Surgery - Breast Flashcards by Seb Mitchell

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 - can be creamy

multiple ducts and associated nipple inversion

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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

single duct - labstix shows blood traces

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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

bothersome duct ectasia / young - is total duct removal if old

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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 carcinoma 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

Weepy and crusty - excludes areola

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When is the mammography screening in the UK?

Age 50-73 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) | cannot be used for patients with CVS disease

What score is used to guide prognosis in breast cancer?

Nottingham prognostic index Tumour Size x 0.2 + Lymph node score(From table below)+Grade score(From table below).

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

Main reason for neo - adjuvant therapy in breast cancer

Downsize the tumour before surgery, allow conservation of the breast | No masectomy

What are the 5 main methods for treating Breast Cancer?

surgery radiotherapy hormone therapy biological therapy chemotherapy

How does the presence of palpable axillary lymphadenopathy pre surgery determine Mx of breast cancer?

1. No palpable axillary - USS - if negative - SLNB 2. If Yes - axillary node clearance | 2. Can lead to arm lymphoedema and functional arm impairment

# Not wide - excision Factors to have a masectomy

* Multifocal tumour * Central tumour * Large lesion in small breast * DCIS > 4cm

When is whole breast radiotherapy offered to women?

After wide-local excision | reduce risk of reoccurance by 2/3

When is adjuvant hormonal therapy offered?

Tumours positive for hormonal receptors

If systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection; what should be done with a patient with lactational mastitis

Non - lactional mastitis management | e.g. PO flucloxacillin

If less than 3 lymph nodes post breast conserving surgery with adjuvant radiotherapy show micromets at sentinel node biopsy what should be done?

No further management Only regional adjuvant therapy and radiotherapy if >4 / poor prognostic factors

What is a sentinel lymph node and what is the biopsy?

* First lymph node cancer would spread to * Radioactive substance, determine close lymph nodes -> then removed biopsied to determine presence of cancer | Risks of lymphoedema

Cancer marker for breast cancer

Ca 15-3

Most common type of breast cancer

Invasive ductal carcinoma

Snowstorm sign in breasts indicates what

extracapsular breast implant rupture | leakage of silicone into lymphatic system

What is periductal mastitis mainly associated with?

Smoking

If post breast surgery no nodal involvement and receptor negative what should be done

FEC - chemo | if nodal FEC-D chemo

irregular lump on the lateral aspect of her right breast associated with skin tethering

Fat necrosis | Can go firm to irregular - may follow trauma

What is tamoxifen

selective oestrogen receptor modulator (SERM)

# Anastrozole What is the end effect of aromastase inhibitors?

reduced peripheral synthesis of oxygen

Treatment for cyclical mastasia

supportive bra and simple analgesia | refer if not respond after 3 months

Halo sign

breast cyst

Quantify quality colour

Characterise breast secretions