Surgery - Breast

Question 1

When in the life course is duct ectasia of the breast most common?

Answer 1

Menopause

Question 2

How should duct ectasia be managed?

Answer 2

Conservatively
If troublesome can be managed surgically

Question 3

What are the signs and symptoms of duct ectasia?

Answer 3

Tender lump around areola and green nipple discharge

Question 4

How should fat necrosis be investigated?

Answer 4

Imaging
Core biopsy

Question 5

How does fat necrosis of the breast appear?

Answer 5

Firm, round lump –> hard, irregular lump

Question 6

Which pathogen most commonly causes acute mastitis?

Answer 6

Staphylococcus aureus

Question 7

Recall 2 risk factors for acute mastitis

Answer 7

Smoking
Nipple injury

Question 8

How should lactational mastitis be managed?

Answer 8

Simple analgesia
Warm compresses
Continue breastfeeding

Question 9

How should non-lactational mastitis be managed?

Answer 9

1st line: flucloxacillin
2nd line: co-amoxiclav
If MRSA –> trimethoprim

Question 10

How can breast abscess best be imaged?

Answer 10

USS

Question 11

How should breast abscess be managed?

Answer 11

1st - ultrasound-guided aspiration with abx and reassess in 48 hours
(admit for IV abx if acutely unwell)
2nd - Incision and drainage and culture of fluid - usually ONLY if overlying skin necrosis

Question 12

How big does a fibroadenoma have to be to warrant excision?

Answer 12

> 3cm

Question 13

What is intraductal papilloma of the breast?

Answer 13

Local areas of epithelial proliferation in large mammary ducts

Question 14

What are the symptoms of fibroadenosis of the breast?

Answer 14

Lumpy breasts (BL) which may be painful, symptoms may be worse prior to menstruation

Question 15

What are the symptoms of intraductal papilloma?

Answer 15

Clear/blood-stained discharge

Question 16

How should intraductal papilloma be managed?

Answer 16

Microdochectomy

Question 17

What sort of tumour might arise from a pre-existing fibroadenoma?

Answer 17

Phyllodes tumour

Question 18

Are phyllodes tumours benign or malignant?

Answer 18

Usually benign but occasionally behave aggressively

Question 19

What are the symptoms of phyllodes tumour?

Answer 19

Enlarging mass in women >50 years

Question 20

How does radial scar appear on XR?

Answer 20

Stellate mass

Question 21

How should radial scar be managed?

Answer 21

biposy +/- excision

Question 22

Recall 4 types of breast cancer

Answer 22

Invasive ductal carcinoma
Invasive lobular carcinoma
Ductal carcinoma in-situ
Lobular carcinoa in-situ

Question 23

Which type of breast cancer can demonstrate “comedo necrosis”?

Answer 23

DCIS

Question 24

What is Paget’s disease of the nipple?

Answer 24

An eczematoid change of the nipple associated with an underlying brest malignancy

Question 25

When is the mammography screening in the UK?

Answer 25

Age 43-73 every 3 years

Question 26

Recall the 2ww, consider 2ww and no 2ww criteria for breast Ca

Answer 26

2ww: >30y, unexplained breast lump >50y, any breast changes Consider 2ww: - Skin changes suggestive of breast Ca - >30y, unexplained lump in axilla Non-2ww: <30y, unexplained breast lump

Question 27

What makes up the triple assesment for breast Ca?

Answer 27

1. History and exam 2. Imaging (Mammography >35, USS <35, MRI if implants) 3. Pathology (FNA, core biopsy)

Question 28

Describe the lymphatic drainage of the breast

Answer 28

75% to lateral axillary nodes 25% to parasternal nodes and opposite breast

Question 29

Which receptors are all invasive breast cancers tested for?

Answer 29

Oestrogen receptor Progesterone receptor Her2 receptor

Question 30

What receptors are positive/ negative in low vs high grade breast cancers?

Answer 30

Low grade: ER+, PR+, Her2- High grade: Er-, PR-, Her2 pos

Question 31

What is the receptor status of a basal-like carcinoma of the breast?

Answer 31

ER, PR and Her2 neg

Question 32

How does surgery for breast Ca differ depending on whether there is clinical axillary lymphadenopathy or not?

Answer 32

If there is CAL: axillary node clearance If no CAL: USS and SLNB +/- axillary node clearance

Question 33

Recall 4 types of breast tumour that can be managed using wide local excision rather than mastectomy

Answer 33

Solitary lesion Peripheral tumour Small lesion in large breast DCIS <4cm

Question 34

What are the indications for post-operative radiotherapy in breast Ca?

Answer 34

Following any wide local excision Following a mastectomy IF: - T3 or T4 OR - 4 or more pos LNs

Question 35

When is hormone therapy indicated in breast Ca?

Answer 35

If ER+

Question 36

What options are there for hormone therapy in breast Ca?

Answer 36

If pre/peri-meonpausal --> tamoxifen (SERM) If post-menopausal --> anastrazole (aromatase inhibitor)

Question 37

Recall some side effects of tamoxifen

Answer 37

Amenorrhoea Endometrial Ca PV bleed VTE

Question 38

What is the main side effect of anastrazole to be aware of?

Answer 38

Osteroporosis

Question 39

When is biological therapy indicated in the treatment of breast Ca?

Answer 39

If Her2 +

Question 40

Recall an example of a biological therapy for breast Ca

Answer 40

Trastuzumab (herceptin)

Question 41

What score is used to guide prognosis in breast cancer?

Answer 41

Nottingham prognostic index

Question 42

What is the most important prognostic factor for breast cancer?

Answer 42

Axillary LN spread

Question 43

Describe the different appearanes of nipple discharge and their causes

Answer 43

Green: smokers Yellow multi-duct: duct ectasia Blood-stained: malignancy Milky, bilateral, multi-duct: prolactinoma

Question 44

What are the 2 occasions that an MRI would be used to investigate breast cancer?

Answer 44

Any malignancy suspected after USS in women <40y Lobular cancers

Question 45

At what size should excision be offered for a breast fibroadenoma?

Answer 45

>3cm

Question 46

How does the adjuvant medical treatment of oestrogen receptor-positive breast cancer depending on whether a woman is pre- or post-menopausal?

Answer 46

Pre-menopausal: tamoxifen Post-menopausal: anastrazole