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Y3 Surgery > Breast surgery > Flashcards

Breast surgery Flashcards

1
Q

Under what circumstances should you refer people for a suspected cancer referral in 2 weeks?

A

Aged 30 and over and have an unexplained breast lump with or without pain or

Aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern

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2
Q

When should you consider a suspected breast cancer referral?

A

With skin changes that suggest breast cancer or

Aged 30 and over with an unexplained lump in the axilla

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3
Q

When should you consider a non-urgent referral for breast cancer?

A

Consider non-urgent referral in people aged under 30 with an unexplained breast lump with or without pain.

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4
Q

What are common causes of benign breast lesions?

A
  • Fibroadenoma
  • Breast cyst
  • Sclerosing adenitis
  • Epithelial hyperplasia
  • Fat necrosis
  • Duct papilloma
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5
Q

What is the arterial blood supply to the breasts?

A

The internal thoracic artery and the lateral thoracic artery.

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6
Q

What are four causes of referral for breast cancer?

A

Self exam- GP
NHS breast screening programmes
FH of high risk
Incidental finding on imaging

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7
Q

When do women get mammograms for breast cancer?

A

50 to 70
Every 3 years
Can be done with implants

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8
Q

How often do you get an MRI if you have a TP53 mutation?

A

Annual MRI from the age of 20 years

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9
Q

How often do you get an MRI if you have a BRACA1 and BRACA2 mutations?

A

Twice a year for an MRI

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10
Q

What is the gold standard for breast pathology?

A

A triple assessment

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11
Q

What should you ask in someone’s past medical history for a breast cancer?

A

Breast disease, surgeries and bra size (ask about reconstructinon)

You should also ask about hand dominance for shoulder weakness

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12
Q

If men have a mutation of BRCA1 gene, what cancers apart from breast are they at a higher risk of?

A

Pancreatic, prostate and sarcomas

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13
Q

What do you ask about in a family history of breast cancer?

A

Jewish ancestry

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13
Q

What imaging method is used in axilla assessment?

A

Ultrasound

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13
Q

What imaging do you use for staging of a breast cancer?

A

CT

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13
Q

How do you grade a biopsy?

A

B1-B5

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13
Q

How do you get samples for biopsies?

A

Smear from a nipple discharge
Fine needle aspiration- cytology
Core biopsy of breast tissue and axilla lymph node- apple core
Vaccuum assisted biopsy and excision

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14
Q

Why would you remove a fibroadenoma greater than 5cm?

A

It could be a phyllodes tumor which a small percentage of those can be malignant.

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15
Q

What is mondor’s disease?

A

Rare disease which is thrombophlebitis of the superficial veins of the breast.

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16
Q

What is a risk of radiotherapy of the breast?

A

It can cause an adenofibroma

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17
Q

What are the three receptors in the breast?

A

Progesterone
Estrogen
HER2

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18
Q

What causes puckering in breast cancer?

A

The suspensory ligaments of Cooper act like internal “strings” within the breast tissue, supporting its shape. When breast cancer spreads to these ligaments, it disrupts their normal function, causing them to contract and pull on the skin, resulting in a puckered or dimpled appearance.

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19
Q

How many groups of axillary lymph nodes are there?

A

The axillary lymph nodes are divided into three main groups: the anterior (pectoral), the central, and the posterior (subscapular) lymph nodes. These groups are arranged in the armpit region and play a crucial role in draining lymphatic fluid from the breast and surrounding areas.

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20
Q

What are the key points about the triple assessment?

A

The triple assessment comprises of the history + examination, imaging, and histology
Each part of the assessment is combined for a case-by-case evaluation to the likely diagnosis
Cases suspicious for breast cancer are discussed by the MDT to create a suitable treatment plan

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21
Q

What is a milk line?

A

The milk line, also known as the mammary ridge, is a primitive structure in embryonic development that extends from the armpit (axilla) down to the groin area. It represents the potential locations where mammary glands could develop along the body. In humans, the mammary glands typically only develop along the chest area, but the milk line concept helps explain certain anomalies, such as supernumerary nipples, which can occur anywhere along this line.

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22
Q

What is a complication of mastitis?

A

Abscess

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23
Q

How do you treat intra-ductal papillomas?

A

Managed conservatively

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24
Q

What is a fibroadenoma

A

Breast mouse- very mobile
18-25, young female
Most common benign growth
They are proliferations of stromal and epithelial tissue of the duct lobules.

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25
Q

When would you do a lumpectomy for a fibroadenoma?

A

When it is greater than 3cm

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26
Q

Where are most fibroadenomas

A

Upper and outer quadrant

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27
Q

Which breast is more common to find breast pathology?

A

More people are right handed- more likely to be picked up on the left.
Husbands/partners are right handed- more likely to feel left breast

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28
Q

What percentage of fibroadenomas will go away?

A

30%
70% will stay as they are

29
Q

What can breast cancer be split into?

A

Ductal Carcinoma:
Invasive Ductal Carcinoma (IDC): Around 70-80% of all breast cancer cases.
Ductal Carcinoma in Situ (DCIS): Accounts for a smaller percentage of cases, where cancer cells are confined to the milk ducts and haven’t spread into surrounding tissue.

Lobular Carcinoma:
Invasive Lobular Carcinoma (ILC): Represents about 5-10% of breast cancer cases.
Lobular Carcinoma in Situ (LCIS): A less common type where abnormal cells are found in the lobules, but they haven’t invaded surrounding tissue.

30
Q

What is more invasive ductal or lobular?

A

Lobular is more likely to spread, more likely to recur (seen 20% of the time)

31
Q

Symptoms patients with breast cancer present with?

A
  • A lump or thickening in the breast or underarm area.
  • Changes in the size, shape, or appearance of the breast.
  • Dimpling or puckering of the skin on the breast.
  • Changes in the nipple, such as inversion, discharge, or a change in appearance.
  • Redness, swelling, or warmth in the breast.
    Persistent pain or discomfort in the breast or armpit.
32
Q

What are signs of breast cancer?

A

Lump
Skin changes
Nipple changes
Pain
Swelling
Redness

33
Q

What is paget’s disease of the breast?

A

Eczematous changes around the nipple- sign of subdermal infiltration of the lymphatics
Paget’s disease of the breast is typically associated with an underlying breast cancer

34
Q

What is accessory breast tissue in the UOQ called?

A

Axillary tail of spence
May get adenomas and carcinomas there

35
Q

What is the most common breast cancer?

A

Invasive ductal carcinoma

36
Q

Complication of axillary node clearance

A

Long thoracic nerve- winged scapula

37
Q

Who might need a prophylactic breast cancer?

A

Prophylactic mastectomy involves surgical removal of one or both breasts to reduce the risk of developing breast cancer.

It may be recommended for individuals with BRCA gene mutations, strong family history of breast cancer, previous breast cancer diagnosis, high-risk breast lesions, or previous chest radiation therapy.

38
Q

How does Trastuzumab work?

A

Trastuzumab works by targeting and blocking the HER2 protein on breast cancer cells, inhibiting their growth and promoting the immune system’s ability to destroy them.

39
Q

How do you manage a breast abscess?

A
  • Incision and drainage
  • Flucloxacillin
40
Q

How would you describe fat necrosis?

A
  • Firm lump
  • Non-mobile
  • No attached to underlying muscle
41
Q

Should breast cysts be aspirated?

A

Yes
Breast cysts should be aspirated as there is a small chance it can progress to cancer in young patients

42
Q

Which metastatic bone tumours have the greatest risk of pathlogical

A

Peritrochanteric lesion from CA breast

Peritrochanteric lesions have the greatest risks of fractures (due to loading)
Breast cancer is more likely to cause lytic lesions. Prostate cancer is more likely to cause sclerotic lesions.

43
Q
A
44
Q

How is paget’s disease of the nipple diagnosed?

A

Diagnosis is made by punch biopsy

45
Q
A

MRI

46
Q

What is the most appropriate surveillance for a woman with BRACA1 gene?

A

Annual breast MRI
Young females at very high risk of breast CA should have an annual MRI

47
Q

What does Anastrazole put you at risk of?

A

Anastrazole is an aromatase inhibitor used for the treatment of oestrogen receptor-positive breast cancer in postmenopausal women, such as this patient. Aromatase inhibitors reduce peripheral oestrogen synthesis.

Osteoporosis

48
Q

What are potential side-effects of SERMS (Selective oestrogen receptor modulators) like Tamoxifen?

A
  • Amenorrhoea
  • Endometrial cancer
  • Vaginal bleeding
  • Venous thromboembolism
49
Q

A 72 year old woman presents with 2 breast lumps. She has a history of breast cancer in the opposite breast 5 years ago. What is the most likely underlying lesion?

A

Invasive lobular CA
This is likely to be an invasive lobular carcinoma, mainly due to the multifocal lesions and the history of previous breast CA in the opposite breast

50
Q

A 48 year old lady presents with discomfort in the right breast. On examination, she has a discrete, soft, fluctuant area in the upper outer quadrant of her right breast. A mammogram is performed and a halo sign is seen by the radiologist. What is the most likely explanation for this process?

A

Breast cyst
Lesions such as breast cysts compress the underlying fat and produce a radiolucent area (halo sign). If symptomatic, these cysts should be aspirated. Potential for malignant transformation.

51
Q

When is a mammography not indicated?

A

Does not detect all cancers, ie (young, dense breasts, HRT, lobular cancer). Not routinely advocated <35 years

52
Q

What features would a malignant breast cancer have on ultrasound?

A

Irregularly defined margin
Low internal echo
Acoustic shadow

53
Q

Options for carrying out breast biopsy

A

Guided
Freehand
Wide bore needle/core
Fine needle aspiration
Nipple discharge
Punch biopsy
Mammotome- vacuum assisted breast biopsy
Surgical- open
MRI

54
Q

What is the most important prognostic factor for breast cancer

A

Nodal status

55
Q

What is stereotactic guided biopsy?

A

Precisely focused radiation beams

56
Q

What is the difference between the roles of the breast surgeon and the breast care nurse inthe breast results clinic?

A

Breast surgeon
- Diagnosis and results
- Overview of management/treatment options
- Primary treatment/benefits and risks (usually surgical)
- Possible adjuvant (after surgery) therapies

Breast care nurse sees patient/relatives
- Ensures patient can mKe an informed decision
- Answers further questions
- Written info
- Advises on how to access the breast clinic
- Organises pre op staging

57
Q

What makes up pre-operative staging

A

Primary lesion
- Breast MRU or repeat biopsy

Axilla
- Ultrasound and biopsy (if needed)

Screen for distant metastases
- FBC, U&E, LFTs, calcium
- Tumour markers
- CT chest/abdo/pelvis
- Bone scan

58
Q

How do you localise an impalpable breast cancer?

A

US or stereotactic (mammographic)

59
Q

What is explained in post-operative breast results clinic?

A
  1. Explains results to patient and family
  2. Discusses adjuvant treatment
  3. Oncology referral
  4. Cancer follow up
60
Q

What chemotherapy drugs are offered in adjuvant therapy for breast cancer?

A

Combination of Anthracycline, 5-FU and Cyclophosphamide
FEC- 5-FU, Epirubicin and Cyclophosphamide
FDC- 5-FU, Doxorubicin and Cyclophsphamide

61
Q

What are the side effects of chemotherapy?

A

Nausea, vomiting, alopecia and neutropenia

62
Q

When is the first adjuvant therapy given?

A

4-6 weeks post surgery

63
Q

What are the side effects of Tamoxifen?

A

Increases the risk of endometrial cancer and thromboembolism

64
Q

What is Zolodex?

A

Leutinising hormone releasing hormone analogue

65
Q

What is a benefit to neo-adjuvant chemotherapy for breast cancer?

A

It can shrink the size of the cancer- meaning you can do breast conserving surgery instead of mastectomy.

66
Q

Why do antibiotics not work with breast abscesses?

A

They are walled off- antibiotics will not work.
They will need incision and drainage.

67
Q

How do you stage breast cancers?

A

Small tumours under 2cm in size score T1.

If cancerous cells are found in 4-9 local lymph nodes (axillary or internal mammary), an N2 score is given. If fewer than 4 are affected, then the score is N1. If more than 9, or it has spread to supra- or infra-clavicular lymph nodes, the score will be N3.

If no metastasis is found, the score will be M0. If there is metastasis, the score will be M1.

68
Q

What is a well documented side effect of Trastuzumab?

A

This patient has a Her2 positive tumour and is therefore likely to be treated with Trastuzumab( Herceptin). A well documented side effect of Trastuzumab ( Herceptin) is cardiotoxicity resulting in heart failure. This would fit with the patients clinical features of heart failure: shortness of breath on exertion, peripheral oedema, ascites and paroxysmal nocturnal dyspnoea

69
Q

What does B1-B5 mean?

A

B1- Normal
B2- Benign
B3- Lesions of uncertain malignant potential
B4- suspicious
B5- malignant

70
Q

What is axillary web syndrome?

A

Axillary web syndrome, also known as cording, is a potential complication of breast surgery that involves the formation of fibrous cords that extend from the axilla to the ipsilateral hand. It typically presents within a few weeks to months after surgery and is characterised by a visible and palpable cord-like structure in the axillary region, as well as a sensation of tightness and pulling in the chest area, restricted shoulder movement, and pain. Treatment typically involves physical therapy and stretching exercises.

71
Q

What are the main histological differences between ductal carcinoma and lobular carcinoma in situ?

A

DCIS= areas of micro-calcification

LCIS= does not present with micro-calcification, stromal reactions or palpable breast masses.
Thus, it is always an incidental finding on a biopsy that was carried out for a different reason

72
Q

What imaging is carried out if there are concerns of metastasis?

A

CT or PET

73
Q

What is a rare complication of anastrazole?

A

Anastrozole’s side effects include arthralgia, menopausal symptoms, hypercholesterolemia, osteoporosis, and rarely Henoch–Schönlein purpura

74
Q

With paget’s disease of the breast, what is the lump if found?

A

There can often be an underlying lump (which is ductal carcinoma in situ)

Y3 Surgery (7 decks)

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