Passmedicine - Breast Surgery Flashcards
when is physiological breast feeding most common?
during pregnancy
what are causes of galactorrhoea?
response to emotional events
drugs, e.g. histamine receptor antagonists
what is the commonest pituitary tumour?
prolactinoma
define a microadenoma
<1cm diameter
define a macroadenoma
> 1cm diameter
describe the typical discharge produced in mammary duct ectasia
thick, green
or can present with cheese like nipple discharge + slit like retraction of nipple
in which group of people is mammary duct ectasia most common?
smokers
at what age does mammary duct ectasia tend to happen?
post-menopausally
what is the discharge of a breast carcinoma often like?
blood stained
+ mass/axillary LNs
what should ALL breast mass lesions undergo?
triple assessment
how are investigations for breast disease reported?
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
how is duct ectasia managed?
smoking cessation
severe - total duct excision may be warranted
what causes duct ectasia?
dilation of the milk duct due to ageing
apart from a green discharge what are other features of duct ectasia?
may have small lump right under nipple
finish the sentence:
‘duct ectasia is a normal variant of _____’
breast involution
how might periductal mastitis present?
inflammation
abscess
mammary duct fistula
what thing is strongly associated with periductal mastitis?
smoking
how is periductal mastitis treated?
antibiotics (co-amoxiclav)
if abscess - drainage
what is intraductal papilloma?
growth of a papilloma in a single duct
how does intraductal papilloma tend to present?
clear/blood stained discharge originating from a single duct
what organism tends to cause a breast abscess?
staph aureus
what commonly precedes a breast abcess?
lactational mastitis
how does breast abscess tend to present?
tender, fluctuant mass
how is breast abscess treated?
antibiotics
US guided aspiration
what is an indication for surgical debridement in breast abscess?
overlying skin necrosis
how might surgical debridement in breast abscess be complicated?
mammary duct fistula
what is present in 50% of cases of TB in the breast?
chronic breast/axillary sinus
how do you diagnose breast TB?
biopsy culture + histology
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)
what are the treatment options for breast cancer?
surgery radiotherapy hormone therapy biological therapy chemotherapy
what pts with breast cancer are offered surgery?
most (unless v. frail with metastatic disease)
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
what are complications of axillary node clearance surgically?
arm lymphedema, functional arm impairment
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
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
who should be offered breast reconstruction after their breast cancer surgery?
ALL women regardless of the op they have
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
who is offered adjuvant hormonal therapy for their breast canacer?
those with tumours that have +ve hormone receptors
what drugs are used for adjuvant hormone therapy in those with +ER status?
Tamoxifen (5Y) if pre/perimenopausal
Aromatase inhibitors if post-menopausal
give an example of an aromatase inhibitor
anastrozole, letrozole
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
what are SEs of tamoxifen?
increased risk of endometrial cancer VTE menopausal symptoms (hot flushes) osteoporosis menstrual disturbance (vaginal bleeding, amenorrhoea)
what is the most common biologic therapy used in breast cancer?
trastuzumab (herceptin)
who is herceptin useful for?
those with breast cancer with HER2 +ve status
who is herceptin CI in?
those with hx heart disease
what chemo regimen is used for breast cancer?
FEC-D
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
how common is mastitis in breastfeeding women?
affects 1 in 10
what is the first line management of mastitis?
continue breastfeeding
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
what is the first line antibiotic for treating mastitis?
flucloxacillin
what is the most common organism causing mastitis?
staph aureus
should you continue to breastfeed if on flucloxacillin for mastitis?
yes
if mastitis is left untreated what can develop?
breast abscess
what kind of tissue do ductal carcinomas arise from?
duct tissue
what kind of tissue do lobular carcinomas arise from?
lobular tissue
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
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
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
what is paget’s diseases of the nipple?
eczematoid change of the nipple associated with underlying breast malignancy (usually ductal invasive carcinoma)
what is inflammatory breast cancer?
where cancerous cells block the lymph drainage –> inflamed appearance of the breast
what do breast fibroadenomas develop from?
a whole lobule
how do fibroadenomas present?
as mobile firm breast lumps that are discrete and non-tender
what fibroadenomas would you excise?
those >3cm
do fibroadenomas come with an increase in risk of malignancy?
no
what kind of drug is tamoxifen?
SERM - selective oestrogen receptor modulator
it is a partial oestrogen receptor antagonist + partial agonit
how do aromatase inhibitors work?
reduce peripheral oestrogen synthesis
what adverse effects are associated with aromatase inhibitors?
osteoporosis (DEXA scan before start on Rx)
hot flushes
myalgia, arthalgia
insomnia
in which age group are fibroadenomas common?
those under 30
what is fibroadenosis?
lumpy breasts with are painful and may worsen prior to menstruation
who is fibroadenosis most common in?
middle aged women
how does breast cancer tend to present?
hard, irregular lump
nipple inversion/skin tethering
what are papillomas?
local areas of epithelial proliferation
who is fat necrosis of the breast more common in?
obese women with large breasts
what does fat necrosis tend to follow?
trivial/unnoticed trauma
how do fat necrosis lumps present?
initial inflammatory response so lesion is firm + round, but may develop into hard, irregular breast lump
should you investigate fat necrosis further?
yes it is rare and may mimic breast cancer, always investigate
how do breast abscesses present?
red, hot tender swelling
how to breast cysts tend to present?
smooth, soft, discrete lumps (may be fluctuant)
is there an increased risk of breast cancer with a breast cyst?
small increased risk, especially if younger
how should breast cysts be managed?
aspiration
if blood stained/persistently refilling - biopsy/excise
how should fat necrosis be investigated?
imaging + core biopsy
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
is there an increased risk of malignancy with sclerosing adenosis?
no
what does sclerosing adenosis cause?
distortion of the distal lobular unit without hyperplasia
how should sclerosing adenosis be managed?
biopsy lesion
excision is not manadatory
how might epithelial hyperplasia in the breast present?
anything from generalised lumpiness to a discrete lump
what is epithelial hyperplasia?
increased cellularity of the terminal lobular unit
does epithelial hyperplasia carry an increased risk of malignancy?
only if there is a FH of breast cancer or atypical features present
how is epithelial hyperplasia managed?`
if no atypical features - conservative
atypical features - close monitoring/surgical resection
how is duct papilloma managed?
US scan/galactogram
microdochectomy (surgical removal of a lactiferous duct)
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
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
how often are women screened for breast cancer?
every 3 years
what imaging method is used to screen for breast cancer?
mammography
under what age is the breast still undergoing development?
under 25
what is happening during breast development?
lobular units are being formed + a dense stroma is formed within the breast tissue
what are the 3 types of fibroadenomas?
juvenile
common
giant (>4cm)
what size of fibroadenoma should you take a core biopsy and why?
> 4cm
to exclude a phyllodes tumour
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
how can fibroadenomas be removed?
shelled out through a circumareolar incision
smaller lesions can be removed using a mammotome
who do breast cysts tend to occur in?
perimenopausal women
what causes breast cysts?
distended + involuted lobules
what sign do breast cysts sometimes show on mammography?
halo appearance
how should breast cysts be managed?
if symptomatic - aspirate + re-examine later to ensure lump has gone
how does paget’s disease differ from eczema of the nipple?
it involves the nipple primarily + often spreads laterally to areola (opposite for eczema)
how do you diagnose paget’s disease?
punch biopsy
mammography
US of breast
how do you manage paget’s?
treat underlying malignancy
how is duct ectasia managed?
if nipple discharge is troublesome can be treated with microdochectomy (if young) or total duct excision (if older)
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
if you have a BRCA mutation what is the lifetime risk of developing breast or ovarian cancer?
40%
what % of breast cancers do BRCA1 + 2 mutations account for?
5-10%
how are BRCA mutations inherited?
AD
what kind of nipple discharge is most likely to be associated with hormonal changes?
bilateral pale/colourless discharge during a pubertal age
what is mondor’s disease of the breast?
localised thrombophlebitis of a breast vein
What size of tumour tends to attract recommendation for mastectomy?
> 4cm
give examples of reconstructive breast surgery?
latissmus dorsi myocutaneous flab
pectoral implants
what prognostic index is used to give an indication of survival in breast cancer?
Nottingham Prognostic Index
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
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
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
who should you consider for a non-urgent referral to a breast cancer specialist?
<30 + unexplained breast lump with or without pain
