadenoma from Phyllodes tumour

Treatment

Core biopsy with cytology is recommended
- - mammography in older women
- To ensure not cancer
Consider excision

Usual ductal hyperplasia

Increased number of cells within the ductal space
Incidental finding on biopsy
Low risk of breast cancer

Mammary duct ectasia

à Inflammation and dilation of mammary ducts.  

Most commonly occurs in the perimenopausal years.  
Presentation: Noncyclical breast pain with lumps under nipple/areola  with or without a nipple discharge.

Clinical features

Palpable lumps under areola, possible nipple discharge.

Diagnosis

Based on exam; excision biopsy required to rule out cancer.

Treatment

Excision of affected ducts.  
Phyllodes Tumour*

à A variant of fibroadenoma

Majority are benign 
Patients tend to present later than those with fibroadenoma (>30 years)

Characteristics

Indistinguishable from fibroadenoma by ultrasound or mammogram
The distinction between the two entities can be made on the basis of their histologic features
- Phyllodes tumours have more mitotic activity
Most are benign and have a good prognosis.  
Exam: Large, freely movable mass with overlying skin changes.

Diagnosis

Definitive diagnosis requires biopsy with pathologic evaluation.

Treatment

Smaller tumours: Wide local excision with at least a 1-cm margin.  
Larger tumours: Simple mastectomy.

Other lesions

Fat necrosis

Uncommon, result of trauma (may be minor, positive history in only 50%), after breast surgery (i.e. reduction)
Firm, ill-defined mass with skin or nipple retraction, ± tenderness  
Regress spontaneously, but complete imaging ± biopsy to rule out carcinoma

Answer 23

A

Breast cancer

Breast cancer is the most common cancer in females, affecting 1 in 11–15 women in Australia
Breast cancer is uncommon under the age of 30 but it then steadily increases to a maximum at the age of about 60 years, being the most common cancer in women over 50 years.  
About 25% of all new cancers in women are breast neoplasms.  
A ‘dominant’ breast lump in an older woman should be regarded as malignant.

Risk factors

Sex: Female
Age: Increasing risk with age
Family history
- BRCA 1 BRCA 2
- Cancer families: Up to 50%
- First degree relatives: 2-3x
Previous Hx cancer
- 2x elderly to 8x <45 years
DCIS same, other breast
Atypical epithelial hyperplasia 4x

Minor

Early menarche, late menopause
Nulliparity
Late first child, no breast feeding
Postmenopausal obesity
High fat, low fibre diet, Alcohol, smoking
HRT: long term

Types

Ductal: most common (80%)
- Various histological types: NOS, scirrhous, medullary, comedo, colloid, papillary, tubular
- Most common in perimenopausal and postmenopausal women
- Originates from ductal epithelium and infiltrates supporting stroma
- Characteristics: hard, scirrhous, infiltrating tentacles, gritty on cross section
Lobular (8-15%)
- Originates from lobular epithelium terminal duct cells
- Typically familial, younger age
- Ill-defined thickening of the breast
- Single file cells (Indian file)
- Don’t form microcalcifications therefore harder to detect on mammogram
Paget’s disease
- Ductal carcinoma that invades nipple with scaling, eczematoid lesion
- Usually associated with underlying LCIS or ductal carcinoma extending within the epithelium of main excretory ducts to skin of nipple and  areola.  
- Presentation: Tender, itchy nipple with or without a bloody discharge  with or without a subareolar palpable mass.  
- Treatment: Usually requires a modified radical mastectomy.  
Inflammatory carcinoma
- Ductal carcinoma that invades dermal lymphatics 
- Most aggressive form of breast cancer 
- Clinical features: erythema, skin oedema, warm, swollen, and tender breast ± lump
- Peau d’orange indicates advanced disease (IIIb-IV)
Carcinoma in situ (DCIS/LCIS)
- Proliferation of malignant ductal epithelial cells completely contained within breast ducts
  - Often multifocal
- Intact myoepithelial cells: determined by microscopy
- DCIS: Proliferation of ductal cells that spread through the ductal system but lack the ability to invade the basement membrane
- LCIS: A multifocal proliferation of acinar and terminal ductal cells

Clinical features

The majority of patients with breast cancer present with a lump
- The lump is usually painless, hard and irregular
- Fixed/immobile
- Irregular, hard, gritty/stony
- Very dense scarring, no necrosis
Location: Upper outer quadrant (50%), central 20%.
Skin tethering
- Fibrous tissue pulls the skin into the tumour
- Dense central scar with bands pulling the overlying skin towards the cancer
Puckering
Nipple changes, discharge, retraction or distortion.  
- Nipple retraction: If tumour is within the tubules
Painless lymphadenopathy
Rarely cancer can present with Paget disease of breast  (nipple eczema) or inflammatory breast cancer
Rarely it can present with bony secondaries
- e.g. back pain, dyspnoea, weight loss, headache

Diagnosis

Triple assessment
- Clinical: History, examine
- Imaging: Mammography, ultrasound, MRI
- Biopsy: Fine needle aspirate (cytology), core needle biopsy (histology), excision (histology)
By the time you have reached CNB: 90% of BrCa is diagnosed

Limitations in diagnosis

Clinical
- <1cm
- Other causes for thickening, lumps
- Density
Imaging
- Mammograms <50 years of age
- Ultrasound for screening: takes a long time for full US
Pathology
- Representative sampling
- Impalpable lesions
  - Surgery + ultrasound + Hookwire

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