Breast Surgery Flashcards
(36 cards)
risk factors breast cancer
FH BRCA1+2 Early menarche, late menopause • HRT, OCP (Million Women Study) • First child >35yrs • Obesity being old
breast feeding is protective
ductal carcinoma in situ, breast
DCIS/LCIS
• Non-invasive pre-malignant condition
• Microcalcification on mammography
• 10x ↑ risk of invasive Ca
invasive ductal carcinoma
Invasive Ductal Carcinoma
• Commonest: ~70% of cancers
• Feels hard (scirrhous)
other subtypes of breast ca aside from DCIS + invasive ductal
Other subtypes
• Invasive lobular: ~20% of cancers
- Medullary: affects younger pts, feels soft
- Colloid/mucinous: occur in elderly
- Inflammatory: pain, erythema, swelling, peau d’orange
- Papillary
Phyllodes Tumour =
• Stromal tumour
• Large, non-tender mobile lump
signs of breast cancer metastasis + key sites
Direct extension → muscle and/or skin • Lymph → p’eau d’orange + arm oedema • Blood → § Bones: bone pain, #, ↑Ca § Lungs: dyspnoea, pleural effusion § Liver: abdo pain, hepatic impairment § Brain: headache, seizures
breast cancer screening
- Every 3yrs from 47-73
- Craniocaudal and oblique views
- ↓ breast Ca deaths by 25%
- 10% false negative rate.
on examination presentation of breast cancer
Lump: commonest presentation of Ca breast § Usually painless § 50% in upper outer quadrant § ± axillary nodes • Skin changes § Paget’s: persistent eczema § Peau d’orange • Nipple § Discharge § Inversion • Mets § Pathological # § SOB § Abdominal pain § Seizures • May present through screening
ddx of breast cancer
- Cysts
- Fibroadenomas
- DCIS
- Duct ectasia
triple assessment of breast ca
Triple Assessment: any breast lump • Hx and Clinical Examination • Radiology § <35yrs: US § >35ys: US + mammography • Pathology § Solid lump: tru-cut core biopsy § Cystic lump: FNAC (green / 18G needle) - Reassure if clear fluid - Send cytology if bloody fluid - Core biopsy residual mass - Core biopsy if +ve cytology
other inv forbreast ca aside from triple assessment
Other Ix • Bloods § FBC, LFTs, ESR, bone profile • Imaging: help staging § CXR § Liver US § CT scan § Breast MRI: multifocal disease or ¯c implants § Bone scan and PET-CT • May need wire-guided excision biopsy
clinical staging breast cancer
Clinical Staging • 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
TNM Staging
• Tis (no palpable tumour): CIS
• T1: <2cm, no skin fixation
• T2: 2-5cm, skin fixation
• T3: 5-10cm, ulceration + pectoral fixation
• T4: >10cm, chest wall extension, skin involved
• N1: mobile nodes
• N2: fixed nodes
principles of managing breast ca
Manage in an MDT ¯c an individual approach § Oncologist § Breast surgeon § Breastcare nurse § Radiologist § Histopathologist • Try to enrol pts. in a trial • Factors: age, fitness, wishes, clinical stage § 1-2: surgical § 3-4: chemotherapy and palliation
breast ca surgery
Aim = gain local control • Two options § WLE + radiotherapy (80% treated like this) § Mastectomy - Typically large tumours >4cm - Multifocal or central tumours - Nipple involvement - Pt. choice - Not radical: no longer used • Same survival, but WLE has ↑ recurrence rates Sentinel Node Biopsy: gold standard
surgical complications shoulder surrg
• Haematoma, seroma • Frozen shoulder • Long-thoracic nerve palsy • Lymphoedema • Upper inner arm numbness § Intercostobrachial nerve injury
Nottingham prognostic index breast cancer
Predicts survival and risk of relapse
• Guides appropriate adjuvant systemic therapy
• (0.2 x tumour size) + histo grade + nodal status
§ Histo grade: Bloom-Richardson system (1-3)
radiotherapy in breast ca
Radiotherapy • Post-WLE: ↓ local recurrence • Post-mastectomy: only if high risk of local recurrence § Large, poorly differentiated, node +ve • Axillary: node +ve disease • Palliation: bone pain
chemotherapy breast ca
• Pre-menopausal, node +ve, high grade or recurrent
tumours.
• Neo-adjuvant chemo improves survival in large tumours
• 6 x FEC: 5-FU, Epirubicin, Cyclophosphamide
• Trastuzumab (anti-Her2) is used if Her2+ve
§ SE: cardiac toxicity
endocrine therapy breast ca
Endocrine Therapy
• Used in ER or PR +ve disease: ↓ recurrence, ↑ survival
• 5yrs of adjuvant therapy
• Tamoxifen
§ SERM: antagonist @ breast, agonist @ uterus
§ SE: menopausal symptoms, endometrial Ca
• Anastrazole / Letrozole
§ Aromatase inhibitor → ↓ oestrogen
§ Better cf. tamoxifen if post-men (ATAC trial)
§ SE: menopausal symptoms
• If pre-menopausal and ER+ve may consider ovarian
ablation or GnRH analogues (e.g. goserelin)
treating stage 3 or 4 breast ca
Treating Advanced Disease (Stage 3-4)
• Tamoxifen if ER+ve
• Chemo for relapse
• Her2 +ve tumours may respond to trastuzumab
upportive
• Bone pain: DXT, bisphosphonates, analgesia
• Brain: occasional surgery, DXT, steroids, AEDs
• Lymphoedema: decongestion, compression
breast reconstruction surgery
• Offered either at 1O surgery or as delayed procedure.
Implants: silastic or saline inflatable
Lat dorsi myocutaneous flap
• Pedicled flap: skin, fat, muscle and blood supply
• Supplied by thoracodorsal A. via subscapular A.
• Usually used ¯c an implant
Transverse rectus abdominis myocutaneous flap
• Gold-standard
• Pedicled (inf. epigastric A.)
• Or free: attached to internal thoracic A
• No implant necessary and combined tummy tuck
• CI if poor circulation: smoke
causes of gynaecomastia
Occurs in 30% of boys at puberty
• Hormone secreting tumours: e.g. sex-cord
testicular
• Chronic liver disease: hypogonadism + ↓E2
metabolism
• Drugs: spironolactone, digoxin, cimetidine
breast pain / mastalgia
Cyclical • ~35yrs • Pre-menstrual pain • Relieved by menstruation • Commonly in upper outer quadrants bilaterally
Non-cyclical
• ~45yrs
• Severe lancing breast pain
treating mastalgia
- Reassurance + good bra for most
- 1st line: Evening primrose oil (contains gamma-linoleic acid)
- OCP
- Topical NSAIDs (e.g. ibuprofen)
- Bromocriptine
- Danazol
- Tamoxifen
inflammatory breast disease
acute mastitis
fat necrosis
duct ectasia
periductal mastitis
