Surgery - Breast

Question 1

What are the major types of benign breast lump?

Answer 1

Fibroadenosis/Fibrocystic Change
Fibroadenoma
Cysts

Question 2

What is Fibroadenosis/Fibrocystic change?

Answer 2

Combination of localised fibrosis, inflammation, cyst formation, hormone driven breast pain

Question 3

How does Fibroadenosis/Fibrocystic change present?

Answer 3

Between menarche/menopause
‘lumpy breasts’
cyclical pain/swelling

Question 4

What is Fibroadenoma?

Answer 4

Benign overgrowth of one lobule of the breast, usually solitary

Question 5

How does Fibroadenoma present?

Answer 5

25-35
Painless, or v. localised pain
Highly mobile, firm, smooth lumps that evade palpation

Question 6

What are Breast Cysts?

Answer 6

Cavities lined by flattened epithelium derived from the ductal unit, filled with watery fluid

Question 7

How do Breast Cysts present?

Answer 7

Perimenopausal women

Round symmetrical lumps, occasionally w/ pain

Question 8

What is the most common type of breast cancer?

Answer 8

Invasive adenocarcinomas

• 90% invasive ductal carcinoma
• 5% invasive lobular carcinoma
• 5% lobular/ductal in-situ

Question 9

What is the role of oestrogen receptors in breast cancer treatment?

Answer 9

Oestrogen receptor +ve or -ve
-+ve has a better prognosis
HER2 & progesterone receptors are therapeutic targets

Question 10

How common is breast cancer?

Answer 10

Lifetime risk of 1 in 8
Incidence increases w/ age
5% related to BRCA1/2
40% detected on screening

Question 11

What are the pathological consequences of breast cancer?

Answer 11

Paget’s disease of the nipple
Local spread
Lymphatic spread
Vascular spread

Question 12

Describe Paget’s disease of the nipple

Answer 12

Spread of intra-ductal carcinoma leading to eczematous changes around nipple

Question 13

Describe local spread

Answer 13

Into overlying skin –> tethering/nipple retraction

Intro pectoral mm –> deep fixation of tumour

Question 14

Describe lymphatic spread

Answer 14

Can prevent lymphatic drainage –> Peau d’orange

Axillary/clavicular nodes commonly involved

Question 15

Describe vascular spread

Answer 15

Distal dissemination commonly to bone, lung, ovaries

Question 16

What are the risk factors for carcinoma of the breast?

Answer 16

Genetic factors (PH, FH, BRCA) make up 25% of risk
Environmental factors make up 75% of risk
-early menarche/late menopause
-nulliparity (late age of first child)
-not breast feeding
-HRT
-obesity
-smoking

Question 17

Describe the diagnosis of a breast lump

Answer 17

Triple assessment

• clinical examination
• breast imaging (USS + mammography if >35)
• cytology (FNAC if cystic, biopsy if solid)

Question 18

How does a typical carcinoma appear on mammography?

Answer 18

Spiculated mass lesion with associated microcalcification

Question 19

What is the drawback of FNAC cytology?

Answer 19

Cannot distinguish b/w in situ and invasive cancers

Question 20

What is the advantage of core biopsies?

Answer 20

Tissue architecture preserved

Invasion and grading determined

Question 21

How should fibroadenosis/fibrocystic change be managed?

Answer 21

Reassurance
Anti-inflammatories
Topical evening primrose oil
Hormone manipulation (COC)

Question 22

How are fibroadenomas managed?

Answer 22

1/3 regress, 1/3 stay the same, 1/3 enlarge

• generally don’t require treatment
• remove if >4cm

Question 23

How should breast cysts be managed?

Answer 23

Drain w/ USS guidance

-if fluid suspicious sent away from cytology

Question 24

What is fat necrosis?

Answer 24

Occurs following trauma to breast

-mimics neoplastic disease

Question 25

What is a phylloides tumour?

Answer 25

Rapidly growing benign tumours of stroma

Question 26

How are breast carcinomas staged?

Answer 26

TNM

• T1 <2cm, T2 2-5cm, T3 >5cm, T4 fixed to chest wall
• N0 = no nodes, N1 = mobile ipsilateral N2 = fixed
• M0 = no distant mets M1 = distant mets

Question 27

What investigations are appropriate in suspected metastatic breast carcinoma?

Answer 27

Liver USS
CXR
Bone scan

Question 28

What are the surgical options for treating breast cancer?

Answer 28

Wide local excision
Simple mastectomy
Regional lymph node removal +/- sentinal biopsy

Question 29

What is wide local excision?

Answer 29

Breast-conserving surgery used if breast is of adequate size & tumour not central
-check margins

Question 30

When is a simple mastectomy preferred?

Answer 30

Large tumours
Small breasts
Central location of tumour
Late presentation w/ complications

Question 31

How is a sentinel node biopsy performed?

Answer 31

Dye injected into/around tumour bulk

• identifies nodes draining tumour
• if +ve requires full axillary clearance

Question 32

What additional options are available for managing breast cancer?

Answer 32

Adjuvant radiotherapy
Chemotherapy (if nodal disease/high grade)
Hormonal therapy (if ER/HER +ve)

Question 33

What hormonal management options are available for breast cancer?

Answer 33

Tamoxifen (pre/peri menopausal)
Aromatase inhibitors (if post menopausal)
Herceptin (if HER2 +ve)

Question 34

What is the NPI?

Answer 34

Nottingham Prognostic Index

-(tumour size*0.2) + grade + nodal status

Question 35

What is the prognosis of breast cancer?

Answer 35

10 YEAR SURVIVAL
NPI <2.4 = 95%
NPI 2.4-3.4 = 85%
NPI 3.4-4.4 = 70%
NPI 4.4-5.4 = 50%
NPI >5.4 = 20%

Question 36

How should nipple discharge be managed?

Answer 36

Clear = physiological sx 
Milky = preg/hyperprolactinaemia
Green = physiological (peri-menopausal) OR fibroadenotic cyst
Bloody = urgent referral

Question 37

What is periductal mastitis?

Answer 37

Infection of ducts beneath nipple

-more common in smokers/nipple piercings

Question 38

How should periductal mastitis be managed?

Answer 38

Flucloxacillin

Question 39

What is mastalgia?

Answer 39

Breast Pain

Either cyclical/non-cyclical

Question 40

How should mastalgia be managed?

Answer 40

Evening primrose oil

Tamoxifen/danazol if cyclical pain