PACES Hawthorne > Breast > Flashcards

Breast Flashcards

(29 cards)

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1
Q

Breat examination

Inspect: breast, and some + palpation: breast, and some + completeion

A

Expose pt. from waist up and start c¯ her sitting up

  • Request a chaperone
  • Ask pt. if they have noticed lump in breast: which breast?/point to the lump

Inspection

  • Breast
    • Positions
      • Hands relaxed by sides
      • Leaning forwards
      • Hands behind head
      • Hands pressing hips
    • Shape: asymmetry, masses
    • Skin
      • Scars: periareolar, submammary
      • Radiotherapy tattoos
      • Eczema, erythema, ulceration
      • Peau d’orange, dimpling
      • Accessory nipples: look along the milk line
    • Nipple: inversion, discharge, discolouration, destruction
  • Peripheral
    • Axillae: LN dissection
    • Arm: lymphoedema
    • Abdomen / Suprapubic: DIEP or TRAM flap harvest
    • Back: lat-dorsi flap harvest

Palpation

  • Breast
    • Pt. @ 45 with hand behind head, start c¯ normal breast
    • Any pain or discharge?
    • Palpate each breast quadrant, subareolar area and the axillary tail
    • If lump found:
      • SSS CCC TTTT FS
  • Axillae
    • Right axilla: hold pts. right arm with your right hand (and vice versa)
    • Gently palpate axillary node:
      • Apical
      • Anterior
      • Posterior
      • Medial
      • Lateral
  • Supraclavicular and cervical nodes
  • Lateral Chest Wall: Inflatable port sites for implants

Completion

  • Spine: palpate / percuss for tenderness, masses
  • Abdo: hepatomegaly
  • Lungs: Percuss and auscultate lungs for signs of mets: e.g. effusion
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2
Q

Breast: Presentations

A
  • Lump
  • Breast pain
  • Skin or nipple changes
  • Mets
    • Bones: bone pain, #s
    • Lungs: dyspnoea
    • Liver: abdo pain
    • Brain: headache, seizures
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3
Q

RF for breast lumps

(BOOBYS)

A

OBESITY

  • Bleeding: early menarche (<13), late menopause (>55)
  • Oestrogen: OCP, HRT
  • Other breast disease: previous Ca, DCIS, atypia
  • Breast feeding: protective
  • Young ‘un: first child >35yrs (↑ risk)
  • Sister: FH of Ca breast
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4
Q

Radiology options in Breast lumps

A
  • <35yrs: US
  • >35yrs: US + mammography
    • Oblique and craniocaudal
  • MRI
    • Multifocal disease
    • Cosmetic implants
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5
Q

cytology options for breast lumps

A
  • Solid lump: Tru-Cut biopsy
  • Cystic lump: FNAC
    • Reassure if clear fluid
    • Send cytology if bloody fluid
    • Core biopsy residual mass
    • Core biopsy if +ve cytology

hormone receptor testing: OR/PR

and HER2

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6
Q

Investigations for breast lumps

A

​Tripple assessment: Clinical: Hx and Ex + Radiology + Histology

  • Radiology: US + Mammography + MRI
  • Histology: Tru cut Bx + FNAC

Other:

  • Bloods: LFTs + Bone profile + ESR + U&E +FBC
  • Imaging for staging:
    • CXR
    • Liver US
    • CT scan
    • Breast MRI
    • Bone scan + PET CT
  • May need wire guided excision Bx
  • LFT/bone profile may suggest malignancy*
  • In oncology, a high ESR has been found to correlate with overall poor prognosis for various types ofcancer*
  • and FBC+U&E pre chemo?/prognosis*
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7
Q

Commonest single breast lumps

(4)

A
  1. fibroadenoma
  2. cyst
  3. fat necrosis
  4. cancer
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8
Q

Features of a malignant breast lump

(6)

A
  1. Irregular, nodular surface
  2. Poorly defined edge
  3. Hard / scirrhous consistency
  4. Painless
  5. Fixation to skin or chest wall
  6. Nipple involvement
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9
Q

Classification of Malignant breast diseases (6)

A
  1. Ductal carcinoma NOS: c.70% of cancers
  2. Lobular carcinoma: 20% of cancers
  3. Other: mucinous
  4. Other: medullary
  5. Other: papillary
  6. Other: phylloides
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10
Q

Classification of benign breast lumps

Congenital (2)

Stromal (1)

Epithelial (3)

Inflammatory (4)

A
  • Congenital
    • Supernumerary nipples
    • Hypoplasia
  • Stromal Tumour: fibroadenomas
  • Epithelial Lesions
    • ANDI: fibroadenosis, cysts (abberation in normal development and involution)
    • Papillomas
    • Cystic disease
  • Inflammatory Lesions
    • Mastitis
    • Abscess
    • Fat necrosis
    • Duct ectasia & periductal mastitis
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11
Q

Examination of Post-Mastectomy breast

Examination: Inspection + palpation + completion

A

Inspection

  • Note asymmetry
  • Describe scar
  • Look at surrounding skin and axilla
  • Evidence of radiotherapy
  • Ask pt. to press her hips: pec major present
  • Arm lymphoedema

Palpate

  • Remaining breast
  • Axilla
  • Supraclavicular fossa

Completion

  • Palpate / percuss spine for tenderness, masses
  • Examine abdomen for hepatomegaly
  • Percuss and auscultate lungs for signs of mets
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12
Q

Post Mastectomy breast history

Past 3/Present 4/future 2

A

What happened?

  • Presentation
  • Risk factors
  • Surgery

How are things now?

  • Post-op pain, anaesthetised skin (@ T1)
  • Arm swelling
  • Psych
  • Symptoms of mets

What will happen in the future?

  • Chemo and radiotherapy
  • Reconstruction
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13
Q

Indications for mastectomy

A
  • Modern oncological breast surgery involves breast conservation wherever possible.
    • Typically WLE and SNB (sentinal nobe Bx)
  • Mastectomy may be considered if
    • Pt. preference
    • Multifocal disease
    • Large lump in small breast: e.g. >4cm
    • Large area DCIS: e.g. >4cm
    • Nipple involvement
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14
Q

Types of masectomy

(4)

A
  • Simple mastectomy
    • Removal of breast alone: commonest type
    • Still need to Mx the axilla

Other types not performed as no survival benefit

  • Modified radical: breast, pec minor, axilla
  • Radical: breast, pec minor and major, axilla
  • Extended radical: radical + internal mammary LNs
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15
Q

Post mastectomy breast

Pt preparation: physical and psychological

A
  • Physical
    • Mark side prior to anaesthetic
    • Explanation including use of suction drain to close cavity and ↓ risk of haematoma or seroma formation.
    • There will be an anaesthetised patch of skin in the upper medial part of the arm
    • Division of intercostobrachial nerve (T1)
  • Psychological
    • Pts. should see breast care nurse pre-op
    • Options for reconstruction should be discussed
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16
Q

Masectomy: post of drains?

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A

Typically 2 drains: axilla and site of surgery
Left for 3-5d or until draining <50ml/d
Pts. can go home c¯ drains and district nurse support.

17
Q

Breast reconstruction examination

Inspection: gen and flap vs implant

Study These Flashcards
A

General

  • Note asymmetry
  • Arm lymphoedema
  • Evidence of radiotherapy
  • Evidence of axillary clearance / radiotherapy

Flap Reconstruction

  • Scars extend over back or abdominal wall
  • Recess on back where lat dorsi has been removed
  • Ask pt. to lift head of bead (when lying supine) to see recess in the rectus muscle

Implant Reconstruction

  • Rounder shape than normal breast
  • Breast usually lies higher
  • Becker implant may have palpable SC filling port in the axilla
18
Q

Timing of breast reconstruction

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A
  • Immediate: single operation
  • Delayed
    • ↑ pt. decision time
    • Avoidance of detrimental effects of adjuvant therapy
19
Q

Techniques for breast reconstruction

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A

Tissues expansion reconstruction with implants (becker’s=combined)

Autologous tissue reconstruction with myocutaneous flaps

20
Q

Implants for breast reconstruction

Advantages and disadvantages

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A
  • Advantages:
    • simpler techniques
    • primary or delayed
  • Disadvantages:
    • cosmetic result not as good
      • lies higher than other breast
    • requires plenty of available skin
    • Late complications:
      • capsular contracture
      • Implant leakage
      • Infection requiring removal
21
Q

Myocutaneous flaps

Advantages and disadvantages

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A
  • AdvantagesL
    • useful when little remaining skin or muscle
    • good costmetic result
    • Primary or delayed
  • Disadvantages:
    • blood loss ^
    • Op time and complications ^
    • Use of rectus impossible if pt has had abdo surgery
      • late complications: flap necrosis and infections
22
Q

Types of Myocutaneous Flap:
Latissimus Dorsi myocutaneous flap

Study These Flashcards
A
  • Pedicled: skin, fat, muscle and blood supply
  • LD mobilised and tunnelled medially to form neo-breast
  • Supplied by thoracodorsal A. via subscapular A.
  • Often augmented c¯ an implant
23
Q

Types of Myocutaneous Flap

Transverse Rectus Abdominis Myocutaneous (TRAM) Flap

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A
  • Pedicled: inf. epigastric A. Or free: attached to internal thoracic A
  • No implant necessary and combined tummy tuck
  • CI if poor circulation: smokers, obese, PVD, DM
  • Risk of abdominal hernia
24
Q

Types of Myocutaneous Flap

Deep Inferior Epigastric Perforator (DIEP) Flap

Study These Flashcards
A
  • Evolution of the TRAM flap
  • Free: skin and fat only, no muscle
  • Spares the rectus: ↓ pain and ↓ risk of hernia
  • May not be possible if small perforators
25
Gynaecomastia Examination (Inspection/palpation/completion)
* *Inspect:** Unilateral or bilateral breast swelling * *Palpation:** Must feel ***glandular tissue*** to differentiate from pseudogynaecomastia (fat). * *Completion** * **Look** for cause * External genitalia * Thyroid examination * Evidence of CLD * Visual fields * Take Hx * Prescription and recreational drugs
26
Causes of gynaecomastia: 3 Ps Potions Physiological Pathological
**Potions** * Recreational * Marijuana * Diazepam * Anabolic steroids * Prescription * Spiro * Digoxin * Captopril * Verapamil * Ranitidine **Physiological** * Especially at puberty where breast tissue may be unilaterally or bilaterally enlarged. * Usually resolves by adulthood **Pathological** * ↓ androgen production: hypogonadism * Hyperprolactinaemia * Renal failure * Testicular atrophy * Post-orchitis * Bilat torsion * Klinefelter’s: XXY * ↑ oestrogens * ↑ production * Sex-cord stromal tumours * Lung Ca * ↑ peripheral aromatisation * Chronic liver disease * Thyrotoxicosis
27
Investigation of Gynaecomastia
* Testicular Ca: AFP, βhCG * Hypogonadism: testosterone and LH levels * Prolactinoma: PRL level * TFTs
28
What is Gynaecomastia?
*enlargement of a man's breasts, which may be a result of physiological changes, drugs (recreational or pescription) or pathological changes (driven by hormonal imbalances)*
29
Features of gynaecomastia suggestive of breast Ca
*1% of breast Ca occurs in men* * Older age * FH * Unilateral gynaecomastia * Firm or hard nodules w/i breast tissue * Axillary LNs
PACES Hawthorne
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