General Surgery Flashcards
- How would you go about investigating a 60 year old lady who presented to you having found a lump, about 2cm across, in her left breast?
- History
- Examination
- Imaging
- Biopsy (FNA/Core)
63.Key points of history taking re: lump in breast tissue? (9)
- Lump location, size, changes, first noticed, tender, associated skin changes
- Hx of breast lumps, cysts, fibroadenomas,
- Menstrual hx,
- Medications, including the contraceptive pill and HRT
- Fx hx, including relatives affected by cancers
- Ethnic background
- Risks that suggest genetic susceptibility, such as family history, male breast cancer.
- Trauma – accidental/iatrogenic
- Systemic symptoms
- Examination technique re: lump in breast tissue
Inspection
- Hands by side and above head
- Breast contour
- Skin changes: erythema, dimpling, puckering, peau d’orange
- Nipple changes: inversion, distortion, eczema, nodules, ulders, discharge
Palpation
- Four quadrants with a systematic approach
- Nipple
- Axillary tail
- Lymph nodes
- Axillary and supraclavicular
Imaging requests re: lump in breast tissue (5)
- Mammography
- Investigation of choice if >30yrs
- USS should always accompany to increase accuracy -
- US <30yrs
- MRI
- Is only funded under medicare for high-risk women (e.g. BRCA1/BRCA2 mutation carrier
- CT (preoperative staging)
- Bone scan (preoperative staging)
Algorithm for managing a breast symptom or screening abnormality

What are the risk factors for breast cancer? (11)
- increasing age
- family hx (1st>2nd degree relatives, onset, bilaterality, BRCA1/2 (autosomal dominant)
- previous hx of breast cancer or carcinoma in-situ
- early age of menarche (<12 years)
- late age of menopause (age >55years)
- late age at first full time pregnancy (age <20 years protective)
- nulliparity
- previous breast biopsies showing non-malignant abn. (ductal carcinoma insitu, lobar carcinoma in situ, atypical ductal hyperplasia
- hormal therapy - OCP, HRT
- Radiation at a young age
- physical activity (reduces circulation of oestrogren)
- chronic alcohol intake
List the options for adjuvant treatment for breast cancer (5)
- radiotherapy
- hormone therapy (tamoxifen, aromatase inhibitors)
- chemotherapy (Anthracyclines, taxanes)
- adjuvant anti-HER2 treatment (Trastuzumab - Herceptin)
- Others (Aspirin, Bisphosphonates,Neoadjuvant treatment, lifestyle, radiotherapy)
Define Adjuvant Therapy
Aims at adding to definitive treatment to reduce the risk of both local recurrence and distant metastases in patients in whom there is a high risk of occult disease (micrometastases)
Describe Tamoxifen (Hormone Therapy) in Breast Cancer
- MOA
- Blocks oestrogen receptor inside the breast cancer cell. This stops oestrogen making the breast cancer cell grow.
- Course
- 1 daily tablet, 5 year course after other treatments
- Benefits
- Reduces risk of early breast cancer, new breast cancer developing. Can be used with other treatments for breast cancer like radiotherapy and chemotherapy
- Strengthens bones rather than reducing bone density (unlike aromatase inhibitors can)
- May lower cholesterol and reduce the risk of developing heart disease
- Works either before or after menopause.
- Agonist at bones and endometrial tissue (endometrial cancer)
- Side effects
- Does not cause menopause but side effects may be similar
- Common
- Hot flushes and sweats
- Irregular vaginal bleeding in women who have not been through menopause
- Vaginal irritation, dryness or discharge
- Fluid retention and weight gain
- rare
- DVT, PE (similar risk to OCP)
- Fertility
- Do not become pregnant or breast feed for 1-2 months after stopping.
- Can increase fertility so must use barrier contraception (do not take OCP with tamoxifen)
- Can interact with warfarin

Describe Aromatase Inhibitors (Hormone Therapy) in Breast Cancer
- First line and only work in post-menopausal women with PR or ER positive cancers.
- Cannot use in pre-menopausal as it muffs up negative feedback to pituitary and makes things worse ☹
- MOA
- Blocks aromatase, which helps make oestrogen in body tissues such as muscle, fat and the adrenal glands.
- course
- Tablets taken once daily
- Usual treatment course 5 years.
- Anastrazole, letrozole, exemestane
- Benefits
- Reduce risk of early breast cancer coming back, reduce risk of new breast cancer developing
- Can be used with radio/chemotherapy
- Can be substituted for tamoxifen in post-menopausal women
- Less likely to cause DVT/PE or cancer of the endometrium than tamoxifen.
- Side effects
- Common
- Muscle aches and pains
- Hot flushes
- Vaginal dryness
- Common
- Contraindications
- Osteoporosis
- Follow-ups
- Check Vit D levels, take daily calcium and Vit D supplements
- Yearly bone scan

Describe Tratsuzumab (Adjuvant anti-HER2 treatment) in Breast Cancer
- monoclonal antibody directed against the extracellular domain of human growth factor receptor 2 (HER2), a tyrosine kinase involved in cell growth and proliferation
- prognosis
- HER2 pos à worse prognosis
- Clinical trials:
- use of trastuzumab with chemotherapy improves disease-free and overall survival.
- Side effects
- Main risk is cardiac toxicity (up to 4%), hence baseline and surveillance echocardiograms are required.
- Contraindicated
- Anthracycline (due to cardiac toxicity)
Describe other adjuvant Therapies for Breast Cancer
- Aspirin
- Recent data from a large population cohort study suggests aspirin has a role in prevention of recurrence, although no randomised data exists and optimal dose is undefined.
- Bisphosphonates
- Six-monthly IV, or weekly orally,
- Lowers cancer recurrence (both bone and other organs)
- Direct anti-tumour effect is in keeping with that seen in metastatic breast cancer
- Neoadjuvant treatment
- Chemotherapy, hormone therapy, trastzumab may be considered for large or locally advanced tumours.
- Lifestyle factors
- Healthy diet
- Regular exercise
- Healthy weight range
- Radiotherapy
- After surgery
- Down staging for neoadjuvant
- supportive care
- cancer-centre psychologists
- information packs through National Breast and Ovarian cancer centre and cancer council websites
- support groups
- When is systemic therapy used in breast cancer?

- What are the surgical options for a small confirmed cancer which is sited laterally in the breast, is not fixed to the skin, deep tissue or nipple? what are the advantages and disadvantages of the options?
- Mastectomy
- Radical (Halsted) - removal of breast, axillary lymph nodes and both pectoralis muscles - No longer indicated
- Modified Radical (Patey) Mastectomy: Similar to radical but with preservation of pectoralis major
- simple mastectomy: removal of the breast with no dissection of the axilla, except for the region of axillary tail, which usually has a few nodes attached to it in the anterior group - standard for invasive breast cancer
- Breast Conserving Surgery (“Lumpectomy”)
- Wide local excision: remove tumour with 1cm macroscopic margin of normal breast tissue.
- quadrantecomy: removal of an anatomic quadrant
- what are the advantages and disadvantages of mastectomy?
- advantages
- No post-op RT needed unless high risk cancer
- Lower rates of local recurrence
- Can have reconstructive surgery
- No follow-up imaging needed for that side
- Psychologically better re: recurrence fears
- Better for small breasts
- disadvantages
- Longer operation
- Poorer cosmesis
- Psychological impact on appearance and sexual dysfunction
- what are the advantages and disadvantages of lumpectomy
- advantages
- Similar survival benefits
- Preservation of breast shape and skin
- Shorter operation
- Psychological advantage for appearance
- disadvantages
- Needs post-op RT
- Higher rates of local recurrence
- May need re-operation for margins
- Quadrantectomy has poor cosmetic outcome
- What are important differential diagnoses for a breast lump?
- Common
- Fibroadenoma
- Fibrocystic breast
- Fat necrosis
- Intraductal papilloma
- Breast abscess
- Atypical ductal hyperplasia (ADH) and atypical lobular hyperplasia (ALH)
- Invasive breast cancer
- Ductal carcinoma in-situ
- Uncommon
- Phyllodes tumor
- Adenoma
- Radial scar
- Lobar carcinoma in situ (LCIS)
- What is the influence of a patients age on the choice of imaging for breast cancer?
In women >30 years breast lump should have diagnostic mammogram plus ultrasound to increase diagnostic accuracy, better characterize lesions and identify the presence of satellite lesions.
- Mammography has a high false positive rate in young patients
In women <30 years – USS is the investigation of choice because the presence of denser breast tissue make evaluation with mammography less useful. Another consideration is the radiation to the breast tissue of younger women if mammography is performed.
- USS Is most useful for Cystic lesions
MRI is the most sensitive investigation for breast cancer and the non-ionising nature makes it ideal for younger patients, however it is expensive and relatively less available and therefore not largely used.
- A 26 year old woman presents to the ED with a painful, hot swollen left breast. she is 5 week spost partum with her first child and has been breast feeding successfully. She was prescribed anti-biotics for the problem 5 days ago by her GP but has been getting worse. she has no systemic previous medical hx, and takes no regular medications.
Check for sepsis:
- SIRS criteria:
- HR > 90bpm
- Temperature > 38˚C or < 36 ˚C
- RR > 20 or PaO2 < 32mmHg (< 4.2kPa)
- WCC > 12 or < 4
Lactational mastitis: usually occurs in first 3 months of breast feeding
- Risk factors;
- Cracked nipple
- Poor feeding technique
- Organism
- Staph. Aureus
- Typical presentation
- Pain, swelling, erythema
- Tx
- Simple analgesia: paracetamol or NSAIDs
- Empirical antibiotics (flucloxacillin)
- Continued feeding or milk expression
- If septic, IV antibiotics
- If abscess develops, should be drained with repeated US-guided aspiration until resolution.
- Surgery only if skin is threatened or necrotic
- How would you go about investigating a 16 year old girl who presented to you having found a lump, about 2cm across, in her left breast?
History:
- Duration – when and how was the lump first noticed
- Change – has the lump gotten bigger/ smaller, does it change with the menstrual cycle
- Trauma – accidental or iatrogenic breast trauma
- Pain – is the lump painful
- Skin changes – erythema, skin puckering
- Nipple changes – inversion, distortion, discharge
- Risk factors – previous breast lesions, FHx of breast cancer, menarche, menstrual history and OCP use, smoking, alcohol, pregnant?
- Systemic symptoms – weight loss, fever, night sweats, back pain, neurological changes, SOB, cough etc.
Inspection and examination with chaperone present
Document details of any findings – size, shape, consistency, mobility, tenderness, fixation and exact position
Management ‘
- Benign breast lumps are very common in this age group, so it’s important to provide reassurance while ruling out breast cancer.
- An appropriate management strategy can be to watch and wait to see if the lump resolves over the period of 2-3 menstrual cycles
- If lump has not resolved then USS should be performed.
Most likely fibroadenoma
- Localized form of ANDI (abnormalities of normal development and involution).
- Smooth, firm, highly mobile
- Larger fibroadenomas should be distinguished from benign phyllodes tumours.
- A 30 yao woman presented with a painful lump in her left breast 5 days after childbirth. This is a photograph of the breast. What do you see?
Describe lesion:
- Location on a clock face or quadrant
- Size and symmetry when compared to the other breast
- Erythema
- Purulence
Likely diagnosis: (in picture)

- What is the most likely organism that might be causing acute, lactation associated, breast abscess?
- Commensal skin bacterium. Almost always Staphylococcus Aureus.
- Enters through lactiferous duct or nipple trauma (cracks, fissures).
- What is the management of an acute lactation associated breast abscess
- Mastitis
- Rf: cracked nipple, poor feeding technique causing milk stasis
- Flucloxacillin 500mg PO, 6hr x 5 days
- Continued feeding and milk expression
- Paracetamol or ibuprofen for pain control
- In persistent cases: midstream milk sample MCS, and consider treating for MRSA.
- US, and biopsy if palpable mass remains after the infection is cleared.
- Abscess
- Flucloxacillin
- Refer to surgeon for needle aspiration to drain abscess
- Incision and drainage if not effected.
- Can occur with mastitis except a fluctuant mass is palpable

- a 34 yoa woman presented with a painful lump in her left breast 5 days after childbirth. This is a photograph of the breast. What is the likely diagnosis and what is the management?
Describe the lesion:
- Location on a clock face or quadrant
- Size and symmetry when compared to the other breast
- Erythema
- Purulence
Likely diagnosis – Lactation mastitis +/- breast abscess
DDx: Galactocele (usually non-painful), Inflammatory breast cancer
Management:
- Continued breast feeding/ expression of milk
- Simple analgesia
- Education and reassurance
- Antibiotics (flucloxacillin)
- Aspiration with USS guidance or surgical incision and drainage – milk and pus aspirated should be sent for MCS

































