Breast surgery

Question 1

Describe the histology of benign breast cancer conditions.

Answer 1

• Well circumscribed
• Unencapsulated
• Clean margins
• Columnar cell hyperplasia
• Fibrocystic changes

Question 2

Name the benign breast conditions.

Answer 2

• Fibrocystic changes
• Fibroadenoma
• Breast cyst
• Lactational mastitis
• Periductal mastitis
• Duct ectasia
• Fat necrosis

Question 3

Benign breast conditions

What are the symptoms and presentation of fibroadenoma?

Answer 3

• Common in adolescent women;
• Firm;
• Non tender;
• Highly mobile;
• Upper outer quadrant.

Question 4

Benign breast conditions

How is the diagnosis of fibroadenoma made?

Answer 4

Most appropriate investigation:
- Ultrasound

If required:
- FNAC
- Biopsy

Question 5

What is the histology presentation of fibroadenoma?

HIGH YIELD

Answer 5

• ⬇︎ stromal cellularity;
• Overgrowth of fibrous and glandular tissue;
• Duct-like epithelium with fibrous bridging (????);
• Well circumscribed;
• Unencapsulated;
• Clear margins;
• Separated from the surrounding fatty tissues.

Question 6

Benign breast conditions

What are the symptoms and presentation of fibrocystic changes?

Answer 6

• Affects premenopausal women;
• Pain and lumpiness of breast.

Question 7

Benign breast conditions

What are the symptoms and presentation of breast cyst?

Answer 7

• Fluid filled round mass;
• Asymptomatic or painful.

Question 8

What are the symptoms and presentation of lactational mastitis?

Answer 8

Symptoms:
- Unilateral and firm;
- Erythema in a wedged shaped area;
- Tender breast;
- Usually on the first 3 months of breast-feeding;

Cause:
- S. Aureus

Rx:
- Analgesics;
- Warm compress;
- Keep on breast-feeding;
- Flucloxacillin;
- Penicillin allergy: erytromycin / clarithromycin

Question 9

Benign breast conditions

What are the symptoms and presentation of periductal mastitis?

Answer 9

Symptoms:
- Green nipple discharge;
- Peri-areolar mass;
- Nipple rectration;
- Periareolar redness
- Hot and tender breast

Cause:
- S. Aureus

Risk factor:
- Smoking

Rx:
- Analgesics;
- Warm compress;
- Co-amoxiclav;
- Penicillin allergy: erytromycin / clarithromycin

Question 10

Benign breast conditions

What are the symptoms and presentation of duct ectasia?

Answer 10

Symptoms:
- Green or brown nipple discharge;
- Nipple rectration;
- Subareolar mass (near the nipple);
- Perimenopausal and postmenopausal women;

Cause:
- Dilation of breast ducts;

Risk factor:
- Smoking

Question 11

Benign breast conditions

What are the symptoms and presentation of fat necrosis?

Answer 11

Symptoms:
- Firm localized lump
- Erythema

Cause:
- Trauma

Question 12

What are the symptoms and presentation of duct / mamillary fistula?

Answer 12

Cause: sequelae of periductal mastitis.

Symptoms:
- Pain around areola;
- Sweeling;
- Redness;
- Fever;

Risk factor:
- Smoking
- Periductal mastitis

Rx:
- Fistulectomy
- Antibiotics

Question 13

Describe the types of mastalgia.

Answer 13

Cyclical:
- Bilateral breast pain;
- Starts 1-3 days before the menstrual cycle;
- Common in young women;

Non-cyclical:
- Not related to menstrual cycle;
- Usually unilateral;
- > 40 years of age;

Question 14

What is the Rx of mastalgia?

Answer 14

• Analgesia
• Supportive better fitting bra during the day;
• Soft supportive bra at night.

Question 15

In relation to mastalgia, when should a patient be given an urgent referral?

Answer 15

If presenting with:
➜ Mastalgia + Discrete lump + Family h/o of breast cancer.

Question 16

What are the symptoms of intercostobrachial neuralgia?

Answer 16

➔ Pain in the area of the intercostobrachial nerve.

Affects the:
- Chest;
- Upper arm;
- Axilla.

Question 17

What is the cause of intercostobrachial neuralgia?

Answer 17

• Breast surgery;
• Axillary lymph node dissection.

Question 18

What is the cause of intraductal papilloma?

Answer 18

➔ Benign tumour due to a papilloma (wart) within the breast ducts.

Common in women between 35-55 YO.

Question 19

What are the symptoms of intraductal papilloma?

Answer 19

• Serous or bloody nipple discharge;
• (Sometimes) lump near the areola;

Question 20

DDx between:
- Duct ectasia;
- Breast cancer;
- Intraductal papilloma.

Answer 20

Duct ectasia
- Green/brown discharge;
- Inverted nipples;
- Mass near areola;

Breast cancer
- Hard, irregular mass;
- Not restricted to the areola area;

Intraductal papilloma
- Serous/bloody discharge;
- Lump near areola.

Question 21

What are the symptoms of Paget’s disease (breast)?

Answer 21

• Bloody nipple discharge;
• Dry areolar skin ➝ itching;
• Ulcerated nipples;

◆ Chronic: Inverted nipple.

Question 22

What is the investigation of Paget’s disease (breast)?

Answer 22

• Skin punch biopsy.

Question 23

What are the investigations of choice for breast disorders?

In terms of age.

Answer 23

➜ Ultrasound:
- Women < 40 years.

➜ Mammography:
- Women ≥ 40 years.

Question 24

Describe how is the mammogram screening done.

Answer 24

Age 50-70 years:
- Every 3 years.

Age 40-70 years
Every 1 year if:
- Family history;
- BRCA gene positive

Question 25

Describe what is **Phyllodes tumour.**

Answer 25

- Benign fibro-epithelial tumour; - Common in 40-50 year (pre-menopausal women); - Fast growing; - Painless; - Large size.

Question 26

What are the `indications` for **prophylatic mastectomy**?

Answer 26

- Strong family history; - Positive BRCA; - Breast cancer in one breast; - Biopsy suggestive of lobular carcinoma; - Biopsy suggestive of atypical hyperplasia.

Question 27

What are the `complications` seen **post mastectomy**?

Answer 27

- Upper limb `lymphoedema` (due to removal of axiliary lymph nodes); - `Frozen` `shoulder` (due to reduced shoulder movement); - `Scar tissue cording` in the armpit.

Question 28

What is the *`management`* of `complications` seen **post mastectomy**?

Answer 28

- Exercise - Compression bandaging for lymphoedema - Scar mobilisation

Question 29

What is the **management** when **breast cancer** is suspected?

Answer 29

- 2 week wait referral to breast clinic; **Breast clinic:** - < 40 Ultrasound - > 40 Mammogram - Biopsy (core needle or FNAC)

Question 30

# Histopathology What are the **labs requested** in `breast cancer`?

Answer 30

**Histopathology** - Oestrogen receptor (ER) - Progesterone receptor (PR) - Human epidermal growth receptor 2 (HER2) `ER positive breast cancer:` - Premenopausal ➝ Tamoxifen - Postmenopausal ➝ Anastrozole (aromatose inhibitors) - Men ➝ Tamoxifen `HER 2 positive breast cancer:` - Trastuzumab

Question 31

When doing **treatment** for breast cancer with tamoxifen, which `medication should be added`?

Answer 31

Biphosphonates.

Question 32

In a `pregnant woman`, what *`treatment`* is recommended for **breast cancer**?

Answer 32

- Surgery; - Chemotherapy (not on the 1st trimester). | Radiotheraphy is not recommended.