Year 3 Surgery > Breast Surgery > Flashcards

Breast Surgery Flashcards

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1
Q

Wha is the Breast Triple Assessment?

Suggest 2 critertia for referral by GP

A

A hospital-based assessment clinic, allowing early+rapid detection of breast cancer

  • Signs/symptoms that meet the breast cancer 2ww referral criteria
  • Suspicious finding on routine screening
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2
Q

Outline the Breast Triple Assessment stages

A
  • History (PC, RFs, FHx, Dx, PMHx, Sx etc) + Exam
  • Imaging
  • Biopsy
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3
Q

Outling the Imaging stage of the Breast Triple Assessment

(MRI can be useful in assessing lobular breast cancers + response to neoadjuvant therapy. Whilst it has high sensitivity, it has a low specificity)

A

Mammography (can be done w/ Contrast)

  • Compression views of breast across 2 views
  • Allows to detect Mass Lesions or Micro-calcifications

USS;

  • More useful in Women <35 and Men (due to tissue density)
  • Also routiney used during core biopsies
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4
Q

Outline the Biopsy/ Histoloy stage of the Breast Triple Assessment

(Required of any suspicious mass/ lesion presenting to the clinic, most commonly via core biopsy)

A

Core Biopsy;

  • Provides histology, allowing differentiation between Invasive and In-situ Carcinoma
  • Higher Sensitvity + Specifcity than FNA

FNA Biopsy; (Fine needle aspiration)

  • Provides Cytology
  • Used if Recurrent Cystic disease, to relieve symptoms
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5
Q

Malignancy suspicion is graded at each stage

Outline how an Overall Risk Index is created by Triple Assessment, to determine if;

  • Benign/ Malignant
  • Further intervention+biopsy needed
A

P= Examination Score, B= Histology score
Imaging (Mammography/ USS) Score= M/U

1= Normal
2= Benign
3= Uncertain/ Likely Benign
4= Suspicious of Malignancy
5= Malignant
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6
Q

What is a common way to categorise types of Breast Pain

A
  • Cyclical (most common)
  • Non-cylical
  • Extra Mammary (E.g Chest wall/ Shoulder pain)
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7
Q

Outline Cyclical Breast Pain

A
  • Pain assosciated with Menstrual cycle
  • Begins few days before beginning and subsiding at end
  • Typically, affects both breasts
  • Mostly in those activlely Menstruating or using HRT
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8
Q

Outline Non-Cyclical Breast Pain

A

33% of Breast pain cases

Can be caused by Medications, e.g;

  • Hormonal contraceptives
  • Anti-depressants (Sertraline)
  • Anti-psychotics (Haloperidol)
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9
Q

What features do you ask about in a pt with Mastalgia

A

Lumps, Skin changes, Discharge, Fevers
Assosciation with menstrual cycle
Pregnancies, Breast-feeding

Dx, PMHx, Fx

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10
Q

Outline Investigations for Breast pain

A

Mastalgia alone does not qualify for Imaging

All pts within reproductive age should have a Pregnancy test

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11
Q

Outline Breast pain managment

Most cases are Idiopathic

A

1st: Reassurance + Pain control;
- Better fitting or Soft support bra during night
- Oral Ibuprofen/ Paracetamol or Topical NSAIDs

2nd: Refer to specalist;
- Consider Danazol (Anti-Gonadotrophin agent)
- ADRs: Nausea, Dizziness, Weight gain

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12
Q

What is Galactorrhoea

A

Copious, Bilateral, Multi-ductal, Milky discharge not assosciated with Pregnancy or Lactation

(Includes Milk production 6-12mths after pregnancy and cessation of breast-feeding)

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13
Q

Dopamine acts to inhibit PRL secretion, which is the main hormone regulating Lactation

Outline the effects of TRH and Oestrogen on Prolactin secretion from Ant Pit gland

A

Both increases PRL secretion

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14
Q

Hyperprolactinaemia is the most commn cause of Galactorrhoea

List causes of Hyper-PRL

A
  • Idiopathic: 40% of cases
  • Pituitary Adenoma
  • Drugs: SSRIs, Anti-psychotics, H2 Antagonists
  • Neurological: Dopamine inhibited (VZ infection)
  • HypoTism: Elevated TRH
  • Renal/ Liver failure
  • Pituitary Stalk damage: Reduced inhibition from Dopamine
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15
Q

Normoprolactinaemic galactorrhoea is less common and is typically idiopathic, the diagnosis only being made once all other causes of galactorrhoea have been excluded (i.e. normal blood markers and regular menstruation).

How are these pts treated

A

These patients can often safely be reassured and observed

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16
Q

What features do you ask about in a pt with Galactorrhoea

Important to confirm True Galactorrhoea

A

Lumps, Mastalgia, LMP

Features of Endocrine disease
Neurological symptoms (Headache, Vision changes)

Dx very important

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17
Q

Outline Investigations for Galactorrhoea

A

Pregnancy test if reproductive age

  • TFTs, LFTs, U&Es
  • Serum PRL (>1000mU/L suggests Prolactinoma)

MRI w/ Contrast: If Pituitary tumour suspected
Breast imaging: Consider if Palpable Lumps/ L Nodes

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18
Q

Outline Galactorrhoea management

A

Confirmed Pituitary tumours;

  • Dopamine Agonist therapy (Cabergoline, Bromocriptine)
  • Potentially, Trans-Sphenoidal surgery

Idiopathic Normoprolactinaemic;

  • Resolves on its own
  • If persistent, can trial Dopamine agonist therapy

Troublesome Galactorrhoea + Medication intolerance;
- Bilateral Total Duct Excision

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19
Q

Carcinomas in situ are malignancies that contained within BM tissue. They are seen as pre-malignant condition, typically found on imaging and are asymptomatic

What are the 2 main types in Breast disease

A
  • DCIS, Ductal Carcinoma In Situ

- LCIS, Lobular Carcinoma In Situ

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20
Q

DCIS is themost common non-invasive breast malignancy. It represents 20% of all diagnosed breast cancers

Describe it and its Prognosis

A

Malignancy of Ductal tissue of beast, contained within the BM

Left untreated, 20-30% will develop invasive disease

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21
Q

Outline Investigations for/ Diagosis of DCIS

A

Often detected during screening;

  • Appears as Microcalcifications on Mammography
  • Either Localised OR Wide-spread

This is confirmed on Biopsy

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22
Q

List the Subtypes of DCIS and compare their most likely apperance on Mammography

(Most lesions are mixed)

A

Comedo- Microcalcifications
Cribriform- Multi-focal
Micropapillary- Multi-focal
Solid- Multi-focal

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23
Q

Outline DCIS Management

A

Localised DCIS;

  • Complete wide excision
  • Ensure surroundng tissue of all magins have no residual disease

Cases of Widespread or Multifocal DCIS;
- Usually, Complete Mastectomy

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24
Q

Describe LCIS

Compare it to DCIS

A

Malignancy of the Secretory lobules of the breast, contained within BM

Compared to DCIS, LCIS is;

  • Rarer
  • More at risk of developing Invasive malignancy
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25
Outline Diagnosis of LCIS
Usually diagnosed; - Before Menopause (>90%) - Incidentally during Biopsy
26
Outline LCIS Managment
Low grade LCIS; - Monitoring rather than Excision If pt has BRCA1/2 genes; - Consider Bilateral Prophylactic Mastectomy
27
How do Breast Carcinomas-in-situ usually present?
Usually Asymptomatic, found incidentally/ by screening
28
Carcinoma of the breast is the most common cancer in the Western world and accounts for 20% of all cancers in women in the UK, with 1 in 10 women developing breast cancer in their lifetime List the classes of Invasive Breast Carcinoma
- IDC, Invasive Ductal Carcinoma (75-85%) - ILC, Invasive Lobular Carcinoma (10%) Others (5%) - E.g Medullar or Colloid Carcinoma
29
Why is the division of Breast carcinomas into Ductal and Lobular WRONG? Why is it still used as a classification
Almost all breast carcinomas arise in the Terminal Duct Lobular Unit The 2 subtypes behave differently
30
IDCs are the most common breast carcinomas (80% of all cases) List their further classifications Which 3 are Well-circumscribed and show the best Prognoses?
Further subtypes of IDCs; - Tubular* - Cribriform* - Papillary* - Mucinous/ Colloid - Medullary
31
ILCs are; - The 2nd most comon type of breast cancer (10% of all invasive cancers) - More common in older women Describe them
Characterised by diffuse/ stromal pattern of spread, that makes detection harder (hence by diagnosis, tumors are quite large)
32
List RFs for Invasive Breast Cancer | Similar to Breast Carcinomas In-Situ
2 Most significant RFs; - Female sex - Age (risk doubles every 10yrs until menopause) - Gene mutations, Previous Benign disease - Obesity, Alcohol, Geographic variation - High exposure to unopposed Oestrogen - Fx in 1st degree relative
33
List examples of High exposure to unopposed Oestrogen
- Early menarche - Late menopause - No children - Oral contraceptive - 1st pregnancy after 30y/o - HRT use
34
How can Invasive Breast Cancer present | Can be Symptomatic or Asymptomatic
- Breast pain, Breast lump - Palpable axilla lump - Asymmetry, Skin changes (Paget’s, Dimpling) - Swelling (all or part of breast) - Nipples: Retraction, Abnormal discharge
35
Outline Investigations for Invasive Breast Cancer | Managment is Extensive+Variable
Gold standard: Triple Assessment
36
Which factors affect the Prognosis of Invasive Breast Cancer
- Nodal status (most important) - Size - Grade - Vascular Invasion - Receptor status (all malignancies should be checked for ER, PR and HER2 status, influencing treatment)
37
Name the system widely used to stage Primary Breast Cancer Prognosis
Nottingham Prognostic Index (NPI)
38
Outline the UK Breast Screening Programme
Women 50-70 to have a Mammogram every 3yrs
39
What is Paget’s Disease of the Nipple
When is involvement of the epidermis by malignant ductal carcinoma cells
40
How does Paget’s disease present
- Itching/ redness of Nipple and/or Areola - Flaking + Thickened skin on/ around nipple - Area often Painful+Sensitive - Nipple may be Flattened w/ or w/o Yellow/ Bloody discharge
41
List ddx of Paget’s
Dermatitis or Eczema | Paget’s: Always affects Nipple, sometimes Areola (Eczema: Only involves Areola)
42
Outline Investigations for Paget’s Disease
Biopsy to confirm, entire nipple may be removed for histology exam Breast+Axilla exam (strong link to cancer) May need Mammograms, USS, MRI Breast
43
Outline Management of Paget’s Disease
1st line: Surgical - Type depends on how advanced underlying cancer is - IN ALL CASES, Nipple+Areola removed Radiotherapy may be needed if underlying malignancy
44
List 4 examples of Inflammatory Breast Disease
Mastitis Breast Cysts Mammary Duct Ectasia Fat Necrosis
45
What is Mastitis? Whats the most common cause?
Inflammation of breast tissue (Acute/ Chronic) Infection- Typically S. aureus, but can be Granulomatous
46
Mastitis can be classed by Lactation status Outline this
Lactational Mastitis; - More common, in upto 33% of breastfeeders - Usually during Weaning or 1st 3mths of Breastfeeding - Assosciated with Cracked Nipples + Milk Stasis - More common in 1st child Non-lactational Mastitis; - Especially in women with Duct Ectasia-> Peri-ductal Mastitis - Tobacco smoking is a RF
47
How does Mastitis present?
- Tenderness, Swelling, Erythrema - Over area of infection Lactational Mastitis: Usually Peripheral Non-L Mastitis: Usually Central
48
Outline Mastitis Management
Systemic Abx, Simple Analgesia In Lactational Mastitis; - Continued milk drainage/ feedig If Persistent/ Multiple areas of infection; - Consider Dopamine agonists to cessate breastfeeding
49
What is a Breast Abscess? | Most commonly develops from Acute Mastitis
Collection of pus within breast, lined with granulation tissue
50
How may a Breast Abscess present
- Tender Fluctuant + Erythrematous masses - May be a Punctum - Fever, lethargy
51
Outline Investigations and Management for a Breast Abscess
Can be confirmed via USS Intial phase; - Often fully reversible - Empirical Abx + US-guided needle aspiration Advanced; - Incision + Drainage under LA
52
List a complication of Drainage of a non-lactational breast abscess How are these managed, and what is the prognosis?
Formation of a Mammary Duct Fistula (between Skin and Subareolar breast duct) - Fistulectomy + Abx - Can often recur
53
What is a Breast Cyst How do they form? (Cysts make up 15% of palpabe breast mass cases)
- Epithelial lined fluid-flled cavities | - When lobules become distended due to blockage, usually in Peri-menopaual age groups
54
How may a Breast Cyst present?
- Singular/ Multiple lumps - Uni- or Bi-lateral On Palpation; - Distinct smooth massess - May be Tender
55
Outline Investigations for Breast Cysts
Mammography: Identified by “Halo’ shape USS: Definitive diagnosis Aspirated, freehand or US-guided; - If Persisting/ Symptomatic/ Undeterminable Cancer may be excluded if; - fluid has no Blood or Lump dissappears - Otherwise send fluid for Cytology
56
Outline Management of Breast Cysts
Once diagnosed, usually self-resolve Larger cysts; - Can be aspirated for Aesthetics/ Pt reassurance
57
List complications of Breast Cysts | 2% of pts have an unrelated Carcinoma at presentation
- 2-3x greater risk of breast cancer in future | - Fibroadenosis (fibrocytic changes) which can mask malignancy
58
How can most cases of breast Fibroadenosis be managed
Analgesia Any cyclical pain: High dose Danazol or GLA (Gamolenic acid)
59
What is Mammary Duct Ectasia? | Common in Peri-menopausal women, 40% of women have significant duct dilation by 70
Dilation + Shortening of major lactiferous ducts
60
How may Mammary Duct Ectasia present?
- Green/ Yellow Nipple discharge - Palpable mass - Nipple retraction (often slit-like) (Any blood stained discharge requires Triple Assessment)
61
Outline Investigations for Mammary Duct Ectasia
Mammography; - Dilated Calcified ducts w/o any features of malignancy On Biopsy; - Mass contains multiple plasma cells on Histology (AKA ‘Plasma Cell Mastitis’)
62
Outline Mammary Duct Ectasia Management
Conservatively, unless radiology can’t exclude cancer Unremitting nipple discharg; - Duct excision
63
What is Fat Necrosis? (AKA Traumatic fat necrosis) What can cause it?
- Ischaemic necrosis of fat lobules Acute inflammatory response in breast; - Blunt trauma to breast (40% in cases) - Previous Surgery/ Radiology (60%)
64
How may Fat Necrosis present?
Usually: Asymptomatic OR a Lump Less commonly; - Fluid discharge, Skin dimpling, Pain - Nipple inversion Acute inflammatory response can persist-> Chronic Fibrotic change that can-> Solid Irregular lump
65
Outline Investigations for Fat Necrosis of the breast
+ve traumatic history and/or Hyperechoic Mass on USS Advanced Fibrotic lesions mimic Carcinoma; - Mammogram: Calcified irregular speculated masses Core biopsy often taken to rule out malignancy
66
Outline Fat Necrosis Management
Self-limiting Only need Analgesia + Reassurance
67
What is Gynaecomastia? How common is it? (1% of cases-> Breast cancer)
Males develop breast tissue, due to imbalanced Oestrogen and Androgen activity At least 33% of men experienc it in their lifetime (Usually fully reversible)
68
Compare the 2 types of Gynaecomastia
Physiological; - Mostly in teens, due to Delayed Testosterone surge relative to Oestrogen - Less commonly, in Elderly due to decreasing Testosterone w/ increasing age Pathological; - Changes in Oestrogen:Androgen activity ratio
69
List 4 mechanisms of Pathological Gynaecomastia | Changes in Oestrogen:Androgen activity ratio
Idiopathic Lack of Testosterone; - Androgen insensitivity, Renal disease, Testicular atrophy, Klinefelter’s Syndrome Increased Oestrogen; - Liver disease, HyperTism, Obesity, Adrenal tumours, some Testicular tumours Medication; - Digoxin, Metronidazole, Spironolactone, Chemo-, Goserelin, Antipsychotics, Anabolic Steroids
70
How may Gynaecomastia present?
O/E; - Rubbery/ Firm mass - Starts from under nipple, spreads outwards over breast region
71
Outline Investigation + Results for Gynaecomastia
Testicular exam Tests: Only if cause unknown; - LFTs, U&Es, Hormone profile if these are normal High LH, Low Testosterone= Testicular failure Low LH, Low Testosterone= Increased Oestrogen High LH, High Testosterone= Androgen resistance or Gonadotrophin-secreting malignancy
72
Outline Gynecomastia Management Depends on Cause+Phase
Most cases, Reassurance is all that’s needed Tamoxifen: To alleviate symptoms, esp Tenderness Later Fibrosis stages: Surgery, if medical treatments failed
73
List types of Benign Breast Tumours
``` Fibroadenoma (most common) Ductal Adenoma Intraductal Papilloma Lipoma Phyllodes Tumours ```
74
Fibroadenomas usually occur in women of reproductive age Describe them How do they present O/E
Proliferations of Stromal+Epithelial tissue of Duct Lobules Most are <5cm in diameter Can be Multiple+Bilateral O/E; - Highly mobile, Well-defined, Rubbery
75
Outline the prognosis of Fibroadenomas List the main indications for potential excision
Very low malignant potential Can be left alone with follow-ups over a 2yr period Diameter >3cm or Pt preference
76
Describe Ductal Adenomas
Benign Glandular tumour Usually in Older Females Lesions are Nodular, Can mimic Malignancy (So most cases undergo Triple Assessment)
77
Describe Intraductal Papillomas How may they present?
Usually in Females 40–50 Mostly in Subareolar region (Usually <1cm from Nipple) Bloody/ Clear nipple discharge Larger ones can present as a mass initially
78
How are Intraductal Papillomas investigated? How are they managed? (Breast cancer risk only increased with Multi-ductal papillomas)
Can appear similar to Ductal Carcinomas on Imaging, so usually need Biopsy Some cases may be excised, most treated with Microdochectomy
79
Describe Lipomas, their prognosis and treatment
Soft, Mobile adiopose tumour Low malignant potential Usually only removed if; - Significantly enlarging - Compressive symptoms - Aesthetic issues
80
What are Phyllodes Tumours? | Describe them
Rare Fibroepithelial tumours, made of Epithelial+Stromal Tissu Large, Grow rapidly and occur in Older people
81
Outline Phyllodes Tumour Investigation, Management and Prognosis (Phyllodes means ‘Leaf’, due to characteristic leaf-like fibrous tissue projections on microscopy)
Hard to differentiate from Fibroadenomas clinically and microscopically Most Phyllodes Tumours; - Widely Excised - Mastectomy if Large lesion - 33% of Phyllodes Tumours have malignant potential - 10% recur after excision
82
How may Benign Breast Tumours present? Investigation+Management: Triple assessment, Reassurance+Routine check-ups. Excised if can’t exclude malignancy
Variable, but generally; - Mobile, Smooth borders Can have Multiple Lumps Pain/ Discomfort if they grow (Malignant: Single lump, Craggy surfaces, Firm, Fixed to different tissue layers)
83
What’s the main Ddx for Gynaecomastia
Pseudogynaecomastia: Adipose in breast region, assosciated with being overweight (Can be tested by pinching to see if there is an obvious disc of breast tissue present, however if not palpable then further imaging and/or histology may be required to definitively exclude)
84
Niipple retraction is often benign Compare the usual causes of Slit-like and Circumferential
Slit-like: Duct Ectasia | Circumferential: Carcinoma
85
How would Fibrocystic change present What condition could this be associated with
Painful thickening, rather than a lump Associated with Breast Cysts
86
What are Cooper’s ligaments? What can happen when they lengten/ loosen/ get damaged? What can happen when they tighten/ constrict (due to cancer, fat atrophy or necrosis)
Connect tissue around chest muscle to under the skin of the breast Sagging/ drooping Puckering/ Dimpling
87
Outline process of Peau d’orange development?
Oedema in beast causes Epidermis to expand, but evenly spaced pores on skin holds down spots of skin This looks like the skin of an orange
88
List some potential causes of Peau d’orange
Breast cancer (most common) Mastitis, Pregnancy Thyroid disease, Heart Failure, Clots
Year 3 Surgery
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