Surgery - Breast Flashcards
What is duct ectasia?
Inflammatory disorder of sub-areolar ducts characterised by dilation + tortuosity of the ducts
When is duct ectasia of the breast most common?
Peri- + post-menopause
40-70y
In which group is duct ectasia more common?
Smokers
How may duct ectasia present?
+/- asymptomatic
Subareolar pain
Nipple discharge: multiduct green, brown or white discharge (+/- bilateral)
Give 3 features of duct ectasia on examination
Slit-like retraction of nipples
Subareolar mass
Multiduct nipple discharge +/- cheesy
How should duct ectasia be managed?
Reassurance + Sx control
If troublesome can be managed surgically: total duct excision
What investigations are performed for duct ectasia?
USS/ Mammogram
Core biopsy
Discharge sent for cytology
Given demographic 2ww
What are breast cysts?
Common fluid filled epithelial lined sac within breast
At what age are breast cysts most commonly seen?
30-50y
What is thought to play a part in development of breast cysts?
Increased sensitivity to oestrogen
(given regression of cystic changes post-menopause)
Give 5 S/S of breast cysts
Soft + fluctuant
Solitary or multiple
Smooth + mobile
Non-tender
Increase in size/ become tender prior to menstruation
What investigations are used for breast cysts?
USS: fluid filled nature
Mammogram: ‘halo appearance’
+/- FNA to aspirate cyst: diagnostic + therapeutic
Describe the aspirate of breast cysts
Straw coloured
If atypical e.g. bloody, send for cytology
Describe the management of breast cysts
Asymptomatic: self-resolve
Symptomatic: aspirate, can recur + may need future aspiration
Define mastalgia
Breast pain
Cyclical (majority) or non cyclical
a/w menstruation- exaggerated response to hormonal changes
Usually women in 30s
What is chest wall pain?
Pain which patients localise to the breast but is actually extra-mammary
= pulled muscle or costochondritis
Give 4 symptoms of cyclical mastalgia
Bilateral breast tenderness
Sx worsen 2w prior to menstruation, relieved with onset
Lumpiness
Fullness + heaviness of breast
Give 3 characteristics of non-cyclical mastalgia
Unilateral breast tenderness
Not a/w menstruation
More common in older women
Investigations for mastalgia
In absence of lump: advice direct from GP + no referral
Conservative management of mastalgia
Verbal advice + reassurance + leaflet on breast pain
Pain chart to identify pattern of pain
Well-fitting soft, supportive bra
Medical management for mastalgia
Regular analgesia
OCP can alleviate Sx in some
When should patients with mastalgia be referred to the breast team? What for?
Ongoing refractory pain >3/12
Consideration of Tamoxifen or Danazol
Give 3 S/S of fat necrosis
Firm round lump(s), may develop to hard irregular lump
Usually painless, may feel tender
Skin red, bruised, occassionally dimpled
In which patients is fat necrosis typically seen?
Obese women with large breasts
Following trivial/ unnoticed trauma
How should fat necrosis be investigated?
Imaging
Core biopsy
How does fat necrosis of the breast appear?
Firm, round lump –> hard, irregular lump
What is mastitis?
Inflammation of breast tissue
Lactational or non-lactational
What are the 2 types of mastitis?
Non-infectious/ idiopathic
Infectious: usually due to retrograde spread through lactiferous duct or traumatised nipple
What usually causes mastitis in lactating women?
Milk stasis
Accumulated milk causes inflammatory response
What usually causes msatitis in non lactating women?
Infection:
Central/ subareolar: 2nd to periductal mastitis
Peripheral (less common): a/w DM, RhA, trauma, CS
Granulomatous (rare)
What is a breast abscess?
Localised collection of pus in breast
May be a severe complication of mastitis
Where do lactational vs non-lactational breast abscesses tend to occur?
L: peripheral, upper outer
NL: central/ sub-areolar/ lower quadrants
Which pathogen most commonly causes acute mastitis?
Staphylococcus aureus
Give 3 predisposing factors to milk stasis and lactational mastitis
Poor infant attachment
Reduced no./ duration of
feeds (bottle feeds, painful, preferred breast)
Pressure on breast (tight bra, sleeping position)
Give 4 general risk factors for mastitis
Smoking
Age
Nipple damage
Breast trauma
List 3 S/S of mastitis
Painful breast
+/- fever + malaise
Tender, red, hot, swollen + hard area in wedge distribution
List 3 signs suggestive of infection in mastitis
Nipple fissure
Purulent discharge
Influenza Sx + pyrexia lasting >24h
Give 4 S/S indicative of breast abscess
Hx recent mastitis
Fever
Painful swollen lump in breast, red, hot
Fluctuant lump with skin discolouration
How should lactational mastitis be managed?
Continue breastfeeding
Simple analgesia
Warm compresses
What are the indications for antibiotics in lactational mastitis?
Infected nipple fissure
Sx not improved (or worsening) after 12-24h despite milk removal
+ve milk culture
What antibiotics are used in lactational mastitis?
Flucloxacillin 500mg QDS 10-14d
Erythromycin if Pen allergy
How should all non-lactational mastitis be managed?
Flucloxacillin 500mg QDS 10-14d
If MRSA: Trimethoprim or Clindamycin
Erythromycin if pen allergy
How can breast abscess best be imaged?
USS
How should breast abscess be managed?
1st: US-guided aspiration with abx + reassess in 48h
(admit for IV abx if acutely unwell)
2nd: I+D + culture of fluid; usually ONLY if overlying skin necrosis
What is a fibroadenoma?
Common benign breast lump in pre-menopausal women (peak 20-25)
Due to focal growth of stromal + epithelial components
Give 3 characteristics of fibroadenoma
Rubbery firm mobile mass
Solitary, well circumscribed + smooth
Non-tender
What size is a fibroadenoma classified as a ‘giant fibroadenoma’?
> 5cm
Describe the progression of fibroadenomas
50% resolve spontaneously
25% stay the same
25% increase in size
What causes fibroadenomas?
Unknown, but hormonal factors as present/ change with menstruation/ pregnancy
What investigations are used for fibroadenomas?
USS (<30)
Mammogram (>30)
Core biopsy if >5cm
What are the indications for fibroadenoma excision?
Symptomatic: painful/ contour change
Growing rapidly
Cellular on histology (risk missing phyllodes)
>3cm
What is intraductal papilloma of the breast?
Local areas of epithelial proliferation in large mammary ducts
Give 2 S/S of duct papilloma
Discharge +/- bloody, usually from single duct
Mass (if large)
Management for duct papilloma
Microdochectomy (excision of duct)
What are the symptoms of fibroadenosis of the breast?
Lumpy breasts (BL) which may be painful, symptoms may be worse prior to menstruation
What are the symptoms of intraductal papilloma?
Clear/blood-stained discharge
How should intraductal papilloma be managed?
Microdochectomy
What sort of tumour might arise from a pre-existing fibroadenoma?
Phyllodes tumour
Are phyllodes tumours benign or malignant?
Usually benign but occasionally behave aggressively
What are the symptoms of phyllodes tumour?
Enlarging mass in women >50 years
How does radial scar appear on XR?
Stellate mass
How should radial scar be managed?
biposy +/- excision
Recall 4 types of breast cancer
Invasive ductal carcinoma
Invasive lobular carcinoma
Ductal carcinoma in-situ
Lobular carcinoma in-situ
What is the most common type of breast cancer?
Invasive ductal carcinoma
(now renamed “no special type”)
Which types of breast cancer now come under the heading of ‘special type’?
Lobular carcinoma
Rarer types:
Medullary, Mucinous, Phyllodes, Papillary etc
Which type of breast cancer can demonstrate “comedo necrosis”?
DCIS
(feature of high nuclear grade, a/w focused of invasion)
What is Paget’s disease of the nipple?
Eczematoid change of the nipple a/w an underlying breast malignancy
How is Paget’s disease of the nipple related to breast cancer?
In 50% there is an underlying mass lesion, of these 90% will have invasive carcinoma
In those without a mass lesion, 30% have underlying carcinoma, the rest have carcinoma in situ
How is Paget’s disease of the nipple investigated?
Punch biopsy
Mammography
USS
How does Paget’s disease differ from eczema of the nipple?
Paget’s: starts at nipple, spreads to the areolar. Usually unilateral + persistent despite eczema Tx
Eczema: starts at areola, spreads to nipple
Give features of Paget’s disease of the nipple
Weeping
Ulceration
Erosions
Reddening
Thickening
What is inflammatory breast cancer?
Where cancerous cells block the lymph drainage resulting in an inflamed appearance of the breast
1/10,000 cases
Which tumour marker may be raised in inflammatory breast cancer?
CA 15-3
When is the mammography screening in the UK?
Age 50-71 every 3y
>71 encouraged to make own appointments
Recall the 2ww, consider 2ww and no 2ww criteria for breast Ca
2ww:
>30y, unexplained breast lump
>50y, any Sx in 1 nipple: discharge, retraction, other changes of concern
Consider 2ww:
- Skin changes suggestive of breast Ca
- >30y, unexplained lump in axilla
Non-urgent:
<30y, unexplained breast lump +/- pain
What makes up the triple assesment for breast Ca?
- History and exam
- Imaging (Mammography >35, USS <35, MRI if implants)
- Pathology (FNA, core biopsy)
Describe the lymphatic drainage of the breast
75% to lateral axillary nodes
25% to parasternal nodes and opposite breast
How does chemotherapy differ for node positive and node negative breast cancer?
Node +ve: FEC-D chemo
Node -ve: FEC chemo
Which receptors are all invasive breast cancers tested for?
Oestrogen receptor
Progesterone receptor
Her2 receptor
What receptors are positive/ negative in low vs high grade breast cancers?
Low grade: ER+, PR+, Her2-
High grade: Er-, PR-, Her2 pos
What is the receptor status of a basal-like carcinoma of the breast?
ER, PR and Her2 neg
How does surgery for breast Ca differ depending on whether there is clinical axillary lymphadenopathy or not?
CAL: axillary node clearance indicated
No CAL: USS + SLNB +/- axillary node clearance
No CAL: Pre-op axillary US, if -ve, do sentinel node biopsy to assess nodal burden
Give 2 complications of axillary clearance
Arm lymphadema
Functional arm impairment
What is an alternative to axillary node clearance? How does this compare?
Axillary radiotherapy
Equivalent oncological control with fewer SE
Recall 4 types of breast tumour that can be managed using wide local excision rather than mastectomy
Solitary lesion
Peripheral tumour
Small lesion in large breast
DCIS <4cm
What are the indications for post-operative radiotherapy in breast Ca?
Following any wide local excision
Following a mastectomy IF:
- T3 or T4 OR
- >,4 +ve LNs
When is hormone therapy indicated in breast Ca?
If ER+
What drugs are used for oestrogen receptor positive breast Ca?
If pre/peri-meonpausal: Tamoxifen (SERM)
If post-menopausal: Anastrazole/ Letrozole (aromatase inhibitor)
Describe the MOA of Tamoxifen in breast cancer
Selective oestrogen receptor modulator
Primarily antagonises ERs in breast tissue in preference to other ERs
Some agonism of other ERs e.g. endometrium; increases risk endometrial ca in postmenopausal
Mixed agonist + antagonist activity depending on site
ER = Oestrogen receptor
Recall 4 side effects of tamoxifen
Menstrual disturbance: Amenorrhoea, PV bleed
Endometrial Ca
VTE
Hot flushes
Describe the MOA of Anastrazole
Aromatase inhibitor
Aromatase is a key enzyme in converting androgens to oestrogen, thus inhibition reduces peripheral oestrogen synthesis
What are 4 side effects of anastrazole to be aware of?
Osteoporosis: DEXA at start
Hot flushes
Arthralgia, myalgia
Insomnia
When is biological therapy indicated in the treatment of breast Ca?
If Her2 +
Recall an example of a biological therapy for HER2 +ve breast cancer
Trastuzumab (herceptin)
What score is used to guide prognosis in breast cancer?
Nottingham prognostic index
What is the most important prognostic factor for breast cancer?
Axillary LN spread
Describe 1 benefit of neoadjuvant chemotherapy prior to surgery for breast cancer
Downsize primary tumour- breast conserving surgery can be performed instead of mastectomy
Smaller surgery, less peri-operative risks + better cosmetic outcomes
Describe the different appearanes of nipple discharge and their causes
Green: smokers
Yellow multi-duct: duct ectasia
Blood-stained: malignancy
Milky, bilateral, multi-duct: prolactinoma
What are the 2 occasions that an MRI would be used to investigate breast cancer?
Any malignancy suspected after USS in women <40y
Lobular cancers
At what size should excision be offered for a breast fibroadenoma?
> 3cm
How does the adjuvant medical treatment of oestrogen receptor-positive breast cancer depending on whether a woman is pre- or post-menopausal?
Pre-menopausal: tamoxifen
Post-menopausal: anastrazole
What is seen on USS of axillary lymph nodes in extracapsular implant rupture?
‘Snowstorm’ sign
Due to leakage of silicone, which drains via lymphatic system in breast + LNs
