surgery - breast Flashcards
what Is galactorrhea?
copious, bilateral, multi-ductal, milky discharge, not associated with pregnancy or lactation.
when does galactorrhea present in postpartum females?
6-12 months after pregnancy and the cessation of breastfeeding
what is lactation regulated by?
prolactin - produced + secreted by ant pituitary gland
what is prolactin secretion controlled by?
dopamine - released by hypothalamus and inhibits prolactin secretion
TRH and oestrogen stimulate prolactin release from pituitary
aetiology of galactorrhoea
MAIN = hyperprolactinaema
idiopathic
pituitary adenoma
drugs - SSRI, antipsychotics, H2 antagonists
neurological - VZV, spinal cord injury
hypothyroid, Cushing’s, acromegaly, Addisons
renal/liver failure
damage to pituitary stalk - surgical resection, MS, sarcoidosis, TB
features of galactorrhoea
multi-ductal milky white nipple discharge, typically bilateral
exclude other causes - lumps, mastalgia, LMP, endocrine or neurological causes
investigations of galactorrhoea
exclude pregnancy - B-hCG test
serum prolactin levels
thyroid function
liver function
renal function
further - IGF-1, ACTH
what imaging for galactorrhea?
MRI head with contrast
breast imaging if palpable lumps of lymph nodes present
management of galactorrhea?
confirmed pituitary tumour = dopamine agonist eg cabergoline/bromocriptine, refer for trans-sphenoidal surgery
Idiopathic normoprolactinaemic galactorrhoea often resolves spontaneously
troublesome galactorrhoea who are intolerant of medication, bilateral total duct excision
what is mastalgia?
breast pain
incidence of breast malignancy assoc with mastalgia
LOW
Which men may experience mastalgia
generally rare, but those who have developed gynaecomastia may
causes of mastalgia?
cyclical, non-cyclical or extra mammary
what is cyclical mastalgia?
presentation + cause
most common
assoc with menstruation + HRT use
bilateral,. few days before period
caused by hormonal changes
what is non-cyclical mastalgia?
caused by meds - hormonal contraception, anti-depressants, antipsychotics
what is extramammary pain?
chest wall or shoulder pain
features of mastalgia?
lumps, skin changes, fevers, or discharge, as well as association with menstrual cycle.
ask about drug history, breast-feeding, pregnancies, previous medical history, and family history.
investigations for mastalgia?
reproductive age - pregnancy test
management of mastalgia?
reassurance and pain control is the primary form of management
cyclical - supportive bra
oral ibuprofen or paracetamol or topical NSAIDs can help alleviate pain
non-cyclical may resolve spontaneously
refer if 1st line unsuccessful
2nd line - danazol a antigonadotrophin agent
s/e of danazol?
nausea, dizziness, and weight gain
what does mammography look at?
compression views of the breast across two views (oblique and craniocaudal), allowing for the detection mass lesions or microcalcifications.
what is USS used for in breast?
more useful in women <35 years and in men, due to the density of the breast tissue in identifying anomalies. This form of imaging is also routinely used during core biopsies.
when is MRI useful in breast?
not used in the mainstay of triple assessment however can be useful in the assessment of lobular breast cancers (and in assessing response to neoadjuvant therapy)
what imaging is included in the triple assessment?
mammography + USS
when is breast biopsy needed?
biopsy is required of any suspicious mass or lesion presenting to the clinic, most commonly obtained via core biopsy.
what does core biopsy do in breast?
core biopsy - full histology, differentiation between invasive + in-situ caricnoma
tumour grading + staging
If a woman has recurrent cystic disease (and the lesion is clinically a cyst), how can this can be aspirated?
using FNA at this stage for cytology and to relieve symptoms.
how is suspicion for breast malignancy graded?
what are types of benign breast tumours?
fibroadenoma
adenoma
intraductal papilloma
lipoma
phyllodes tumour
who is fibroadenoma seen in?
most common benign areas growth
women of reproductive age
what are fibroadenoma?
proliferations of stroll and epithelial tissue of duct lobules
highly mobile, well-defined and rubbery
most <5cm
can be multiple and bilateral
malignant risk of fibroadenoma?
VERY LOW
excision if >3cm
what is a breast adneoma?
benign glandular tumour
usually older females
nodule and can easily mimic malignancy - will be escalated for triple assessment
what is breast intraductal papilloma?
females 40-50
subareolar region
present with bloody or clear nipple discharge
require biopsy + excision
which intraductal papillomas may be malignant?
if multi-ductal
treated with microdochectomy
what is microdochectomy?
a surgical procedure that involves the removal of one or more milk ducts in the breast
what is breast lipoma?
soft + mobile benign adipose tumour
low malignant potential
removed if enlarging or causing symptomatic compressive/aesthetic issues
what is phyollodes tumour?
rare fibroepithelial tumours
older age
both epithelial + stromal tissue
often grow rapidly
malignant potential of phyllodes tumour?
1/3 malignant potential
1% recur post excision
hence, most should be widely excised
which benign breast tumour?
fibroadenom
which benign breast tumour?
phyllodes
which benign breast tumour?
intraductal papilloma
which benign breast tumour?
adenoma
investigations for benign breast tumours?
triple assessment, examination, imaging and histology if concerning
what is gynaecomastia?
males developing breast tissue due to imbalanced ratio of oestrogen and androgen activity
usually benign but breast cancer can develop in 1%
usually entirely reversible
what is this?
hyperplasia of breast tissue as seen in gynaecomastia
pathophysiology of gynaecomastia?
physiological gynaecomastia - commonly in adolescence due to delayed testosterone surge relative to oestrogen at puberty
pathological - changes in oestrogen:androgen activity ratio due to lack of testosterone, increased oestrogen, medication or idiopathic
what can cause lack of testoerstone leading to Gynaecomastia?
Klinefelter’s, androgen insensitivity, testicular atrophy or renal disease
what can cause increased oestrogen leading to Gynaecomastia?
liver disease, hyperthyroid, obesity, adrenal tumours, testicular tumours eh Leydig’s
what meds cause Gynaecomastia?
digoxin
metronidzaole
spironolactone
chemo
goserelin
antipsychotics
anabolic steroids
clinical features of gynaecomastia?
insidious onset
rubbery or firm mass, usually >2cm that starts from under the nipple and spreads outwards over the breast region
examine for breast malignancy and testicles
DD in gynaecomastia?
pseudogynaecomastia - adipose tissue in breast region assoc with being overweight
*This can usually be tested on examination by pinching to see if there is an obvious disc of breast tissue present however if not palpable then further imaging and / or histology may be required to definitively exclude
investigations for gynaecomastia?
Tests are only necessary if the cause for gynaecomastia is unknown
liver + renal function, then hormone profile
what levels of LH indicate testicular failure
LH high and testosterone low
what levels of LH indicate increased oestrogen?
LH low and testosterone low
what levels of LH indicate androgen resistance or gonadotrophin-secreting malignancy?
LH high and testosterone high
management of gynaecomastia?
treat underlying cause if possible
reassurance
tamoxifen can also be used in cases to help alleviate symptoms, especially tenderness.
surgery if medical tx failed
what is mastitis?
inflammation of the breast tissue, both acute or chronic.
commonly caused by infection with S.aureus
how is mastitis classified?
classified dependent on lactation status: lactational or non-lactational
what is lactational mastitis?
Lactational mastitis (more common) is seen in up to a third of breastfeeding women; it usually presents during the first 3 months of breastfeeding or during weaning
It is associated with cracked nipples and milk stasis (often caused by poor feeding technique), and is more common with the first child
what is non-lactational mastitis?
Non-lactational mastitis (less common) can also occur, especially in women with other conditions such as duct ectasia, as a peri-ductal mastitis
Tobacco smoking is an important risk factor, causing damage to the sub-areolar duct walls and predisposing to bacterial infection
clinical features of mastitis?
tenderness, swelling or induration, and erythema over the area of infection
Ensure to assess for any developing breast abscess
management of mastitis?
simple analgesics and a warm compress
lactational - continued milk drainage or feeding
If symptoms do not improve after 12-24 hours, then antibiotics
breast abscess - needle aspiration
Cessation of breastfeeding using dopamine agonists (such as Cabergoline) can be considered in women with persistent or multiple areas of infection.
what is breast abscess?
A breast abscess is a collection of pus within the breast lined with granulation tissue. They most commonly develop secondary to acute mastitis.
how does breast abscess present?
They will present with a tender, fluctuant, erythematous mass, often with a puncutum present that may or may not be discharging pus. Associated systemic symptoms include fever and lethargy.
ix + tx for breast abscess?
USS
Ultrasound-guided needle therapeutic aspiration can be performed, both to help resolution of the abscess and to help guide antibiotic prescribing.
complication of non-lactational abscess?
formation of a mammary duct fistula (a communication between the skin and a subareolar breast duct), which, whilst they can be managed surgically with a fistulectomy and antibiotics, can often recur.
what are breast cysts?
epithelial lined fluid-filled cavities, which form when lobules become distended due to blockage, usually in the perimenopausal age group.
features of breast cyst?
singularly or with multiple lumps and can affect one or both breasts. On palpation, cysts appear as distinct smooth masses that may also be tender.
ix for breast cyst?
halo shape on mammography
definitively diagnosed using ultrasound
Persisting, symptomatic, or undeterminable cystic masses may be aspirated
Cancer may be excluded if the fluid is free of blood or the lump disappears
management of breast cyst?
no further management and self-resolve
Larger cysts can be aspirated for aesthetic reasons or patient reassurance.
complications of breast cyst?
Patients with cysts also have a 2-3 times greater risk of developing breast cancer in the future.
Some women may develop fibroadenosis (fibrocystic change) caused by multiple small cysts and fibrotic areas. may mask malignancy
what is mammary duct ectasia?
dilation and shortening of the major lactiferous ducts.
peri-menopausal women
features of mammary duct ectasia?
coloured green/yellow nipple discharge, a palpable mass, or nipple retraction.
ix of mammary duct ectasia?
mammography by dilated calcified ducts
If biopsied, the mass typically contains multiple plasma cells on histology, which is often referred to as ‘plasma cell mastitis’.
mx of mammary duct ectasia?
managed conservatively, unless radiological findings cannot exclude malignancy. Unremitting nipple discharge can be treated with duct excision.
what is breast fat necrosis?
caused by an acute inflammatory response in the breast, leading to ischaemic necrosis of fat lobules.
It is often referred to as traumatic fat necrosis due to its association with trauma, however blunt trauma to the breast is only implicated in 40% cases, with previous surgical or radiological intervention making up the remaining proportion.
features of fat necrosis?
usually asymptomatic or presenting as a lump
less common - fluid discharge, skin dimpling, pain and nipple inversion.
acute inflammatory response can persist, causing a chronic fibrotic change that can subsequently develop into a solid irregular lump
ix for fat necrosis??
suggested by a positive traumatic history and/ or a hyperechoic mass on ultrasound.
developed fibrotic lesions will mimic carcinoma on mammogram, appearing as calcified irregular speculated masses and the solid irregular lump may feel suspicious on palpation. Therefore a core biopsy is often taken to categorically rule out malignancy.
management of fat necrosis
self-limiting and usually only requires analgesic management and reassurance.
what is breast carcinoma in situ?
neoplasms that are contained within the breast ducts and have not spread into the surrounding breast tissue.
pre-malignant
what are the two main types of in situ breast carcinoma?
Ductal Carcinoma In Situ (DCIS) and Lobular Carcinoma In Situ (LCIS).
what is ductal carcinoma in situ?
most common
malignancy of ductal tissue that is contained within the breast membrane
what are the types of DCIS?
comedo, cribriform, micropapillary, papillary, and solid types, however most lesions are mixed.
ix for DCIS?
often detected during screening
90% of patients with DCIS will have suspicious microcalcifications seen on mammography, with the diagnosis then subsequently confirmed via biopsy
management of DCIS?
treated with surgical excision
breast conserving surgery (wide local excision) or (in cases of widespread or multifocal DCIS) with mastectomy.
what is lobular carcinoma in situ?
non-invasive lesion of the secretory lobules of the breast that is contained within the basement membrane
much rarer than DCIS however individuals with LCIS are at greater risk of developing an invasive breast malignancy.
ix for LCIS?
usually asymptomatic
usually diagnosed as an incidental finding during biopsy of the breast
mx of LCIS?
mx dependent on extent of disease
Low grade LCIS is usually treated by monitoring
Bilateral prophylactic mastectomy can be potentially indicated if individuals possess the BRCA1 or BRCA2 genes.
lifetime risk of breast cancer in UK
1 in 7 in females
how is invasive carcinoma of breast classified?
Invasive ductal carcinoma (70-80%)
Invasive lobular carcinoma (5-10%)
Other subtypes, such as medullary carcinoma, invasive micropapillary carcinoma, or metaplastic carcinoma
what is invasive ductal carcinoma comprised of?
nests and cords of tumour cells with associated gland formation.
what is invasive lobular carcinoma comprised of?
more common in older women.
diffuse (stromal) pattern of spread that makes detection more difficult
which invasive cancer is this?
invasive ductal
which invasive cancer is this?
invasive lobular
risk factors for invasive breast cancer?
Female sex and increasing age - doubles approximately every ten years until the menopause
FH
BRCA1, BRCA2 - increase the risk of ovarian, prostate, and pancreatic cancer.
exposure to unopposed oestrogens - early menarche, late menopause, nulliparity, and long term use of HRT
Previous benign breast disease, obesity, alcohol consumption, smoking and geographic variation
features of invasive breast cancer?
symptomatically or asymptomatically via screening.
breast or axillary lump(s), asymmetry, or swelling, abnormal nipple discharge, nipple retraction, skin changes (dimpling/peau d’orange, or Paget’s-like nipple changes) and mastalgia.
ix of invasive breast cancer?
gold standard for diagnosis of breast lumps is via triple assessment
examination, imaging with mammography and ultrasound (MRI is used in a minority of cases), and biopsy.
mx of invasive breast cancer?
surgery, radiotherapy, chemotherapy, hormonal therapy, and / or antibody therapy.
what influences breast cancer prognosis>
nodal status, size, grade, and receptor status.
Nottingham Prognostic Index (NPI)* is a widely used clinicopathological staging system for primary breast cancer prognosis. It is calculated by: (Size x 0.2) + Nodal Status + Grade
how does NPI score predict 5 yr survival?
who is invited for breast cancer screening in UK?
women aged 50-71yrs to have a mammogram every three years
what Is Paget’s disease of the nipple?
rare condition, presenting as a persistent roughening, scaling, ulcerating or eczematous change to the nipple.
majority will also have an underlying neoplasm, either in-situ or invasive disease
pathophysiology of pagets?
involvement of the epidermis by malignant intraepithelial adenocarcinoma cells within the nipple epidermis.
either malignant cells migrate from the ducts to the nipple surface or the cells of the nipple themselves become malignant
clinical features of pagets?
itching or redness in the nipple and/or areola, with flaking and thickened skin on or around the nipple
The area is often painful and sensitive. A flattened nipple, with or without yellowish or bloody discharge, may also be indicative of the disease.
what is this?
PAGET’S
DD for pagets?
dermatitis or eczema.
Paget’s disease can be differentiated from eczema on the basis that the former always affects the nipple and only involves the areola as a secondary event, whilst eczema nearly always only involves the areola and spares the nipple
ix of paget’s dsease?
A biopsy is needed to confirm diagnosis. Given its association with malignancy, a complete breast and axilla examination should also be performed; mammograms, ultrasounds, or MRI breast may also be warranted.
mx for pagets?
operative - removal of nipple + areola
+/- radiotherapy
what does it mean if tumour is ER positive?
oestrogen receptor positive - tumour growth can be driven by oestrogen binding at the oestrogen receptor and endocrine treatments will target this pathway.
how is ER positive tumour treated?
selective oestrogen receptor modulators (SERMs), e.g. tamoxifen, and aromatase inhibitors, e.g. letrozole
dependent on menopausal status
what do pre-menopausal women get for ER positive cancer?
Pre-menopausal women depend primarily upon ovarian oestrogen production (an aromatase independent process), which renders aromatase inhibitor use in this group ineffective without ovarian suppression. As such, tamoxifen is offered to pre-menopausal ER positive breast cancer patients,
who else may receive endocrine tx for breast cancer?
frail or co-morbid patients who may not tolerate surgery and / or chemotherapy.
how does immunotherapy work for breast cancer?
monoclonal antibody treatments designed to target specific receptors or proteins that certain cancer cells produce
slow cancer cell growth and/or generate host immune responses against the cancer cells.
what immunotherapy can be given for breast cancer?
Herceptin (Trastuzumab, Fig. 2) is a monoclonal antibody that binds to the Her-2 receptor, which acts to halt the cell cycle and induce an immune response against the bound tumour cell.
when. is chemo used?
ocalised or advanced breast cancer. It has been found to reduce breast cancer recurrence risk and mortality. Benefit can vary greatly from case to case depending on patient and disease factors.
who is chemo beneficial for?
younger patients, in larger tumours, high grade disease, and in disease with local or distant spread.
who is breast conserving surgery suitable for?
ocalised disease and no evidence of metastatic disease.
how is breast conserving surgery done?
wide local excision (WLE), which comprises removing the breast cancer with a cuff of healthy tissue around it. Breast conserving surgery can be considered when the size of the breast cancer is small relative to the breast size.
how are breast cancers localised prior to surgery?
image-guided guidewire or magseed insertion, which allow for more accurate surgery.
what techniques used in excision?
incision placement directly over the area of disease, to approaches which hide scars beneath clothing, around the areola, or within the Infra mammary fold. More recently oncoplastic techniques (discussed below) can allow reshaping of the breast or transposition of local tissue flaps to ensure optimal cosmetic outcomes whilst still achieving oncological control.
what is mastectomy?
removing the entirety of the breast tissue
indicated in cases of multifocal disease, high tumour:breast tissue ratio, disease recurrence, patient choice, or for risk-reduction.
how is mastectomy performed?
preservation of the breast skin envelope (and nipple).
“simple mastectomies” involve excision of an area of skin overlying the breast to result in a flat cosmesis, skin-sparing (SSM) and nipple-sparing mastectomy (NSM) can also be performed. Both SSM and NSM allow for the preservation of a breast envelope so as to facilitate reconstruction.
what is risk-reducing mastectomy?
operation to remove healthy breast tissue in order to reduce the risk of developing breast cancer.
only suitable for patients with a high risk of developing breast cancer and requires appropriate counseling to reach this difficult decision. In cases of suspected genetic risks, then patients are often referred to a genetic counsellor.
factors conferring risk?
A strong family history of breast or ovarian cancer
Testing positive for genetic mutations, such as BRCA1 or BRCA2, PTEN, or TP53 mutations
Previous history of breast cancer
types of axially surgery?
Sentinel Lymph Node Biopsy (SLNB) and Axillary Node Clearance (ANC)
what is SLNB?
removal of the sentinel lymph node - first one the breast drains into
enable assessment of potential lymphatic spread
identified using technetium-99 injection + gamma probe
what is ANC?
removing all nodes in the axilla. This is performed when nodal spread is confirmed on biopsy during initial investigations. It allows both staging the extent of axillary disease involvement (so as to guide adjuvant treatments) and controls or removes axillary disease.r
risk of ANC?
paraesthesia, seroma formation, and lymphedema in the upper limb
what Is oncoplastic surgery?
reshaping breasts or replacing volume with local or distant autologous tissue, so as to replace volume in larger excisions which would previously have resulted in mastectomy.
what is local flap technique?
mobilisation of regional tissue to replace volume lost after wide local excision or mastectomy. These include the dermis and skin flaps perfused by local artery perforators, such as the lateral intercostal artery perforator (LICAP) or anterior intercostal artery perforator (AICAP).
what Is latissimus dorsi flap?
A Latissimus Dorsi Flap involves mobilisation of the latissimus dorsi off its spinous processes insertions posteriorly so it can be transposed onto the chest wall anteriorly. This can be performed as a reconstructive option following mastectomy.
what is free flap technique?
Deep Inferior Epigastric Perforator (DIEP) flaps can be used, which utilises tissue from the abdomen and its overlying skin to reconstruct the breast following mastectomy.
These tissues are harvested and their blood supply disconnected and anastamosed to chest wall vessels (classically the internal thoracic). This requires microsurgical expertise and is commonly performed by plastic surgical teams.
who gets referred to secondary care if asymptomatic?
Breast cancer in a first-degree male relative of any age
Breast cancer in a first-degree relative under the age of 40
Bilateral breast cancer in a first-degree relative under the age of 50
Breast cancer in two first-degree relatives
