Surgery - Breast Flashcards by Rebecca Doherty

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

Menopause

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How should duct ectasia be managed?

Conservatively

If troublesome can be managed surgically

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What are the signs and symptoms of duct ectasia?

Tender lump around areola and green nipple discharge

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How should fat necrosis be investigated?

Imaging

Core biopsy

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How does fat necrosis of the breast appear?

Firm, round lump –> hard, irregular lump

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Which pathogen most commonly causes acute mastitis?

Staphylococcus aureus

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Recall 2 risk factors for acute mastitis

Smoking

Nipple injury

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How should lactational mastitis be managed?

Simple analgesia
Warm compresses
Continue breastfeeding

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How should non-lactational mastitis be managed?

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

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How can breast abscess best be imaged?

USS

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How should breast abscess be managed?

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

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

> 3cm

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What is intraductal papilloma of the breast?

Local areas of epithelial proliferation in large mammary ducts

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What are the symptoms of fibroadenosis of the breast?

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

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What are the symptoms of intraductal papilloma?

Clear/blood-stained discharge

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How should intraductal papilloma be managed?

Microdochectomy

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

Phyllodes tumour

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Are phyllodes tumours benign or malignant?

Usually benign but occasionally behave aggressively

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What are the symptoms of phyllodes tumour?

Enlarging mass in women >50 years

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How does radial scar appear on XR?

Stellate mass

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How should radial scar be managed?

biposy +/- excision

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Recall 4 types of breast cancer

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

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

DCIS

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What is Paget’s disease of the nipple?

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

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When is the mammography screening in the UK?

Age 50-70 every 3 years

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

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

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)

Describe the lymphatic drainage of the breast

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

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?

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

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 or more pos LNs

When is hormone therapy indicated in breast Ca?

If ER+

What options are there for hormone therapy in breast Ca?

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

Recall some side effects of tamoxifen

Amenorrhoea Endometrial Ca PV bleed VTE

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

Osteroporosis

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

If Her2 +

Recall an example of a biological therapy for breast Ca

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 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 meant by comedonecrosis?

The central necrosis of cancer cells in the ducts

What is a relatively common complication of breast implants?

Capsular contracture - the formation of a capsule around the implant in the body's attempt to expel it form the body

What are the symptoms of capsular contracture?

* Breasts may feel firm or tight * Pain, especially when lying on breasts * Hardened pockets or ball-like areas * Misshapen or unnatural looking breasts

When is there a higher risk of capsular contracture?

In breast reconstructions after mastectomy

What is the prevalence of capsular contracture?

Thought to be 1 in 6 women (but can be to varying degrees)

How is DCIS treated?

* Usually with a wide local excision * Specimen is then sent to the lab to determine if the margins are clear and whether there is any evidence of invasive disease * If margins are not clear or there is invasive disease present, revision surgery will be required within 2 weeks

What is always given alongside breast-conserving surgery?

Radiotherapy (usually 5 fractions but can be 15 depending on patient/background)

How is the decision as to whether chemotherapy is required after breast cancer made?

Specimen is sent to a lab in US for oncotyping to determine whether the benefit from chemotherapy outweighs the survival risk

What is a therapeutic mammoplasty?

A form of breast-conserving surgery where large sections of tissue are required to be removed but skin is also taken so that the shape of the breast can be conserved

What are some complications of breast-conserving surgery?

* Seroma * Lymphoedema * Infection * Bleeding - not usually life-threatening but may require return to theatre * DVT/PE * Need for further revision surgery

What treatment can be given to patients with nodal metastasis who refuse surgical nodal clearance?

Axillary node radiotherapy

What is the first-line hormonal therapy for ER +ve tumours in pre- and post-menopausal women?

Pre = tamoxifen Post = anastrozole

What is the MoA of anastrozole?

Aromatase inhibitor that works to reduce peripheral synthesis of oestrogen

What is the MoA of tamoxifen?

Partial oestrogen receptor antagonism

Why is whole-breast radiotherapy given after wide local excision?

Has been shown to reduce recurrence by up to 2/3rds

When would axillary lymph node clearance be offered at the time of primary surgery?

If the pre-operative ultrasound-guided needle aspiration came back positive

'Symmetrical slit-like retraction' of the nipple is seen in what condition?

Duct ectasia

Is unilateral or bilateral radiotherapy given after surgery?

Unilateral

How may fibroadenomas change during pregnancy?

May enlarge

Up to what size tumour is wide local excision considered?

4cm

What is a common complication of axillary node clearance that patients should be warned of?

Lymphoedema causing functional arm impairment

Aside from nodal clearance, what other adjunctive therapy can be given to patients who are node +ve?

FEC-D chemotherapy

What is the major complication of anastrozole (aromatase inhibitors)?

Osteoporosis

What are some side effects of SERMs?

* Amenorrhoea * Endometrial cancer * Vaginal bleeding * VTE

What is bilateral nipple discharge typically due to?

Hormonal changes

What is meant by fibroadenosis?

Most common in middle-aged women 'Lumpy' breasts which may be painful. Symptoms may worsen prior to menstruation

What is the cause of duct ectasia?

Dilation and shortening of the mammary ducts as a woman ages

If sentinel lymph node biopsy comes back as positive, what threshold would then require axillary node clearance there and then?

3 or more positive nodes

What is Mondor's disease of the breast?

Local thrombophlebitis of a breast vein

Which patients is periductal mastitis commonly seen in?

Smokers

How may periductal mastitis present?

Recurrent infections

What is the Mx of cyclical mastalgia?

* Supportive bra * Paracetamol/simple analgesia

What would a 'snowstorm' appearance on USS of the breast indicate?

Extracapsular implant rupture

What is a key reason for using neo-adjuvant chemotherapy in breast cancer?

Can shrink down the tumour size so that a wide local excision may be able to be done rather than a full mastectomy

Blood-stained discharge is most commonly associated with what?

Intraductal papillomas (but also should consider/rule out breast cancer)

What is the typical presentation of inflammatory breast cancer?

* Progressive erythema and oedema of the breast * In the absence of raised inflammatory markers (CRP/WCC) * Raised CA 15-3

What inheritance pattern do the BRCA1/2 genes follow?