SpC Surgery > Case Study: Breast Surgery > Flashcards

Case Study: Breast Surgery Flashcards

(17 cards)

Study These Flashcards
1
Q

***DDx of Breast lump

A

Benign:

  1. Fibroadenoma
  2. Breast cysts
  3. Phyllodes tumour (Benign / Borderline)

Malignant:

  1. In-situ breast cancer
  2. Invasive breast cancer
  3. Phyllodes tumour (Malignant)

Uncommon:

  1. Idiopathic granulomatous mastitis (with / without inflammatory signs)
  2. Fat necrosis (history of trauma)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

History taking in Breast lump

A
  1. Characterisation of lump
    - Duration
    - Change in size
  2. Associated symptoms
    - Nipple discharge
    - Mastalgia
  3. Risk factor
    - Family history of Breast / Ovarian cancer
    - Hormonal: Early menarche, Late menopause, Nulliparity, Exogenous hormone (OC pills, HRT)
    - Personal history of Breast cancer / Pre-malignant conditions: Atypical ductal hyperplasia
  4. Surgical history
    - Previous breast surgery
  5. Past medical history
  6. Drug history
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Triple assessment

A

Triple assessment:

  1. Clinical
    - History + P/E
    - S/S
  2. Radiological
    - Mammography
    - USG
    - MRI
  3. Pathological
    - FNAC
    - Core biopsy
    - Incisional biopsy
    - Excisional biopsy

—> sensitivity 99.6% + specificity 93%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Mammogram / USG interpretation

A 
Mammogram:
1. Patient name
2. Date
3. View (MLO / CC view)
4. Striking feature of lesion
- Size
- Shape
- Density
- Location: Right / Left, Upper / Lower, Medial / Lateral quadrant
- Look for:
—> ***Architectural distortion
—> ***Spiculation
—> ***Suspicious (Micro)calcification (***Pleomorphic: different size / shape, in cluster / segment)
—> Mass lesion
—> Relation with skin / underlying muscle
—> Any LN involvement
5. Compare to other side

USG:
1. Striking feature of lesion
- Size
- Shape
- Look for:
—> ***Irregular hypoechoic mass
—> ***Posterior shadowing
—> ***Taller than wide
—> ***Microcalcification (within the mass)
—> ***Hypervascularity (Doppler USG)
—> ***Dilated duct (for Nipple discharge)
- Compare to other side
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

FNAC vs Core needle biopsy (CNB)

A

FNAC:
Pros:
- Less invasive than CNB
- Good specificity (96%)

Con:

  • Only give cytology assessment
  • Without architectural assessment (don’t know invasive or not)
  • Less accurate than CNB
  • Not allow good immunohistochemical assessment
  • Poor sensitivity (74%)

CNB (Trucut: brand name):
Pros:
- Allow histological diagnosis
- High sensitivity (90%) + specificity (~100%)

Cons:
- More invasive

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Management of Breast cancer (Any cancer in general)

A
  1. Confirm diagnosis
  2. Stage disease
  3. Assessment of co-morbidities
  4. Nutritional assessment + optimisation
  5. Definitive treatment
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Staging disease

A 
Radiological:
1. PET-CT
Alternatives:
2. CT thorax / abdomen
3. Bone scans

(Cheap options:

  1. CXR (Lung)
  2. Liver USG (Liver)
  3. Bone scan (Bone))

Pathological:
1. TNM staging

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

(Classification of 4 molecular subtypes of breast cancer)

A

Luminal A: ER+, PR+/-, HER2-, Ki-67 <14% (Low proliferation), Good prognosis (most common type)
Luminal B: ER+, PR+/-, HER2+/-, Ki-67 = 14% (High proliferation)
HER2+: ER-, PR-, HER2+
Triple negative: ER-, PR-, HER-, Poor prognosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Neoadjuvant systemic treatment

A

Neoadjuvant therapy:

  • Chemotherapy (for HER2 +ve, Triple negative)
  • Hormonal therapy (for Hormonal +ve)

Indication:

  1. Better locoregional control (for advanced / LN +ve disease)
  2. Downstage disease (shrink tumour) to enable Breast Conserving Surgery (esp. in Large size tumour)
  3. Special circumstance
    - **HER2 +ve breast cancer (respond well to chemo) —> Targeted therapy needed —> Neoadjuvant + Targeted therapy
    - **    Triple negative breast cancer (respond well to chemo)

(Hormonal +ve breast cancer —> respond to hormonal therapy, less respond to chemotherapy)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Surgery for Breast cancer

A
  1. Breast management
    - Simple Mastectomy (SM) —> Always offer Breast reconstruction as an option
    - Breast Conserving Surgery (BCS (Lumpectomy))
  2. Axillary management
    - Sentinel LN biopsy (for N0 disease) (SLNB) (preferred unless large tumour load in axillary region)
    - Axillary LN dissection (AD)

4 combinations:

  1. BCS + SLNB
  2. BCS + AD
  3. SM + SLNB
  4. SM + AD (aka ***Modified radical mastectomy (Radical mastectomy: Remove pectoralis as well))

Consideration:

  1. Size of tumour
  2. Size of breast
  3. Multicentric lesions (rule out Breast Conserving Surgery)
  4. Patient wish
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Case 1:

  • 45 yo lady
  • Self-detected right breast lump for 6 months
  • Mass increase in size gradually
A 
History:
- No pain / nipple discharge
- No family history of breast / ovarian cancer
- Hormonal history:
—> Menarche 13 yo
—> Premenopausal
—> G1P1
—> Never on OCP
- Unremarkable past medical history apart from chronic Hep B carrier

P/E:
- General: Unremarkable
- Breast:
—> No scars suggestive of previous breast surgery
—> Slight bulge over R12-2 o’clock position
—> 2cm tumour, periareolar in location
- LN:
—> No palpable axillary LN
—> No palpable supraclavicular LN

Investigations:
- CNB
—> Invasive ductal carcinoma
—> ER positive (Allred score 8/8)
—> PR positive (Allred score 8/8)
—> HER2 score 0
—> Ki-67 index 8% (Proliferative index: show how fast cell divide + grow)
  • Metastatic workup
    —> PET-CT: no evidence of distant metastasis / suspicious local lymphadenopathy

Diagnosis:

  • T1N0M0 disease
  • Luminal A disease (ER+, PR+, HER2-, Low proliferative index)

Treatment:
- Neoadjuvant not needed
- SM + SLNB without immediate reconstruction
- Pathology
—> 18mm Invasive ductal carcinoma grade 1
—> ER positive (Allred score 8/8)
—> PR positive (Allred score 8/8)
—> HER2 score 0
—> Ki-67 index 8%
—> Margins all clear
—> Sentinel LN: 3 harvested, none involved by metastatic carcinoma

Pathological staging:
- T1cN0M0 disease

Subsequent management
- Multidisciplinary: Surgeon + Oncologist + Radiologist + Pathologist
- Prognostic tools (e.g. Gene signature)
—> High risk: Adjuvant chemotherapy
—> Low risk: Adjuvant hormonal therapy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

DDx for Nipple discharge

A

Benign (more common):

  1. Intraductal papilloma (Bloody)
  2. Ductal ectasia (Serous)

Malignant:

  1. In-situ breast cancer (Bloody)
  2. Invasive breast cancer (Bloody)

General:

  1. Physiological lactation (Milky)
  2. Hyperprolactinaemia (Milky)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

History taking in Nipple discharge

A
  1. Characterisation of nipple discharge
    - Unilateral / Bilateral
    - Blood / Serous / Milky / Yellow discharge
    - Spontaneous (stain on underwear) vs Manual expression of nipple
  2. Associated breast symptoms
    - Mass
    - Mastalgia
  3. Risk factor
    - Family history of Breast / Ovarian cancer
    - Hormonal: Early menarche, Late menopause, Nulliparity, Exogenous hormone (OC pills, HRT)
    - Personal history of Breast cancer / Pre-malignant conditions: Atypical ductal hyperplasia
  4. Surgical history
    - Previous breast surgery
  5. Past medical history
  6. Drug history
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

P/E in Nipple discharge

A
  1. Breast mass
    - Inspection
    - Palpation
  2. Nipple discharge
    - Ask patient to express discharge
    - Unilateral / Bilateral (Bilateral: **Visual field examination)
    - Blood / Serous / Milky / Yellow discharge
    - **    Single ductal (more pathological) / Multiductal (more physiological / systemic)
    - Sampling for cytology
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Investigations in Nipple discharge

A 
Radiological
1. USG
(high frequency linear probe, adjust depth of scan, radial placement of probes, try to identify any intraductal lesions should there be any dilated ducts)
- ***Dilated duct (for Nipple discharge)
- Mass lesion within duct
  1. **Ductogram (Mammogram / MR ductogram)
    - Mammogram: Cannulate diseased nipple —> **    Contrast mammogram —> Dilated duct + **Filling defect
    - MR ductogram: Performed with heavily T2-weighted sequence, non-invasive, no radiation —> Dilated duct
    —> **    Distance of filling defect from nipple orifice
    —> Mass lesion within duct
  2. Ductoscopy

Histological

  1. Core biopsy
    - can be difficult for small intraductal lesions —> may result in sampling error
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Surgery in Nipple discharge

Study These Flashcards
A
  1. **Microdochectomy (Excision of breast duct)
    - **    Ductogram-guided / **Ductoscopy-guided
    - May need help of blue dye injection into pathological duct
    - Removal of diseased duct for pathology examination
    - Usually done by **    periareolar incision —> Excision + Ligation of breast duct —> Pathological examination

In case of incidental breast cancer diagnosed by Microdochectomy:

  1. Review pathology report (margin, type of cancer, histology type, immunohistochemistry)
  2. Review ***operation record
  3. Start usual workup for cancer
    - Confirm diagnosis
    - Stage disease
    - Assessment of co-morbidities
    - Nutritional assessment + optimisation
    - Definitive treatment
17
Q

Case 2:

  • 50 yo lady
  • Right blood stained nipple discharge for 1 month
Study These Flashcards
A

History

P/E:
- Single duct, right nipple blood stained discharge on manual expression

Pathology on Microdochectomy:

  • Intraductal papilloma
  • No evidence of in-situ / invasive malignancy
SpC Surgery
flashcards
Decks in class (11)
# Cards
Brainscape helps you reach your goals faster, through stronger study habits.
© 2026 Bold Learning Solutions. Terms and Conditions