Passmedicine - Breast Surgery Flashcards
1
Q
when is physiological breast feeding most common?
A
during pregnancy
2
Q
what are causes of galactorrhoea?
A
response to emotional events
drugs, e.g. histamine receptor antagonists
3
Q
what is the commonest pituitary tumour?
A
prolactinoma
4
Q
define a microadenoma
A
<1cm diameter
5
Q
define a macroadenoma
A
> 1cm diameter
6
Q
describe the typical discharge produced in mammary duct ectasia
A
thick, green
or can present with cheese like nipple discharge + slit like retraction of nipple
7
Q
in which group of people is mammary duct ectasia most common?
A
smokers
8
Q
at what age does mammary duct ectasia tend to happen?
A
post-menopausally
9
Q
what is the discharge of a breast carcinoma often like?
A
blood stained
+ mass/axillary LNs
10
Q
what should ALL breast mass lesions undergo?
A
triple assessment
11
Q
how are investigations for breast disease reported?
A
investigation type (e.g. M for mammography) + numerical code: 1 = no abnormality 2 = abnormality with benign features 3 = indeterminate probably benign 4 = indeterminate probably malignant 5 = malignant
12
Q
how is duct ectasia managed?
A
smoking cessation
severe - total duct excision may be warranted
13
Q
what causes duct ectasia?
A
dilation of the milk duct due to ageing
14
Q
apart from a green discharge what are other features of duct ectasia?
A
may have small lump right under nipple
15
Q
finish the sentence:
‘duct ectasia is a normal variant of _____’
A
breast involution
16
Q
how might periductal mastitis present?
A
inflammation
abscess
mammary duct fistula
17
Q
what thing is strongly associated with periductal mastitis?
A
smoking
18
Q
how is periductal mastitis treated?
A
antibiotics (co-amoxiclav)
if abscess - drainage
19
Q
what is intraductal papilloma?
A
growth of a papilloma in a single duct
20
Q
how does intraductal papilloma tend to present?
A
clear/blood stained discharge originating from a single duct
21
Q
what organism tends to cause a breast abscess?
A
staph aureus
22
Q
what commonly precedes a breast abcess?
A
lactational mastitis
23
Q
how does breast abscess tend to present?
A
tender, fluctuant mass
24
Q
how is breast abscess treated?
A
antibiotics
US guided aspiration
25
what is an indication for surgical debridement in breast abscess?
overlying skin necrosis
26
how might surgical debridement in breast abscess be complicated?
mammary duct fistula
27
what is present in 50% of cases of TB in the breast?
chronic breast/axillary sinus
28
how do you diagnose breast TB?
biopsy culture + histology
29
what does snowstorm sign on US of axillary LNs indicate?
Extracapsular breast implant rupture (due to leakage of silicone which drains into the lymphatic system)
30
what are the treatment options for breast cancer?
```
surgery
radiotherapy
hormone therapy
biological therapy
chemotherapy
```
31
what pts with breast cancer are offered surgery?
most (unless v. frail with metastatic disease)
32
prior to surgery for breast cancer what determines management?
presence/absence of axillary lymphadenopathy
no palpable axillary LNs - have pre-op US before primary surgery (if +ve --> SNB to assess global burden)
palpable LNs - axillary node clearance is indicated at primary surgery
33
what are complications of axillary node clearance surgically?
arm lymphedema, functional arm impairment
34
what are the criteria for having a wide local excision as treatment for breast cancer?
```
solitary lesion
peripheral tumour
small lesion in large breast
DCIS <4cm
patient choice
```
35
what are the criteria for having a mastectomy as treatment for breast cancer?
```
multifocal tumour
central tumour
large lesion in small breast
DCIS >4cm
patient choice
```
36
who should be offered breast reconstruction after their breast cancer surgery?
ALL women regardless of the op they have
37
which women should get radiotherapy after their surgery? why is this? what type of radiotherapy should they get?
those who have had a wide-local excision OR those who've had a mastectomy for T3-4 tumours or have 4+ +ve axillary LNs
it decreases risk of recurrent by 2/3rd
whole breast radiotherapy
38
who is offered adjuvant hormonal therapy for their breast canacer?
those with tumours that have +ve hormone receptors
39
what drugs are used for adjuvant hormone therapy in those with +ER status?
Tamoxifen (5Y) if pre/perimenopausal
Aromatase inhibitors if post-menopausal
40
give an example of an aromatase inhibitor
anastrozole, letrozole
41
why are different hormone therapies given to pre/peri and post menopausal women with +ER breast cancer?
in post-menopausal women aromatisation accounts for the majority of oestrogen production
42
what are SEs of tamoxifen?
```
increased risk of endometrial cancer
VTE
menopausal symptoms (hot flushes)
osteoporosis
menstrual disturbance (vaginal bleeding, amenorrhoea)
```
43
what is the most common biologic therapy used in breast cancer?
trastuzumab (herceptin)
44
who is herceptin useful for?
those with breast cancer with HER2 +ve status
45
who is herceptin CI in?
those with hx heart disease
46
what chemo regimen is used for breast cancer?
FEC-D
47
when might chemo be used for breast cancer treatment?
prior to surgery to downstage a primary lesion
| after surgery, e.g. if there is nodal dx
48
how common is mastitis in breastfeeding women?
affects 1 in 10
49
what is the first line management of mastitis?
continue breastfeeding
50
what are indications for giving antibiotics for mastitis?
if systemically unwell, nipple fissure present, if symptoms do not improve after 12-24h wiht effective milk removal or culture indicates infection
51
what is the first line antibiotic for treating mastitis?
flucloxacillin
52
what is the most common organism causing mastitis?
staph aureus
53
should you continue to breastfeed if on flucloxacillin for mastitis?
yes
54
if mastitis is left untreated what can develop?
breast abscess
55
what kind of tissue do ductal carcinomas arise from?
duct tissue
56
what kind of tissue do lobular carcinomas arise from?
lobular tissue
57
what is the difference become a breast carcinoma in situ and an invasive breast cancer?
in situ = cancer hasn't spread beyond local tissue
| invasive = spread
58
what are the most common breast cancer types?
invasive ductal carcinoma - most common (recently been renamed no special type)
Special type - invasive lobular carcinoma, ductal carcinoma in situ, lobular carcinoma in situ
59
give examples of rarer types of breast cancer
```
medullary breast cancer
mucinous (mucoid/colloid) breast cancer
tubular breast cancer
adenoid cystic carcinoma of the breast
metaplastic breast cancer
lymphoma of the breast
basal type breast cancer
phyllodes or cystosarcoma phyllodes
papillary breast cancer
```
60
what is paget's diseases of the nipple?
eczematoid change of the nipple associated with underlying breast malignancy (usually ductal invasive carcinoma)
61
what is inflammatory breast cancer?
where cancerous cells block the lymph drainage --> inflamed appearance of the breast
62
what do breast fibroadenomas develop from?
a whole lobule
63
how do fibroadenomas present?
as mobile firm breast lumps that are discrete and non-tender
64
what fibroadenomas would you excise?
those >3cm
65
do fibroadenomas come with an increase in risk of malignancy?
no
66
what kind of drug is tamoxifen?
SERM - selective oestrogen receptor modulator
| it is a partial oestrogen receptor antagonist + partial agonit
67
how do aromatase inhibitors work?
reduce peripheral oestrogen synthesis
68
what adverse effects are associated with aromatase inhibitors?
osteoporosis (DEXA scan before start on Rx)
hot flushes
myalgia, arthalgia
insomnia
69
in which age group are fibroadenomas common?
those under 30
70
what is fibroadenosis?
lumpy breasts with are painful and may worsen prior to menstruation
71
who is fibroadenosis most common in?
middle aged women
72
how does breast cancer tend to present?
hard, irregular lump
| nipple inversion/skin tethering
73
what are papillomas?
local areas of epithelial proliferation
74
who is fat necrosis of the breast more common in?
obese women with large breasts
75
what does fat necrosis tend to follow?
trivial/unnoticed trauma
76
how do fat necrosis lumps present?
initial inflammatory response so lesion is firm + round, but may develop into hard, irregular breast lump
77
should you investigate fat necrosis further?
yes it is rare and may mimic breast cancer, always investigate
78
how do breast abscesses present?
red, hot tender swelling
79
how to breast cysts tend to present?
smooth, soft, discrete lumps (may be fluctuant)
80
is there an increased risk of breast cancer with a breast cyst?
small increased risk, especially if younger
81
how should breast cysts be managed?
aspiration
| if blood stained/persistently refilling - biopsy/excise
82
how should fat necrosis be investigated?
imaging + core biopsy
83
how does sclerosing adenosis (radial scars + complex sclerosing lesions) tend to present?
breast lump or breast pain
nb it is a disorder of breast involution
84
is there an increased risk of malignancy with sclerosing adenosis?
no
85
what does sclerosing adenosis cause?
distortion of the distal lobular unit without hyperplasia
86
how should sclerosing adenosis be managed?
biopsy lesion
| excision is not manadatory
87
how might epithelial hyperplasia in the breast present?
anything from generalised lumpiness to a discrete lump
88
what is epithelial hyperplasia?
increased cellularity of the terminal lobular unit
89
does epithelial hyperplasia carry an increased risk of malignancy?
only if there is a FH of breast cancer or atypical features present
90
how is epithelial hyperplasia managed?`
if no atypical features - conservative
atypical features - close monitoring/surgical resection
91
how is duct papilloma managed?
US scan/galactogram
microdochectomy (surgical removal of a lactiferous duct)
92
who is eligible for breast cancer screening?
women aged 50-70
(being extended to 47-73)
over 70 - make own appointments but still encouraged to have mammogram
93
who may be referred for earlier screening due to their risk of familial breast cancer?
1 1st or 2nd degree relative diagnosed with breast cancer +:
- age of diagnosis <40
- bilateral breast cancer
- male breast cancer
- ovarian cancer
- jewish ancestry
- sarcoma in relative younger than 45
- glioma or childhood adrenal cortical carcinomas
- complicated patterns of multiple cancers at a young age
- paternal hx of breast cancer (2+ relatives on father's side)
or if 2 first degree or one first and one second degree relative diagnosed with breast/ovarian cancer at any age or 3 first/2nd degree relatives diagnosed at any age
94
how often are women screened for breast cancer?
every 3 years
95
what imaging method is used to screen for breast cancer?
mammography
96
under what age is the breast still undergoing development?
under 25
97
what is happening during breast development?
lobular units are being formed + a dense stroma is formed within the breast tissue
98
what are the 3 types of fibroadenomas?
juvenile
common
giant (>4cm)
99
what size of fibroadenoma should you take a core biopsy and why?
>4cm
| to exclude a phyllodes tumour
100
what is the natural history of fibroadenomas?
10% increase in size
30% regress
remainder stay the same
BUT during pregnancy + lactation may increase in size and sequester milk
101
how can fibroadenomas be removed?
shelled out through a circumareolar incision
| smaller lesions can be removed using a mammotome
102
who do breast cysts tend to occur in?
perimenopausal women
103
what causes breast cysts?
distended + involuted lobules
104
what sign do breast cysts sometimes show on mammography?
halo appearance
105
how should breast cysts be managed?
if symptomatic - aspirate + re-examine later to ensure lump has gone
106
how does paget's disease differ from eczema of the nipple?
it involves the nipple primarily + often spreads laterally to areola (opposite for eczema)
107
how do you diagnose paget's disease?
punch biopsy
mammography
US of breast
108
how do you manage paget's?
treat underlying malignancy
109
how is duct ectasia managed?
if nipple discharge is troublesome can be treated with microdochectomy (if young) or total duct excision (if older)
110
what are RFs for breast cancer?
```
BRCA1, BRCA2 genes
1st degree premenopausal with breast cancer
nulloparity, 1st pregnancy >30y
early menarche, late menopause
combined HRT, COCP
past breast cancer
non-breastfeeding
ionising radiation
p53 gene mutations
obesity
prev. surgery for benign disease
```
111
if you have a BRCA mutation what is the lifetime risk of developing breast or ovarian cancer?
40%
112
what % of breast cancers do BRCA1 + 2 mutations account for?
5-10%
113
how are BRCA mutations inherited?
AD
114
what kind of nipple discharge is most likely to be associated with hormonal changes?
bilateral pale/colourless discharge during a pubertal age
115
what is mondor's disease of the breast?
localised thrombophlebitis of a breast vein
116
What size of tumour tends to attract recommendation for mastectomy?
>4cm
117
give examples of reconstructive breast surgery?
latissmus dorsi myocutaneous flab
| pectoral implants
118
what prognostic index is used to give an indication of survival in breast cancer?
Nottingham Prognostic Index
119
how do you calculate nottingham prognostic index?
tumour size x 0.2 + LN score (see below) + grade score (see below)
score 1 - 0 LN involved - grade 1
score 2 - 1-3 LNs involved - grade 2
score 3 - >3 LNs involved - grade 3
120
what pts should you refer using a suspected cancer pathway referral (for an appt within 2w) for breast cancer?
age 30+ + unexplained breast lump w/wo pain
| age 50+ + symptoms in 1 nipple only: discharge, retraction, or other changes of concern
121
what pts should you CONSIDER referring using a suspected cancer pathway referral (for an appt within 2w) for breast cancer?
Someone with skin changes that suggest breast cancer or age 30+ with unexplained lump in axilla
122
who should you consider for a non-urgent referral to a breast cancer specialist?
<30 + unexplained breast lump with or without pain
