Surgery Flashcards
What are the characteristics of breast cysts and what is their prognosis?
Flattened epithelium derived from lobular-ductal unit forming round, symmetrical lumps. Occasionally painful but almost always benign.
Often associated with fibrocystic change (fibrosis, cysts and hormone-driven breast pain)
What are the characteristics of adenocarcinoma and what is their prognosis?
Women 25-35 years
Highly mobile, firm, smooth,painless
1/3 regress, 1/3 stay the same, 1/3 get bigger
What are the benign tumours of the breast?
Hamartomas (disorganised growth of normal tissue)
Adenomas
Duct papillomas
Phyllodes tumours (tumour arising from periductal stroma)
What are the most common types malignant of breast cancer?
Invasive adenocarcinomas arising from terminal ducts (invasive ductal carcinoma) or lobular units (invasive lobular carcinoma). These have a poor prognosis.
Rarer types (tubular carcinoma, mucinous carcinoma) have better prognosis
What is Paget’s disease?
Spread of intraductal carcinoma –> nipple
Reddening, thickening and scaling of nipple and areola resembling eczema .: consider with any rash!!
What is the spread of breast cancer?
Local –> adjacent breast, skin (-> tethering), pectoral muscles (deep fixation)
Lymphatic –> lymphatics of skin (peau d’orange), axillary nodes and internal mammary chain
Vascular –> bone, brain, liver, lung
What are the risk factors for breast Ca?
Western culture
PMHx breast Ca
FH breast Ca (BRCA1,2 and p53 = 5% of cases)
Proliferative breast disease
Increased oestrogen exposure (early menarche, late menopause, nulliparity/1st child > 30 years, not breast feeding, HRT and COC)
Obesity and alcohol
How sensitive is mammography and what features of cancer would you see?
Sensitivity 88% women >40 (worse in women <35 so not performed)
Presence of a mass
Microcalcification (benign = coarse and chunky, malignant = fine and linear)
Architectural distortion
Asymmetry
How would you image the breast?
Mammography
USS (solid vs cysts)
How would you biopsy a breast lump and what are the sensitivities and differences between techniques?
Fine needle aspiration cytology (FNAC) - 95% sensitivity, can detect malignancy, cannot stage
Core biopsy - 97% sensitivity, can stage
Excisional biopsy - staging and first step in controlling local disease
Punch biopsy - vs Paget’s disease of the nipple
How would you manage fibroadenoma, fibroadenosis, and cysts?
Fibroadenoma - excision only if concern vs. diagnosis, cosmesis or symptoms
Fibroadenosis - reassurance, anti-inflammatories, hormone or cellular manipulation (linoleic acid, COC pill, cyst aspiration)
Cyst - repeated aspiration, hormone manipulation if multiple recurrent cysts
What is the staging of breast cancer?
Stage 1 - confined to breast, mobile
Stage 2 - confined to breast, mobile, nodes in ipsilateral axilla
Stage 3 - tumour fixed to muscle, skin involvement larger than tumour
Stage 4 - complete fixation of tumour to chest wall, distant metastases
Management of breast cancer
Wide local excision - breast conserving, eu combined with local radiotherapy
Simple mastectomy - vs large tumours, central location, complications (eg. ulcers). Adjuvant radiotherapy rarely required
Endocrine therapy - best vs ER +ve tumours - Anti-oestrogens (Tamoxifen), Lutenising hormone releasing hormone antagonists, aromatase inhibitors
Monoclonal antibodies - Traztuzumab (Herceptin) vs HER-2 +ve
Chemotherapy - anthracyclines, cyclophosphamide, 5-FU methotrexate vs high risk features
Radiotherapy - vs sym from bone/liver/brain mets
Management of regional lymph nodes in breast cancer
Axillary node sampling = retrieve minimum 4 nodes, avoids disruption lymph drainage BUT inadequate for treatment (adjuvant radiotrX if +ve)
Axillary node clearance = treatment of axilla BUT increased risk lymphoedema
Sentinel node biopsy = ID +ve drainage nodes with radioactive tracer and then remove avoiding major axillary surgery
What is the Nottingham Prognostic Index and what are it’s survival rates?
NPI = 0.2 x tumour size cm + histological grade + nodal status
10yr survival with only surgery
5.4 = 20%
How would you investigate a breast lump?
1) Clinical exam
2) Radiology - USS 35
3) Histology/cytology - FNA or core biopsy
What are the types of nipple discharge and what are their causes?
Milky - pregnancy, hyperprolactinaemia
Clear - physiological
Green - perimenopausal ,duct ectasia, fibroadenotic cyst
Blood stained - Carcinoma, intraduct papilloma, REFER!!!
Describe the structure of the breast
The breast overlies ribs 2-6 with an axillary tail extending into the axilla. It is composed of 15-20 lobes seperated by fibrous septa which acts as suspensory ligaments and attaches the breast to the pectoral mm beneath
The retromammary space is a layer of loose areolar tissue between the deep fascia of the breast and mm
What is the vasculature of the breast?
aa = Internal and intercostal aa perforating branches
Axillary –> L thoracic and thoracoacrromial branches
vv follow aa
What are the lymphatics of the breast?
L quadrants –> axillary lymph nodes and pectoral
M quadrants –> internal thoracic (behind sternum so v. hard to treat)
Which quadrant do the majority of breast cancers originate in?
Outer L quadrant (60%)
What are the important urological symptoms and how would you classify them?
Storage sym = urgency, frequency, nocturia
Voiding sym = hesitancy, poor stream, post micturition dribble, incomplete emptying
Misc sym = haematuria, dysuria
What is the difference between a keloid and a hypertrophic scar?
Hypertrophic scar = follows boundaries of wound
Keloid scar = grows over boundaries of wound
How do you manage keloid scars?
Do NOT try to re-excise them!!
Corticosteroid injections
In the presence of parotid swelling what should you check and why?
Facial nn function (mm of facial expression), divides into its five branches within the parotid gland
When would you use clips instead of stitches?
Mainly if there is a concern about post-op bleeding. Clips can be removed rapidly whereas stitches take longer.
How do x-rays cause damage?
Ionising radiation
What is the difference between dose-dependent and dose-independent x-ray damage?
Dose-dependent = burns etc. Dose-independent = cancer
What are the fortes of CT and MRI?
CT = bone MRI = soft tissue
What is “windowing”?
MRI gives images in approx 2000 shades of grey. Humans can only see 15 or so. Windowing allows focusing in on a specific part of that spectrum and better images to be given.
What are the definitions and infection rates of clean, potentially contaminated, contaminated and dirty operations?
Clean - Infection rate 2-5%, does not enter colonised viscus/lumen of body, eu = skin commensals
Potentially contaminated = infection rate 10%, enters colonised viscus/lumen but under controlled conditions,
Contaminated = infection rate 20%, contamination present without obvious infection eg. vs penetrating injury with intestinal spillage
Dirty = infection rate >30%, surgery when active infection already present
What constitutes pre-op evaluation?
Identification & details of patient Diagnosis & proposed op Cardiac and respiratory exam PMHx vs complicating factors Relevant laboratory/diagnostic factors Informed consent Advise patient re. nature of procedure Expected benefits and possible risks Need for HDU/ICU care
What constitutes operative records?
Pre-op and post-op Dx
Important anatomical and physiological observations about pt
Operative procedure performed and incision used
Name of surgeonn and anaesthetist
Anaesthetic used
Estimated blood loss and fluid given during procedure
Results of intraoperative tests
Complications
Tubes/drains/prosthesis used and location
Condition of pt at end of surgery
What constitutes post-op assessment?
Dx Pt condition Vital signs Analgesia assessment Activity restrictions? Wound care Tube and drain care Dietary requirements? Fluids & meds aB prophylaxis
What are the indications for rigid sigmoidoscopy/proctoscopy?
Sigmoidoscopy = examination of rectum --> rectosigmoid junction Proctoscopy = examination of anal canal
Any sym suggesting colonic neoplasia Inflammatory BD Taking biopsies of pathology within direct visualisation Before ano-rectal ops/procedure Proctoscopy can treat haemorrhoids
What are the indications for flexible sgmoidoscopy?
Visualises up to descending colon
Screening for CRC Pre-op eval before anorectal surgery Surveillance of previous Dx malignancy Removal of rectal foreign body Endoluminal stent insertion for strictures, balloon dilatation, decompression Haematochezia (passing fresh blood)
What are the indications for a tube thoracostomy?
(Chest drain)
Anything in lungs (pneumo-, haemo-, haemopneumo-, hydro-, chylo-, empyema, plearal effusion)
Post op for thoracotomy, oesophagectomy, cardiac surgery
Where should you insert a chest drain?
“Safe triangle”
A. border lat dorsi, L. border pec major, horizontal level of nipple, apex at axilla
Aim for upper border of lower rib to avoid neurovascular bundle
What sites should you use for central venous access?
Internal jugular vein (right= preferred)
Lies in carotid sheath, A. to SCM in upper neck, carotid = anteromedial
Subclavian also possible