Senior Surgery > Breast

Question 1

Define axillary dissection

Answer 1

Axillary dissection (or axillary clearance) is a surgical procedure that incises the axilla to identify, examine, or remove lymph nodes. Axillary dissection has been the standard technique used in the staging and treatment of the axilla in breast cancer. Patients presenting with symptomatic early breast cancer have a 30-40% chance of having positive axillary nodes and 20-25% chance if presenting through a screening program

Question 2

Indications for axillary dissection

Answer 2

• Proven axillary disease

- Positive sentinel node biopsy

Question 3

Complications of axillary dissection

Answer 3

• No absolute contraindications
• If widespread disease, procedure controversial
• Not very painful
• Slight risk of wound infection
• Seroma 2-50%
• Temporary shoulder stiffness
• Lymphoedema of arm and breast
• Numb patch on upper arm - division of intracostobrachial nerve

Question 4

Types of benign ductal disease

Answer 4

Duct ectasia

Papilloma

Question 5

Intraductal papilloma describe

Answer 5

This is a benign, warty lesion usually located just behind the areola.

A small lump or a sticky, possibly blood-stained discharge may be noticed.
Women aged in their 40s are more likely to have just one but younger women may have multiple lesions.
Triple assessment is required in a specialist breast clinic, with examination, imaging and biopsy

Question 6

Mammary duct ectasia describe

Answer 6

This is a benign breast disease that can mimic invasive carcinoma clinically. The process that causes the condition is still being debated but histologically it is characterised by dilation of major ducts in the subareolar region. The ducts contain eosinophilic granular secretions and foamy histiocytes. The secretions may undergo calcification and this may be the presenting sign

Blood stained nipple discharge
Nipple inversion

Question 7

Management plan for intraductal papilloma

Answer 7

Breast biopsy is required for a definitive diagnosis and to rule out cancer.

Ultrasound, ductogram, and cytological examination of discharge for malignant cells are also useful

Usually surgical removal of papilloma and duct that it is in

Regular mammography (if multiple) as increased risk of developing cancer

Question 8

Prognosis for intraductal papilloma

Answer 8

Having a single (solitary) papilloma does not raise breast cancer risk unless it contains other breast changes, such as atypical hyperplasia. However, having multiple papillomas increases breast cancer risk slightly

Question 9

Management plan for mammary duct ectasia

Answer 9

Non-invasive imaging to investigate as most are benign

Ultrasound, ductography, ductal lavage and cytology. Mammogram useful screening tool in older women.

Usually self limiting

Persistent or recurrent cases are managed with surgical excision of the ducts below the nipple. A focused excision is preferable, as there are lower rates of seroma formation, nipple numbness and nipple inversion.

Question 10

Prognosis for mammary duct ectasia

Answer 10

Duct ectasia is completely benign and unrelated to breast cancer. It often occurs around the time of menopause, and is most common in older women. The development of duct ectasia has also been linked to the use of breast implants.

Question 11

Management of breast cysts

Answer 11

Cysts are most common between the ages of 35 and 50. They are palpable as discrete lumps and may be recurrent. They cannot be reliably distinguished from solid tumours on clinical examination. They often do not need aspiration, as they may settle spontaneously; however, guidelines advise all should be referred to a breast clinic for imaging

If causing patient discomfort, can drain using fine needle and ultrasound may be used

Question 12

Prognosis for breast cysts

Answer 12

Completely benign, not linked to breast cancer

Question 13

Define breast reconstruction

Answer 13

During reconstruction, a plastic surgeon creates a breast shape using an artificial implant (implant reconstruction), a flap of tissue from another place on your body (autologous reconstruction), or both.

Question 14

Summarise indications for breast reconstruction

Answer 14

Discuss immediate breast reconstruction with all patients who are being advised to have a mastectomy, and offer it except where significant comorbidity or (the need for) adjuvant therapy may preclude this option. All appropriate breast reconstruction options should be offered and discussed with patients, irrespective of whether they are all available locally. (NICE Guidelines)

Question 15

Complications for breast reconstruction

Answer 15

The possible risks of breast reconstruction include, but are not limited to, bleeding, infection, poor healing of incisions, and anesthesia risks. You should also know that: Flap surgery includes the risk of partial or complete loss of the flap and a loss of sensation at both the donor and reconstruction site.

Question 16

Define mastectomy

Answer 16

Mastectomy is the removal of the whole breast. There are five different types of mastectomy: “simple” or “total” mastectomy, modified radical mastectomy, radical mastectomy, partial mastectomy, and subcutaneous (nipple-sparing) mastectomy.

Question 17

Indications for mastectomy

Answer 17

• Large/malignant/centrally located tumours
• Recurring tumours
• Conservative surgery ineffective
• Unacceptably high risk of invasive carcinoma in situ developing
• Prophylactically -BRCA1/BRCA2 genes

Question 18

Complications of mastectomy

Answer 18

• Temporary swelling of the breast
• Breast tenderness
• Hardness due to scar tissue that can form at the site of the incision
• Wound infection or bleeding
• Lymphedema, or swelling, of the arm due to lymph node removal. This is preceded by early symptoms, which include a feeling of tightness in the arm, pain, redness, and decreased flexibility of the arm, hand, and wrist.
• Phantom breast pain. Symptoms include unpleasant -itching, “pins and needles,” pressure, and throbbing. —These sensations may be managed with medications, exercise, or massage. Phantom breast pain does not mean that cancer cells are still present in the breast or that the cancer may return.
• Seroma (clear fluid trapped in a wound) is normally present after a mastectomy. Troublesome seromas can be drained in a surgeon’s office and treated with compression or an injection that helps to harden the space in the breast if necessary.
• A linear scar is likely to result at the site of the mastectomy, and many patients experience a pulling sensation near or under their arm after mastectomy.
• Depression and feelings of loss of sexual identity may occur after a mastectomy

Question 19

Define sentinal node biopsy

Answer 19

Sentinel node biopsy is a surgical procedure used to determine if cancer has spread beyond a primary tumor into your lymphatic system. Sentinel node biopsy is used most commonly in evaluating breast cancer and melanoma. The sentinel nodes are the first few lymph nodes into which a tumor drains.

Question 20

Complications of sentinal node biopsy

Answer 20

Pain or bruising at the biopsy site. Infection. Allergic reaction to the dye used for the procedure. Lymphedema — a condition in which your lymph vessels are unable to adequately drain lymph fluid from an area of your body, causing fluid buildup and swelling.

Question 21

Define wide local excision

Answer 21

A wide local excision (WLE) is a surgical procedure to remove a small area of diseased or problematic tissue with a margin of normal tissue. This procedure is commonly performed on the breast and to skin lesions, but can be used on any area of the body.

Question 22

Indications for wide local excision

Answer 22

Tumours < 4cm

Mammogram excluding multifocal disease

Question 23

Complications of wide local excision

Answer 23

Nerve injury (esp intercostobrachial nerve)
Secondary lymphoedema
Haematoma (avoided by diathermy + drains)

Question 24

DDx Breast lump

Answer 24

Fibroadenoma
Fibrocystic breast
Fat necrosis
Intraductal papilloma
Breast abscess
Atypical ductal hyperplasia (ADH) and atypical lobular hyperplasia (ALH)
Invasive breast cancer
Ductal carcinoma in situ (DCIS)
Phylloides tumour
Adenoma
Radial scar
Lobular carcinoma in situ (LCIS)

Question 25

DDx Breast pain

Answer 25

Cyclical breast pain - fibroadenosis, PMS symptoms
Non-cyclical breast pain - Medications - hormonal, antidepressants, antipsychotics, cardiovascular drugs, antibiotics (metronidazole), ketoconazole
Mastitis.
Breast trauma.
Thrombophlebitis/Mondor’s syndrome.
Breast cysts.
Benign breast tumours.
Breast cancer.
Lactation-associated - may have an infectious aetiology.
Postoperative breast pain.
Musculoskeletal pain too -chostochondritis etc