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Clinical conditions > Surgery > Flashcards

Surgery Flashcards

1
Q

What are the two main things that usually cause acute pancreatitis?

A

Cholelithiasis (gallstones) and drinking excessive amount of alcohol

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2
Q

What are the four main types of acute pancreatitis?

A
  1. Gallstone pancreatitis with cholangitis
  2. Gallstone pancreatitis with bile obstruction
  3. Gallstone pancreatitis without cholangitis or bile obstruction
  4. Alcohol related pancreatitis
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3
Q

What are the risk factors of acute pancreatitis?

A
  1. Middle aged women (gallstone)
  2. Young to middle aged men (high alcohol intake)
  3. Gallstones
  4. Alcohol
  5. Use of causative drugs (thiazide diuretics)
  6. ERCP (can cause pancreatic inflammation)
  7. Systemic lupus erythematosus (rare)
  8. Sjogren’s syndrome (rare)
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4
Q

What is cholangitis?

A

Inflammation of the bile duct system - normally caused by blocked bile duct

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5
Q

What is Charcot’s triad?

A

Manifestation of biliary obstruction with RUQ pain, fever and jaundice

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6
Q

What is cholesystitis?

A

Inflammation of the gallbladder - normally caused by complete cystic duct obstruction

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7
Q

Where is the site of pain in acute pancreatitis?

A

Mid-epigastric pain or LUQ which often radiates to the back

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8
Q

What is the onset of acute pancreatitis?

A
  • Onset is sudden
  • Increases over hours but eventually plateaus
  • Onset is more acute in gallstone pancreatitis than in alcohol related pancreatitis
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9
Q

What is the character of pain in acute pancreatitis?

A

Pain is usually constant and severe - however in rare occasions it can be painless

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10
Q

What are the symptoms associated with acute pancreatitis?

A
  • Nausea and vomiting
  • Signs of hypovolemia
  • Pleural effusion
  • Anorexia
  • Jaundice
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11
Q

What are the exacerbating symptoms of acute pancreatitis?

A
  • Lying down flat
  • Movement
  • Fatty foods
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12
Q

What position helps with pain in acute pancreatitis?

A

Leaning forwards/curling into a ball helps

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13
Q

What are the main investigations you would carry out for acute pancretitis?

A
  • Serum lipase or amylase
  • FBC and differential
  • CRP
  • Urea/creatinine
  • Pulse oximetry
  • LFTs (liver function)
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14
Q

To confirm diagnosis of acute pancreatitis what would the results of serum lipase or amylase say?

A

> 3 times the upper limit in the normal range with acute abdominal pain

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15
Q

What is preferred lipase or amylase for the diagnosis of acute pancreatitits?

A

Lipase because even though they have a similar sensitivity and specificity lipase levels remain elevated for longer providing a higher likelihood of picking up diagnosis in patients with a delayed presentation

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16
Q

What would FBC show in acute pancreatitis?

A
  • Leucocytosis (with left shift)

- Haematocrit > 44% also indicates poorer prognosis

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17
Q

What would CRP show in acute pancreatitis?

A

if >200 units/L associated with pancreas

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18
Q

What do elevated levels of urea/creatinine suggest?

A

Dehydration/hypovolemia and increased risk for development of severe disease

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19
Q

What does ALT >3 times upper limit predict ?

A

Gallstones are the cause of acute pancreatitis

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20
Q

Is a transabdominal ultrasound always needed when diagnosing acute pancreatitis?

A

Not needed for most patients as diagnosis is normally based off clinical symptoms and serum lipase/amylase

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21
Q

When should you request abdominal ultrasound of right upper abdomen?

A

In a patient with acute pancreatitis - this is to look for biliary aetiology

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22
Q

What determines the treatment the patient gets for acute pancreatitis?

A

The cause of the pancreatitis - gallstone and bile obstruction

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23
Q

What is the 1st line treatment for all patients with acute pancreatits?

A

Fluid resuscitation - very important even in those with mild disease

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24
Q

What is given for acute pancreatitis alongside fluid resuscitation?

A

Analgesia - use the standard pain ladder approach to select monitor and adjust dose

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25
Q

What are the analgesic options for acute pancreatitis?

A
  • Ibuprofen
  • Codeine phosphate
  • Morphine sulfate
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26
Q

What else should be considered with acute pancreatitis?

A
  • Whether an infection is present - antibiotics may need to be given if pancreatic infection
  • Nutritional support (avoid fatty foods)
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27
Q

How is gallstone pancreatitis with cholangitis best treated?

A
  • Fluid resuscitation, analgesia, nutritional therapy
  • Additional ERCP within 24 hours
  • Cholecystomy should be done for any patients with gallstones as confirmed cause
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28
Q

How is gallstone pancreatitis with bile duct obstruction best treated?

A
  • Fluid resuscitation, analgesia, nutritional therapy
  • ERCP with sphincterotomy but only in some patients
  • EUS first strategy -Arrange bile duct imaging with endoscopic ultrasound (EUS) or (MRCP) if available if bile duct obstruction is suspected in the absence of cholangitis - this can help prevent unnecessary ERCP procedures
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29
Q

How is gallstone pancreatitis without cholangitis or bile duct obstruction best treated?

A
  • Fluid resuscitation, analgesia, nutritional therapy

- Cholecystectomy (surgical removal of gallbladder)

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30
Q

What should you do about cholecystectomy in patients with more severe disease?

A

Delay the procedure until inflammation has resolved

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31
Q

How is alcohol-related pancreatitis treated?

A
  • Fluid resuscitation, analgesia, nutritional therapy
  • Additional vitamin replacement and alcohol abstinence programme if needed
  • In vitamin replacement replace thiamine and B12 beside a well balanced diet
  • Consider alchol withdrawal pro
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32
Q

What is the 1st line treatment for patients with acute pancreatitis failing to improve after 5-7 days?

A

CECT

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33
Q

What is CECT?

A

Contrast-enhanced tomography this can evaluate for pancreatic complications

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34
Q

What develops in 20% of patients with acute pancreatitis?

A

Pancreatic and/or peri-pancreatic necrossis

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35
Q

What are the two types of necrosis that can develop in acute pancreatitis?

A

Sterile or infected

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36
Q

What should you do for any patient who has severe pancreatitis or is being considered for intervention?

A

Refer to specialist

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37
Q

What do you do to confirm infection in acute pancreatitis?

A

FNA and culture

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38
Q

What is the management for patients with infected pancreatic necrosis?

A
  • Fluid resuscitation, analgesia, nutritional therapy
  • CECT
  • IV antibiotics
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39
Q

What are the management steps in a patient with infected necrosis where antibiotics fail?

A

-Catheter drainage, if this fails then consider necrosectomy

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40
Q

What is the management for patients with sterile pancreatic necrosis?

A
  • Try to manage conservatively
  • Fluid resuscitation, analgesia, nutritional therapy
  • Consider catheter drainage or necrosectomy
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41
Q

Why must you closely monitor patients with acute pancreatitis?

A
  • Organs can fail

- Always assess signs for systemic inflammatory response syndrome (SIRS)

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42
Q

What are the signs for SIRS?

A

This is defined by at least of two of the following four criteria and is associated with a worse prognosis

  • Heart rate >90 bpm
  • Respiratory rate >20 breaths/min (or PaCO2 <32 mmHg)
  • Temperature >38°C or <36°C
  • WBC count >12 x 109/L or <4 x 109/L
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43
Q

What is appendicitis?

A

Acute inflammation of the vermiform appendix

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44
Q

Where is the site of pain in acute appendicitis?

A

Acute abdominal pain in the mid abdomen which later localises to the right lower quadrant

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45
Q

What can make the appendicitis pain worse?

A

Pressing on the abdomen, coughing or walking

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46
Q

What is the onset and character of the pain?

A

May come and go but then becomes constant and severe

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47
Q

What are the main symptoms of acute appendicitis?

A
  • Nausea
  • Being sick
  • Constipation or diarrhoea
  • High temperature (pyrexia) and a flushed face
  • Anorexia
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48
Q

On clinical examination of the abdomen what may be present in a patient with appendicitis?

A
  • Right lower quadrant tenderness
  • Reduced bowel sounds
  • Potential palpable mass (peri-appendiceal abcess)
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49
Q

What do reduced bowel sounds indicate in appendicitis?

A

Signs of perforated appendicitis

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50
Q

When is psoas sign present?

A

In retrocaecal appendicitis

flexed right hip

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51
Q

What are the risk factors of appendicitis?

A

-Low fibre diet (causes constipation)
-Improved personal hygiene (may impact GI microbial flora)
-Smoking
NOTE: All of these risk factors are weak

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52
Q

What investigations should you 1st consider with suspected appendicitis?

A
  • FBC
  • CRP
  • Abdominal ultrasound
  • Contrast-enhanced abdominal CT
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53
Q

What would FBC show in a patient with appendicitis?

A
  • Leukocytosis (10-18 x 109/L) with neutrophilia

- This is present in 80-90% of people with appendicitis

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54
Q

What would you expect CRP levels to be in patient with appendicitis?

A

-Raised CRP

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55
Q

What can abdominal ultrasound be used for in suspected appendicitis?

A
  • Aperistaltic or non-compressible structure with outer diameter >6mm
  • Acute appendicitis can be ruled out if normal appendix is visualised
  • Ultrasound is useful for detecting alternative causes of abdominal pain
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56
Q

When would you consider a CECT in appendicitis?

A
  • If abdominal ultrasound is inconclusive and there is clinical suspicion of appendicitis
  • You suspect malignancy
  • You suspect an appendicular mass or abscess
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57
Q

What would CECT show i patient has appendicitis?

A

Abnormal appendix (diameter >6 mm) identified or calcified appendicolith seen in association with peri-appendiceal inflammation

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58
Q

When would you consider MRI for acute appendicitis?

A

When ultrasound is inconclusive in a pregnant women

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59
Q

What other investigations should be considered in a patient with acute appendicitis?

A
  • Urinalysis (exclude urinary tract infection - however urinalysis may be abnomral in 50% of people with acute appendicitis)
  • Pregnancy test
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60
Q

If red cells, white cells or nitrates are present in urinalysis with suspecting appendicitis what should you consider?

A

Alternative diagnosis such as, renal colic or UTI

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61
Q

What are the 3 main types of appendicitis we need to consider when formulating a management plan?

A
  • Uncomplicated appendicitis: fit for surgery
  • Uncomplicated appendicitis: unfit/does not want surgery
  • Complicated appendicitis
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62
Q

What is the 1st line treatment for a patient with uncomplicated appendicitis that is fit for surgery?

A
  • Supportive treatment

- This includes keeping the patient nil by mouth, running IV maintenance fluids and giving analgesia

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63
Q

What are the primary options of analgesia in patients with uncomplicated appendicitis fit for surgery?

A
  • Paracetamol

- Morphine sulfate

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64
Q

What is the standard treatment for uncomplicated appendicitis (fit for surgery)?

A
  • Appendicectomy within 24 hours

- Ensure it is not delayed unnecessarily (especially in those over 65 as may be at increased risk of perforation)

65
Q

What type of appendicectomy is preferred?

A

A laparoscopic appendectomy is preferred over open surgery for most adults including pregnant women

66
Q

What should be given to all patients before surgery to reduce the risk of postoperative complications?

A

Prophylactic antibiotics

67
Q

How should prophylactic antibiotics be given to patients with uncomplicated appendicitis?

A

One single preoperative dose

68
Q

What is the 1st line for uncomplicated appendicitis where patient is not fit/does not want surgery)?

A
  • Supportive treatment

- This includes keeping the patient nil by mouth, running IV maintenance fluids and giving analgesia

69
Q

What is the standard for uncomplicated appendicitis where patient is not fit/does not want surgery)?

A
  • Antibiotics with conservative management

- Ensure patient is aware of risk of recurrence appendicitis

70
Q

What are the choices of antibiotics for acute appendicitis in patients with uncomplicated appendicitis?

A
  • When prescribing antibiotics check local protocols and seek advice from microbiology
  • Amoxicillin and metroniazole
  • Piperacillin/tazobactam
  • Amoxicillin/clavulanate
71
Q

What are the two further subtypes of complicated appendicitis?

A
  • With free perforation and/or acutely unwell

- Stable with abscess of phlegmon

72
Q

What is the first line treatment for a patient with complicated appendicitis with free perforation and/or acutely unwell?

A
  • Supportive treatment, this involves critical care and immediate surgical input (shock and sepsis)
  • Keep patient nil by mouth
  • Appropriate analgesia (paracetamol or morphine sulfate)
73
Q

What should you do if the patient has signs of shock?

A

Always give fluid challenege to correct hypotension anc/or tachycardia

74
Q

What is the standard treatment recommended for all patients complicated appendicitis with free perforation and/or acutely unwell?

A
  • An emergency appendectomy

- Patients with a perforated appendix will need urgent appendicectomy

75
Q

How should prophylactic antibiotics be given to patients with complicated appendicitis with perforation and/or an acutely unwell patient ?

A
  • Continue antibiotics typically 3-5 days after surgery
  • Start with oral and switch to oral
  • Discontinue antibiotics based on resolving clinical signs
76
Q

What is the first line treatment for patient with stable complicated appendicitis with abscess or phlegmon?

A

Supportive treatment, including

  • Nil by mouth
  • IV maintenance fluid
  • Analgesia
  • Laparoscopic appendicectomy
77
Q

How should prophylactic antibiotics be given to patients with appendicitis with abscess or phlegmon?

A
  • Continue antibiotics typically 3-5 days after surgery
  • Start with oral and switch to oral
  • Discontinue antibiotics based on resolving clinical signs
78
Q

What is the second-line treatment for a patient with stable complicated appendicitis with abscess or phlegmon?

A
  • supportive treatment (analgesia)
  • If laparoscopic expertise not available conservative treatment with intravenous antibiotics and percutaneous image-guided drainage is a reasonable alternative for a stable patient with an abscess/phlegmon
  • Continue with antibiotics for up to 6 weeks later and consider interval appendicectomy if symptoms persist
79
Q

When should a interval appendicectomy be considered for a patient with stable complicated appendicitis with abscess or phlegmon?

A

-If patient has had conservative management for longer than 6 weeks

80
Q

What do you need to rule out in any patient over 40 years old who has stable complicated appendicitis with abscess or phlegmon that is being treated conservatively?

A
  • Rule out colon malignancy

- Colonoscopy and interval full-dose contrast-enhanced CT scan

81
Q

What is aortic dissection?

A

A serious condition where a tear occurs in the aortic wall intimia, this causes blood flow into a new flase channel composed of the inner and outer layers of media - if blood goes through the outside aortic wall the aortic dissection is often deadly

82
Q

When is aortic dissection considered acute?

A

If the process is less than 14 days old

83
Q

How does aortic dissection typically present?

A

With abrupt onset chest, back or abdominal pain that is severe in intensity - often described as ripping or tearing

84
Q

How does the pain of aortic dissection radiate?

A

Often interscapular and lower pain which occurs with dissection of the descending aorta

85
Q

What would you find in a cardio clinical exam in someone with aortic dissection?

A
  • Left and right blood pressure differential - this is a hallmark of aortic dissection (pulse differences in the lower limbs may also be present)
  • A pulse deficit
  • Diastolic murmur
86
Q

When is a pulse deficit more common in aortic dissection?

A

-More common in a proximal dissection affecting the aortic arch

87
Q

When is a diastolic murmur more common in aortic dissection?

A

-More common in proximal dissections

88
Q

What are some other symptoms/presentations associated with aortic dissection?

A
  • Syncope (10% patients may present with syncope and no pain)
  • Hypotension (associated with cardiac tamponade and/or hypovolemic shock)
  • Hypertension
  • Dyspnoea
  • Altered mental status
  • paraplegia (spinal cord ischaemia)
  • hemiparesis/paraparesis
  • Abdominal pain
  • Limb pain/pallor
  • Left side decreased breath sounds/dullness due to left pleural effusion
89
Q

What group of people are predominantly affected by aortic dissection?

A

-Males 50 older than 50

90
Q

What are some strong risk factors of aortic dissection?

A
  • Atherosclerotic aneurysmal disease
  • Marfan’s syndrome (connective tissue disorder that can cause weakness of the aortic wall)
  • Ehlers-Danlos syndrome (connective tissue disorder that can cause weakness of the aortic wall)
  • Bicuspid aortic valve (aortic valve that has two cusps instead of three)
  • Annulo-aortic ectasisa (enlargement or dilation of ascending aorta)
  • Coarctation (narrowing of aorta can cause long term hypertension)
  • Smoking
  • Family history of aortic aneursym or dissection
  • Hypertension
91
Q

What are some weak risk factors of aortic dissection?

A
  • Older age
  • Giant cell arteritis
  • Overlap connective-tissue disorders
  • Surgical/catheter manipulation
  • Cocaine/amphetamine use
  • Heavy lifting
  • Pregnancy
  • Non-diabetic
92
Q

What are the 1st investigations to order in someone with aortic dissection?

A
  • ECG
  • Echocardiography
  • Chest x-ray
  • CT (chest, abdo and pelvis)
  • High-sensitivity troponin
  • Renal fucntion tests
  • Liver fucntion tests
  • Lactate
  • FBC
  • CRP
  • Blood gas
  • Creatine kinase
  • Procalcitonin
93
Q

What would ECG result be if aortic dissection present?

A

ST segment depression may occur

NOTE: always perfrom an ECG in patient with acute chest pain to rule out ST-elevation myocardial infarction

94
Q

What would echocardiography show if aortic dissecion present?

A
  • intimal flap in acute or chronic dissection

- Two lumens may be seen in chronic dissection

95
Q

What would chest x-ray show if aortic dissection present?

A
  • Widened mediastinum in acute or chronic dissection
  • Pleural effusion in acute dissection
  • Aortic knob in chronic dissection
96
Q

What would CT scan show in aortic dissection?

A
  • Intimal flap in acute and chronic dissection

- In chornic dissection the flap may be thickened and there may be evidence of calcification and fewer peri

97
Q

What would high-sensitivity troponin result show if aortic dissection present?

A

Usually a negative result

98
Q

If the result of high-sensitivity troponin is usually negative why is it important in aortic dissection ?

A

Important to exclude myocadial infarction

NOTE: myocardial ischaemia or infarction may be present in 10-15% of patients with aortic dissection

99
Q

What would the result of renal function tests show in aortic dissection?

A

Elevated creatinine and urea if renal perfusion is compromised

100
Q

What the result of liver function test show in aortic dissection?

A

Elevated aspartate transaminase and alanine transaminase if hepatic perfusion is compromised

101
Q

What what the result of lactate show in aortic dissection?

A

Elevated or normal - indicative of bowel ischaemia or metabolic acidosis due to ischaemia caused by aortic dissection

102
Q

What would FBC result show in aortic dissection?

A
  • Reduced or normal RBC count
  • anaemia may be present if haemorrhage
  • Signs of SIRS as a consequence of aortic dissection
103
Q

What would CRP result show in aortic dissection?

A

May be elevated if SIRS as consequence of aortic dissection

104
Q

What may blood gas show in aortic dissection?

A

-May show metabloic acidosis

105
Q

What creatine kinase result would you expect if aortic dissection present?

A

May be elevated due to reperfusion injury or rhabdomyolysis

106
Q

What result would procalcitonin show in aortic dissection?

A

May be raised with infection - can differentiate between SIRS which may present as a consequence of aortic dissection and sepsis

107
Q

What are the other investigation you should consider in aortic dissection?

A
  • D dimer
  • Magnetic resonance angiography
  • Intravascular ultrasound
108
Q

What is the most accurate, specific and sensitive test for aortic dissection?

A

Magnetic resonance angiography

ONLY IF PATIENT IS HEMODYNAMICALLY STABLE

109
Q

What would magnetic resonance angiography show if aortic dissection present?

A
  • Intimal flap in acute and chronic dissection
  • In chronic dissection the flap may be thickened and there may be evidence of calcification and fewer periaortic changes
  • Two lumens may be seen in chronic dissection
110
Q

What are the three broad categories of aortic dissection?

A
  • Initial
  • Acute
  • Chronic
111
Q

What is the initial aortic dissection called?

A

Suspected aortic dissection: hemodynamically unstable

112
Q

What does haemodynamically unstable mean?

A

Abnormal/unstable blood pressure - can cause inadequate blood flow

113
Q

What are the three types of acute aortic dissection?

A
  • Confirmed type A aortic dissection
  • Confirmed type B aortic dissection:complicated
  • Confirmed type B aortic dissection: uncomplicated
114
Q

What is a type A dissection?

A

Where there is a tear in the ascending aorta - the tear may extend from the upper part of the aorta and down towards the abdomen

115
Q

What is a type B dissection?

A

Type B dissection originate in the descending aorta which extends from the arch at the top of the ascending aorta

116
Q

What is a type B complicated aortic dissection?

A

A type B aortic dissection that involving malperfusion syndrome?

117
Q

What is malperfusion syndrome?

A

When there is loss of blood supply to a vital organ caused by branch arterial obstruction secondary to dissection

118
Q

What is uncomplicated type B aortic dissection?

A

Type B aortic dissection without the presence of malperfusion syndrome

119
Q

What is chronic aortic dissection?

A

Patient not diagnosed at time of onset due to absent/atypical symptoms - patient normally remains stable

120
Q

What is the 1st line treatment for a patient with suspected aortic dissection that is hemodynamically unstabel?

A

ALL PATIENTS

  • Advanced life support with haemodynamic support
  • Aim for oxygen 94-96% (88-92% is patient is at risk of hypercapnic respiratory failure)
  • Give IV fluid resuscitation
  • Give opioid analgesia - normally IV morphine sulfate
121
Q

What is the 1st line treatment for type A aortic dissection?

A

ALL PATIENTS
-Beta blockers (decrease HR <60 bmp and decrease systolic BP 100-120 mmHg to decrease wall stress)
-If beta blocker not suitable for patient give non-dihydropyridine calcium channel blocker
-Opioid analgesia - give IV morphine sulfate
-IMMEDIATELY REFER PATIENT FOR EMERGENCY SURGERY
SOME PATIENTS
-Add vasodilator

122
Q

Why would you give a patient with type aortic dissection a vasodilator?

A

If heart rate and systolic blood pressure is not controlled with beta blocker

123
Q

What surgery is usually given to patient with type A aortic dissection?

A
  • Open aortic arch replacement
  • Transposition of supra-aortic branches with endovascular repair
  • Total endovascular repair
  • Frozen elephant trunk repair technique
124
Q

What is the 1st line treatment for a complicated type B aortic dissection?

A

ALL PATIENTS

  • Beta blockers (decrease HR <60 bmp and decrease systolic BP 100-120 mmHg to decrease wall stress)
  • If beta blocker not suitable for patient give non-dihydropyridine calcium channel blocker
  • Opioid analgesia - give IV morphine sulfate
  • Vasodilator if beta blocker does not control heart rate and systolic blood pressure
  • URGENTLY REFER PATIENT FOR TEVAR OR OPEN SURGERY
125
Q

What is TEVAR?

A

Thoracic endovascular aortic repair

126
Q

When would you perform open surgery instead of TEVAR?

A

If patient has:

  • Arterial disease in lower extremities
  • Severe tortuosity of iliac arteries
  • A sharp angulation of aortic arch
  • Absence of a proximal landing zone for the stent graft
127
Q

What is the 1st line treatment for uncomplicated type B aortic dissection?

A

ALL PATIENTS
-Beta blockers (decrease HR <60 bmp and decrease systolic BP 100-120 mmHg to decrease wall stress)
-If beta blocker not suitable for patient give non-dihydropyridine calcium channel blocker
-Opioid analgesia - give IV morphine sulfate
SOME
-Vasodilator if beta blocker does not control heart rate and systolic blood pressure
-TEVAR

128
Q

When would you consider TEVAR for patients with uncomplicated type B aortic dissection?

A

Those with features that indicate they are high risk of developing complications e.g. bloody pleural effusion, aortic diameter and malperfusion

129
Q

What is the 1st line treatment for those with chronic aortic dissection?

A

ALL
-Beta blocker to manage systolic blood pressure and heart rate (<120/80 mmHg and <60 bpm)
-Lifestyle advice (avoid contact sports, strenuous activities, cocaine and methamphetamines)
-Risk factor management (smoking cessation, lipid lowering therapy)
SOME/CONSIDER
-Additional hypertensive such as ACE
-TEVAR

130
Q

When should you consider TEVAR for a patient with chronic aortic dissection?

A

If any of the following complications occur

  • Rupture
  • Chronic visceral or limb malperfusion
  • Progressive aneurysmal enlargement
  • False lumen aneurysms
  • Persistent or recurrent pain
131
Q

What are the three main categories of breast cancer?

A
  • Metastatic breast cancer
  • Primary invasive breast cancer
  • Breast cancer in situ
132
Q

What is metastatic breast cancer?

A

When the disease has spread beyond the breast and the ipsilateral lymph nodes (axillary, internal mammary, infra and supraclavicular)

133
Q

What is primary invasive breast cancer?

A

A malignancy originating in the breasts and nodal basins, the term invasive indicates that the malignancy has penetrated past the membrane of the duct or lobule of the breast and has spread to surrounding tissues, but has not spread to other organs

134
Q

How is invasive breast cancer classified?

A

The TNM (tumour, node, metastasis staging system)

135
Q

What are the presentations/symptoms of breast cancer?

A
  • Breast mass
  • Nipple discharge
  • Axillary lymphadenopathy
  • skin thickening or discoloration
  • Retraction or scaling of nipple
136
Q

What are the strong risk factors associated with primary invasive breast cancer?

A
  • Increasing age
  • Female
  • Ethnic origin
  • Positive family history
  • Genetic mutations (BRCA1 and BRCA2)
  • Endogenous and oestrogen exposure (risk of breast cancer decreases with an older age of menarche and younger age of menopause)
  • Exogenous oestrogen/progestin exposure (HRT and hormonal contraception)
  • Alcohol consumption
  • Radiation exposure
  • Benign breast disease
  • Increased breast density
  • Mild, moderate or marked background parachymal enhancmeent (BPE) on breat MRI
137
Q

What are the weal risk factors associated with primary invasive breast cancer?

A
  • Reduced physical activity
  • Poor diet
  • High socioeconomic class
  • Smoking
  • Obesity
  • High dibutyl-phthalate exposure
138
Q

What is the first line investigation to consider when suspecting breast cancer?

A

A mammogram

139
Q

What findings from a mammogram would be suggestive of breast malignancy?

A
  • An irregular spiculated mass
  • Clustered microcalcifications
  • Linear branching calcification
140
Q

If a patient has a clinically detected breast mass but the mammogram shows no abnormalities what should be done?

A

Additional imaging such as ultrasound, and MRI in high risk patients

141
Q

What other investigations should you consider in suspected breast cancer?

A
  • Breast ultrasound
  • Breast MRI
  • Biopsy
  • Hormone receptor testing
  • HER2 testing
  • Gene expression assays
  • Computed tomography
  • Genetic testing
  • FBC
  • LFTs
  • Alkaline phosphates
142
Q

What would breast ultrasound show that are suggestive of malignancy?

A
  • Hypoechoic mass
  • Irregular mass with internal calcifications
  • Enlarged axillary lymph nodes
143
Q

When would you perform MRI in patients with suspected primary invasive breast cancer?

A

In patients with:

  • Clinically positive axillary node
  • Occult primary breast cancer
  • Paget’s disease of the nipple
  • Also recommended as a supplementary screening if risk factor present such BRCA1 or BRCA23 mutation
  • Normally when ultrasound and mammogram are not diagnostic
144
Q

What findings would suggest breast malignancy in MRI?

A
  • Heterogeneously enhanced area

- Significant architectural distortion

145
Q

What is the test required for a definitive diagnosis of breast cancer?

A

A biopsy

146
Q

What would biopsy show in breast cancer?

A

histological findings can confirm:

  • Invasive ductal carcinoma
  • Invasive lobular carcinoma
  • Medullary carcinoma
  • Mucinous carcinoma
  • Meteaplastic carcinoma
147
Q

What is useful in obtaining a rapid diagnosis of breast maliganncy?

A
  • Fine needle aspiration

- Very reliable if experienced clinicians

148
Q

What accounts for 80% of breast cancers?

A

Invasive ductal carcinoma

149
Q

What is hormone receptor testing?

A
  • Determination of oestrogen and progesterone receptor status
  • Result is positive or negative
150
Q

What is HER2?

A
  • HER2 is a growth-promoting protein on the outside of all breast cells
  • Breast cancer cells with a higher than normal level of HER2 are HER2 positive
151
Q

Why is it important to determine the HER2 status of breast cancer?

A

HER2 positive cancer grows and spreads much faster than others, and are much more likely to respond to treatment with drugs that target HER2

152
Q

Why are gene expression assays used in diagnosis of breast cancer?

A

May be used for prognostication and to guide decisions on adjuvant chemotherapy

153
Q

What do gene expression assays analyze in breast cancer?

A

The number of different genes within your cancer cells to predict your risk of cancer recurrence

154
Q

When should additional computed tomography scan be performed in breast cancer patients?

A

If they have symptoms or signs that are associated with metastatic disease

155
Q

What may CT scan show if metastatic breast cancer is present?

A

-Pulmonary or abdominal metastases

156
Q

When should genetic testing be performed on breast cancer patient?

A

For female patients with breast cancer who are diagnosed <45 years, or aged 46-50 with unknown/limited family history or second breast cancer

157
Q

What would genetic testing show that indicates increased breast cancer risk?

A

gene mutation e.g. BRCA1, BRCA2, CHEK2, PALB2, ATM, NBN

158
Q

When should FBC, LFTs and alkaline phosphatase be performed with breast cancer?

A

In women with stage III invasive breast cancer or if patient has signs and symptoms of metastatic disease

  • FBC may show anemia
  • LFTs and alkaline phosphatase may be elevated

Clinical conditions (1 decks)

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