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Breast And Hernias Flashcards

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1
Q

Breast lump differentials

A

Fibroadenoma
Cancer
Fat necrosis
Abscess
Cyst

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2
Q

3 hormonal factors that increase risk of breast cancer

A

Early menstruation
Late menopause
No children

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3
Q

Why does breastfeeding reduce risk of breast cancer

A

Matures breast cells making them less likely to be cancerous

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4
Q

What is herceptin

A

A form of targeted chemotherapy
Acts on the HER2 gene protein

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5
Q

What investigations are done in the 2WW breast cancer service triple assessment

A

Clinical examination
Breast imaging: US + mammogram if >35
Cytology: fine needle aspiration if cystic, core biopsy if solid

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6
Q

Aetiology and epidemiology of a fibroadenoma

A

Is the most common benign breast lump (50% of all biopsies)
Most common in ages 25-35
Likely hormonal cause but unknown

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7
Q

Pathophysiology of a fibroadenoma

A

Benign overgrowth of one lobule of the breast, usually solitary

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8
Q

Clinical features of fibroadenoma

A

Highly mobile, firm and smooth lumps that evade palpation
Usually painless or cause localised pain

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9
Q

Management of fibroadenoma

A

Generally dont require treatment
Removal may be indicated if >4cm

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10
Q

Prognosis for fibroadenoma

A

1/3 regress, 1/3 remain and 1/3 grow
Not usually an increased risk of breast cancer only if there is a strong FH

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11
Q

Clinical features of fibroadenosis / fibrocystic change

A

Lumpy breast and cyclical pain / swelling
Localised fibrosis, inflammation and cyst formation
Nodules in one / both breasts
Areas of thickened / firm tissue
Discrete cystic swellings

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12
Q

Management of fibroadenosis / fibrocystic change

A

Anti-inflammatories
Hormonal manipulation with the combined OC pill can help symptoms
Topical evening primrose oil

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13
Q

Pathophysiology of breast cysts

A

Fluid filled, round or ovoid masses from the terminal duct lobular unit
Can be associated with fibrocystic change or occur alone

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14
Q

Clinical features of breast cysts

A

Classically present in perimenopausal women as round symmetrical lumps
Acute enlargement can present with severe, localised pain

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15
Q

Management of breast cysts

A

Generally referred for triple assessment
Drained with US guidance
Fluid is sent to cytology to rule out malignancy
Symptomatic management

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16
Q

Other causes of benign breast lumps

A

Fat necrosis: occurs following trauma to the breast but can clinically mimic neoplastic disease

Phylloides tumour: rapidly growing benign tumours of the stroma

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17
Q

What is mastitis

A

Inflammation of the breast tissue
+/- infection

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18
Q

Pathophysiology of lactational mastitis

A

Poor milk drainage leads to engorgement of breast tissue due to prolonged stagnation of the breast milk, infection develops as breast milk contains bacteria

Most commonly staph aureus

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19
Q

Clinical features of mastitis

A

Breast pain
Swelling
Erythema
Fever
Malaise
Reactive axillary lymphadenopathy

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20
Q

Management of lactational mastitis

A

Oral abx and oral analgesia
Advise to continue breastfeeding through the sore breast first and express milk between feeds
Cold / warm compresses may provide symptomatic relief

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21
Q

What is non-lactational mastitis

A

Similar to lactational mastitis occasionally with purulent nipple discharge

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22
Q

What is a breast abscess

A

A localised collection of pus within breast tissue

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23
Q

Aetiology of breast abscesses

A

Develops when mastitis does not respond to abx treatment

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24
Q

Clinical features of breast abscess

A

Localised, painful inflammation of the breast
Associated fever and malaise
A fluctuating tender palpable mass is seen OE

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25
Breast abscess management
US + needle drainage Abx therapy
26
What is galactorrhoea
Physiologic nipple discharge unrelated to pregnancy of breastfeeding Usually bilateral and white / clear
27
Red flag symptoms associated with nipple discharge
Unilateral, persistent and spontaneous discharge - usually localised to a single duct Blood stained Any symptom suggestive of malignancy
28
Risk of breast cancer in UK
1 in 8 women
29
What ages are invited for NHS mammogram
50-71
30
Breast cancer risk factors
Genetic (5% are related to BRCA1/2) Early menarche / late menopause Nulliparity (or late age of first child) Not breast feeding HRT Obesity Smoking
31
Morphology of breast tumours
Most are invasive adenocarcinoma 90% are invasive ductal carcinoma 5% are invasive lobular carcinoma 5% are lobular / ductal in situ
32
What is Paget’s disease of the nipple
Spread of intra ductal carcinoma of the breast leading to eczematous changes around the nipple
33
Where can breast cancer locally spread to
- into overlying skin to produce tethering or nipple retraction - into pectoral muscles to cause deep fixation of the tumour
34
What causes the peau d’ orange appearance
When a breast cancer prevents lymphatic drainage
35
Consequences of vascular spread of breast cancer
Distal dissemination is most commonly to the bone Presents with pathological fractures and hypercalcaemia Other sites are the lung and ovary
36
Clinical presentation of breast cancer
Breast lump found on self examination or screening - pathological nipple discharge - Paget’s disease of the nipple - nipple retraction - peau d’ orange - axillary / supraclavicular lymphadenopathy
37
TNM classification for breast cancer
T1 <2cm, T2: 2-5cm, T3 >5cm T4 = fixed to chest wall or peau d’ orange N0= no nodes, N1= ipsilateral nodes, N2 = fixed nodes M0= no distant metastases, M1= distant metastases
38
Management of non metastatic breast cancer
Wide local excision - breast conserving that can be used providing the breast is of adequate size and the tumour is not central Mastectomy - preferred for large tumours or small breasts, central location or late presentation Breast reconstruction can be performed Sentinel lymph node biopsy also performed
39
How does a sentinel lymph node biopsy work
Dye is injected into/around the tumour bulk to identify the first 1/2 nodes that drain the tumour which are removed and analysed histologically If positive, full axillary clearance is required and further investigations for metastases
40
Chemotherapy / radiotherapy for breast cancer
Most breast surgery is combined with adjuvant radiotherapy for invasive disease If there is nodal disease or high grade tumours, chemo is considered
41
Treatment if a tumour is ER positive
Tamoxifen if pre / peri menopausal Aromatase inhibitors if post menopausal to stop peripheral oestrogen production
42
Treatment for a HER positive tumour
Herceptin if HER2 positive Combined with chemo
43
What is the Nottingham prognostic index
Assesses survival and risk of relapse helping to select appropriate adjuvant therapy NPI = (tumour size cm x 0.2) + histological grade (1-3) + nodal status (1-3)
44
Define hernia
The protrusion of an organ or part of an organ through a defect in the wall of the cavity containing it into an abnormal position
45
Define reducible
The contents of the hernia can be completely replaced into the cavity
46
Define obstructed (hernia)
Bowel contents cannot pass through the herniated bowel
47
Define strangulated (hernia)
There is ischaemia of the contents of the hernia (due to obstructed venous return), which unless relieved will lead to gangrene and perforation
48
Define incarcerated (hernia)
The contents of the hernial sac are stuck inside by adhesions
49
Describe the anatomy of an inguinal hernia
The inguinal canal is formed by the relocation of the testes during foetal development - it is about 4cm long and lies parallel and medial to the first part of the inguinal ligament - deep inguinal ring is the entrance to the inguinal canal located 1cm superior to the mid point of the inguinal ligament
50
What does the inguinal canal contain
3 arteries: testicular / ovarian artery, artery to vas deferens, cremasteric artery 3 nerves: genital branch of genitofemoral, ilioinguinal and sympathetic Vas deferens, round ligament of the uterus, pampiniform plexus and testicular lymphatics
51
3 fascial coverings of the inguinal canal
Internal spermatic fascia - from the transversalis fascia Cremasteric fascia - from the internal oblique fascia External spermatic fascia - from external oblique fascia
52
What are the boundaries of the inguinal ligament (MALT)
2 muscles (superior wall): internal oblique, transversalis abdominus 2 aponeuroses (anterior wall): aponeuroses of internal and external oblique 2 ligaments (inferior wall): inguinal ligament, lacunar ligament 2 T’s (posterior wall): transversalis fascia, conjoint tendon
53
What is an indirect inguinal hernia
The most common type of inguinal hernia, occurs in younger patients The contents of the hernia pass through the inguinal canal due to a patent processus vaginalis The hernia is covered by the processus vaginalis and all 3 fascial coverings Exits superficial ring inside spermatic cord, frequently passing into the scrotum / labia majorus Indirect hernias are more likely to strangulate than direct as the superficial ring is not dilated
54
What is a direct inguinal hernia
Contents pass through a weakness of the anterior abdominal wall in the inguinal triangle Make up about 1/3 of inguinal hernias and are covered by the peritoneum and transversalis fascia as they lie outside the inner coverings of the spermatic cord They exit the superficial ring but lateral to the cord
55
Risk factors for direct inguinal hernia
Things that increase intra-abdominal pressure eg chronic cough, heavy lifting, smoking, micturition / defecation
56
How do you differentiate between indirect and direct inguinal hernias
Can only be done in surgery where the inferior epigastric arteries demarcate the median edge of the deep ring thus the indirect hernia will pass lateral and the direct hernia medial to these vessels
57
What is an intraductal papilloma
A benign tumour that grows within the lactiferous duct Usually no palpable lump Presents with bloodstained nipple discharge
58
What is mammary duct ectasia
A benign breast condition occurs when large breast ducts dilate Discharge is often thick and green tinged
59
Complication of axillary node clearance
Lymphoedema Can cause functional arm impairment
60
Why is complete axillary lymph node dissection not done in involvement of single lymph node
If less than 3 nodes are involved and the patient has had breast conserving surgery and adjuvant radiotherapy then no further management of axilla is needed
61
When is FEC-D chemotherapy used
In patients with node positive breast cancer (multi-nodal involvement)
62
Potential complication of aromatase inhibitors
Osteoporosis AI’s reduce peripheral oestrogen synthesis Increase bone loss - bone mineral density should be checked
63
What course and abx is given in mastitis
Flucloxacillin 10-14 days
64
Why is anastrozole only used in post menopausal women
It targets aromatase and reduces the conversion of androgens into oestrogens in peripheral tissues (the main source of oestrogen in post menopausal women as oppose to ovaries in pre-menopausal)
65
Management for a woman <30 presenting with a breast lump that is not painful
Routine referral to breast clinic (not urgent)
66
When is tamoxifen used as oppose to aromatase inhibitors
Tamoxifen is used in ER+ve women who are pre or peri menopausal Aromatase inhibitors in post menopausal
67
When is whole breast radiotherapy recommended
After a wide-local excision
68
How does inflammatory breast cancer present
Progressive, erythema and oedema of the breast in the absence signs of infection eg fever, discharge or elevated WCC and CRP
69
What is inflammatory breast cancer caused by
Obstruction of lymph drainage causing erythema and oedema
70
Management of inflammatory breast cancer
Neo-adjuvant chemotherapy first line Total mastectomy +/- radiotherapy
71
What is the likely pathology of an irregular lump of the right breast associated with skin tethering Malignancy been ruled out
Fat necrosis
72
What is a femoral hernia
More common in women than men Located in the femoral triangle
73
Anatomy of the femoral hernia
Femoral triangle (inguinal ligament, medial border of sartorius, lateral border of adductor longus) contains the femoral nerve, artery and vein Femoral canal lies at the medial extremity of the femoral sheath and is the site of the femoral hernia Bowel exits abdominal cavity through femoral ring As hernia enlarges it passes out of saphenous opening and into deep fascia
74
Why is there a high risk of strangulation with femoral hernia
Femoral canal opening is relatively small with strong borders
75
How do femoral hernias present
50% as a surgical emergency due to obstructed contents 50% as a globular lump below and lateral to the pubic tubercle
76
Differentials for groin lump
Inguinal hernia Lipoma Femoral artery aneurysm Saphenous ovarix Lymph node
77
What is a richter’s hernia
A hernia involving only one sidewall of the bowel and not the bowel lumen, can result in bowel strangulation and perforation without causing obstruction or any of its warning signs More likely in femoral sac
78
Management of groin hernia (5)
1. Assess for signs of obstruction / strangulation (if present - urgent surgical intervention repair) 2. Attempt to reduce the hernia to reduce chance of complications 3. Patients with asymptomatic or minimally symptomatic inguinal hernias can be safely observed without a need to progress to operative management 4. If it becomes symptomatic, laparoscopic day case indicated 5. All patients with femoral hernia should be referred to surgical repair due to high complication rates
79
What is a true umbilical hernia
Occur in 3% of live births due to a defect in the transversalis fascia at the umbilical ring - incomplete closure of the umbilical cicatrix - covered by skin - asymptomatic, more prominent on coughing, reduce easily, rarely obstructed - rarely need surgical management, 90% retract by age 2
80
Who do true umbilical hernias most commonly affect
Black, male and premature babies
81
What is a paraumbilical hernia
An acquired hernia just above / below umbilicus - caused by raised IAP (obese, Middle Aged, multiparous women) - present with a localised dragging pain and enlarging hernia over time - mainly reducible but due to small neck they commonly strangulate - surgical intervention
82
What is an incisional hernia
Make up 10% of hernias 1% of abdominal incisions are followed by a hernia
83
Risk factors for incisional hernia
Pre op: old age, poor nutrition, sepsis, uraemia, jaundice, obesity, steroids Operative: vertical incisions, knots that are too loose / too tight, drains Post op: post operative ileus, coughing, obesity, wound infection
84
Symptoms of incisional hernia
Bulge in the scar and local discomfort Subacute bowel obstruction Adhesions can develop so hernia becomes irreducible and chance of strangulation increases
85
Management of incisional hernia
Surgical repair generally indicated, but contraindicated if the risk factors that caused the hernia remain
86
What is an epigastric hernia
1 or more protrusions through the linea alba above the umbilicus usually containing only extra peritoneal fat - 75% are asymptomatic but some are painful which is worse on exertion or after meals - pain indicates strangulation - surgical intervention
87
What is divarification of the Rectus muscle
Rectus muscles dont meet in the midline at the linea alba and thus split apart when the patient flexes the abdo muscles Common in obese men, parous women and people with chronic IAP No indication for surgical management
88
Summarise the different treatments for different types of breast cancers
Radiotherapy - wide local excision or mastectomy + T3-T4 tumours with 4+ positive axillary nodes Tamoxifen - pre and peri menopause when +ve for hormone receptors Aromatase inhibitors - +ve for hormone receptors, post menopause Trastuzumab (Herceptin) - HER2 positive FEC-D chemo - axillary node disease
89
Side effects of tamoxifen
Increased risk of endometrial cancer Venous thromboembolism Menopause symptoms
90
Management of total duct ectasia
Total duct excision in older women if the condition is bothering them Otherwise none
91
Mode of action of aromatase inhibitors
Reducing peripheral synthesis of oestrogen
92
How does inflammatory breast cancer present
Progressive Erythema Oedema Absence of signs of infection, fever, discharge, elevated WCC and CRP

Junior Surgery (7 decks)

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