Last minute surgical revision Flashcards
What is the blood supply to the breast?
Axillary artery and the internal mammary artery.
What characteristics of a mass would make you think it required no immediate action in the breast?
Tiny nodules <4mm in the subcut tissue in the areolar margin, elongated ridges, bilateral in the lower breasts, or rounded soft nodues around the areolar margins.
Discuss the differences betwee cyclical and non cyclical. Which ddx do you not want to miss?
Note that 30-50 is the typical age of getting mastalgia.
Cyclical mastalgia is often diffuse, and occurs in the latter half of the menstrual cycle, especially in the premsentrual days, and subsides with the onset of menstruation. It has a hormonal basis, and is likely prolactin. The main underlying disorder is usually fibrocystic changes.
Non cyclical mastalgia is quite common, and has a poorly understood cause. It may be associated with duct ectasia and periductal mastitis.
You don’t want to miss neoplasms, inflammatory breast cancer, fibroadenoma, duct ectasia, sclerosing adenosis, infections, or even myocardial ischaemia.
How do we manage mastalgia after excluding serious pathologies?
Mild: regular review with proper bra support. Paracetamol if it’s bad, and adjust oral contraception or HRT if they are on it.
Moderate: as for mild, but also add mefanamic acid, and vitamin B1+B6. Consider ceasing COCP.
Aside from ab’s how do we treat mastitis
Therapeutic USS
Commonest ddx for a bloodstained nipple discharge?
Intraductal papilloma.
DDx if there is a radial scar? What about calcification?
Breast ca, fat necrosis, post surgery
Calcification ddx is malignancy, DCIS, fat necrosis, fibrocystic changes, degenerating fibroadenoma.
Pleomorphic calcification is a key feature that is highly suspicious.
Uses of USS when evaluating breast?
Useful when under 35, wen pregnant (radiation risk plus denser breasts here), when differentiating between a mass and a cyst, and for more accurately assessing the location for a fine needle aspiration.
Most common non-proliferative lesion vs proliferative?
Non is cyst, prolif is fibroadenoma.
Why do you need to do a core biopsy for fibroadenomas?
They can’t differentiate between a phylodes and a fibroadenoma on USS and FNA.
To be far, age and clinical features should give this away. The age of a person with a phylodes is older than a patient with a fibroadenoma. Although, it is in itself a variant of a fibroadenoma, and in fact a phyloddes can be MOBILE!!
Important to make the distinction, because you can have some phylodes tumours that are malignant.
What is duct ectasia?
Mammary duct ectasia
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.
- Associated with smoking!!!
Diagnosis
- Based on exam; excision biopsy required to rule out cancer.
Treatment
- Excision of affected ducts.
Breast cancer risk factors?
Risk factors - Sex: Female - Age: Increasing risk with age - Family history o BRCA 1 BRCA 2 o Cancer families: Up to 50% o First degree relatives: 2-3x - Previous Hx cancer o 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
What are the types of breast cancer?
Ductal
can be comedo, colloid, papillary etc.
Most common.
Lobular
Comes from the terminal epithelium of the breast lobules at the back of the breast
These don’t form microcalcifications, and so they are harder to detect on a mammogram.
Paget’s
This forms a dermatitis like lesion on the nipple due to local invasion.
Inflammatory
MOst aggressive form, it appears oedematous, warm, swollen, tender and lumpy. Peau d’orange is associated with this subtype.
DCIS/LCIS
Proliferation of malignant ductal epithelial cells completely contained within the breast ducts.
Where do most breast cancers occur?
Upper outer quadrant, even involving the tail of spence. Hence we need to be palpating all the way up here.
Two new ways to biopsy a breast?
Hookwire biopsy, and of course can do an excisional biopsy.
Some key staging points of breast cancer?
T1: <2cm
T2: 2-5
T3 >5cm
T4: Extends to chest wall or skin
N1: axillary
N3: infraclavicular
(both ipsilateral)
When do we do a sentinel node biopsy?
If there are no palpable nodes. If they are palpable, just do an FNA.
It uses both a blue dye and a technetium 99 contrast, so we detect it with imaging and in surgery. This is how we know if there is lymph involvement.
If there is confirmation of nodal involvement.
Describe the use of adjuvant / neoadjuvant treatments with breast cancer?
Radiation is done if there is breast conservation surgery (another reason to get a mastectomy), or if there is inoperable locally advanced cancer. Axillary nodal radiation may be added if there is nodal involvement.
Hormonal therapy can be used if there is ER positive. Used for 5-10 years. Nastrozole is an aromatase inhibitor used for similar duration in post menopausal.
Other oestrogen therapies include oophorectomy and GnRH agonist.
Chemo is used if triple negative (human epidermal growth factor)
How do follow up breast cancer?
- Assessment and physical exam
o 3-6 monthly first 3 years
o 6-12 monthly next 2 years
o Annually thereafter - Following BCS mammography q6-12mo; can reduce to annual once stable, no other routine imaging unless clinically indicated
- Women who receive tamoxifen should have regular gynecologic follow-up: Increased risk of endometrial cancer
4 types of BCC?
Nodular, superficial, morphoiec/ sclerosing, ulcerative.
Treatment is either with topcial 5-FU or imiquimod if they are willing to spend the money and apply it, but this is mainly superficials. The mainstay is to excise nodulars.
Melanoma is an important disease in NQ. What are the two growth phases?
Radial and verticle. Radial is the major growth phase of 85% of melanomas (superficial spread, lentigo maligna, acral lentiginous), and it’s characterised by the ABCDE. Approximately 15% grow vertically, and this is when they are nodular in appearance. They usually do this much earlier than a superficial spreading.
What is Hutchinson’s sign?
It’s the melanoma in the nail
How can we biopsy?
Punch, shave, incisional, excisional,
Discuss the surgical margins for these things?
Smaller lesions: standard is 3mm.
Melanomas we base on the Breslow thickness.
Based on Breslow thickness
- Melanoma in situ: 5mm
- Melanoma <1mm: 1cm
- Melanoma 1-4mm: 1-2 cm
- Melanoma >4mm: 2cm
Blood supply to the leg please:
Femoral - deep femoral (profunda femoris)
Femoral becomes popliteal at the adductor hiatus.
Popliteal becomes the anterior and posterior tibial artery. Anterior goes to become the dorsalis pedia, and the posterior gives off the fibula artery. Post tib goes on to become the medial and lateral plantar arteries.
Define critical limb ischaemia?
Rest/ night pain, tissue loss (gangrene or arterial ulceration) and ABI <0.4
Note it wil often require opioids.
Also remember pulseless, perishingly cold, parasthesia, paralysed, pale
Also note it can have a chronic presentation…. Not really sure how.
Signs of poor perfusion on examination?
Hair loss, hypertrophic nails, atrophic muscles, skin ulcerations and infections, slow cap refil, prolonged pallor with elevation and rubor on dependency (Burger’s).
Discuss some common patterns of the PVD?
- Common patterns
o Superficial femoral as it passes through adductor hiatus (approx. 60%) as the adductor cant expand
o Aorto-iliac (approximately 30%) L´e Riche syndrome involving buttock and thigh claudication with impotence (common iliac external and common femoral and profunda femoris
o Combined disease – 10% diabetics and smoke
ABI method: pressure for highest ankle (either the dorsalis paedis or the posterior tibial. Remember also to do angiography. A duplex ultrasound is done with the venous disease. Formula?
Leg pressure over the arm pressure. Done with a doppler and a cuff
Management steps of PVD?
Conservative: reduce risk factors.
Do exercise. Improves collateral circulation.
Foot care.
Pharm:
Antiplatelet
Cilostazol: cAMP-phosphodiesterase inhibitor with antiplatelet and vasodilatory effects:
Improves walking distance for some patients with claudication
Surgical options:
Endovascular repair (stenting/ angioplasty)
Endarterectomy (removal of plaque and repair with patch). Usually distal aorta or common/ profunda femoral.
Bypass: aortofemoral, axillofemoral, femoropopliteal, distal arterial - graft choices are vein grafts or dacron.
Amputation
Describe the management of acute arterial occlusion?
Happens without a history of claudication. Skeletal muscle can tolerate 6 hours of ischaemia. Exception is acute on chronic because of colaterals.
These can either be thrombi at the vessels or emboli.
How do workup acute arterial occlusion? Manage?
- History and physical exam are essential: depending on degree of ischaemia one may have to forego investigations and go straight to the operating room
- ABI: extension of physical exam, easily performed at bedside
- ECG, troponin: rule out recent MI or arrhythmia
- FBC: rule out leucocytosis, thrombocytosis or recent drop in platelets in patients receiving heparin
- PT/INR: patient anticoagulated/sub-therapeutic INR
- Echo: identify wall motion abnormalities, intracardiac thrombus, valvular disease, aortic dissection
- CT angiogram: underlying atherosclerosis, aneurysm, aortic dissection
- Conventional catheter based angiography: can be obtained in OR; prelude to thrombolytics
Manage with heparin bolus then infusion to maintain high aPTT.
If impaired NV status, emergent revascularisation.
If intact NV status, do the workup above.
To definitively treat, either do an embolectomy, a thrombectomy +/- bypass
Amputate if there is absent blood flow or complete loss of power/ sensation.
Continue post op heparin and start on warfarin.
Complications of the actue arterial ischaemia?
Compartment syndrome: fasciotomy.
Arrythmia and death with reperfusion injury
Renal failure/ multi organ failure.
Debakey types?
3 is just stanford B. 1 is whole aorta, and 2 is just ascending.
What is a new clinical feature you learnt re. dissections? Discuss the management please?
They can rupture into the pleura.
Urgent surgical consult if thoracic aortic dissection is diagnosed or suspected. Type A go to cardiac, type B go vascular. We resect the section with the intimal tear and replace the affected aorta with a prosthetic graft. 2/3 of patients die of operative or post operative complications????
Types of abdominal aortic aneurysma?
Infrarenal (98%) Suprarenal Pararenal - this is when the renal arteries arise from the aneurysmal segment of artery. Juxtarenal Infrarenal
Aetiology of AAA?
Degenerative Traumatic Mycotic Connective tissue (Marfan's, Ehlers Danlos) Vasculitis Infectious (syphilis)
What imaging do we use to work up? Management?
USS can be used to determine size
CT with contrast helps plan EVAR etc.
Aortogram is also done for EVAR planning.
We treat at 5.5cm because the risk of rupture is greater than the risk of complications. There is a 2-5% chance of dying for an open repair, and a 1-2% for EVAR.
Other indications are if it’s ruptured, symptomatic.
Contraindications if they have some terminal illness, advanced age, severe dementia, or comorbidities that mean they will not tolerate the surgery.
Complications of an Aortic Aneurysm repair?
General complications more common in an open repair, but local complications more common in an EVAR.
Long term benefit may not be sustained including device failure or there can be leaks leading to pseudoaneurysma.
Renal dysfunction, paraplegia, ischaemic colitis, infection, aorto-enteric fistulae.
REMEMBER AN ANEURYSM OF THE AAA is when it’s 1.5X the diameter of expected. This means in the aorta is 3cm. This same rule applies elsewhere too!
Indications for a catheter?
Acute monitoring of urine output Relief of retention Temporary therapy for urine incontinence Perineal wounds Clot prevention Post operative monitoring Sterile diagnostic specimens.
What are the LUTS?
o Hesitancy o Poor stream o Intermittency o Terminal dribbling o Increased frequency during the day or night o Nocturia o Urinary tract infection
