SURG: Breast Flashcards
Management of breast abscess?
- <5cm = needle aspiration with US guidance under LA (may need to be repeated daily 5-7d)
- > 5cm / persistent = surgical incision and drainage with washout or percutaneous drainage with indwelling catheter
- +antibiotics - oral fluclox, IV vanc if severe
Most common type of breast cancer?
Invasive ductal carcinoma
Scoring system for breast cancer?
Nottingham Prognostic Index
Tumour Size x 0.2 + Lymph node score + Grade score
How does the presence/absence of axillary lymphadenopathy determine management in breast cancer?
No palpable axillary lymphadenopathy at presentation:
- Pre-operative axillary ultrasound before primary surgery
- If negative - sentinel node biopsy to assess the nodal burden
Clinically palpable lymphadenopathy at presentation:
- Axillary node clearance indicated at primary surgery
- May lead to arm lymphedema and functional arm impairment
Management of breast cancer?
Surgery:
- Wide local excision (solitary, peripheral, DCIS<4cm)
- Mastectomy (multifocal, central, DCIS>4cm)
Whole breast radiotherapy:
- After wide-local excision
- After mastectomy for T3-T4 tumours
- Four or more positive axillary nodes
Hormonal therapy:
- Offered if tumours positive for hormone receptors
- ER positive, pre-menopausal = SERMs e.g. tamoxifen for 5 years after diagnosis
- ER positive, post-menopausal = aromatase inhibitors e.g. anastrozole
Biological therapy:
- Trastuzumab (Herceptin)
- Only if tumour HER2 positive
- Cannot be used in patients with a history of heart disorders
Chemotherapy:
- Cytotoxic therapy may be used to either downstage a primary lesion or after surgery depending on the stage of the tumour, for example if there is axillary node disease
Breast cancer screening?
Mammogram every 3 years between 47-73yrs
Clinical features of fibroadenoma?
- Painless / non-tender
- Mobile / non-tethered
- Smooth
- Well-circumscribed
- Solitary
- 2-3 cm in diameter (except for giant fibroadenoma, which comprises 1% of breast masses and can measure up to 5cm)
Imaging for breast lumps?
- Ultrasound = women < 35 and men (greater sensitivity in denser breast tissue)
- Mammograms = women > 35
- MRI is not routinely used
Management of fibroadenomas?
> > Asymptomatic = no treatment
Symptomatic = removed if troublesome
- Surgical lumpectomy or excisional biopsy
- Vacuum-assisted biopsy
- Cryoablation
- High intensity focussed ultrasound for ablation of fibroadenoma tissue (still in preliminary use, as suggested by NICE)
> > If >3cm surgical excision is usual
Clinical features of duct ectasia?
- Nipple retraction
- Occasionally creamy nipple discharge
> > Patients with troublesome nipple discharge may be treated by microdochectomy (if young) or total duct excision (if older).
Management of mastitis?
Treat if:
- systemically unwell
- nipple fissure present
- if symptoms do not improve after 12-24 hours of effective milk removal
- if culture indicates infection
> > the first-line antibiotic is oral flucloxacillin
Clinical features of Paget’s?
Typically presents as unilateral changes in the appearance and texture of the nipple and areola. Symptoms may include:
- Erythema, scaling, and thickening of the skin
- Itching, burning, or pain in the nipple and areola
- Nipple discharge, which may be bloody or serous
- Nipple inversion or retraction
- Ulceration or erosions in advanced cases
Investigations for Paget’s?
Punch or shave biopsy of the nipple or areola is essential for histopathological confirmation of Paget’s disease.
The presence of Paget cells—large, round, and pale-staining cells with abundant cytoplasm and large nuclei—confirms the diagnosis.
Management of Paget’s?
- Breast conserving surgery (BCS) / wide local excision
- +Followed by radiotherapy
- Mastectomy
SE of Aromatase inhibitors (e.g. anastrozole)?
Osteoporosis
