Surgery - Breast Flashcards
What does a Triple Assessment involve?
Who should be referred?
Look (Mammogram if >35, USS if <35), Feel (Clinical Examination), Stab (FNA/Core Biopsy)
Anyone over 30 years old who have a breast lump should be referred under urgent 2ww
Describe the characteristics of a malignant lump
Describe the characteristics of a benign lump
Malignant: Hard, painless, irregular, fixed, bloody discharge/nipple retraction
Benign: Firm, painful, regular, mobile, no dimpling, yellow discharge if present, no nipple retraction
Pre-Malignant Breast Cancer
Define the pre-malignant cancers:
Name the pre-malignant cancer types/% appearance:
How would these pre-malignant cancers be treated:
Define: Carcinomas in situ that are contained within the basement membrane tissue. Rarely symptomatic.
Types: Ductal carcinoma in situ - 80% - microcalcifications on mammogram.
Lobular carcinoma in situ - aggressive - malignancy of secretory lobules, usually diagnosed pre-menopause.
Treatment:
DCIS - complete wide excision.
LCIS - low grade = active surveillance. If BRCA1/2, do prophylactic double mastectomy due to high invasion risk.
Breast Cancer Classifications: Screening programmes: Symptoms: Risk factors: Investigations: Management:
Classifications: Invasive Ductal Carcinoma, Invasive Lobular Carcinoma (more dangerous, presents in older women)
Screening: 50-71 every 3 years - mammography
Symptoms: Breast lump, nipple discharge, nipple retraction/inversion (early), dimpling/peau d’orange, mastalgia, axillary lump
Risk factors: Female, Age >50, FH of breast cancer or BRCA1/2, Increased exposure to oestrogen: Early menarche, later menopause, nulliparity, HRT, COCP, children after 30, obesity
Investigations: Check if oestrogen receptive (respond to SERMS), HER-2 positive (more aggressive), Ca-15-3 tumour marker
Management:
Surgical (always unless not fit): Mastectomy or Wide local excision (if <4cm) + sentinel lymph node biopsy + ALWAYS DO RADIOTHERAPY AFTER
Medical:
- SERMS eg. Tamoxifen if ER positive, pre-menopausal women - increases clotting and uterine cancer risk
- Aromatase inhibitors eg. Anastrozole - post-menopausal women (blocks peripheral fat conversion to oestrogen)
- Herceptin - HER-2 binder, stops proliferation
Paget's disease Pathophysiology: Symptoms/signs: Investigations: Treatment:
Patho: Cancer of the nipple - Reddened nipple ulceration, with almost all having underlying malignancy.
Symptoms: Painful, sensitive roughened, red ulceration of the nipple
Investigation: Triple assessment
Treatment: Removal of at least nipple and areola
Fibroadenoma Target age: Pathophysiology: Symptoms: Management:
Target age: 15-25 years old
Pathophysiology: Benign neoplasm - most common. Proliferations of tissue of duct lobules.
Symptoms: Painless, smooth, rubbery, highly mobile (breast mouse), multiple/bilateral
Management: Majority resolve over several years and pose no risk of malignancy. Conservative measures usually taken.
Excision biopsy can be done if increasing in size or causing pain.
Fibroadenosis
Target age:
Pathophysiology:
Management:
Age: 25-40 years old
Pathophysiology: Pre-menopausal hormonal changes leading to nodularity within the breast, described as “lumpy” and “painful”
Management: No surgical intervention required, give firm, supportive bra, evening primrose oil
Papilloma Target age: Symptoms: Pathophysiology: Management:
Age: 40-50 years
Symptoms: Occur in subareolar region (1cm from nipple), BLOODY or clear nipple discharge
Patho: Benign epithelial tumour
Management: Usually require biopsy as appear similar to DCIS - often excised to be sure. Only increased risk of BC if multi-ductal papilloma.
Lipoma
Pathophysiology:
Pathophysiology: Benign adipose tumour, usually asymptomatic. Low malignant potential and only removed if rapidly enlarging or causing aesthetic issues.
Phyllodes tumour
Pathophysiology:
Complications and management:
Patho: Rare fibroepithelial tumours. Larger, occur in older age group. Often grow rapidly.
Complications: 1/3rd become malignant. Widely excised as management.
Breast Cysts Pathophysiology: Target age: Symptoms: Investigations: Management: Complications:
Pathophysiology: Epithelial fluid-filled cavities (form when lobules become distended due to blockage).
Target age: 35-55 years old, hormone dependent
Symptoms: Small, painful, tender lump on examination, usually multiple
Investigations: Mammography and USS - aspiration may be done using USS (can check if blood is in fluid for cancer risk)
Management: Conservative, can aspirate if needed
Complications: 2-3x higher chance of developing breast cancer
Duct ectasia Pathophysiology: Target age: Symptoms: Investigations: Management:
Pathophysiology: Dilatation and shortening of the subareolar ducts
Target age: (Peri) Menopausal women (35-55) - 40% have duct ectasia by 70yo
Symptoms: Bilateral nipple inversion, yellow discharge (if blood, do triple assessment), subareolar mass, mastalgia
Investigations: Mammography - dilated and calcified ducts
Management: Conservative unless nipple discharge continues, in which case duct excision can be offered.
Mastitis Pathophysiology: Target age: Classification: Symptoms: Risk factors: Investigations: Management: Complications:
Pathophysiology: Inflammation of the breast tissue, often due to infection by S. aureus of the subareolar ducts
Target age: 35-55 years old
Classification: Based on lactation status. Lactational (common) - poor feeding technique/milk stasis. Non-lactational - common in duct ectasia
Symptoms: Tenderness/mastalgia, swelling, erythema, localised abscess formation
Risk factors: Smoking - damages subareolar duct walls
Management: Antibiotics, localised analgesia, continued lactation, cabergoline (D2 agonist) can be used in recurrence to stop milk production
Complications: Breast abscess - can do USS and aspirate to diagnose. Must be careful, as this can lead to mammary duct fistula.
Fat Necrosis Pathophysiology: Symptoms: Investigations: Management:
Pathophysiology: Acute inflammatory response to trauma leading to ischemic necrosis of fat lobules
Symptoms: Asymptomatic usually, palpable lump, can become irregular over time and look like cancer
Investigations: Trauma history, mammogram (but may look cancerous on mammogram), so must do core biopsy to rule out malignancy
Management: Conservative
Breast Anatomy
What nerves can be commonly damaged during axillary clearance?
What is the blood supply to the breast?
What is the venous drainage of the breast and what does this cause?
What is the name of the ligament that holds the breast up?
Nerves: Long thoracic (winged scapula), axillary nerve, thoracodorsal nerve
Blood supply: Thoracic arteries (lateral and internal)
Drainage: Long thoracic vein -> spreads to vertebrae
Cooper’s ligament
