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Breast surgery Flashcards

(91 cards)

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1
Q

Ix of breast

A

USG- <35
Mammo >35

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2
Q

Arterial supple of breast

A
  • Internal mammary (thoracic) artery
  • External mammary artery (laterally)
  • Anterior intercostal arteries
  • Thoraco-acromial artery
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3
Q

Which muscles do the breasts lie on

A
  1. Pectoralis major
  2. Serratus anterior
  3. External oblique
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4
Q

Radial scar features

A

Usually presents as a breast lump or breast pain
* Causes mammographic changes which may mimic carcinoma
* Cause distortion of the distal lobular unit, without hyperplasia

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5
Q

Radial scar tx

A

Lesions should be biopsied, excision is not mandatory

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6
Q

Fat necrosis features

A

Up to 40% cases usually have a traumatic aetiology
* Physical features usually mimic carcinoma

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7
Q

Fat necrosis tx

A

Imaging and core biopsy

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8
Q

Intraductal papilloma features

A

Growth of papilloma in a single duct
* Usually presents with clear or blood stained discharge originating from a single duct

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9
Q

Excessive milk cause

A

Pituitary tumour

  • Microadenomas <1cm in diameter
  • Macroadenomas >1cm in diameter
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10
Q

Features of fibroadenoma

A

Smooth; Fram; Mobile; Round mass

Can fluctuate size with menstrual cycle

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11
Q

Phyllode tumour pathology and features

A

● Both epith. + fibrous stromal elements
● Stroma shows hypercellularity; atypia; mitosis

Leaf like
Grows quickly
Ulceration

● Painless >3cm; Mobile
● Massive size - uneven bosselated surface
● Recent & rapid ↑size

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12
Q

Tx of phyllodes tumour

A

WLE
<5cm- 2cm margin
>5cm- 5cm margin

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13
Q

Duct ectasia features

A

Duct ectasia is the dilation and shortening of the major lactiferous ducts. It is a common presentation in peri-menopausal women, with 40% of women having significant duct dilatation by 70yrs.

● Nipple retraction; Tenderness(+)
● Mass under areola ± erythema
● Cheesy Green discharge; can be Brown

multiple plasma cells on histology

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14
Q

Types of ductal carcinoma in situ

A

Sub types include; comedo, cribriform, micropapillary and solid

Comdeo DCIS is most likely to form microcalcifications

Cribriform and micropapillary are most likely to be multifocal

Low grade- cribriform, papillary and micro

High- Solid and combeo

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15
Q

Tx of DCIS

A

This is done with breast conserving surgery (wide local excision) or (in cases of widespread or multifocal DCIS) with mastectomy.

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16
Q

LCIS features

A

Greater risk of developing an invasive breast malignancy.

Doesn’t show up on mammography well- no micro calcifications
No necrosis

LCIS is usually diagnosed before menopause, with only 10-20% of women diagnosed being post-menopausal.

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17
Q

LCIS mx

A

Low grade LCIS is usually treated by monitoring rather than excision.

When an invasive component is identified, it is less likely to be associated with axillary nodal metastasis than with DCIS.

Bilateral prophylactic mastectomy can be potentially indicated if individuals possess the BRCA1 or BRCA2 genes.

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18
Q

Invasive lobular carcinoma features

A

Only bilateral carcinoma

Multifocal lesions

Worst prognosis- pleomorphic

Bull eye pattern- pathology

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19
Q

Invasive ductal carcinoma features

A

● Large irregular surface - hard consistency

White necrotic area Branching micro
- calcificaation Stellate lesion(+)

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20
Q

Which subtype of DCIS has recurrence after surgery

A

Only comedo

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21
Q

FNAC vs Core / True-cut Biopsy

A

FNAC- shows cytology
If FNAC inconclusive or If features shows (e.g. hard mass, skin tethering present) carcinoma; in these cases, the
only appropriate Investigation is Core / True-cut Biopsy.

Biopsy- histology
A Positive core biopsy is mandatory before surgery

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22
Q

When to do mastectomy vs WLE

A

Mastectomy
Multifocal tumour
Central
Large lesion in small breast
DCIS >4cm

WLE
Solitary
Peripheral tumour
Small lesion in large breast
DCIS <4cm

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23
Q

SE of axillary node clearance

A

Lymphoedema, increased risk of cellulitis and
frozen shoulder.

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24
Q

Complications of breast surgery

A
  • Long thoracic nerve injury: Occurs during the Axillary dissection and result in winging of the scapula.
  • Intercostobrachial nerve injury: These nerves traverse the axilla. When they are divided (which they often
    are) the patient will notice an area of parasthesia in the armpit.
  • Injury to the thoracodorsal trunk: This nerve and vessels supply Latissimus Dorsi. If they are damaged the
    functional effects are not too serious, the greatest setback is that a latissimus dorsi flap cannot be used for
    reconstruction purposes.
  • Infections: Cellulitis of the chest wall and arm may be a major problem if axillary nodal clearance is
    undertaken. Infections may run a protracted course and require polytherapy for treatment.

*Lymphoedema: Usually complicates axillary node clearance or irradiation. Treatment is with manual lymphatic
drainage and compression sleeves.

  • Seroma: This is an accumulation of fluid at the site of surgery. The fluid is usually straw coloured and may re- accumulate despite drainage. Most will resolve with time.
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25
Axillary LN clearance levels
1- LN upto lat.border of P.Minor (removes nodes around Ax.V. superficial to PM & Ax tail) 2- All LN upto med.border of P.minor (nodes deep to PM) 3- All LN of axilla (requires division of P.minor) (upto apex of axilla)
26
When is hormonal therapy used
ER & PR (+)ve patient cases to downstage Or older who refuse surgery
27
Types of hormonal therapy
3 types drug used- SERM(Selective Estrogen Receptor Modulator) , Aromatase inhibitor, LHRH agonist - Tamoxifen – SERM . It binds with estrogen receptor and blocks estrogen action -Anastrozole(ArimidexTM); Letrozole; Aminoglutethemide; Exemestane:- Aromatase inhibitor. They block peripheral convertion of androgen to estrogen and also block intra-tumoral synthesis of estrogen- used in post menopausal women - Goserelin(ZoladexTM): - LHRH agonist. Used incase of pre-menopausal ER(+) ve women
28
When can tamoxifen not be used
History of thrombosis
29
What to use if patient has ER- tumour
In these cases (+)ve C-erb B2 (HER2/neu) suggests TRASTUZUMAB (Herceptin) may be effective
30
When is chemotherapy used
Downstagign advanced lesions to facilitate surgery Grade 3 lesions Axillary nodal disease - Young / pre-menopausal - LN (+)ve & lymphoreticular invasion - ER (-)ve - Grade III pt. - Large tumor
31
When is Neo adjuvant chemo used
- Young pt. with high grade ca specially if >3cm - To down-stage the tumors with an aim to provide breast conserving surgery
32
Tx of periductal mastitis in postmenopausal
Anaerobic bacteria cause so tx would be metronidazole.
33
Most important prognostic factor for breast cancer
Nodal status
34
Firbocystic disease
Cyclical mastalgia Pain 2 weeks leading to period then settles with menstruation Bilateral
35
Tietze Syndrome
Chest pain Costchondral swelling of upper ribs attaching to sternum Pain can spread to arms or shoulders
36
Duct ectasia tx
Reassure If older and persistent discharge - total duct excision
37
Tx of duct papiloma
Microdochectomy
38
Pagets vs eczema of nipple
Pagets- affect nipple first then areola area Eczema- affects areola
39
Inflammatory carcinoma of breast features
Aggressive Mets early Tx resistant In pregnancy or lactation Mistaken for mastitis- red hot
40
Screening of breast cancer
Mammography 50-70 every 3 years Strong FH - can be offered screening from 47
41
Reconstruction options
Lat dorsi myocutaneous flap and subpectoral implants
42
Tamoxifen cancer risks
Endometrial
43
When to use aromatase inhibitors
When tamoxifen no longer effective
44
Post mastectomy with skin flap- large fluctuant mass under neath, Dx?
Seroma Very common post breast surgery Straw coloured fluid Tx with drainage
45
Radical vs simple mastectomy
A simple mastectomy (left) removes the breast tissue, nipple, areola and skin but not all the lymph nodes. A modified radical mastectomy (right) removes the entire breast — including the breast tissue, skin, areola and nipple — and most of the underarm (axillary) lymph nodes- rarely done anymore- maybe if spread to chest muscles
46
Tx of 1.5cm malignant lesion in upper outer breast with no evidence of LN spread
WLE and node biopsy
47
Tx of 2.5 lesion in centre of breast with FNA of LN showing mets
Simple mastectomy and axillary LN clearance
48
Histology shows lobular carcinoma present at 3 of resection margins, mx?
Mastectomy Lobular- often multifocal
49
When is radiotherapy used
If breast conserving surgery used- e.g WLE To breast alone
50
When is each medical therapy used
Pre menopausal - goserlein - LRH agonist Women who are perimenopausal start on tamoxifen and switch at 3 years. Post menopausal - managed by endocrine therapy alone- aromatase inhibitors
51
Nottingham prognostic score
Tumour size x 0.2 +LN score + grade score 5 year survival 2-2.4 93% 2.5-3.4 85% 3.5-5.4 70% >5.4 50%
52
Mucinous tumour features
Grey gelatinous surface Soft
53
Young female found to have BRCA1 mutation, what is the survailence
Annual MRI
54
Drugs causing gynaeocmastia
Digoxin Isoinazid Spiro Cimetidne Oestrogen
55
Most common cause of painless lump in postmenopausal woman
Invasive Ductal carcinoma
56
Woman with lump with hx of implants ix
USS first Non conclusive MRI If implants related problems- MRI
57
Halo sign on mammography
Breast cyst
58
Breast cancer with lymphocytic infiltration
Medullary
59
When endo vs radio vs chemo is used
Endocrine therapy Oestrogen receptor positive tumours Downstaging primary lesions Definitive treatment in old, infirm patients Irradiation Wide local excision Large lesion >4cm, high grade stage 3 or marked vascular invasion following mastectomy Chemotherapy Downstaging advanced lesions to facilitate breast conserving surgery Patients with grade 3 lesions or axillary nodal disease
60
What does nipple retraction/dimpling indicate
tumour infiltration of the breast ducts and ligaments respectively
61
Which artery is damaged in level 3 nodal clearance
Thoracoacromial
62
Most sensitive imaging for breast cancer
MRI
63
Indications of breast MRI
1. Lobular carcinomaQ: Difficult to detect and measure by conventional method because of multifocal and infiltrating growth pattern 2. Staging of primary breast cancerQ 3. Occult primary tumour with malignant axillary lymphadenopathy and normal mammogram and breast USGQ 4. Screen younger women with high familial risk of breast cancerQ 5. Assessing the integrity of breast implantQ
64
Micro vs macrocalcifications breast
Macro- bening Micro- tumour
65
Malignant signs on mammography
Ill defined margin Irregular stellate Spiculatede Comet tail Wide Halo Microcalcifications
66
Popcorn calcifications
Fibroadenoma
67
BRCA 1 vs 2
1 13 Poor differentiation HR negative 2 13 HR positivitie
68
Hereditary breast cancer
BRCA PALNCH PJS Li Fraumeni Atacia tel Cowden HNPCC
69
Features of medullary breast cancer
Soft rapid increase in size Dense lymphocytes Sheet like growth
70
TNM staging breast cancer
T1 <2cm 2 2-5 3 >=5 4- chest wall N1- 1-3 axillary 2- 4-9 axillary, or internal with no axillary 3- >10 axillary or internal mammary/infra/supraclavicular with axillary
71
Risk factor for male Breast cancer
Excess endogenous or exogenous estrogen (Testicular disease, infertility, obesity, cirrhosis)Q * Radiation therapy, Klinefelter’s syndrome and testicular feminizing syndromesQ. * BRCA2 mutationsQ * Gynecomastia is not a risk factor for carcinoma male breast
72
Stromal cells on FNA of phyllodes vs FA
Polyclonal/mono on FA Always Monoclonal on Phyllodes Phyllodes- higher activity
73
What ligaments run from deep layer of superficial fasciae to dermis in breast
Suspensory ligaments of Cooper
74
Prevalence of breast cancer in women in the UK
12.5%
75
When is a Sentinel lymph nodes biopsy performed
If mammographic mass, palpable mass or mastectomy
76
Top 2 causes of mastalgia
Cyclical- 2w leading up to menstruation then settles with 2nd- trigger point in pec major
77
Types of free flap for breast reconstruction
TDAP (thoracodorsal) TRAM (rectus abdo) DIEP (inferior epi) IGAP (inferior gluteal) TUG (upper gracilis)
78
Timings of free flap and radio
Should be done before As radio will make attachment hard
79
What does screening involve
Mammography of cranial-caudal and lateral oblique view Double read by 2 trained personal No examiantion
80
% of phyllodes that malignantly transform
25%
81
BMI and breast cancer
Post menopausal obesity linked with breast cancer
82
RF for breast cancer
Increasing age BRCA1/2 FH of breast or early ovarian Ionising radiation <30 First preg after 35 Early menarch Late meno Alcohol consumption Postmenopausal obesity Prolonged HRT
83
Lymphoma rate after axillary dissection
20%
84
BRCA chance of developing breast cancer by 50
50%
85
Area where breast lesions are most commonly found
Upper outer quadrant
86
Incision for entering axilla
Retract pec major medially to expose pec minor (lies underneath) and clavipectorla fascia Incise the fascia at edge of pec minor
87
When to send breast milk cultures
Masitits severe or recurrent Hospital infection likely Severe pain
88
Lump associated with oral contraception
Cyst formation
89
Tamoxifen SE post menopausal
Bleeding as agonist in endometrium
90
Young woman with BCRA1 + with lump ix
MRI
91

eMRCS questions (45 decks)

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