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General Surgery > Part two - breast > Flashcards

Part two - breast Flashcards

1
Q

Differential diagnosis for nipple discharge

A
  • Physiological/lactational
    • Infection
    • Fibrocystic disease
    • Duct ectasia
    • Intraduct papilloma
    • Intraduct carcinoma
    • Rare - hypothyroidism and pituitary tumours
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2
Q

Assessment and treatment for nipple discharge

A

Reassure if multiduct and sebaceous or bilateral and mammogram up-to-date

Triple assess otherwise and treat findings.

If triple assessment negative review in 3 months and reassess. If persistent offer microdochectomy or total duct excision

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3
Q

Pathological breast lesions associated with the terminal duct lobular unit

A 
Cyst
Sclerosing adenosis
Hyperplasia
Atypical hyperplasia
Small duct papilloma
Carcinoma
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4
Q

Pathological breast lesions associated with the lobular stroma

A

Phylloides tumour

Fibroadenoma

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5
Q

Pathological breast lesions associated with the large ducts and lactiferous sinuses

A

Duct ectasia
Recurrent subareolar abscess
Single duct papilloma
Paget’s disease

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6
Q

Pathological breast lesions associated with the interlobular stroma

A 
Fat necrosis
Lipoma
Fibrous tumour
Fibromatosis
Sarcoma
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7
Q

Describe the breast

A

A glandular appendage of the skin lying within the subcutaneous tissue and superficial fascia overlying ribs 2-6 from the midline to the MAL.

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8
Q

What is the blood supply to the breast?

A
  • Branches from the 2nd part of the axillary artery
    • Pectoral branches of the thoracoacromial trunk
    • Lateral thoracic artery
  • Internal thoracic artery (ITA / IMA)
    • Gives off prorating branches
      Largest perforators are the 2nd to 4th
  • Intercostal arteries from ITA
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9
Q

What is the anatomical basis of bony vertebral metastases in breast cancer?

A

Venous drainage via the posterior intercostal veins which join the vertebral veins

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10
Q

Describe the lymphatic drainage of the breast

A

Subareolar lymph plexus
80% to axilla
Remainder supraclavicular, parasternal (ITA) and posterior intercostal nodes
When there is lymph obstruction, drainage to opposite breast, cervical nodes, peritoneal cavity or inguinal nodes more common

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11
Q

What are the attachments of pectorals major?

A 
3 heads:
- Lateral sternum
- Medial clavicle
- 2nd - 6th costal cartilages
Inserts into bicipital groove of humerus
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12
Q

Nerve supply of pectorals major

A

Medial pectoral nerve C8 supplies lateral fibres

Lateral pectoral nerves (C6-7) supplies medial fibres

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13
Q

Describe the breast

A

A glandular appendage of the skin lying within the subcutaneous tissue and superficial fascia overlying ribs 2-6 from the midline to the MAL.

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14
Q

What is the blood supply to the breast?

A
  • Branches from the 2nd part of the axillary artery
    • Pectoral branches of the thoracoacromial trunk
    • Lateral thoracic artery
  • Internal thoracic artery (ITA / IMA)
    • Gives off prorating branches
      Largest perforators are the 2nd to 4th
  • Intercostal arteries from ITA
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15
Q

Levels of axillary lymph nodes

A

I - lateral to pec minor
II - behind pec minor
III - beyond medial border pec minor

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16
Q

Describe the lymphatic drainage of the breast

A

Subareolar lymph plexus
80% to axilla
Remainder supraclavicular, parasternal (ITA) and posterior intercostal nodes
When there is lymph obstruction, drainage to opposite breast, cervical nodes, peritoneal cavity or inguinal nodes more common

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17
Q

Insertions of pectorals minor

A

Variable origin form the ribs on the chest but usually 3rd to 5th

Inserts into coracoid process

Divides axillary artery into three parts

  • 1st part - proximal to muscle
  • 2nd part - behind
  • 3rd part - distal to muscle
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18
Q

Insertions serratus anterior

A
  • Digitations from the outer surface of the first 8 ribs near the costal cartilages
  • Inserts into medial border of scapula
  • Holds scapular to chest wall
  • Innervated by long thoracic nerve
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19
Q

Spinal roots of the brachial plexus

A

Ventral rami of C5-8 and T1

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20
Q

Contents of the axilla

A

Muscles - Long & short heads biceps, lat dirsi, trees major, pec minor, coracobrachialis
Vessels - axillary vein and artery
Nerves - cords of brachial plexus, long thoracic nerve
Lymph nodes - APICAL = anterior, posterior, infraclavicular, central, apical, lateral

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21
Q

Levels of axillary lymph nodes

A

I - lateral to pec minor
II - behind pec minor
III - beyond medial border pec minor

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22
Q

Structures piercing clavipectoral fascia

A

C - cephalic vein
A - acromiothoracic trunk
L - lateral pectoral nerve
L - lymphatics

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23
Q

Insertions of pectorals minor

A

Variable origin form the ribs on the chest but usually 3rd to 5th

Inserts into coracoid process

Divides axillary artery into three parts

  • 1st part - proximal to muscle
  • 2nd part - behind
  • 3rd part - distal to muscle
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24
Q

Insertions serratus anterior

A
  • Digitations from the outer surface of the first 8 ribs near the costal cartilages
  • Inserts into medial border of scapula
  • Holds scapular to chest wall
  • Innervated by long thoracic nerve
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25
Q

Spinal roots of the brachial plexus

A

Ventral rami of C5-8 and T1

26
Q

Axillary artery

A 
Continuation from SCA at lateral border 1st rib
1st part medial to upper border pec mini
- Superior thoracic
2nd part behind pec minor
- Thoraco-acromial trunk 
     - clavicular
     - humeral
     - acromial
     - pectoral
- Lateral thoracic
3rd part  lower pec minor to lower teres major
- Subscapular
     - thoracodorsal artery
     - circumflex scapular artery
- Anterior circumflex humeral
- Posterior circumflex humeral

Some Times Life Seems A Pain

27
Q

What is Paget’s disease of the breast?

A

Eczema-like eruption on the nipple and areola due to Paget’s cells in the nipple epidermis

Paget’s cells are large cells with pale cytoplasm and prominent nucleoli

28
Q

What are the two theories for the pathogenesis of Paget’s disease of the breast?

A

EPIDERMOTROPHIC THEORY
Paget cell arises from underlying mammary adenocarcinoma with neoplastic ductal epithelial cells migrating through the ductal system of the breast into the epidermis of the nipple

IN SITU TRANSFORMATION THEORY
Epidermal keratinocytes within the nipple transform into malignant Paget cells
PDB is an epidermal carcinoma in situ that is independent of any underlying ductal carcinoma

29
Q

Define fibroadenoma

A

Benign breast tumour, containing both glandular (epithelial) and stromal (connective tissue) components

30
Q

What is Li-Fraumeni syndrome

A

Rare autosomal dominantly inherited abnormality of p53 resulting in increased rate of sarcoma, breast, leukaemia and adrenal cancers

31
Q

Risk factors for male breast cancer

A 
Hyperoestrogenic states
- Klinefelter's syndrome (47XXY)
- Testicular dysgenesis/cryptorchidism
- Obesity
- Alcoholism and liver disease
Chest irradiation
Occupational exposures
- Electromagnetic fields
- High temperature
Genetic causes
- Up to 20% have a first degree relative with breast cancer
- BRCA2 mutation most common in males
- Cowden syndrome is rare
- CHEK2 rare
32
Q

Treatment of male breast cancer

A

Usually total mastectomy with SLNB +/- ALND
Post-mastectomy radiotherapy if:
- Large tumour
- > 3 axillary nodes involved
- High grade disease
Tamoxifen for 5 years if ER/PR positive (improves survival)
Adjuvant chemotherapy if lymph node positive

33
Q

Prognosis of male breast cancer

A

Same stage for stage but is usually more advanced at presentation

34
Q

Breast Birads Classification

A 
0 - needs additional imaging evaluation and/or prior mammograms for evaluation
1 - negative
2 - benign
3 - probably benign
4 - suspicious
5 - highly suspicious of malignancy
6 - known malignancy
35
Q

Indications for breast MRI

A
  • All woman less than 40 even if having mastectomy to check for contralateral disease
    • Lobular cancer (multifocality and bilaterally)
    • Suspicion of multifocal disease
    • Tumour size uncertain and planning WLE
    • Suspicion of chest wall invasion
    • High grade DCIS 20mm or more for WLE
    • Dense breasts in those less than 50 years
    • History of breast cancer < 40 years
    • Node positive with occult primary
    • Assessing loco-regional recurrence and differentiating from scar, particularly in reconstructed breasts
    • Assess silicone implant integrity when suspicion of rupture and USS negative
36
Q

Nottingham Prognostic Index (NPI)

A

Size - 0.2 x size in cm
Grade - I=1, II=2, III=3
Nodes - nil=1, 1-4=2, >4 =3

5.4 = 30% annual mortality

37
Q

Contraindications to breast conserving surgery with radiotherapy

A 
Large tumour (>4 cm)
Small breast vs tumour ratio
Multi-focal /-centric disease/ 
Extensive co-existent DCIS (>1 quadrant)
Skin involvement / Fixation
Inflammatory
Contraindications to radiotherapy
- Previous radiotherapy at the site
- Connective tissue disease
- Severe heart and/or lung disease
- Pregnancy
- +/- subareaolar tumour - cosmesis may be greatly compromised but can be done
Patient preference for mastectomy
- May not want the risk of having to undergo further surgery if margins not adequate
- Strong family history of breast cancer
38
Q

Margin for WLE for BCS

A

2mm

If margin less than this, consider the following before re-excision:

  * Patient age
  * Tumour histology - LVI, grade, extensive in situ component, type - eg lobular)
  * Which margin  - smaller margins may be accepted for superficial and deep margins
39
Q

Bloom-Richardson histologic grading system for breast cancer

A

Tubule formation 1-3
Mitotic count 1-3
Nuclear pleomorphism 1-3

Low grade (I) = 3-5
Intermediate grade (II) = 6-7
High grade (III) = 8-9
40
Q

Indications for SLNB in DCIS

A 
Large volume (palpable mass, mammographic mass, >3cm - definitely if >5cm)
High grade
Suspicion for invasive disease
Mastectomy (further SLNB impossible)
Reconstruction involving axilla
41
Q

What is DCIS

A

Abnormal proliferation of ductal epithelial cells with morphological features of malignancy but no basement membrane or stromal invasion and involving at least two ducts

42
Q

What is inflammatory breast cancer

A

A form of locally advanced breast cancer characterised by erythema, oedema, induration, warmth and tenderness of the skin resulting in peau d’orange - attributed to tumour emboli in derma lymphovascular spaces.

43
Q

What is HER2?

A

Human Epidermal Growth Factor Receptor 2
Transmembrane glycoprotein receptor
Critical regulator of cell cycle signalling
Over-expressed due to a gene mutation in up to 20% of breast cancers
Independent poor risk factor

44
Q

What is Herceptin

A

Trastuzumab (Herceptin) is a monoclonal antibody that binds to the extracellular domain of the human epidermal growth factor receptor 2 protein (HER-2).

It mediates antibody-dependent cellular cytotoxicity by inhibiting proliferation of cells which overexpress HER-2 protein.

45
Q

Define accessory breast and nipples

A

Residuals of mammary gland tissue due to incomplete regression of the mammary ridges.

Most commonly in the axilla but may occur anywhere along the milk lines

46
Q

Risk factors for male breast cancer

A

AGREE
Age
Genetics - BRCA 2, Cowden syndrome, CHEK2
Radiation
Estrogen exposure - Klinefelter’s, testicular dysgenesis, cryptorchidism, obesity, alcoholism, liver impairment
Exposure occupational - Electromagnetic fields, high temperature

47
Q

What is the association between Paget’s disease of the nipple and malignancy?

A

> 95% have an underlying malignancy of which half are clinically and mammographically occult.

  • 90% invasive
  • 10% DCIS
  • 90% HER2 positive
  • 50% hormone receptor positive
48
Q

Life time risk of breast cancer

A

3%
15% with ADH/ALH (5x)
30% with DCIS/LSIS (10x)

49
Q

How do you identify the axillary vie during axillary dissection?

A

Follow the anterior branches of the axillary vein
Follow the medial pectoral leash
Groove between biceps and triceps at 90 degrees
1cm above latissimus dorsi tendon
Immediately below axillary artery pulsation

50
Q

Risk factors for lymphoedema

A 
Extent of dissection
Number of nodes removed
Post-operative radiotherapy
Obesity
Arm infection
Trauma
51
Q

Hereditary breast cancer syndromes

A 
5% of all breast cancers
BRCA1 and BRCA2
Li-Fraumeni syndrome
Cowden's syndrome
Muir-Torre syndrome
Ataxia telangectasia
Hereditary diffuse gastric cancer
Peutz-Jegher's syndrome
52
Q

Five things to assess on a mammogram

A 
Symmetry
Architectural distortion
Masses
Calcifications
Densities
53
Q

Classify calcifications on mammogram

A

Typically benign

  • skin
  • vascular
  • popcorn-like
  • rod-like
  • round
  • punctate
  • milk of calcium
  • eggshell
  • dystrophic
  • suture

Intermediate concern

  • amorphous
  • indistinct

Concern for malignancy

  • pleomorphic microcalcifications
  • heterogeneous microcalcifications
  • fine linear calcifications
  • linear/branching calcifications
54
Q

Indications for mastectomy in DCIS

A 
Multifocal or multicentric
DCIS > 4cm
Contra-indication to radiotherapy
     - previous radiotherapy
     - CTD
     - severe cardiorespiratory disease
     - radiotherapy
Residual diseae / positive margins
Poor cosmesis
     - large tumour in small breast
     - location of disease
Patient preference
55
Q

Van Nuys Prognostic Index

Pronounced Van Nye

A

TRAP

Tumour size - 40
Resection margin - >10, 1-9, 60, <5 - no benefit from radiotherapy

56
Q

Role of tamoxifen in DCIS

A

Lowers disease recurrence or prevent development of invasive cancer in hormone receptor positive DCIS especially in those <50 years

57
Q

Granulomatous mastitis

A

Rare benign chronic non-caseating granulomas and microabscess confined to a breast lobule

58
Q

Management of granulomatous mastitis

A 
Drain sepsis
Exclude malignancy
Exclude secondary causes
- Infection
     -Tb
     -Histoplasmosis
- Systemic granulomatous disease
     -Sarcoidosis
     -Wegeners granulomatosis
High dose tetracycline and penicillin
Avoid excision due to persistent wound & discharge
Try steroids
Mastectomy
59
Q

Classify granulomatous mastitis

A 
Primary
- Aetiology unknown
- ? Corynebacterium
Secondary
- Granulomatous disease - sarcoid, Wegeners
- Granulomatous infection - Tb, histo
60
Q

Sub-types of DCIS

A

Comedo = central necrosis
Non-comedo
* Cribriform = sieve-like appearance
* Solid = ducts filled with malignant cells
* Papillary = papillary projections
* Micro-papillary

61
Q

Required information from breast cancer pathology report

A 
Size
Grade
Lymph nodes
Margins
Receptors

General Surgery (25 decks)

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