General Surgery Breast Flashcards

Question

Breast abscess treatment

Answer 1

consider IV antibiotics abscess drainage by needle aspiration or incision & drainage (I & D)

Answer 2

premammary, intramammary, retromammary

Answer 3

benign breast mass more likely in younger premenopausal women malignant breast mass more likely in older post menopausal women usually differential diagnosis listed below are differentially diagnosed based on pathology of breast biopsy of lesion 1) Benign structural: cyst, fibrocystic breast disease, fibrosis, adenosis, galactocele, epithelial related calcification infection: abscess, granulomatous mastitis, papilloma benign tumor: lipoma, lactational adenoma, papillary aprocrine change, mild hyperplasia of usual type, neurofibroma pre-malignant tumor proliferative without atypia (relative risk of ~2 for future breast malignancy): ductal hyperplasia of usual type, intra-ductal papilloma, sclerosing adenosis, fibroadenoma atypical hyperplasia (relative risk of ~4 for future breast malignancy): atypical ductal hyperplasia, atypical lobular hyperplasia iatrogenic: silicone implant other: papillary apocrine change, epithelial related calcification, fat necrosis 2) Malignant lobular carcinoma in situ, invasive lobular carcinoma ductal carcinoma in situ, invasive ductal carcinoma (with subtypes) connective and epithelial: phyllodes tumor, carcinosarcoma, angiosarcoma

Answer 4

older age post-menopausal early menarche, late menopause hormone use null-parity first live birth

Answer 5

characteristics of benign lesion: small (<2cm) superficial, smooth, round, rubbery, mobile with well defined border characteristics of malignant lesion: large (>2cm), hard, irregularly bordered, non-mobile, fixed to skin or chest wall and with less well defined borders

Answer 6

mammography = 1st imaging study for almost all breast mass breast ultrasound = usually in pre-menopausal women age <30 for fibroadenoma and cyst; may be follow-up imaging after mammography breast biopsy (can be guided by imaging including ultrasound, mammogram or MRI) for definitive diagnosis and rule out malignancy

Answer 7

if malignant features on clinical exam, then mammogram followed by biopsy to rule out malignancy and for definitive diagnosis if no malignant features on clinical exam, proceed with mammogram + ultrasound if cystic changes on ultrasound, then aspirate for diagnosis if lesion visualized, then core biopsy if not visualized on mammogram and ultrasound, then consider CT or MRI of breast

Answer 8

Mammogram with biopsy to confirm diagnosis and rule out breast malignancy for all cases

Answer 9

purpose is to find cancer that is clinically undetectable (i.e. not detected on breast self exam nor clinical breast exam) sensitivity of screening mammography is 75-90%

Answer 10

purpose is to follow up on a positive breast finding on mammography screen, symptoms or clinical finding symptoms: pain, nipple discharge, skin change, nipple inversion, shrinking breast, enlarging breast clinical finding: palpable lump

Answer 11

in asymptomatic women <40 years of age, mammogram is not recommended in asymptomatic women 40-49 years of age, annual screening mammogram can be done at discretion of physician in asymptomatic women 50-74 years of age, mammogram screening every 1-2 years is recommended, which is evidence based and generally accepted mammogram every year if recommended by radiologist, personal history of breast cancer, strong family history of breast / ovarian cancer or increased breast density in asymptomatic women >74, mammogram screening every 1-2 years is recommended if she is in good health condition mammogram and MRI sometimes recommended for screening in very high risk groups such as BRCA mutation carriers

Answer 12

main abnormal mammogram findings include microcalficiation, architectural distortion, mass and asymmetry 90% breast cancer present as micro calcification and / or mass 10% breast cancer present with uncommon signs of architectural distortion and asymmetry

Answer 13

BIRADS is a standardized system for reporting mammography for uniformity and improve utility BIRADS applies to all imaging including mammography, ultrasound and MRI BIRADS 0 - further imaging is required further imaging usually ultrasound or cones down mammography view usually any abnormality on any single imaging will be BIRADS 0 until further imaging is done BIRADS 1 - normal BIRADS 2 - benign (e.g. cyst, fibroadenoma) BIRADS 3 - probably benign with very low chance (2%) of malignancy where follow-up imaging is recommended (usually in 6 months) presence of malignancy features such as non-calcified circumscribed solid mass, focal asymmetry, cluster of round punctate calcification BIRADS 4 - suspicious abnormality with 2-95% chance of malignancy, where biopsy is recommended BIRADS 4a have lower chance of malignancy than 4b BIRADS 5 - likely to be cancer (>95% chance of malignancy), so a biopsy and surgical consultation is recommended BIRADS 6 - confirmed malignancy with biopsy

Answer 14

BIRADS 0 requires further imaging (usually coned compression & magnification view mammogram and ultrasound) usually, any lesion detected on mammogram is BIRADS 0 until further imaging is done BIRADS 1 and 2 require no further work-up BIRADS 3 requires follow-up imaging in 6 months BIRADS 4 and 5 requires biopsy BIRADS 6 is post-biopsy

Answer 15

based on standard 2 view mammography alone, it is not possible to definitively diagnose benign vs. malignant any lesion detected on standard 2 view mammography alone is classified as BIRAD 0 until further imaging is done workup of abnormal lesion comprised of 2 steps: 1) localization of lesion on initial mammogram on CC and MLO views 2) follow-up imaging, which may include combination of additional mammogram view (coned compression & magnification view), ultrasound and / or MRI any lesion detected on mammogram need to be followed up with additional imaging (additional mammographic view, ultrasound or MRI) for correlation, in order to give BIRAD >0 in general, additional mammogram views and ultrasound are always done for all abnormalities in women age >35 years, always start with additional mammogram views and then followed by ultrasound indication for MRI of breast include a) high risk screening: BRCA 1 or 2 mutation, >25% lifetime risk of developing breast cancer, radiotherapy to anterior chest wall b) complex cases e.g. palpable lump not visualized on mammogram nor ultrasound c) local staging of diagnosed breast cancer d) assess response to chemotherapy 3) further work-up based on BIRAD score after follow-up imaging BIRADS 1 and 2 require no further work-up BIRADS 3 requires follow-up imaging in 6 months BIRADS 4 and 5 requires biopsy

Answer 16

usually, breast biopsy follows imaging work up with a BIRAD of 4 or 5 breast biopsy is mandatory for diagnosis of breast cancer

Answer 17

breast biopsy is done by radiologist biopsy is usually guided by the imaging on which the lesion is best visualized 1) ultrasound guided biopsy 1st line except when lesion cannot be visualized on ultrasound ultrasound guided is in real time, fast and cheap good for solid and complex solid cystic mass 2) stereotactic (i.e. mammogram guided) biopsy good for biopsying microcalcification seen on mammogram good for asymmetry on mammogram that is absent on ultrasound use X, Y and Z coordinates based on mammogram 3) MRI guided biopsy 2nd last line, usually when lesion cannot be seen on ultrasound nor mammogram 4) excisional biopsy based on palpation clinically last line, usually when all imaging fails and lesion is palpable on clinical exam biopsy needle can be fine needle, core needle or vacuum assisted fine needle aspiration (FNA) is used for lymph node or cyst biopsy, where it produces the smallest amount of sample core needle biopsy (CNB) is usually used only with some exceptions vacuum assisted device (VAD) biopsy is used for microcalcification or diffuse lesion or under MRI guidance, where it produces the largest amount of sample post biopsy if biopsying for calcification, view biopsy under X-ray to ensure that the calcification is in the biopsy deploy marker clip at site of biopsy to mark area of original lesion in case of surgery afterwards

Answer 18

most common cancer in women (1 in 9 women will develop breast cancer during her lifetime; 1 in 29 women will die from it) 2nd most common cause of cancer death in women most of cancer (~90%) are sporadic only minority of cancer (5-10%) are hereditary (e.g. BRCA 1 or 2 mutation) 5 year survival rate for breast cancer is ~90% for women and ~80% for men

Answer 19

demographics female gender older age, where incidence steadily increase after age 30 and peak at age 80 female gender and age are the most significant risk factor for breast cancer ``` medical history personal history of breast cancer increased breast density on mammogram prior biopsy for breast abnormalities pre-malignant breast lesion including atypical ductal or lobular hyperplasia on biopsy radiation to chest wall for lymphoma ``` family history of breast cancer breast or ovarian cancer in 1st degree relatives including mother, sister, daughter ``` unopposed estrogen early menarche (age <12) late menopause (age >55) long term (>5 years) hormone replacement therapy (for menopause) nulliparity or first birth after age 30 no breast feeding ``` modifiable lifestyle risk factors alcohol obesity, especially after menopause physical inactivity other possible factors smoking

Answer 20

age medical history or breast cancer, ductal carcinoma in situ, lobular carcinoma genetic syndrome associated with increased risk of breast cancer (BRCA 1, BRCA 2) age of menarche nulliparity, age of first live birth family history of breast cancer prior breast biopsy race / ethnicity any high risk (lifetime breast cancer risk >20%) is refered to breast high risk clinic in high risk patients, selective estrogen receptor modulators (SERMS) such as tamoxifen and raloxifene decrease breast cancer risk

Answer 21

Non-invasive epithelial cancers Invasive epithelial cancer Mixed connective and epithelial tumours

Answer 22

atypical hyperplasia confined in basement membrane and duct

Answer 23

lobular carcinoma in situ (LCIS), which is a marker of developing breast cancer in either breast ductal carcinoma in situ (DCIS) with 5 subtypes of DCIS from least to most aggressive: intra-ductal, papillary, cribriform, solid, comedo DCIS is a marker of developing breast cancer in that breast and not the other breast

Answer 24

invasive lobular carcinoma (~10% of invasive cancer) ``` invasive ductal carcinoma (~90% of invasive cancer), which have many subtypes not otherwise specified (50-70% of invasive ductal carcinoma) medullary carcinoma (5%) tubular carcinoma (3%) mucinous or colloid carcinoma (3%) invasive cribiform carcinoma (3%) invasive papillary carcinoma (2%) adenoid cystic carcinoma (1%) metaplastic carcinoma (1%) ```

Answer 25

invasion beyond the basement membrane and duct

Answer 26

phyllodes tumors, which can be benign or malignant carcinosarcoma angiosarcoma, which is usually due to radiotherapy to chest wall or post mastectomy

Answer 27

cancer can be in any breast quadrant: 50% in upper outer quadrant; 20% around areola; 15% in upper inner quadrant; 10% in lower outer quadrant; 5% in lower inner quadrant most breast cancers are asymptomatic and detected by screening breast cancer usually present as lump in breast other symptoms / signs: nipple charge or discharge (clear or bloody fluid), change in breast skin colour or texture, skin dimpling, skin inversion, axillary lymphadenopathy Paget’s disease of breast (malignancy involving nipple of breast spreading to areola): eczema of areola (flaky, scaly) which may have nipple discharge, burning sensation or inversion; usually no breast mass and no mammogram abnormality; diagnosed by pathology of punch biopsy or full thickness biopsy of nipple inflammatory breast cancer (diffuse tumor involving lymphatic channel within breast and overlying skin): peau d’orange (thickening skin, erythema, edema and warmth of firm breast due to lymphatic obstruction); typically requiring neo-adjuvant chemotherapy followed by surgical mastectomy inflammatory breast cancer (diffuse tumor involving lymphatic channel within breast and overlying skin): peau d’orange (thickening skin, erythema, edema and warmth of firm breast due to lymphatic obstruction); typically requiring neo-adjuvant chemotherapy followed by surgical mastectomy lobular carcinoma: classically in elderly women presenting as bilateral and multifocal lesions with high recurrence rate (ductal or lobular) in contralateral breast; metastasis to meninges, pleura, GI series and urinary series; usually ER+ and PR+; requires mastectomy metastasis: most commonly to axillary lymph nodes, bone, lung and liver; may metastasis to pleural, pericardium and abdominal cavity bone metastasis have better prognosis than other metastases

Answer 28

mammogram and ultrasound to visualize lesion and guide biopsy biopsy to confirm malignancy and for tumor staging MRI to better visualize lesion, rule out multicentric (multiple tumor sites in >1 quadrant) or multifocal lesion (multiple tumor sites within 1 quadrant) and surgical planning chest X-ray, liver ultrasound to rule out metastasis other imaging as indicated by symptoms bone scan for bone metastasis if bone pain or high alkaline phosphatase brain CT for brain metastasis if CNS symptoms such as confusion, fall, ataxia chest CT for lung metastasis if pulmonary symptoms abdomen and pelvis CT for metastases to bone, liver or GI tract if high alkaline phosphatase, abnormal liver function test, abdominal symptoms or signs

Answer 29

TNM staging Pathological staging (microscopic features for prognosis): Tumour size, focality, margin Tumour grade (Nottingham histologic score) based on architectural tubular formation, atypia and mitosis Lymph node status Receptor (ER, PR, HER2) status Hormone receptor status

Answer 30

hormone receptors are tested from excised tumor biopsy, which inform chemotherapy and prognosis hormone receptors include estrogen receptor (ER), progesterone receptor (PR) and HER2 neu overexpression (HER2) ER+, PR+ are associated with better prognosis and can be treated with hormone therapy HER2+ can be treated with herceptin PR- associated with more aggresive cancer ER- PR- have a worse prognosis

Answer 31

1. TNM staging 2. receptor status (ER and HER2) 3. women's age and menopausal status

Answer 32

a) lumpectomy (aka breast conservative surgery) procedure = removal of lump with some surrounding healthy tissue (wide local excision), combined with radiotherapy indication: stage 1 and 2 breast cancer contraindication: high risk of local recurrence (extensive malignant calcification on mammogram, lobular carcinoma, multi-focal tumor, failure to obtain tumour free margin after excision); contraindication to radiotherapy (see below); inflammatory chest cancer; lobular carcinoma b) mastectomy radical mastectomy = removal of entire breast, skin, pectoralis muscle and axillary nodes modified radical mastectomy = removal of entire breast, skin and axillary nodes simple mastectomy = removal of entire breast and skin indication: invasive lobular carcinoma; multi centric or multifocal breast cancer complication: skin necrosis following lumpectomy or mastectomy, breast and nipple can be reconstructed with TRAM flaps or implants under pectoralis muscle decision of lumpectomy vs. mastectomy depend on size / location / number of tumor, patient decision and cosmesis c) sentinel lymph node biopsy = biopsy of first lymph node that drains the cancer procedure = injection of radioisotope (Technetium-99) and blue dye near cancer which is drained by lymph, where lymph node that take up dye and radioisotope are dissected and sent to pathology for examination if sentinel lymph node is free of cancer, then no lymph node involvement if sentinel lymph node contain cancer, then lymph node dissection d) lymph node dissection procedure: complete excision of all lymph nodes in axilla indication: positive lymph node on fine needle aspiration biopsy; positive sentinel lymph node biopsy complication: injury to brachial plexus nerves (decreased arm sensation, shoulder pain); lymphedema (10-15% risk)

Answer 33

effectiveness of lumpectomy + radiotherapy is equivalent to mastectomy lumpectomy with sentinel lymph node biopsy, followed by radiation lumpectomy with sentinel lymph node biopsy -> axillary lymph node dissection followed by radiation mastectomy with sentinel lymph node biopsy modified radical mastectomy (mastectomy + axillary lymph node dissection)

Answer 34

procedure = external beam radiotherapy indication: radiotherapy always follow lumpectomy to reduce risk of recurrence radiotherapy usually not required in mastectomy especially with lymph node dissection contraindication: pregnancy; previous chest radiotherapy; collagen vascular disease (scleroderma, lupus)

Answer 35

neoadjuvant chemotherapy given before surgery to shrink aggressive tumor followed by surgical resection adjuvant systemic chemotherapy given post surgery to reduce risk of recurrence and prolong survival

Answer 36

chemotherapy based on comprehensive risk assessment of cancer stage, receptor status, pathological stage and other features all breast cancer can be treated with any of the chemotherapies below: anthracyclines (topoisomerase 2 inhibitor): doxorubicin, epirubicin taxanes (microtubule inhibitor): docetaxel and paclitaxel platinums: cisplatin, carboplatin alkylating agent: cyclophosphamide antimetabolite: 5-FU chemotherapy regimen include FEC (fluorouracil, epirubicin, cyclophosphamide

Answer 37

hormone or targeted therapy based on ER and HER2 status ER+ and HER2-, treat with hormone therapy ER- and HER2+, treat with herceptin ER+ and HER2+, treat with hormonal therapy and herceptin ER- and HER2-, no hormone receptor specific treatment, associated with poor outcome a) Hormone therapy selective estrogen modulator for pre-menopausal women: Tamoxifen aromatase inhibitor for post-menopausal women: Anastrozole, Letrozole complication: osteoporosis -> risk of fragility fracture in pre-menopausal women, ovarian ablation or suppression is also a way to lower estrogen level b) Herceptin indication: HER2+ breast cancer

Answer 38

Stage 0 Breast Cancer a) lumpectomy + radiotherapy b) lumpectomy alone if negative margin >1cm and low nuclear grade breast cancer c) simple mastectomy +/- sentinel lymph node biopsy Stage 1 Breast Cancer a) lumpectomy and axillary node dissection + radiotherapy b) simple mastectomy + (axillary node dissection or sentinel lymph node biopsy) adjuvant chemotherapy or hormonal therapy after discussion of risk and benefit Stage 2 Breast Cancer a) lumpectomy and axillary node dissection + radiotherapy + adjuvant chemotherapy (and hormonal therapy if applicable) b) simple mastectomy + (axillary node dissection or sentinel lymph node biopsy) + adjuvant chemotherapy (and hormonal therapy if applicable) Stage 3 Breast Cancer a) if operable, modified radical mastectomy + radiotherapy + adjuvant chemotherapy (and hormonal therapy if applicable) b) if inoperable, neoadjuvant chemotherapy (and hormonal therapy if applicable) or radiotherapy -> modified radical mastectomy + radiotherapy + adjuvant systemic treatment Stage 4 Breast Cancer slow disease progression with systemic chemothrapy (and hormonal therapy if applicable) palliative surgery and / or radiotherapy

General Surgery Breast Flashcards

(62 cards)