Surgery - Breast Flashcards
When in the life course is duct ectasia of the breast most common?
Menopause
How should duct ectasia be managed?
Conservatively
If troublesome can be managed surgically
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
How should fat necrosis be investigated?
Imaging
Core biopsy
How does fat necrosis of the breast appear?
Firm, round lump –> hard, irregular lump
Which pathogen most commonly causes acute mastitis?
Staphylococcus aureus
Recall 2 risk factors for acute mastitis
Smoking
Nipple injury
How should lactational mastitis be managed?
Simple analgesia
Warm compresses
Continue breastfeeding
How should non-lactational mastitis be managed?
1st line: flucloxacillin
2nd line: co-amoxiclav
If MRSA –> trimethoprim
How can breast abscess best be imaged?
USS
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
How big does a fibroadenoma have to be to warrant excision?
> 3cm
What is intraductal papilloma of the breast?
Local areas of epithelial proliferation in large mammary ducts
single duct - labstix shows blood traces
What are the symptoms of fibroadenosis of the breast?
Lumpy breasts (BL) which may be painful, symptoms may be worse prior to menstruation
What are the symptoms of intraductal papilloma?
Clear/blood-stained discharge
How should intraductal papilloma be managed?
Microdochectomy
bothersome duct ectasia / young - is total duct removal if old
What sort of tumour might arise from a pre-existing fibroadenoma?
Phyllodes tumour
Are phyllodes tumours benign or malignant?
Usually benign but occasionally behave aggressively
What are the symptoms of phyllodes tumour?
Enlarging mass in women >50 years
How does radial scar appear on XR?
Stellate mass
How should radial scar be managed?
biposy +/- excision
Recall 4 types of breast cancer
Invasive ductal carcinoma
Invasive lobular carcinoma
Ductal carcinoma in-situ
Lobular carcinoma in-situ
Which type of breast cancer can demonstrate “comedo necrosis”?
DCIS
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
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?
- History and exam
- Imaging (Mammography >35, USS <35, MRI if implants)
- 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?
- No palpable axillary - USS - if negative - SLNB
- 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
