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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
Q

How should fat necrosis be investigated?

A

Imaging

Core biopsy

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26
Q

How does fat necrosis of the breast appear?

A

Firm, round lump –> hard, irregular lump

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27
Q

What is mastitis?

A

Inflammation of breast tissue
Lactational or non-lactational

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28
Q

What are the 2 types of mastitis?

A

Non-infectious/ idiopathic

Infectious: usually due to retrograde spread through lactiferous duct or traumatised nipple

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29
Q

What usually causes mastitis in lactating women?

A

Milk stasis
Accumulated milk causes inflammatory response

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30
Q

What usually causes msatitis in non lactating women?

A

Infection:
Central/ subareolar: 2nd to periductal mastitis
Peripheral (less common): a/w DM, RhA, trauma, CS
Granulomatous (rare)

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31
Q

What is a breast abscess?

A

Localised collection of pus in breast
May be a severe complication of mastitis

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32
Q

Where do lactational vs non-lactational breast abscesses tend to occur?

A

L: peripheral, upper outer

NL: central/ sub-areolar/ lower quadrants

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33
Q

Which pathogen most commonly causes acute mastitis?

A

Staphylococcus aureus

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34
Q

Give 3 predisposing factors to milk stasis and lactational mastitis

A

Poor infant attachment
Reduced no./ duration of
feeds (bottle feeds, painful, preferred breast)
Pressure on breast (tight bra, sleeping position)

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35
Q

Give 4 general risk factors for mastitis

A

Smoking
Age
Nipple damage
Breast trauma

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36
Q

List 3 S/S of mastitis

A

Painful breast
+/- fever + malaise
Tender, red, hot, swollen + hard area in wedge distribution

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37
Q

List 3 signs suggestive of infection in mastitis

A

Nipple fissure
Purulent discharge
Influenza Sx + pyrexia lasting >24h

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38
Q

Give 4 S/S indicative of breast abscess

A

Hx recent mastitis
Fever
Painful swollen lump in breast, red, hot
Fluctuant lump with skin discolouration

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39
Q

How should lactational mastitis be managed?

A

Continue breastfeeding
Simple analgesia
Warm compresses

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40
Q

What are the indications for antibiotics in lactational mastitis?

A

Infected nipple fissure
Sx not improved (or worsening) after 12-24h despite milk removal
+ve milk culture

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41
Q

What antibiotics are used in lactational mastitis?

A

Flucloxacillin 500mg QDS 10-14d
Erythromycin if Pen allergy

42
Q

How should all non-lactational mastitis be managed?

A

Flucloxacillin 500mg QDS 10-14d

If MRSA: Trimethoprim or Clindamycin

Erythromycin if pen allergy

43
Q

How can breast abscess best be imaged?

A

USS

44
Q

How should breast abscess be managed?

A

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
Q

What is a fibroadenoma?

A

Common benign breast lump in pre-menopausal women (peak 20-25)
Due to focal growth of stromal + epithelial components

46
Q

Give 3 characteristics of fibroadenoma

A

Rubbery firm mobile mass
Solitary, well circumscribed + smooth
Non-tender

47
Q

What size is a fibroadenoma classified as a ‘giant fibroadenoma’?

A

> 5cm

48
Q

Describe the progression of fibroadenomas

A

50% resolve spontaneously
25% stay the same
25% increase in size

49
Q

What causes fibroadenomas?

A

Unknown, but hormonal factors as present/ change with menstruation/ pregnancy

50
Q

What investigations are used for fibroadenomas?

A

USS (<30)
Mammogram (>30)
Core biopsy if >5cm

51
Q

What are the indications for fibroadenoma excision?

A

Symptomatic: painful/ contour change
Growing rapidly
Cellular on histology (risk missing phyllodes)
>3cm

52
Q

What is intraductal papilloma of the breast?

A

Local areas of epithelial proliferation in large mammary ducts

53
Q

Give 2 S/S of duct papilloma

A

Discharge +/- bloody, usually from single duct
Mass (if large)

54
Q

Management for duct papilloma

A

Microdochectomy (excision of duct)

55
Q

What are the symptoms of fibroadenosis of the breast?

A

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

56
Q

What are the symptoms of intraductal papilloma?

A

Clear/blood-stained discharge

57
Q

How should intraductal papilloma be managed?

A

Microdochectomy

58
Q

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

A

Phyllodes tumour

59
Q

Are phyllodes tumours benign or malignant?

A

Usually benign but occasionally behave aggressively

60
Q

What are the symptoms of phyllodes tumour?

A

Enlarging mass in women >50 years

61
Q

How does radial scar appear on XR?

A

Stellate mass

62
Q

How should radial scar be managed?

A

biposy +/- excision

63
Q

Recall 4 types of breast cancer

A

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

64
Q

What is the most common type of breast cancer?

A

Invasive ductal carcinoma
(now renamed “no special type”)

65
Q

Which types of breast cancer now come under the heading of ‘special type’?

A

Lobular carcinoma
Rarer types:
Medullary, Mucinous, Phyllodes, Papillary etc

66
Q

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

A

DCIS
(feature of high nuclear grade, a/w focused of invasion)

67
Q

What is Paget’s disease of the nipple?

A

Eczematoid change of the nipple a/w an underlying breast malignancy

68
Q

How is Paget’s disease of the nipple related to breast cancer?

A

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
Q

How is Paget’s disease of the nipple investigated?

A

Punch biopsy
Mammography
USS

70
Q

How does Paget’s disease differ from eczema of the nipple?

A

Paget’s: starts at nipple, spreads to the areolar. Usually unilateral + persistent despite eczema Tx

Eczema: starts at areola, spreads to nipple

71
Q

Give features of Paget’s disease of the nipple

A

Weeping
Ulceration
Erosions
Reddening
Thickening

72
Q

What is inflammatory breast cancer?

A

Where cancerous cells block the lymph drainage resulting in an inflamed appearance of the breast
1/10,000 cases

73
Q

Which tumour marker may be raised in inflammatory breast cancer?

A

CA 15-3

74
Q

When is the mammography screening in the UK?

A

Age 50-71 every 3y
>71 encouraged to make own appointments

75
Q

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

A

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
Q

What makes up the triple assesment for breast Ca?

A
  1. History and exam
  2. Imaging (Mammography >35, USS <35, MRI if implants)
  3. Pathology (FNA, core biopsy)
77
Q

Describe the lymphatic drainage of the breast

A

75% to lateral axillary nodes

25% to parasternal nodes and opposite breast

78
Q

How does chemotherapy differ for node positive and node negative breast cancer?

A

Node +ve: FEC-D chemo
Node -ve: FEC chemo

79
Q

Which receptors are all invasive breast cancers tested for?

A

Oestrogen receptor
Progesterone receptor
Her2 receptor

80
Q

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

A

Low grade: ER+, PR+, Her2-

High grade: Er-, PR-, Her2 pos

81
Q

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

A

ER, PR and Her2 neg

82
Q

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

A

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

83
Q

Give 2 complications of axillary clearance

A

Arm lymphadema
Functional arm impairment

84
Q

What is an alternative to axillary node clearance? How does this compare?

A

Axillary radiotherapy
Equivalent oncological control with fewer SE

85
Q

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

A

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

86
Q

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

A

Following any wide local excision
Following a mastectomy IF:
- T3 or T4 OR
- >,4 +ve LNs

87
Q

When is hormone therapy indicated in breast Ca?

A

If ER+

88
Q

What drugs are used for oestrogen receptor positive breast Ca?

A

If pre/peri-meonpausal: Tamoxifen (SERM)

If post-menopausal: Anastrazole/ Letrozole (aromatase inhibitor)

89
Q

Describe the MOA of Tamoxifen in breast cancer

A

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
Q

Recall 4 side effects of tamoxifen

A

Menstrual disturbance: Amenorrhoea, PV bleed
Endometrial Ca
VTE
Hot flushes

91
Q

Describe the MOA of Anastrazole

A

Aromatase inhibitor
Aromatase is a key enzyme in converting androgens to oestrogen, thus inhibition reduces peripheral oestrogen synthesis

92
Q

What are 4 side effects of anastrazole to be aware of?

A

Osteoporosis: DEXA at start
Hot flushes
Arthralgia, myalgia
Insomnia

93
Q

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

A

If Her2 +

94
Q

Recall an example of a biological therapy for HER2 +ve breast cancer

A

Trastuzumab (herceptin)

95
Q

What score is used to guide prognosis in breast cancer?

A

Nottingham prognostic index

96
Q

What is the most important prognostic factor for breast cancer?

A

Axillary LN spread

97
Q

Describe 1 benefit of neoadjuvant chemotherapy prior to surgery for breast cancer

A

Downsize primary tumour- breast conserving surgery can be performed instead of mastectomy
Smaller surgery, less peri-operative risks + better cosmetic outcomes

98
Q

Describe the different appearanes of nipple discharge and their causes

A

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

99
Q

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

A

Any malignancy suspected after USS in women <40y

Lobular cancers

100
Q

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

A

> 3cm

101
Q

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

A

Pre-menopausal: tamoxifen

Post-menopausal: anastrazole

102
Q

What is seen on USS of axillary lymph nodes in extracapsular implant rupture?

A

‘Snowstorm’ sign
Due to leakage of silicone, which drains via lymphatic system in breast + LNs

YR6 Rotations (22 decks)

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