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YR6 Rotations > Surgery - Breast > Flashcards

Surgery - Breast Flashcards

1
Q

What is duct ectasia?

A

Inflammatory disorder of sub-areolar ducts characterised by dilation + tortuosity of the ducts

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2
Q

When is duct ectasia of the breast most common?

A

Peri- + post-menopause
40-70y

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3
Q

In which group is duct ectasia more common?

A

Smokers

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4
Q

How may duct ectasia present?

A

+/- asymptomatic
Subareolar pain
Nipple discharge: multiduct green, brown or white discharge (+/- bilateral)

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5
Q

Give 3 features of duct ectasia on examination

A

Slit-like retraction of nipples
Subareolar mass
Multiduct nipple discharge +/- cheesy

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6
Q

How should duct ectasia be managed?

A

Reassurance + Sx control

If troublesome can be managed surgically: total duct excision

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7
Q

What investigations are performed for duct ectasia?

A

USS/ Mammogram
Core biopsy
Discharge sent for cytology

Given demographic 2ww

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8
Q

What are breast cysts?

A

Common fluid filled epithelial lined sac within breast

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9
Q

At what age are breast cysts most commonly seen?

A

30-50y

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10
Q

What is thought to play a part in development of breast cysts?

A

Increased sensitivity to oestrogen
(given regression of cystic changes post-menopause)

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11
Q

Give 5 S/S of breast cysts

A

Soft + fluctuant
Solitary or multiple
Smooth + mobile
Non-tender
Increase in size/ become tender prior to menstruation

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12
Q

What investigations are used for breast cysts?

A

USS: fluid filled nature
Mammogram: ‘halo appearance’
+/- FNA to aspirate cyst: diagnostic + therapeutic

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13
Q

Describe the aspirate of breast cysts

A

Straw coloured
If atypical e.g. bloody, send for cytology

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14
Q

Describe the management of breast cysts

A

Asymptomatic: self-resolve
Symptomatic: aspirate, can recur + may need future aspiration

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15
Q

Define mastalgia

A

Breast pain
Cyclical (majority) or non cyclical
a/w menstruation- exaggerated response to hormonal changes
Usually women in 30s

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16
Q

What is chest wall pain?

A

Pain which patients localise to the breast but is actually extra-mammary
= pulled muscle or costochondritis

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17
Q

Give 4 symptoms of cyclical mastalgia

A

Bilateral breast tenderness
Sx worsen 2w prior to menstruation, relieved with onset
Lumpiness
Fullness + heaviness of breast

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18
Q

Give 3 characteristics of non-cyclical mastalgia

A

Unilateral breast tenderness
Not a/w menstruation
More common in older women

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19
Q

Investigations for mastalgia

A

In absence of lump: advice direct from GP + no referral

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20
Q

Conservative management of mastalgia

A

Verbal advice + reassurance + leaflet on breast pain
Pain chart to identify pattern of pain
Well-fitting soft, supportive bra

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21
Q

Medical management for mastalgia

A

Regular analgesia
OCP can alleviate Sx in some

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22
Q

When should patients with mastalgia be referred to the breast team? What for?

A

Ongoing refractory pain >3/12
Consideration of Tamoxifen or Danazol

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23
Q

Give 3 S/S of fat necrosis

A

Firm round lump(s), may develop to hard irregular lump
Usually painless, may feel tender
Skin red, bruised, occassionally dimpled

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24
Q

In which patients is fat necrosis typically seen?

A

Obese women with large breasts
Following trivial/ unnoticed trauma

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25
How should fat necrosis be investigated?
Imaging | Core biopsy
26
How does fat necrosis of the breast appear?
Firm, round lump --> hard, irregular lump
27
What is mastitis?
Inflammation of breast tissue Lactational or non-lactational
28
What are the 2 types of mastitis?
Non-infectious/ idiopathic Infectious: usually due to retrograde spread through lactiferous duct or traumatised nipple
29
What usually causes mastitis in lactating women?
Milk stasis Accumulated milk causes inflammatory response
30
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)
31
What is a breast abscess?
Localised collection of pus in breast May be a severe complication of mastitis
32
Where do lactational vs non-lactational breast abscesses tend to occur?
L: peripheral, upper outer NL: central/ sub-areolar/ lower quadrants
33
Which pathogen most commonly causes acute mastitis?
Staphylococcus aureus
34
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)
35
Give 4 general risk factors for mastitis
**Smoking** Age Nipple damage Breast trauma
36
List 3 S/S of mastitis
Painful breast +/- fever + malaise Tender, red, hot, swollen + hard area in wedge distribution
37
List 3 signs suggestive of infection in mastitis
Nipple fissure Purulent discharge Influenza Sx + pyrexia lasting >24h
38
Give 4 S/S indicative of breast abscess
Hx recent mastitis Fever Painful swollen lump in breast, red, hot Fluctuant lump with skin discolouration
39
How should lactational mastitis be managed?
Continue breastfeeding Simple analgesia Warm compresses
40
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
41
What antibiotics are used in lactational mastitis?
Flucloxacillin 500mg QDS 10-14d Erythromycin if Pen allergy
42
How should all non-lactational mastitis be managed?
Flucloxacillin 500mg QDS 10-14d If MRSA: Trimethoprim or Clindamycin | Erythromycin if pen allergy
43
How can breast abscess best be imaged?
USS
44
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
45
What is a fibroadenoma?
Common benign breast lump in pre-menopausal women (peak 20-25) Due to focal growth of stromal + epithelial components
46
Give 3 characteristics of fibroadenoma
Rubbery firm mobile mass Solitary, well circumscribed + smooth Non-tender
47
What size is a fibroadenoma classified as a 'giant fibroadenoma'?
>5cm
48
Describe the progression of fibroadenomas
50% resolve spontaneously 25% stay the same 25% increase in size
49
What causes fibroadenomas?
Unknown, but hormonal factors as present/ change with menstruation/ pregnancy
50
What investigations are used for fibroadenomas?
USS (<30) Mammogram (>30) Core biopsy if >5cm
51
What are the indications for fibroadenoma excision?
Symptomatic: painful/ contour change Growing rapidly Cellular on histology (risk missing phyllodes) >3cm
52
What is intraductal papilloma of the breast?
Local areas of epithelial proliferation in large mammary ducts
53
Give 2 S/S of duct papilloma
Discharge +/- bloody, usually from single duct Mass (if large)
54
Management for duct papilloma
Microdochectomy (excision of duct)
55
What are the symptoms of fibroadenosis of the breast?
Lumpy breasts (BL) which may be painful, symptoms may be worse prior to menstruation
56
What are the symptoms of intraductal papilloma?
Clear/blood-stained discharge
57
How should intraductal papilloma be managed?
Microdochectomy
58
What sort of tumour might arise from a pre-existing fibroadenoma?
Phyllodes tumour
59
Are phyllodes tumours benign or malignant?
Usually benign but occasionally behave aggressively
60
What are the symptoms of phyllodes tumour?
Enlarging mass in women >50 years
61
How does radial scar appear on XR?
Stellate mass
62
How should radial scar be managed?
biposy +/- excision
63
Recall 4 types of breast cancer
Invasive ductal carcinoma Invasive lobular carcinoma Ductal carcinoma in-situ Lobular carcinoma in-situ
64
What is the most common type of breast cancer?
Invasive ductal carcinoma (now renamed "no special type")
65
Which types of breast cancer now come under the heading of 'special type'?
Lobular carcinoma Rarer types: Medullary, Mucinous, Phyllodes, Papillary etc
66
Which type of breast cancer can demonstrate "comedo necrosis"?
DCIS (feature of high nuclear grade, a/w focused of invasion)
67
What is Paget's disease of the nipple?
Eczematoid change of the nipple a/w an underlying breast malignancy
68
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
69
How is Paget's disease of the nipple investigated?
Punch biopsy Mammography USS
70
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
71
Give features of Paget's disease of the nipple
Weeping Ulceration Erosions Reddening Thickening
72
What is inflammatory breast cancer?
Where cancerous cells block the lymph drainage resulting in an inflamed appearance of the breast 1/10,000 cases
73
Which tumour marker may be raised in inflammatory breast cancer?
CA 15-3
74
When is the mammography screening in the UK?
Age 50-71 every 3y >71 encouraged to make own appointments
75
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
76
What makes up the triple assesment for breast Ca?
1. History and exam 2. Imaging (Mammography >35, USS <35, MRI if implants) 3. Pathology (FNA, core biopsy)
77
Describe the lymphatic drainage of the breast
75% to lateral axillary nodes | 25% to parasternal nodes and opposite breast
78
How does chemotherapy differ for node positive and node negative breast cancer?
Node +ve: FEC-D chemo Node -ve: FEC chemo
79
Which receptors are all invasive breast cancers tested for?
Oestrogen receptor Progesterone receptor Her2 receptor
80
What receptors are positive/ negative in low vs high grade breast cancers?
Low grade: ER+, PR+, Her2- High grade: Er-, PR-, Her2 pos
81
What is the receptor status of a basal-like carcinoma of the breast?
ER, PR and Her2 neg
82
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 ## Footnote No CAL: Pre-op axillary US, if -ve, do sentinel node biopsy to assess nodal burden
83
Give 2 complications of axillary clearance
Arm lymphadema Functional arm impairment
84
What is an alternative to axillary node clearance? How does this compare?
Axillary radiotherapy Equivalent oncological control with fewer SE
85
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
86
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
87
When is hormone therapy indicated in breast Ca?
If ER+
88
What drugs are used for oestrogen receptor positive breast Ca?
If pre/peri-meonpausal: Tamoxifen (SERM) If post-menopausal: Anastrazole/ Letrozole (aromatase inhibitor)
89
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
90
Recall 4 side effects of tamoxifen
Menstrual disturbance: Amenorrhoea, PV bleed Endometrial Ca VTE Hot flushes
91
Describe the MOA of Anastrazole
Aromatase inhibitor Aromatase is a key enzyme in converting androgens to oestrogen, thus inhibition reduces peripheral oestrogen synthesis
92
What are 4 side effects of anastrazole to be aware of?
**Osteoporosis**: DEXA at start Hot flushes Arthralgia, myalgia Insomnia
93
When is biological therapy indicated in the treatment of breast Ca?
If Her2 +
94
Recall an example of a biological therapy for HER2 +ve breast cancer
Trastuzumab (herceptin)
95
What score is used to guide prognosis in breast cancer?
Nottingham prognostic index
96
What is the most important prognostic factor for breast cancer?
Axillary LN spread
97
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
98
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
99
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
100
At what size should excision be offered for a breast fibroadenoma?
>3cm
101
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
102
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

YR6 Rotations (22 decks)

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