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Reproduction > Passmedicine - Breast Surgery > Flashcards

Passmedicine - Breast Surgery Flashcards

1
Q

when is physiological breast feeding most common?

A

during pregnancy

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2
Q

what are causes of galactorrhoea?

A

response to emotional events

drugs, e.g. histamine receptor antagonists

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3
Q

what is the commonest pituitary tumour?

A

prolactinoma

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4
Q

define a microadenoma

A

<1cm diameter

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5
Q

define a macroadenoma

A

> 1cm diameter

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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

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7
Q

in which group of people is mammary duct ectasia most common?

A

smokers

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8
Q

at what age does mammary duct ectasia tend to happen?

A

post-menopausally

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9
Q

what is the discharge of a breast carcinoma often like?

A

blood stained

+ mass/axillary LNs

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10
Q

what should ALL breast mass lesions undergo?

A

triple assessment

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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
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12
Q

how is duct ectasia managed?

A

smoking cessation

severe - total duct excision may be warranted

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13
Q

what causes duct ectasia?

A

dilation of the milk duct due to ageing

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14
Q

apart from a green discharge what are other features of duct ectasia?

A

may have small lump right under nipple

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15
Q

finish the sentence:

‘duct ectasia is a normal variant of _____’

A

breast involution

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16
Q

how might periductal mastitis present?

A

inflammation
abscess
mammary duct fistula

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17
Q

what thing is strongly associated with periductal mastitis?

A

smoking

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18
Q

how is periductal mastitis treated?

A

antibiotics (co-amoxiclav)

if abscess - drainage

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19
Q

what is intraductal papilloma?

A

growth of a papilloma in a single duct

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20
Q

how does intraductal papilloma tend to present?

A

clear/blood stained discharge originating from a single duct

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21
Q

what organism tends to cause a breast abscess?

A

staph aureus

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22
Q

what commonly precedes a breast abcess?

A

lactational mastitis

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23
Q

how does breast abscess tend to present?

A

tender, fluctuant mass

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24
Q

how is breast abscess treated?

A

antibiotics

US guided aspiration

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25
Q

what is an indication for surgical debridement in breast abscess?

A

overlying skin necrosis

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26
Q

how might surgical debridement in breast abscess be complicated?

A

mammary duct fistula

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27
Q

what is present in 50% of cases of TB in the breast?

A

chronic breast/axillary sinus

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28
Q

how do you diagnose breast TB?

A

biopsy culture + histology

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29
Q

what does snowstorm sign on US of axillary LNs indicate?

A

Extracapsular breast implant rupture (due to leakage of silicone which drains into the lymphatic system)

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30
Q

what are the treatment options for breast cancer?

A 
surgery
radiotherapy
hormone therapy
biological therapy
chemotherapy
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31
Q

what pts with breast cancer are offered surgery?

A

most (unless v. frail with metastatic disease)

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32
Q

prior to surgery for breast cancer what determines management?

A

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

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33
Q

what are complications of axillary node clearance surgically?

A

arm lymphedema, functional arm impairment

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34
Q

what are the criteria for having a wide local excision as treatment for breast cancer?

A 
solitary lesion
peripheral tumour
small lesion in large breast
DCIS <4cm
patient choice
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35
Q

what are the criteria for having a mastectomy as treatment for breast cancer?

A 
multifocal tumour
central tumour
large lesion in small breast
DCIS >4cm
patient choice
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36
Q

who should be offered breast reconstruction after their breast cancer surgery?

A

ALL women regardless of the op they have

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37
Q

which women should get radiotherapy after their surgery? why is this? what type of radiotherapy should they get?

A

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

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38
Q

who is offered adjuvant hormonal therapy for their breast canacer?

A

those with tumours that have +ve hormone receptors

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39
Q

what drugs are used for adjuvant hormone therapy in those with +ER status?

A

Tamoxifen (5Y) if pre/perimenopausal

Aromatase inhibitors if post-menopausal

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40
Q

give an example of an aromatase inhibitor

A

anastrozole, letrozole

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41
Q

why are different hormone therapies given to pre/peri and post menopausal women with +ER breast cancer?

A

in post-menopausal women aromatisation accounts for the majority of oestrogen production

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42
Q

what are SEs of tamoxifen?

A 
increased risk of endometrial cancer
VTE
menopausal symptoms (hot flushes)
osteoporosis
menstrual disturbance (vaginal bleeding, amenorrhoea)
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43
Q

what is the most common biologic therapy used in breast cancer?

A

trastuzumab (herceptin)

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44
Q

who is herceptin useful for?

A

those with breast cancer with HER2 +ve status

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45
Q

who is herceptin CI in?

A

those with hx heart disease

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46
Q

what chemo regimen is used for breast cancer?

A

FEC-D

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47
Q

when might chemo be used for breast cancer treatment?

A

prior to surgery to downstage a primary lesion

after surgery, e.g. if there is nodal dx

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48
Q

how common is mastitis in breastfeeding women?

A

affects 1 in 10

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49
Q

what is the first line management of mastitis?

A

continue breastfeeding

50
Q

what are indications for giving antibiotics for mastitis?

A

if systemically unwell, nipple fissure present, if symptoms do not improve after 12-24h wiht effective milk removal or culture indicates infection

51
Q

what is the first line antibiotic for treating mastitis?

A

flucloxacillin

52
Q

what is the most common organism causing mastitis?

A

staph aureus

53
Q

should you continue to breastfeed if on flucloxacillin for mastitis?

A

yes

54
Q

if mastitis is left untreated what can develop?

A

breast abscess

55
Q

what kind of tissue do ductal carcinomas arise from?

A

duct tissue

56
Q

what kind of tissue do lobular carcinomas arise from?

A

lobular tissue

57
Q

what is the difference become a breast carcinoma in situ and an invasive breast cancer?

A

in situ = cancer hasn’t spread beyond local tissue

invasive = spread

58
Q

what are the most common breast cancer types?

A

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
Q

give examples of rarer types of breast cancer

A 
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
Q

what is paget’s diseases of the nipple?

A

eczematoid change of the nipple associated with underlying breast malignancy (usually ductal invasive carcinoma)

61
Q

what is inflammatory breast cancer?

A

where cancerous cells block the lymph drainage –> inflamed appearance of the breast

62
Q

what do breast fibroadenomas develop from?

A

a whole lobule

63
Q

how do fibroadenomas present?

A

as mobile firm breast lumps that are discrete and non-tender

64
Q

what fibroadenomas would you excise?

A

those >3cm

65
Q

do fibroadenomas come with an increase in risk of malignancy?

A

no

66
Q

what kind of drug is tamoxifen?

A

SERM - selective oestrogen receptor modulator

it is a partial oestrogen receptor antagonist + partial agonit

67
Q

how do aromatase inhibitors work?

A

reduce peripheral oestrogen synthesis

68
Q

what adverse effects are associated with aromatase inhibitors?

A

osteoporosis (DEXA scan before start on Rx)
hot flushes
myalgia, arthalgia
insomnia

69
Q

in which age group are fibroadenomas common?

A

those under 30

70
Q

what is fibroadenosis?

A

lumpy breasts with are painful and may worsen prior to menstruation

71
Q

who is fibroadenosis most common in?

A

middle aged women

72
Q

how does breast cancer tend to present?

A

hard, irregular lump

nipple inversion/skin tethering

73
Q

what are papillomas?

A

local areas of epithelial proliferation

74
Q

who is fat necrosis of the breast more common in?

A

obese women with large breasts

75
Q

what does fat necrosis tend to follow?

A

trivial/unnoticed trauma

76
Q

how do fat necrosis lumps present?

A

initial inflammatory response so lesion is firm + round, but may develop into hard, irregular breast lump

77
Q

should you investigate fat necrosis further?

A

yes it is rare and may mimic breast cancer, always investigate

78
Q

how do breast abscesses present?

A

red, hot tender swelling

79
Q

how to breast cysts tend to present?

A

smooth, soft, discrete lumps (may be fluctuant)

80
Q

is there an increased risk of breast cancer with a breast cyst?

A

small increased risk, especially if younger

81
Q

how should breast cysts be managed?

A

aspiration

if blood stained/persistently refilling - biopsy/excise

82
Q

how should fat necrosis be investigated?

A

imaging + core biopsy

83
Q

how does sclerosing adenosis (radial scars + complex sclerosing lesions) tend to present?

A

breast lump or breast pain

nb it is a disorder of breast involution

84
Q

is there an increased risk of malignancy with sclerosing adenosis?

A

no

85
Q

what does sclerosing adenosis cause?

A

distortion of the distal lobular unit without hyperplasia

86
Q

how should sclerosing adenosis be managed?

A

biopsy lesion

excision is not manadatory

87
Q

how might epithelial hyperplasia in the breast present?

A

anything from generalised lumpiness to a discrete lump

88
Q

what is epithelial hyperplasia?

A

increased cellularity of the terminal lobular unit

89
Q

does epithelial hyperplasia carry an increased risk of malignancy?

A

only if there is a FH of breast cancer or atypical features present

90
Q

how is epithelial hyperplasia managed?`

A

if no atypical features - conservative

atypical features - close monitoring/surgical resection

91
Q

how is duct papilloma managed?

A

US scan/galactogram

microdochectomy (surgical removal of a lactiferous duct)

92
Q

who is eligible for breast cancer screening?

A

women aged 50-70
(being extended to 47-73)

over 70 - make own appointments but still encouraged to have mammogram

93
Q

who may be referred for earlier screening due to their risk of familial breast cancer?

A

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
Q

how often are women screened for breast cancer?

A

every 3 years

95
Q

what imaging method is used to screen for breast cancer?

A

mammography

96
Q

under what age is the breast still undergoing development?

A

under 25

97
Q

what is happening during breast development?

A

lobular units are being formed + a dense stroma is formed within the breast tissue

98
Q

what are the 3 types of fibroadenomas?

A

juvenile
common
giant (>4cm)

99
Q

what size of fibroadenoma should you take a core biopsy and why?

A

> 4cm

to exclude a phyllodes tumour

100
Q

what is the natural history of fibroadenomas?

A

10% increase in size
30% regress
remainder stay the same

BUT during pregnancy + lactation may increase in size and sequester milk

101
Q

how can fibroadenomas be removed?

A

shelled out through a circumareolar incision

smaller lesions can be removed using a mammotome

102
Q

who do breast cysts tend to occur in?

A

perimenopausal women

103
Q

what causes breast cysts?

A

distended + involuted lobules

104
Q

what sign do breast cysts sometimes show on mammography?

A

halo appearance

105
Q

how should breast cysts be managed?

A

if symptomatic - aspirate + re-examine later to ensure lump has gone

106
Q

how does paget’s disease differ from eczema of the nipple?

A

it involves the nipple primarily + often spreads laterally to areola (opposite for eczema)

107
Q

how do you diagnose paget’s disease?

A

punch biopsy
mammography
US of breast

108
Q

how do you manage paget’s?

A

treat underlying malignancy

109
Q

how is duct ectasia managed?

A

if nipple discharge is troublesome can be treated with microdochectomy (if young) or total duct excision (if older)

110
Q

what are RFs for breast cancer?

A 
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
Q

if you have a BRCA mutation what is the lifetime risk of developing breast or ovarian cancer?

A

40%

112
Q

what % of breast cancers do BRCA1 + 2 mutations account for?

A

5-10%

113
Q

how are BRCA mutations inherited?

A

AD

114
Q

what kind of nipple discharge is most likely to be associated with hormonal changes?

A

bilateral pale/colourless discharge during a pubertal age

115
Q

what is mondor’s disease of the breast?

A

localised thrombophlebitis of a breast vein

116
Q

What size of tumour tends to attract recommendation for mastectomy?

A

> 4cm

117
Q

give examples of reconstructive breast surgery?

A

latissmus dorsi myocutaneous flab

pectoral implants

118
Q

what prognostic index is used to give an indication of survival in breast cancer?

A

Nottingham Prognostic Index

119
Q

how do you calculate nottingham prognostic index?

A

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
Q

what pts should you refer using a suspected cancer pathway referral (for an appt within 2w) for breast cancer?

A

age 30+ + unexplained breast lump w/wo pain

age 50+ + symptoms in 1 nipple only: discharge, retraction, or other changes of concern

121
Q

what pts should you CONSIDER referring using a suspected cancer pathway referral (for an appt within 2w) for breast cancer?

A

Someone with skin changes that suggest breast cancer or age 30+ with unexplained lump in axilla

122
Q

who should you consider for a non-urgent referral to a breast cancer specialist?

A

<30 + unexplained breast lump with or without pain

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