Breast

Question 1

What types of breast reconstruction are there?

Answer 1

Tissue expander
- silicone implants

Latissimus dori myocutaneous flap

Abdominal flaps

• Transverse rectus abdominis myocutaneous flap
• Deep inferior Epigastric Perforator flap

Nipple reconstruction

• tatoo
• skin flaps

surgery to reduce contralateral breast

Question 2

What types of surgery may be carried out on the breast?

Answer 2

Lumpectomy

Wide local excision

Quadrantectomy
- quadrant is removed

Mastectomy

Question 3

When is axillary clearance offered?

Answer 3

When invasive cancer cells are noted in the axilla.

Question 4

What is a major complications of clearing the axillary nodes?

Answer 4

Lymphoedema

Question 5

Mammograms vs Ultrasound:

Answer 5

Ultrasound:

• used more in younger women
• good at distinguishing solid lumps from cysts

Mammogram

• used more in elderly women
• picks up calcification better than US

Question 6

What is done to assess the lymph nodes?

Answer 6

Ultrasound of the lymph nodes prior to surgery.
- if unusual them biopsy is taking

During surgery

• blue dye or radioactive isotope used to fine sentinel node
• this is biopsied.
• if clear - leave nodes, if positive then clear nodes

Question 7

What tests are performed on all tumours?

Answer 7

ER testing

Her2 testing

*if these are both negative then Gene testing is offered.

Question 8

What are some of the symptoms of radiotherapy to the breast?

Answer 8

General fatigue from the radiation 
Local skin irritation and tissue swelling 
Fibrosis of the breast 
Shrinking of the breast 
Long term skin discolouration of skin

Question 9

When assessing the sentinel node, when is the radioactive isotope injected? and when is the blue dye injected?

Answer 9

Radioactive isotope - morning of surgery / day before surgery

Blue dye - prior to operation
- within 10-15mins will be present

Question 10

What are the indications for mastectomy?

Answer 10

Large tumour on a small breast 
>1 tumour present on breast 
Diffuse DCIS 
Radiotherapy contraindicated 
Recurrence of cancer

Question 11

When is neoadjuvant therapy indicated?

Answer 11

Very large tumours

- to shrink

Question 12

What is the grade of the breast cancer based upon?

Answer 12

Nuclear pleomorphism
Number of mitosis
Degree of gland formation

Question 13

What treatment is given to Her2 positive cancers and how is it given and what are some common side effects?

Answer 13

Trastuzumab
- IV or Subcut
- every 3 weeks for 1 year
Can effect heart - must be monitored and contraindicated in women with heart failure.

Side effects:

• tumour pain
• headaches

Question 14

What treatment is given to ER positive cancers?

Answer 14

Premenopausal women = tamoxifen

Post-menopausal = Aromatase inhibitors (Letrozole

Question 15

When is chemotherapy used in breast cancer?

Answer 15

Neoadjuvant - shrink tumour

adjuvant therapy - after surgery to reduce recurrence

For treatment control of metastatic disease

Question 16

What are the pros and cons of breast implants?

Answer 16

Pro’s:

• minimal scars
• reasonable appearance

Con’s:

• cold
• don’t feel natural
• Long term effects - hardening, leakage, shape change

Question 17

What is a con of Transverse rectus abdominal/ TRAM flap:

Answer 17

Abdominal Hernias

Question 18

When working out the best management for patients with breast cancer, what type of meeting is there?

Answer 18

MDT

Question 19

When is Adjuvant radiotherapy offered?

Answer 19

After WLE

After mastectomy if:
- positive margins
- >5cm tumour
>4 positive lymph nodes

Question 20

What is a common side effect of adjuvant radiotherapy?

Answer 20

Cardiomyopathy

Question 21

Invasive Ductal carcinoma can be further divided into what types?

Answer 21

Tubular, cribriform, medullary, mucinous, papillary

Question 22

What is the single most important prognostic factor for breast cancer?

Answer 22

Lymph nodal status

Question 23

What does the nottingham prognostic index take into account?

Answer 23

Size
Nodal status
Grade

Question 24

How is DCIS managed?

Answer 24

WLE

Question 25

Generally what is meant by grade and stage?

Answer 25

Grade refers to the amount of nuclear abnormalities and cellular changes. Stage is the prognostic risk factors that reflect the likely hood of the patients outcomes, especially the involvement of metastasis - nodal status

Question 26

Which types of invasive breast cancers show the best prognosis?

Answer 26

Tubular Cribriform Papillary

Question 27

Which type of breast cancer tends to have columns of cells stacked upon each other?

Answer 27

invasive lobular carcinoma

Question 28

What are the clinical symptoms of Paget's disease?

Answer 28

Itchiness Redness Flaking/ thickened skin

Question 29

What are the differentials for Paget's disease of the nipple?

Answer 29

Eczema

Question 30

If a patient comes in complaining of lumpy bumpy feeling in breast, which is associated with menstrual pain, what is the likely diagnosis? and what are characteristics of this change?

Answer 30

Fibrocystic changes - cysts - fibrosis - hyperplasia

Question 31

List some inflammatory conditions of the breast:

Answer 31

Acute Mastitis - breast feeding Fat necrosis Granulomatous Mastitis - TB - Sarcoidosis Mammary Duct ectasia - greenish brown discharge - can cause nipple retraction

Question 32

What is another name for fibrocystic changes?

Answer 32

Fibroadenosis

Question 33

On a mammogram which breast condition is likely to produce a halo sign?

Answer 33

Breast cyst

Question 34

Can a family member or friend be used a sa chaperone?

Answer 34

No it has a to an impartial individual

Question 35

What is the screening times for breast?

Answer 35

50- 70 | - every 3 years

Question 36

What pre-operative assessment can be done of the lymph nodes?

Answer 36

Ultrasound

Question 37

When can a fibroadenoma be removed?

Answer 37

>3cm

Question 38

Where does breast cancer spread to?

Answer 38

Lymphatic spread Bones Brain Liver Lungs

Question 39

When imaging for breast cancer, who gets what type of imaging?

Answer 39

<35 years old: Ultrasound >35 years old: mammogram

Question 40

What blood tests do you want to do into breast cancer?

Answer 40

FBC Bone profile LFTs ESR

Question 41

Describe how the sentinel node is analysed:

Answer 41

It is cut out when Identified on surgery. It is then sent for frozen section. If positive then axillary clearance occurs or radiotherapy

Question 42

What are some of the complications of breast surgery?

Answer 42

Damage to long thoracic nerve - winging of scapula Lymphoedema Frozen shoulder Haematoma

Question 43

What is the histology grade of the tumour based upon?

Answer 43

Bloom richardson system

Question 44

When is radiotherapy used post surgery?

Answer 44

WLE Positive nodal status Large tumour resection Bone metastasis

Question 45

What are the stages of breast cancer?

Answer 45

Stage 1: confined to breast Stage 2: 1 node Stage 3: Fixation to muscle, usually large amount of skin involvement Stage 4: Fixation to chest wall. Metastasis

Question 46

What are the symptoms of duct ectasia?

Answer 46

Peri-arelormass Nipple discharge - white - green Calcification on mammogram

Question 47

When should surgery for a fibroadenoma be offered?

Answer 47

>3cm Family history of Ca Patient choice

Question 48

How should LCIS be managed?

Answer 48

Bilateral mastectomy or Close surveillance - usually need MRI for lesions

Question 49

What are some causes of breast pain:

Answer 49

Menstrual cycle pain Inflammatory - Mastitis - Duct ectasia Trauma - fat necrosis Fibrocystic changes

Question 50

What are some causes of nipple discharge?

Answer 50

Physiological - pregnancy Duct ectasia Intraductal papilloma Paget's disease Galactorrhea

Question 51

If the asymmetry or lump on the breast is not clear on physical examination, how can it be made more clear?

Answer 51

Ask patient to put hands on head. To put hands on hips and lean forward

Question 52

If there is tethering, what ligament is involved?

Answer 52

Ligament of cooper/ Suspensory ligament

Question 53

Compare and contrast Paget's disease and eczema:

Answer 53

``` Presence of lump Clear markings in paget's Nipple destroyed Occurs post menopause Unilateral, eczema is often bilateral ```

Question 54

What investigations for staging should be done?

Answer 54

CT chest/ abdo/ pelvis Technetium Bone scan Head CT

Question 55

What are the two views of the mammogram?

Answer 55

Cranial caudal Oblique view

Question 56

On US what would be suggestive of malignancy?

Answer 56

Vertical growth appearance Irregular mass Hypoechoic

Question 57

Disadvantages of FNCA?

Answer 57

NO architecture - so can't see if it is invasive Can't get ER/ PR/ HER status

Question 58

What is the aim of neoadjuvant therapy?

Answer 58

to down stage the cancer to allow for less invasive surgery | - WLE

Question 59

If NPI is >5 what is the 5 year survival?

Answer 59

50%

Question 60

What is the indications for neoadjuvant therapy?

Answer 60

Downstage for breast conservation Downstage to make breast cancer operable if previously not operable Inflammatory breast cancer Improve cosmetics

Question 61

What advise should be given to females post breast cancer?

Answer 61

Monthly self examination Mammogram every year for 5 years

Question 62

How much resection needs to be done in a WLE?

Answer 62

5cm

Question 63

What is a major side effect of letrazole? (aromotase inhibitor)

Answer 63

Osteoporosis