Last minute surgical revision

Question 1

What is the blood supply to the breast?

Answer 1

Axillary artery and the internal mammary artery.

Question 2

What characteristics of a mass would make you think it required no immediate action in the breast?

Answer 2

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.

Question 3

Discuss the differences betwee cyclical and non cyclical. Which ddx do you not want to miss?

Answer 3

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.

Question 4

How do we manage mastalgia after excluding serious pathologies?

Answer 4

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.

Question 5

Aside from ab’s how do we treat mastitis

Answer 5

Therapeutic USS

Question 6

Commonest ddx for a bloodstained nipple discharge?

Answer 6

Intraductal papilloma.

Question 7

DDx if there is a radial scar? What about calcification?

Answer 7

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.

Question 8

Uses of USS when evaluating breast?

Answer 8

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.

Question 9

Most common non-proliferative lesion vs proliferative?

Answer 9

Non is cyst, prolif is fibroadenoma.

Question 10

Why do you need to do a core biopsy for fibroadenomas?

Answer 10

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.

Question 11

What is duct ectasia?

Answer 11

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. 


Question 12

Breast cancer risk factors?

Answer 12

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

Question 13

What are the types of breast cancer?

Answer 13

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.

Question 14

Where do most breast cancers occur?

Answer 14

Upper outer quadrant, even involving the tail of spence. Hence we need to be palpating all the way up here.

Question 15

Two new ways to biopsy a breast?

Answer 15

Hookwire biopsy, and of course can do an excisional biopsy.

Question 16

Some key staging points of breast cancer?

Answer 16

T1: <2cm
T2: 2-5
T3 >5cm
T4: Extends to chest wall or skin

N1: axillary
N3: infraclavicular
(both ipsilateral)

Question 17

When do we do a sentinel node biopsy?

Answer 17

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.

Question 18

Describe the use of adjuvant / neoadjuvant treatments with breast cancer?

Answer 18

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)

Question 19

How do follow up breast cancer?

Answer 19

• 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

Question 20

4 types of BCC?

Answer 20

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.

Question 21

Melanoma is an important disease in NQ. What are the two growth phases?

Answer 21

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.

Question 22

What is Hutchinson’s sign?

Answer 22

It’s the melanoma in the nail

Question 23

How can we biopsy?

Answer 23

Punch, shave, incisional, excisional,

Question 24

Discuss the surgical margins for these things?

Answer 24

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

Question 25

Blood supply to the leg please:

Answer 25

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.

Question 26

Define critical limb ischaemia?

Answer 26

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.

Question 27

Signs of poor perfusion on examination?

Answer 27

Hair loss, hypertrophic nails, atrophic muscles, skin ulcerations and infections, slow cap refil, prolonged pallor with elevation and rubor on dependency (Burger’s).

Question 28

Discuss some common patterns of the PVD?

Answer 28

• 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

Question 29

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?

Answer 29

Leg pressure over the arm pressure. Done with a doppler and a cuff

Question 30

Management steps of PVD?

Answer 30

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

Question 31

Describe the management of acute arterial occlusion?

Answer 31

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.

Question 32

How do workup acute arterial occlusion? Manage?

Answer 32

• 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.

Question 33

Complications of the actue arterial ischaemia?

Answer 33

Compartment syndrome: fasciotomy.
Arrythmia and death with reperfusion injury
Renal failure/ multi organ failure.

Question 34

Debakey types?

Answer 34

3 is just stanford B. 1 is whole aorta, and 2 is just ascending.

Question 35

What is a new clinical feature you learnt re. dissections? Discuss the management please?

Answer 35

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????

Question 36

Types of abdominal aortic aneurysma?

Answer 36

Infrarenal (98%) 
Suprarenal 
Pararenal - this is when the renal arteries arise from the aneurysmal segment of artery. 
Juxtarenal 
Infrarenal

Question 37

Aetiology of AAA?

Answer 37

Degenerative 
Traumatic 
Mycotic 
Connective tissue (Marfan's, Ehlers Danlos) 
Vasculitis 
Infectious (syphilis)

Question 38

What imaging do we use to work up? Management?

Answer 38

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.

Question 39

Complications of an Aortic Aneurysm repair?

Answer 39

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!

Question 40

Indications for a catheter?

Answer 40

Acute monitoring of urine output
Relief of retention 
Temporary therapy for urine incontinence 
Perineal wounds
Clot prevention 
Post operative monitoring 
Sterile diagnostic specimens.

Question 41

What are the LUTS?

Answer 41

o	Hesitancy
o	Poor stream
o	Intermittency
o	Terminal dribbling
o	Increased frequency during the day or night
o	Nocturia
o	Urinary tract infection