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Breast Surgery Flashcards

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1
Q

epidemiology of breast ca?

A

Commonest cause of cancer death in females 15-54

Second commonest cause of cancer deaths overall

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2
Q

presentation of breast ca??

A

Lump: commonest presentation

usually painless, 50% in upper outer quadrant, +/- axillary nodes

skin changes:

Pagets: persistent eczema

Peau d’orange

Nipple:

discharge, inversion

Mets:

pathological #, SOB, abdo pain, seizures

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3
Q

most common site to find breast ca lump?

A

upper outer quadrant

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4
Q

Triple assessment of any breast lump?

A
  1. Hx and clinical examination
  2. Radiology:

<35 yrs: US

>35 yrs: US + mammography

  1. Pathology:

solid lump: core biopsy

Cystic lump: FNA

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5
Q

Ix of breast ca?

A

Triple assessment:

Hx + clinical examination, US/ mammogram, FNA/ core biopsy

Bloods: FBC, LFTs, ESR, bone profile

Imaging for staging: CT scan

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6
Q

Clinical staging of breast cancer?

A

Stage 1: confined to breast, mobile, no LNs

Stage 2: Stage 1 + nodes in ipsilateral axilla

Stage 3: Stage 2 + fixation to muscle (not chest wall)

LNs matted and fixed, large skin involvement

Stage 4: Complete fixation to chest wall + mets

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7
Q

TNM Staging of Breast Ca?

A

T1 <2cm

T2 2-5cm

T3 5+cm

T4a invades chest wall

T4b invades skin (includes ulceration or oedema)

T4c invades chest wall and skin

T4d inflammatory breast cancer.

N1: mobile nodes

N2: fixed nodes

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8
Q

What is amastia?

A

complete absence of breast and nipple

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9
Q

accessory nipples occur where?

A

anywhere along the milk line

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10
Q

causes of gynaecomastia?

A

occurs in 30% of boys at puberty: oestrogen/ testosterone imbalance

hormone secreting tumours e.g. sex-cord testicular

Chronic liver disease: hypogonadism + decreased E2 metabolism

Drugs: spironolactone, digoxin, cimetidine

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11
Q

presentation of acute mastitis?

A

assoc w lactating mother

painful, red breast

may -> abscess

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12
Q

mx of acute mastitis?

A

lactating mothers: conservative, express milk + analgesia

flucloxacillin

fluclox + incision and drainage if fluctuant abscess

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13
Q

presentation of fat necrosis?

A

assoc w previous trauma

painless, palpable, non mobile mass

may calcify simulating Ca

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14
Q

mx of fat necrosis?

A

analgesia

no follow up necessary

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15
Q

duct ectasia presentation?

A

slit like nipple

often bilateral +/- peri-areolar mass

thick white/ green discharge

may be calcified on mammography

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16
Q

mx of duct ectasia?

A

need to distinguish from Ca

surgical duct excision if mass present or discharge troublesome

close follow up

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17
Q

periductal mastitits presentation?

A

painful, erythematous sub-areolar mass

assoc w inverted nipple +/- purulent discharge

may -> abcess of discharging fistula

assoc w smoking

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18
Q

mx of periductal mastitis?

A

broad spectrum abx

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19
Q

presentation of intraductal papilloma?

A

common cause of bloody discharge

not usually palpable

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20
Q

mx of intraductal papilloma?

A

triple assessment

excise due to increased risk of ca

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21
Q

features of fibrocystic disease?

A

premenstrual breast nodularity (lumpiness) and pain

often in upper outer quadrant

lumps in fibrocystic breasts tend to fluctuate in size throughout the month

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22
Q

mx of fibrocystic disease?

A

triple assessment

reassurance

analgesia

good bra

evening primrose oil

danazol may occasionally be used

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23
Q

presentation of fibroadenoma?

A

< 35 yo

rare post menopause

commonest benign tumour

painless, mobile, rubbery mass

often multiple and bilateral

Popcorn calcification

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24
Q

mx of fibroadenoma?

A

Reassurance + f/up if <2.5cm

Shell-out surgically if

  • >2.5cm
  • FH of breast Ca
  • Pt. choice
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25
large fast growing mass in breast mobile, non-tender epithelial and connective tissue elements dx?
Phyllodes tumour tx: wide local excision
26
Presents as **Microcalcification** on mammogram Rarely assoc. with symptoms: - lump - discharge - eczematous change = Paget’s disease → Ca @ 1%/yr (10x ↑ risk) in ipsilateral breast
Ductal Carcinoma in situ
27
mx of Ductal carcinoma in situ?
wide local excision + radiotx extensive or multifocal -\> mastectomy + reconstruction + sentinel node biopsy
28
Pagets Disease of nipple presentation?
unilateral, scaly, erythematous, itchy +/- palpable mass (invasive ca)
29
mx of Paget's Disease of Nipple?
Usually underlying invasive or DCIS breast cancer. Mastectomy + radio ± chemo/endo
30
Presentation of lobar calcification in situ?
Incidental biopsy finding (no calcification) Often bilat (20-40%) Young women ↑ risk Ca risk (x10) in both breasts
31
Mx of Lobar carcinoma in situ?
Bilateral prophylactic mastectomy or close watching w mammographic screening
32
MDT involved in Breast Ca tx?
Oncologist Breast surgeon Specialist Nurse radiologist histopathologist Plastics
33
what is duct ectasia?
dilatation and shortening of the terminal breast ducts within 3cm of the nipple.
34
indications for surgical removal of fibroadenoma?
\> 3cm causing discomfort pt request
35
when to refer pt for suspected breast cancer?
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if they are: ## Footnote - 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
36
fibrocystic disease aka?
fibroadenosis or benign mammary dysplasia
37
what is inflammatory breast cancer?
progressive, erythema and oedema of the breast in the absence signs of infection such as fever, discharge or elevated WCC and CRP + raised CA 15-3 IBC is a rare but rapidly progressive form of breast cancer caused by obstruction of lymph drainage causing erythema and oedema. It is usually a primary cancer and is managed with neo-adjuvant chemotherapy first-line, followed by total mastectomy +/- radiotherapy.
38
assessment of LN in breast ca?
Gold standard: Sentinel Node Biopsy SN= first node that a section of breast drains to minimises the morbidity of an axillary dissection If node +ve -\> axillary clearance or radiotx
39
main operations of breast reconstruction surgery?
latissimus dorsi myocutaneous flap sub pectoral implants: silastic or saline inflatable transverse rectus abdominis myocutaneous flap
40
surgical options for breast cancer?
Mastectomy Wide local excision
41
indications for mastectomy?
\> 4cm typically large tumours multifocal or central tumours large lesion in small breast pt choice nipple involvement
42
what is the Nottingham Prognostic Index?
Predicts survival and risk of relapse of breast ca Calculation of NPI: Tumour Size x 0.2 + Lymph node score + Grade score
43
what drug is used in Her2 +ve breast ca?
Trastuzumab (anti-Her2)
44
Radiotherapy in breast ca? indications
post-wide local excision: decrease local recurrence post-mastectomy: only if high risk of local recurrence axillary node +ve disease palliation: bone pain
45
Mx of oestrogen receptor +ve breast ca?
**Tamoxifen** - selective ER modulator: antagonist @ breast, agonist @ uterus - for pre or perimenopausal women **Anastrazole** aromatase inhibitor -\> decrease oestrogen for post menopausal women
46
Supportive mx of bone pain in br ca?
Radiotx bisphosphonates analgesia
47
supportive mx of lymphoedema from br ca?
decongestion and compression
48
supportive mx of brain mets from br ca?
surgery/ radio tx steroids anti epileptic drugs
49
Breast Cancer Screening?
all women are offered breast cancer screening with mammography every 3 years between the ages of 50 and 70 years.
50
what are the breast cancer markers?
CA 15-3 CA 27.29 CEA
51
Ix of Pagets disease of the nipple?
find underlying ca punch biopsy, mammography and ultrasound of the breast.
52
1st line mx for breast ca?
Surgery!! An exception may be a very frail, elderly lady with metastatic disease who may be better managed with hormonal therapy.
53
when is trastuzumab contraindicated?
SE: cardiac toxicity Trastuzumab cannot be used in patients with a history of heart disorders.
54
fibroadenoma \> 4cm ix?
A size of greater than 4cm attracts a recommendation for core biopsy to exclude a phyllodes tumour.
55
soft, fluctuant swellings on breast examination 'halo appearance' on mammography
breast cyst
56
what chemotx is used for node+ve cancer?
FEC-D chemotherapy
57
what chemotx is used for node-ve breast cancer?
FEC chemotherapy 5-FU, Epirubicin, Cyclophosphamide
58
BRCA1/2 auto dom or recessive?
autosomal dominant
59
mx of breast cyst?
Cysts should be aspirated, those which are blood stained or persistently refill should be biopsied or excised
60
most common type of breast ca?
invasive ductal carcinoma (no special type)
61
mx of duct papilloma?
Microdochectomy
62
mx of post menopausal ER+ve women?
aromatase inhibitor e.g. anastrazole In post menopausal women oestrogens are produced by the peripheral aromatization of androgens and aromatase inhibitors are therefore the most popular agent in this age group.

Surgery (17 decks)

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