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Breast Surgery Flashcards

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1
Q

Give 5 causes of Gynaecomastia.

A 
Physiological: Puberty
Ectopic tumour secretion: Prolactinoma 
Androgen deficiency diseases: Kallman/Klinefelter
Testicular failure: Mumps
Liver disease 
Haemodialysis 
Hyperthyroidism
Drugs: Spironolactone; Cimetidine; Cannabis; Digoxin; Oestrogens; GnRH agonists; Finasteride
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2
Q

How would you conduct a breast examination?

A

Introduction: Name + DOB

Explain procedure: examination of breast tissue for lumps and bumps

Obtain consent

Chaperone

Allow patient to get undressed

Ask about pain/discharge/point to areas

Inspection: normal; hand behind head

Signs: Asymmetry; Scars; Cosmetic augmentation; Tethering/Puckering/ Nipple discharge/ Skin colour/ Pea d’orange/ Paget’s disease of the nipple

Palpation: Clock face technique, moving outward/inward between breast

Cover: 4 quadrants; subareolar area; Tail of Spence; Axilla

Assess Lymph nodes

Closure

Explain next steps

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3
Q

What is Peau d’Orange?

A

Irregular patch of skin due to blocked lymphatic drainage causing superficial oedema and thickening like the peel of an orange

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4
Q

A patient presents with an erythematous, scaly rash on the nipple. The rash is itchy, inflamed. The rash is localised to the nipple and areola.

What is your diagnosis?

A. Eczema

B. Psoriasis

C. Paget’s disease of the nipple

D. Lichen Planus

A

C

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5
Q

What investigations would you conduct in a patient with Paget’s disease of the nipple?

A

Triple assessment: Clinical examination + Mammography/US + Biopsy (punch)

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6
Q

When assessing breast pain, what should you ask regarding the pain?

A

SOCRATES

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7
Q

When assessing breast pain, what should you ask regarding the pain?

A

Mnemonic: SOCRATES

Site

Onset

Character

Radiation

Associated changes: Positions; Activities; Relation to cycle (Cyclical vs Non-Cyclical)

Time

Exacerbating

Severity

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8
Q

What are the clinical features of cyclical breast pain?

A

Bilateral and generalised
Heaviness
Aching

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9
Q

How can you manage breast pain?

A

Supportive: Establish cause; Breast pain diary; Avoid caffeine; Apply heat
+
Medical: NSAIDs; Hormonal Tx (e.g. Tamoxifen)

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10
Q

How should a breast lump be investigated?

A

Triple assessment: Clinical assessment + Imaging + Histology

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11
Q

What are the clinical features of a breast lump which may make you suspicious of breast cancer?

A 
Hard
Irregular
Fixed/tethered
Painless
Nipple retraction
Skin dimpling/oedema (peau d'Orange)
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12
Q

What are the NICE guidelines for a 2 week wait referral for suspected breast cancer?

A

> 30 years with unexplained lump; Unexplained lump in axilla

> 50 years with unilateral nipple changes

Skin changes suggestive of breast cancer

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13
Q

A fibroadenoma is a tumour of which breast tissue?

A

Stromal/Epithelial breast duct tissue

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14
Q

What are the clinical features of a fibroadenoma?

A 
<3cm 
Smooth
Mobile
Discrete
Firm 
Painless
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15
Q

Do Fibroadenomas increase your risk of developing breast cancer?

A

No. However, complex fibroadenomas and positive family history of breast cancer may indicate higher risk

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16
Q

A woman presents with multiple hardened areas in her breast with some areas of softer lumps. There is some mastalgia. Additionally she notices changes in the size of her breast. All these symptoms are peri-menstrual in nature, occurring in the first 10 days then subsiding after.

What is your diagnosis?

A

Fibrocystic breast changes

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17
Q

How do you manage fibrocystic breast changes?

A

Supportive: Breast support; NSAIDs; Avoid caffeine; Apply heat to area

±
Medical: Tamoxifen

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18
Q

What age do breast cysts tend to present at?

A

30-50 - perimenopausal

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19
Q

What are the clinical features of breast cysts?

A

Smooth
Well-circumscribed
Mobile
Possibly fluctuant

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20
Q

How can breast cyst be managed?

A

Confirm diagnosis

Supportive: Watch and wait; Aspiration

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21
Q

What are the clinical features of fat necrosis in the breast?

A 
Firm
Irregular
Fixed
Skin changes
Hx of trauma/surgery/radiotherapy
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22
Q

How do you differentiate between fat necrosis and breast cancer?

A

US/Mammogram

Histology (core biopsy or FNA)

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23
Q

What are the clinical features of a lipoma?

A

Soft
Painless
Mobile
Do not cause skin changes

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24
Q

A 32 year old woman has noticed small lumps around the nipple. There are no skin changes. O/E you notice firm, mobile, painless lumps which are beneath the areola. She has no other PMHx but recently stopped breastfeeding.

What is your diagnosis?

A

Galactocoele

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25
What proportion of Phyllodes tumour are malignant?
25% or 25% borderline too
26
What is a Phyllodes tumour?
Tumour of breast stroma
27
How is a Phyllodes tumour managed?
Surgery: Wide excision ± Malignant/Metastatic Medical: Chemotherapy
28
Which organ produces Prolactin?
Anterior Pituitary Gland (Pars posterior)
29
Which neurotransmitter blocks prolactin secretion?
Dopamine (DA)
30
Which medications can be used to treat Galactorrhoea?
DA agonists: Cabergoline; Bromocriptine
31
What are the causes of Galactorrhoea?
Post-partum Idiopathic hyperPL Ectopic secretion - Prolactinoma Endocrine disorders: Hypothyroidism; PCOS Medication: Antipyschotics
32
What are the consequences of Hyperprolactinaemia?
PL inhibits GnRH thus affects the HPG axis. Gynaecomastia Reduced libido ED Menstrual irregularities (amenorrhoea)
33
Which form of Multiple Endocrine Neoplasia may result in a prolactinoma? List the other features of this form.
MEN Type 1 3Ps Pituitary adenoma + Pancreatic tumour + Parathyroid hyperplasia
34
How are prolactiomas classified?
Based on size MicroPLoma <10mm MacroPLoma >10mm
35
Which conditions may cause discharge from the breast?
Milk discharge: - Idiopathic - Prolactinoma - Endocrine disorders - Dopamine antagonists Non-milk discharge: - Infection - Duct papilloma - Mammary gland ectasia
36
What investigations would you conduct in a patient with galactorrhoea?
FBC U+Es LFTs TFTs Sex hormones: GnRH; T; PL
37
What is the management for galactorrhoea?
Tx cause + Medical: Cabergoline ± Pituitary adenoma >10mm Surgery: Trans-sphenoidal pituitary adenectomy
38
Which patient group does mammary duct ectasia occur in most commonly?
Perimenopausal women Smoking is the biggest RF
39
What are the clinical features of mammary duct ectasia?
Nipple discharge Tenderness or pain Nipple retraction or inversion A breast lump (pressure on the lump may produce nipple dischar
40
How is mammary duct ectasia managed?
Supportive: Reassurance cancer is excluded; manage mastalgia; ABX if infection ± Surgery: Surgical excision (microdochectomy)
41
Which cell type causes an intraductal papilloma?
Overgrowth of epithelial cells
42
What are the clinical features of an intraductal papilloma?
Nipple discharge (clear or blood-stained) Tenderness or pain A palpable lump
43
How is a diagnosis of Intraductal Papilloma made?
Clinical assessment (history and examination) Imaging (ultrasound, mammography and MRI) Histology (usually by core biopsy or vacuum-assisted biopsy) Ductography may show papilloma ('filling defect')
44
How is an intraductal papilloma managed?
Surgery: Surgical excision
45
How may lactational mastitis present?
``` Breast pain and tenderness (unilateral) Erythema in a focal area of breast tissue Local warmth and inflammation Nipple discharge Fever ```
46
How is Lactational mastitis managed?
Supportive: Continue breastfeeding; breast massage; heat packs; warm; simple analgesia ± Bacterial Infection Medical: Flucloxacillin ± Fundal Infection Medical: Fluconazole
47
What is the management in Candida of the nipple when breast feeding?
Medical: Miconazole Both mother and child receives Tx
48
Which bacteria may cause a breast abscess?
S aureus Streptococcus Enterobacteriacae Enterococci
49
How may a breast abscess present?
``` Nipple changes Purulent nipple discharge (pus from the nipple) Localised pain Tenderness Warmth Erythema (redness) Hardening of the skin or breast tissue Swelling: fluctuant, tender lump within the breast ``` Signs of infection
50
How can a breast abscess be categorised?
Lactational (blockage of duct) vs Non-lactational (infection)
51
A concerned mother asks if she should continue to breastfeed when they have a breast abscess?
They should regularly express breast milk if feeding is too painful, then resume feeding when possible. This is not harmful to the baby and is important in helping resolve the mastitis or abscess.
52
Give 5 RFs for Breast cancer.
``` Female sex Smoking Increased oestrogen exposure Alcohol Obesity More dense breast tissue FHx Breast Cancer BRCA1/BRCA2 gene mutation White ethnicity Nulliparity Early menarche and late menopause COCP HRT ```
53
A concerned teenager asks about her risk of breast cancer when taking the pill. What do you tell her?
Risk increases slightly, risk returns to normal 10 years after being on the pill
54
Which genes are related to breast cancer? Where are they found? What diseases are they associated with?
BRCA1 (Chromosome 17) - Breast cancer 80% - Ovarian cancer 40% BRCA2 (Chromosome 13) - Breast cancer 70% - Ovarian cancer 25%
55
How is Breast Cancer categorised?
Location: Ductal or Lobular
56
What are the features of a DCIS?
``` Pre-cancerous/cancerous epithelial duct tissues Localised to single area Potential to spread Potential to become invasive (30%) Good prognosis if fully excised ```
57
What are the features of a IBC-NST?
NST Duct cells 80% of invasive breast cancer fall into this category Can be seen on mammograms
58
What are the majority of invasive breast cancers classified as?
Invasive ductal carcinomas
59
Which type of breast cancer may not be visible on mammograms?
Invasive Lobular Carcinomas
60
How is IDC graded?
Grade 1 = well Grade 2 = moderately Grade 3 = poorly differentiated
61
which form of breast cancer is also known as lobular neoplasia?
Lobular carcinoma in situa (LCIS)
62
What are the four molecular subtypes of breast cancer?
These are based on gene expression. Luminal A Luminal B Basal HER2
63
What does NHS Breast Cancer screening comprise of?
50-71 years old Mammogram - reported by consultant radiologist as: - Satisfactory (no radiological evidence of breast cancer) - Abnormal (further investigation needed) - Unclear (results or imaging inadequate)
64
How does the presence of breast implants, alter the examination of breast tissue by Mammography?
Can make it difficult to visualise the breast tissue thus use the Eklund technique
65
What are the clinical features of breast cancer?
Lump: Hard, irregular, fixed (tethered) Breast pain Skin changes Nipple changes: discharge/inversion/dilated veins Signs of metastasis: bone pain; liver features; lung feature; brain features
66
What does the one-stop breast clinic comprise of?
Triple assessment: Hx + CEx Imaging Histopathology
67
Which investigations may be conducted in suspected breast cancer?
FBC U+E LFT Bone profile ``` USS Mammography -> Breast tomosynthesis MRI Breast CX CT-CAP CT-Brain Bone scan PET/CT ``` Receptor testing ``` Gene testing (patients under 50) FNA of lymph nodes ```
68
How is breast cancer managed?
MDT decision Surgical: Wide local excision or mastectomy + SLNB + Breast reconstruction + Radiotherapy + Chemotherapy: FEC regime ± Biologics - Herceptin (Trastuzumab): HER2 ± Endocrine therapy - Tamoxifen (SERM) - Anastrazole (Aromatase-i)
69
What is the first line drug used in breast cancer of post-menopausal women at medium/high risk of disease recurrence?
Anastrazole
70
What are the side effects of anastrazole?
Menopausal symptoms OP MSK Pain
71
Why would Anastrazole be ineffective in pre-menopausal women?
Anastrazole stops peripheral conversion of androgens to oestrogens however in younger women, production is largely by the ovaries
72
How long does endocrine therapy in breast cancer last?
Commenced after any adjuvant chemotherapy Standard course is 5 years
73
How can ovarian function be suppressed in premenopausal women that are ER positive?
GnRH analogue (Gorserelin) Laparoscopic oophorectomy
74
What is the 5 year survival of women diagnosed with breast cancer?
85%
75
How is lymphoedema managed?
Supportive: Manual lymphatic drainage; compression bandages; exercises; weight loss; good skin care
76
What is the MOA of Tamoxifen?
SERM thus blocks oestrogen receptors in breast tissue and stimulates oestrogen receptors in uterus and bone - prevents OP but increases risk of endometrial cancer
77
What is the MOA of Anastrazole?
Anastrozole is an Aromatase inhibitor which reduces the peripheral conversion of testosterone to oestrogens. Used in postmenopausal women
78
What are the options for reconstructive surgery?
Immediate reconstruction vs Delayed reconstruction ``` Partial reconstruction (flap or fat tissue) Reduction and reshaping ``` Implants vs Flap reconstructions Flap reconstructions: - Lat Dorsi Flap - TRAM flap - DIEP Flap ``` Flaps may be peddled (original blood supply and moving tissue under the skin to a new location) or free flap (cutting tissue away and transplanting) ```

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