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ICSM Year 6 > Surgery - Breast > Flashcards

Surgery - Breast Flashcards

1
Q

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

A

Menopause

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2
Q

How should duct ectasia be managed?

A

Conservatively

If troublesome can be managed surgically

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3
Q

What are the signs and symptoms of duct ectasia?

A

Tender lump around areola and green nipple discharge

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4
Q

How should fat necrosis be investigated?

A

Imaging

Core biopsy

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5
Q

How does fat necrosis of the breast appear?

A

Firm, round lump –> hard, irregular lump

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6
Q

Which pathogen most commonly causes acute mastitis?

A

Staphylococcus aureus

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7
Q

Recall 2 risk factors for acute mastitis

A

Smoking

Nipple injury

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8
Q

How should lactational mastitis be managed?

A

Simple analgesia
Warm compresses
Continue breastfeeding

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9
Q

How should non-lactational mastitis be managed?

A

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

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10
Q

How can breast abscess best be imaged?

A

USS

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11
Q

How should breast abscess be managed?

A

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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12
Q

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

A

> 3cm

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13
Q

What is intraductal papilloma of the breast?

A

Local areas of epithelial proliferation in large mammary ducts

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14
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

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15
Q

What are the symptoms of intraductal papilloma?

A

Clear/blood-stained discharge

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16
Q

How should intraductal papilloma be managed?

A

Microdochectomy

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17
Q

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

A

Phyllodes tumour

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18
Q

Are phyllodes tumours benign or malignant?

A

Usually benign but occasionally behave aggressively

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19
Q

What are the symptoms of phyllodes tumour?

A

Enlarging mass in women >50 years

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20
Q

How does radial scar appear on XR?

A

Stellate mass

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21
Q

How should radial scar be managed?

A

biposy +/- excision

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22
Q

Recall 4 types of breast cancer

A

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

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23
Q

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

A

DCIS

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24
Q

What is Paget’s disease of the nipple?

A

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

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25
Q

When is the mammography screening in the UK?

A

Age 50-70 every 3 years

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26
Q

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

A

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

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27
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)
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28
Q

Describe the lymphatic drainage of the breast

A

75% to lateral axillary nodes

25% to parasternal nodes and opposite breast

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29
Q

Which receptors are all invasive breast cancers tested for?

A

Oestrogen receptor
Progesterone receptor
Her2 receptor

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30
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

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31
Q

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

A

ER, PR and Her2 neg

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32
Q

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

A

If there is CAL: axillary node clearance

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

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33
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

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34
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 or more pos LNs

35
Q

When is hormone therapy indicated in breast Ca?

A

If ER+

36
Q

What options are there for hormone therapy in breast Ca?

A

If pre/peri-meonpausal –> tamoxifen (SERM)

If post-menopausal –> anastrazole (aromatase inhibitor)

37
Q

Recall some side effects of tamoxifen

A

Amenorrhoea
Endometrial Ca
PV bleed
VTE

38
Q

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

A

Osteroporosis

39
Q

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

A

If Her2 +

40
Q

Recall an example of a biological therapy for breast Ca

A

Trastuzumab (herceptin)

41
Q

What score is used to guide prognosis in breast cancer?

A

Nottingham prognostic index

42
Q

What is the most important prognostic factor for breast cancer?

A

Axillary LN spread

43
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

44
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

45
Q

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

A

> 3cm

46
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

47
Q

What is meant by comedonecrosis?

A

The central necrosis of cancer cells in the ducts

48
Q

What is a relatively common complication of breast implants?

A

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

49
Q

What are the symptoms of capsular contracture?

A
  • Breasts may feel firm or tight
  • Pain, especially when lying on breasts
  • Hardened pockets or ball-like areas
  • Misshapen or unnatural looking breasts
50
Q

When is there a higher risk of capsular contracture?

A

In breast reconstructions after mastectomy

51
Q

What is the prevalence of capsular contracture?

A

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

52
Q

How is DCIS treated?

A
  • 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
53
Q

What is always given alongside breast-conserving surgery?

A

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

54
Q

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

A

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

55
Q

What is a therapeutic mammoplasty?

A

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

56
Q

What are some complications of breast-conserving surgery?

A
  • Seroma
  • Lymphoedema
  • Infection
  • Bleeding - not usually life-threatening but may require return to theatre
  • DVT/PE
  • Need for further revision surgery
57
Q

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

A

Axillary node radiotherapy

58
Q

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

A

Pre = tamoxifen
Post = anastrozole

59
Q

What is the MoA of anastrozole?

A

Aromatase inhibitor that works to reduce peripheral synthesis of oestrogen

60
Q

What is the MoA of tamoxifen?

A

Partial oestrogen receptor antagonism

61
Q

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

A

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

62
Q

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

A

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

63
Q

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

A

Duct ectasia

64
Q

Is unilateral or bilateral radiotherapy given after surgery?

A

Unilateral

65
Q

How may fibroadenomas change during pregnancy?

A

May enlarge

66
Q

Up to what size tumour is wide local excision considered?

A

4cm

67
Q

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

A

Lymphoedema causing functional arm impairment

68
Q

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

A

FEC-D chemotherapy

69
Q

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

A

Osteoporosis

70
Q

What are some side effects of SERMs?

A
  • Amenorrhoea
  • Endometrial cancer
  • Vaginal bleeding
  • VTE
71
Q

What is bilateral nipple discharge typically due to?

A

Hormonal changes

72
Q

What is meant by fibroadenosis?

A

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

73
Q

What is the cause of duct ectasia?

A

Dilation and shortening of the mammary ducts as a woman ages

74
Q

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

A

3 or more positive nodes

75
Q

What is Mondor’s disease of the breast?

A

Local thrombophlebitis of a breast vein

76
Q

Which patients is periductal mastitis commonly seen in?

A

Smokers

77
Q

How may periductal mastitis present?

A

Recurrent infections

78
Q

What is the Mx of cyclical mastalgia?

A
  • Supportive bra
  • Paracetamol/simple analgesia
79
Q

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

A

Extracapsular implant rupture

80
Q

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

A

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

81
Q

Blood-stained discharge is most commonly associated with what?

A

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

82
Q

What is the typical presentation of inflammatory breast cancer?

A
  • Progressive erythema and oedema of the breast
  • In the absence of raised inflammatory markers (CRP/WCC)
  • Raised CA 15-3
83
Q

What inheritance pattern do the BRCA1/2 genes follow?

A

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ICSM Year 6 (21 decks)

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