Gen surgery Learning objectives: Flashcards

Question

Causes of post op fever: Overview: Timeline: Wind, Water, Wound, Walk, What did we do?

Answer 1

Urinary retention Causes Common post-op causes * Blocked catheter - clot in urological surgery * Medications & anaesthetic agents - epidural, opioids * Uncontrolled pain * UTI * Constipation * Other causes see urinary retention Clinical features * Anuria (or very little urine) * Sensation of needing to void * Suprapubic pain * Suprapubic mass - dull to percussion Assessment * USS KUB & PVR\* - bladder distention, obstruction, prostate, hydronephrosis * UECs - AKI Management * Treat underlying cause * IDC --\> SPA UTI * Cause - catheterisation

Answer 2

BreastScreen Australia * is a joint initiative of the Australian and state and territory governments and aims to reduce illness and death from breast cancer by detecting the disease early. Women over 40 can have a free mammogram every 2 years and we actively invite women aged 50 to 74 to screen Why breast screening is important? * Your chances of getting breast cancer increase with age. 1 in 7 Australian women will develop breast cancer in their lifetime. * We aim to reduce illness and death from the disease. That’s why we try to screen as many eligible women as we can. * Between 1985–1989 and 2011–2015, 5-year relative survival rates from breast cancer improved from 75% to 94% **Bowel cancer is one of the most common cancers in Australia.** * The National Bowel Cancer Screening Program reduces illness and death from bowel cancer by helping detect the early signs of the disease using a free, simple test that can be done at home Why bowel screening is important * Bowel cancer often develops without any symptoms. The cancer can grow in the bowel for years before spreading to other parts of the body. * Very small amounts of blood can leak from these growths and pass into your faeces (poo). These tiny amounts of blood are not noticeable just by looking – that's where screening comes in. * According to a 2017 study by Cancer Council Australia, screening for bowel cancer can reduce deaths from the disease by between 15% and 25%. * The bowel screening test is called an immunochemical faecal occult blood test (iFOBT). It can detect tiny amounts of blood in your poo that can be a sign of bowel cancer. National cervical screening program: * The National Cervical Screening Program reduces illness and death from cervical cancer. Women and people with a cervix aged 25 to 74 years of age are invited to have a Cervical Screening Test every 5 years through their healthcare provider. * You play an important part in the program. By sharing your knowledge, you’ll increase understanding of, and participation in, the program. You can: * tell patients about the benefits of cervical screening and their options for having a Cervical Screening Test * explain how the new test looks for human papillomavirus (HPV) * explain the difference between self-collected and clinician-collected samples * advise how and when the results are provided * remind them that after their first Cervical Screening Test, screening is every 5 years, if no HPV is found. * reassure them that it’s a straightforward process that is private and confidential. * Refer to our Healthcare provider toolkit. The information in the toolkit helps support you to learn about the National Cervical Screening Program, support patients before, during and after a screening appointment and tailor support to specific groups of people.

Answer 3

Breast examination 1. Lymph node examination - Palpate lymph nodes * o Supraclavicular * o Infraclavicular * o Pectoral * o Subscapular * o Lateral * o Central - Feel for enlargement, tenderness, mobility and texture 2. Breast examination - Positions 1. o At rest 2. o Hands on hips 3. o Roll shoulders forward and back 4. o Arms on head, open and close hands above head 5. o If she has large breasts, get them to lift up their breast up so you can see the underside - Observe for 1. o Scarring 2. o Lumps 3. o Asymmetry of breasts or a visible lump 􀀁 4. o Localised discolouration of the skin 􀀁 o Nipples: - If a suspicious lump is present, inspect liver, lungs and spine.

Answer 4

**Breast lesions can be _Benign or Malignant_;** **When deciding to operate**, consider indication (local, systemic symptoms, malignancy or cosmetic) against 1) associated risks due to comorbidities etc. and 2) whether the patient’s condition is better left alone. * ¼ of women have a breast clinical referral in their life-time – very common * 90% have clinical breast presentations benign * Mostly minor aberrations of normal development (ANDI); consider managing their symptoms here * Also consider however: * Could it be cancer? * Is there a risk of developing cancer? E.g. is this benign process a risk for malignancy Reasons for presentation include: * Lump * **Mastalgia**: Breast pain is common in pre-menstrual women. * Nipple changes * Discharge * Retraction/distortion * Eczema * Skin change * Contour * Colour * Dimpling * Family history **BENIGN LESIONS** **Benign breast lesions** are inclusive of: **_Fibrocystic disease_:** Painful breasts, with focal areas of nodularity or cysts in the upper outer quadrant: * **Additional features** * **Frequently bilateral** * Mobile * Varies with the menstrual cycle * Nipple discharge (straw-like, brown or green * **Treatment**: * Evaluation of _breast mass_ (US + mammogram) and reassuring the patient – triple assessment * **Analgesia** (ibuprofen, ASSA) * **Severe symptoms** (OCP, Danazol, bromocriptine) **_Fibroadenoma_** (localised ANDI rather than a tumour) * Most common breast tumour in women \<30. Comprised of fibroid and epithelial components. * **Clinical features**: * Firm, discrete, rubbery nodule * Well circumscribed, mobile * Non-tender * Hormone dependent * Undergo involution in peri-menopause – but can persist into old age, undergoing **dystrophic calcification**. * _Needle aspiration_: No yield, unlike cysts. * **Diagnosis**: * Triple assessment incl. core biopsy; US + FNA are insufficient to distinguish it from a Phyllodes tumour (biopsy is to confirm diagnosis) * **Management**: * Generally conservative, w/ serial observation: * Review at 3 months after diagnosis (USS and Biopsy) * If stable, review again at 12 months: * If stable, D/C from clinic * If growth, refer for surgical opinion * Consider excision if: (Consider lesion and patient factors) * Size \>2-3cm and/or growing on serial US (q6mo x 2 years is the usual follow up) – as aforementioned point. * Triple test is discordant * If symptomatic * Patient request * Formed after age of 35 * Patient preference * Features of core biopsy suggesting Phylodes tumour * **Prognosis**: * Increased risk if atypical cells + Family Hx of Brest Cancer. Otherwise, doesn’t increase risk of breast cancer. * Regress spontaneously in 85-90% * **DDx**: * **Phyllodes tumour**: Malignant types are sarcomatous; however, most are low-grade, benign ones **_Intraductal papilloma_** * Solitary intra-ductal benign polyp * **Clinical features**: * May present as **nipple discharge** (most common cause of _spontaneous, unilateral, bloody nipple discharge_ = pathologic discharge) * Breast mass * Nodule on U/S * **Treatment**: Surgical excision of involved duct to ensure _no atypia_ (central ductal excision) * **Prognosis**: Can harbour areas of atypia, DCIS **Usual Ductal Hyperplasia** (Proliferative subtype, fibrocystic disease) * **Increased number of cells within the ductal space** * **Clinical features**: * Incidental finding on biopsy of mammographic abnormalities, or breast masses. * **Action**: Empirically none; but often if suspicious mass, will remove anyway. * **Prognosis**: Generally low risk; slightly increased if moderate or florid hyperplasia. **_Sclerosing adenosis_** (continuation of the proliferative subtype, fibrocystic disease) * Lobular lesion with increased fibrous tissue, glandular cells * **Clinical features**: Mass (can mimic cancer) or mammographic abnormality * **Treatment**: Nil required – however, remove for safety and analysis anyway. * **Prognosis**: Low risk. * Can involve _ducts_ (ductal hyperplasia with atypia) or lobules (lobular hyperplasia with atypia) i.e. **continuation of proliferative lesions aforementioned.** * Cells _lose apical-basal orientation_ * **Prognosis**: Increased risk of breast cancer * **Diagnosis**: Core or excisional biopsy (Schimmer: Guide wire with wide excision) * **Treatment**: Complete resection, risk modification (avoid exogenous hormones) and close follow-up. * **Fat necrosis**: Uncommon, result of trauma (may be minor, positive history in only 50%) or **after breast surgery** (e.g. reduction) * **Clinical**: Firm, ill-defined mass with _skin, nipple retraction_ +/- tenderness * **Regresses spontaneously**, but _complete imaging + biopsy_ necessary to **rule out malignancy** * **Granulomatous Mastitis** * **Diabetic fibrous mastopathy** – T1 diabetic girl with scary breast lumps looking like cancer. * Have to work up, to exclude cancer. * **Mammary duct ectasia**: Obstruction of subareolar duct leading to _duct dilation, inflammation and fibrosis_. * **Clinical features**: May present with _nipple discharge, bluish mass under nipple_ and _local pain_. RFs include: * Prior pregnancy, breastfeeding but not for extended period of time, multi-paraous women. * **Risk of secondary infection** (abscess, mastitis) * **Resolves spontaneously** within weeks, years – however, _central duct excision_ is available. * **Abscess**: Lactational vs periductal/subareolar * **Clinical features**: Unilateral, localised pain, tenderness, erythema, subareolar mass, with _nipple discharge, inversion_ * **Rule OUT inflammatory carcinoma** * **Treatment**: Initially broad spectrum antibiotics and _incision and drainage_, if persistent total duct excision. * If mass does not resolve, US to assess for _presence of abscess, core biopsy to exclude cancer, consider MRI_ So for lumps, consider benign causes, chronic mastitis (granulomatous, T1DM, fat necrosis), infections and malignancy + Other skin lump causes. Aberrations of normal development, cyclical change and involution. **Disease** is reserved for _severe disorders._ ![]()

Answer 5

Breast Abscess * If tenderness and redness persist beyond 48 hours and an area of tense induration develops, then a breast abscess may have formed * Requires surgical drainage under general anaesthesia or aspiration with a large bore needle under local anaesthetic every second day (first option) until resolution, antibiotics, rest and complete emptying of the breast **Treatment** *Surgical Drainage* 1. Make an incision over the point of maximal tenderness, preferably in a dependent area of the breast. The surgical incision should be placed as far away from the areola and nipple as possible and the dressings kept clear of the areola to allow breastfeeding to continue. The incision needs to be placed in a radial orientation (like the spoke of a wheel) to minimise the risk of severing breast ducts or sensory nerves to the nipple.   2. Use artery forceps to separate breast tissue to reach the pus.   3. Take a swab for culture.   4. Introduce a gloved finger to gently break down the  septa that separate the cavity into loculations 5. Insert a corrugated drainage tube into the cavity * Remove the tube two days after the operation.   * Change the dressings daily until the wound has healed. Continue antibiotics until resolution of the inflammation. Continue breastfeeding from both breasts but if breastfeeding is not possible because of the location of the incisions or drains, milk should be expressed from that breast.

Answer 6

Mastitis * Basically cellulitis of the interlobular connective tissue of the breast * Mostly restricted to lactating women, it is associated with a cracked nipple or poor milk drainage * Mastitis is a serious problem and requires early treatment **Aetiology** * The infecting organism is usually Staphylococcus aureus * More rare: Escherichia coli * Candida albicans is common in breastfeeding women **Clinical features** * A lump and then soreness (at first)   * A red tender area  possibly   * Fever, tiredness, muscle aches and pains   **Treatment** à Breastfeeding from the affected side can continue as the infection is confined to interstitial breast tissue and doesn’t usually affect the milk supply. * Antibiotics: resolution without progression to an abscess will usually be prevented by antibiotics * Flucloxacillin 500 mg (o) 6 hourly for 7–10 days, if severe = 2g or   * Cephalexin 500 mg (o) 6 hourly for 7–10 days   * For Candida albicans infection: fluconazole 200–400 mg (o) daily for 2–4 weeks * Therapeutic ultrasound (2 W/cm2 for 6 minutes) daily for 2–3 days   * Ibuprofen or paracetamol for pain  

Answer 7

**Breast health** * Any breast problems? * Breast pain, changes, nipple discharge, lumps, areas of concern? * Past history of breast surgeries, biopsies or removal of lesions * Any breast augmentation or reduction? * Personal or family history of female cancers? * Breast, ovarian, cervical, endometrial, vulvar? * History of mammography or breast imaging? * If so when * What was the result * Do you examine your own breasts? *Mastalgia* * Could you be pregnant? * Is your period on time or overdue? * Is the pain in one or both breasts? * Do you have pain before your periods or all the time during your menstrual cycle?   * Do you have pain in your back or where your ribs join your chest bone?   Breast examination *1. Lymph node examination* * Palpate lymph nodes * Supraclavicular * Infraclavicular * Pectoral * Subscapular * Lateral * Central * Feel for enlargement, tenderness, mobility and texture *2. Breast examination* * Positions * At rest * Hands on hips * Roll shoulders forward and back * Arms on head, open and close hands above head * If she has large breasts, get them to lift up their breast up so you can see the underside * Observe for * Scarring * Lumps * Asymmetry of breasts or a visible lump   * Localised discolouration of the skin   * Nipples: * For retraction or ulceration   * For variations in the level (e.g. elevation on one  side)   * Or discharge (e.g. blood-stained, clear, yellow)   * Skin attachment or tethering → dimpling of skin * Accentuate this sign by asking patient to raise her arms above her head)   * Appearance of small nodules of growth   * Visible veins (if unilateral they suggest a cancer) * Peau d’orange due to dermal oedema   * If a suspicious lump is present, inspect liver, lungs and spine.   _Red Flags_ * Hard irregular masses * Nipple inversion or discharge Puckering: skin grows on top of the mass, there is indentation as they move * Paget’s disease: eczema around the nipple: underlying * Peau de orange: Poor prognosis *3. Breast palpation* * Place arm overhead * Assist with pillow placement, pillow under shoulder for large breasted women * Palpate the breast * Light and deep pressure * Circular movements starting light and getting deeper * Pay particular attention to the upper outer quadrant and tail of breast (50% of abnormalities are found) * Make sure to palpate all the way to the axilla: breast tissue still found here * Check the nipple * Place a finger either side of the nipple and palpate with rocking motion * Feel for masses under the nipple, and observe for nipple discharge _Findings_ * Lumps that are usually benign and require no immediate action are * Tiny (\<4 mm) nodules in subcutaneous tissue (usually in the areolar margin) * Elongated ridges * Usually bilateral and in the lower aspects of the breasts * Rounded soft nodules (usually \<6 mm) around the areolar margin   * A hard mass is suspicious of malignancy but cancer can be soft because of fat entrapment * The infra-mammary ridge, which is usually found in the heavier breast, is often nodular and firm to hard.   * Lumpiness (if present) is usually most marked in the upper outer quadrant. Mastalgia (breast pain) * The typical age span for mastalgia is 30–50 years.   * The peak incidence is 35–45 years.   * There are four common clinical presentations: * Diffuse, bilateral cyclical mastalgia   * Diffuse, bilateral non-cyclical mastalgia   * Unilateral diffuse non-cyclical mastalgia   * Localised breast pain   * An underlying malignancy should be excluded.   * Less than 10% of breast cancers present with localised pain * But don’t miss it  **Clinical features** * Usually heaviness, discomfort or pricking, stabbing in breast * Pain may radiate down the inner arm when the patient is carrying heavy objects or when the arm is in constant use **Types** *Cyclical mastalgia* * Commonest diffuse breast pain * Occurs in the later half of the menstrual cycle, especially in the premenstrual days, and subsides with the onset of menstruation * Has a hormonal basis, which may be an abnormality in prolactin secretion * The main underlying disorder is benign mammary dysplasia, also referred to as fibroadenosis, chronic mastitis, cystic hyperplasia or fibrocystic breast disease. *Non-cyclical mastalgia* * Quite common and the cause is poorly understood * May be associated with duct ectasia and periductal mastitis **Differential Diagnosis** *Most likely* * Pregnancy * Cyclical mastalgia *Not to be missed* * Neoplasia * Inflammatory breast cancer * Infection * Mastitis * Abscess * Myocardial ischaemia **Management** à After excluding diagnosis of cancer and other causes *Mild* * Regular review * Proper brassiere support * Adjust oral contraception or HRT * Analgesia *Moderate* à as for mild plus * mefenamic acid 500 mg, three times daily   * vitamin B1 (thiamine) 100 mg daily, and   * vitamin B6 (pyridoxine) 100 mg daily   * consider ceasing OCP   Mastitis * Basically cellulitis of the interlobular connective tissue of the breast * Mostly restricted to lactating women, it is associated with a cracked nipple or poor milk drainage * Mastitis is a serious problem and requires early treatment **Aetiology** * The infecting organism is usually Staphylococcus aureus * More rare: Escherichia coli * Candida albicans is common in breastfeeding women **Clinical features** * A lump and then soreness (at first)   * A red tender area  possibly   * Fever, tiredness, muscle aches and pains   **Treatment** à Breastfeeding from the affected side can continue as the infection is confined to interstitial breast tissue and doesn’t usually affect the milk supply. * Antibiotics: resolution without progression to an abscess will usually be prevented by antibiotics * Flucloxacillin 500 mg (o) 6 hourly for 7–10 days, if severe = 2g or   * Cephalexin 500 mg (o) 6 hourly for 7–10 days   * For Candida albicans infection: fluconazole 200–400 mg (o) daily for 2–4 weeks * Therapeutic ultrasound (2 W/cm2 for 6 minutes) daily for 2–3 days   * Ibuprofen or paracetamol for pain  

Answer 8

Breast Lumps à Common * Many of the lumps are actually areas of thickening of normal breast tissue: mammary dysplasia * The commonest lumps are those associated with mammary dysplasia (32%)  * Common cause of cysts, especially in the premenopause phase.   * Many other lumps are due to mammary dysplasia with either fibrosis or cyst formation or a combination of the two producing a dominant (discrete) lump * Over 75% of isolated breast lumps prove to be benign but clinical identification of a malignant tumour can only definitely be made following aspiration biopsy or histological examination of the tumour  * The investigation of a new breast lump requires a very careful history and the triple assessment   **Aetiology** *Common* * Mammary dysplasia * Fibroadenoma * Cancer * Cysts * Breast abscess/periareolar inflammation *Less common* * Mammary duct ectasia * Duct papilloma * Lactation cysts (galactocoele) * Paget’s syndrome * Fat necrosis * Sarcoma * Lipoma **Clinical features** * Lump (76%)   * Tenderness or pain (10%)   * Nipple changes (8%)   * Nipple discharge (2%) * Bloodstained: * Intraduct papilloma (commonest) * Intraduct carcinoma  * Mammary dysplasia * Green–grey: * Mammary dysplasia * Mammary duct ectasia * Yellow:  * Mammary dysplasia  * Intraduct carcinoma (serous) * Breast abscess (pus) * Milky white (galactorrhoea): * Lactation cysts  * Lactation  * Hyperprolactinaemia * Drugs (e.g. chlorpromazine) * Breast asymmetry or skin dimpling (4%)   * Periareolar inflammation   **Investigations** *Triple Assessment* * Clinical assessment: History, examination * Imaging: mammography +/- ultrasound * Fine-needle aspiration +/- core biopsy **History** * The history should include * Family history of breast disease * Patient’s past history, including trauma * Previous breast pain * Details about pregnancies * Complications of lactation such as mastitis, nipple problems and milk retention *Key questions* * Have you had any previous problems with your breasts?   * Have you noticed any breast pain or discomfort?   * Do you have any problems such as increased swelling  or tenderness before your periods?   * Have you noticed lumpiness in your breasts before?   * Has the lumpy area been red or hot?   * Have you noticed any discharge from your nipple or  nipples?   * Has there been any change in your nipples?   * Does/did your mother or sisters or any close relatives  have any breast problems?   **Lumps that require investigation and referral** * Stony hard lump or area, regardless of size, history or position * New palpable lump in a postmenopausal woman * Persisting painless asymmetrical thickening * Enlarging mass: cyclic or non-cyclic * ‘Slow to resolve’ or recurrent inflammation * Bloodstained or serous nipple discharge * Skin dimpling or retraction of nipple * New thickening or mass in the vicinity of a scar

Answer 9

**Investigations** *x-ray mammography* * Mammography can be used as a screening procedure and as a diagnostic procedure * It is currently the most effective screening tool for breast cancer * Positive signs of malignancy include an irregular infiltrating mass with focal spotty microcalcification. * Screening: * established benefit for women over 50 years   * possible benefit for women in their 40s   * follow-up in those with breast cancer, as 6% develop in the opposite breast   * localisation of the lesion for fine-needle aspiration and wide local excision *Ultrasound* * This is mainly used to elucidate an area of breast density and is the best method of defining benign breast disease, especially with cystic changes * It is generally most useful in women less than 35 years old * Useful for * Pregnant and lactating breast * Differentiating between fluid-filled cysts and solid mass  * palpable masses at periphery of breast tissue (not screened by mammography) * For more accurate localisation of lump during fine- needle aspiration *Needle aspiration and biopsy techniques* * Cyst aspiration   * Fine-needle aspiration biopsy: this is a very useful diagnostic test in solid lumps, and has an accuracy of 90–95% (better than mammography)   * Large needle (core needle) biopsy   * Incision biopsy   *Fine needle aspiration of breast lump* * This simple technique is very useful, especially if the lump is a cyst, and will have no adverse effects if the lump is not malignant * If it is, the needle biopsy will help with the preoperative cytological diagnosis

Answer 10

Lesion types Non-proliferative lesions e.g. fibrocystic changes * Benign breast condition characterized by fibrous and cystic changes in the breast * Most common: breast cysts * Other lesions * Papillary apocrine change * Epithelial related calcifications * Mild hyperplasia * No increased risk of breast cancer * Age 30-menopause * Clinical features * Breast pain/swelling * Often bilateral * Focal areas of nodularity/cysts * Varies with menstruation cycle * Nipple discharge * Treatment * Evaluation of breast mass * Analgesia * Severe: OCP *Breast cysts* * Common in women aged 40–50 years (perimenopausal) * Rare under 30 years  * Associated with mammary dysplasia * Tends to regress after the menopause * Has a 1 in 1000 incidence of cancer  * Usually lined by duct epithelium _Examination_ * Pain and tenderness variable  * Look for a discrete mass, firm, relatively mobile, that is rarely fluctuant. _Diagnosis_ * Mammography   * Ultrasound (investigation of choice)   * Cytology of aspirate   **Proliferative lesions** *Fibroadenoma* à Fibrous stroma surrounds duct-like epithelium and forms a benign tumour that is grossly smooth, white, and well circumscribed   * Most common breast tumour in women \<30 years * Nodules: firm, rubbery, discrete, well-circumscribed, non-tender, mobile * Hormone dependent * Increased risk of breast cancer if complex _Clinical features_ * A discrete, asymptomatic lump   * Firm, smooth and mobile (the ‘breast mouse’)   * Usually rounded   * Usually in upper outer quadrant   * They double in size about every 12 months   _Diagnosis_ * Core/excisional biopsy if confirmed about malignancy * U/S and FNA cannot differentiate Fibroadenoma from Phyllodes tumour _Treatment_ * Core biopsy with cytology is recommended * + mammography in older women * To ensure not cancer * Consider excision *Usual ductal hyperplasia* * Increased number of cells within the ductal space * Incidental finding on biopsy * Low risk of breast cancer *Mammary duct ectasia* à Inflammation and dilation of mammary ducts.   * Most commonly occurs in the perimenopausal years.   * Presentation: Noncyclical breast pain with lumps under nipple/areola  with or without a nipple discharge.   _Clinical features_ * Palpable lumps under areola, possible nipple discharge.   _Diagnosis_ * Based on exam; excision biopsy required to rule out cancer.   _Treatment_ * Excision of affected ducts.   * Phyllodes Tumour* à A variant of fibroadenoma * Majority are benign  * Patients tend to present later than those with fibroadenoma (\>30 years) _Characteristics_ * Indistinguishable from fibroadenoma by ultrasound or mammogram * The distinction between the two entities can be made on the basis of their histologic features * Phyllodes tumours have more mitotic activity * Most are benign and have a good prognosis.   * Exam: Large, freely movable mass with overlying skin changes.   _Diagnosis_ * Definitive diagnosis requires biopsy with pathologic evaluation.   _Treatment_ * Smaller tumours: Wide local excision with at least a 1-cm margin.   * Larger tumours: Simple mastectomy.   **Other lesions** *Fat necrosis* * Uncommon, result of trauma (may be minor, positive history in only 50%), after breast surgery (i.e. reduction) * Firm, ill-defined mass with skin or nipple retraction, ± tenderness   * Regress spontaneously, but complete imaging ± biopsy to rule out carcinoma  

Answer 11

Breast cancer * Breast cancer is the most common cancer in females, affecting 1 in 11–15 women in Australia * Breast cancer is uncommon under the age of 30 but it then steadily increases to a maximum at the age of about 60 years, being the most common cancer in women over 50 years.   * About 25% of all new cancers in women are breast neoplasms.   * A ‘dominant’ breast lump in an older woman should be regarded as malignant.   **Risk factors** * Sex: Female * Age: Increasing risk with age * Family history * BRCA 1 BRCA 2 * Cancer families: Up to 50% * First degree relatives: 2-3x * Previous Hx cancer * 2x elderly to 8x \<45 years * DCIS same, other breast * Atypical epithelial hyperplasia 4x _Minor_ * Early menarche, late menopause * Nulliparity * Late first child, no breast feeding * Postmenopausal obesity * High fat, low fibre diet, Alcohol, smoking * HRT: long term **Types** * Ductal: most common (80%) * Various histological types: NOS, scirrhous, medullary, comedo, colloid, papillary, tubular * Most common in perimenopausal and postmenopausal women * Originates from ductal epithelium and infiltrates supporting stroma * Characteristics: hard, scirrhous, infiltrating tentacles, gritty on cross section * Lobular (8-15%) * Originates from lobular epithelium terminal duct cells * Typically familial, younger age * Ill-defined thickening of the breast * Single file cells (Indian file) * Don’t form microcalcifications therefore harder to detect on mammogram * Paget’s disease * Ductal carcinoma that invades nipple with scaling, eczematoid lesion * Usually associated with underlying LCIS or ductal carcinoma extending within the epithelium of main excretory ducts to skin of nipple and  areola.   * _Presentation_: Tender, itchy nipple with or without a bloody discharge  with or without a subareolar palpable mass.   * _Treatment_: Usually requires a modified radical mastectomy.   * Inflammatory carcinoma * Ductal carcinoma that invades dermal lymphatics  * Most aggressive form of breast cancer  * Clinical features: erythema, skin oedema, warm, swollen, and tender breast ± lump * Peau d’orange indicates advanced disease (IIIb-IV) * Carcinoma in situ (DCIS/LCIS) * Proliferation of malignant ductal epithelial cells completely contained within breast ducts * Often multifocal * Intact myoepithelial cells: determined by microscopy * DCIS: Proliferation of ductal cells that spread through the ductal system but lack the ability to invade the basement membrane * LCIS: A multifocal proliferation of acinar and terminal ductal cells **Clinical features** * The majority of patients with breast cancer present with a lump * The lump is usually painless, hard and irregular * Fixed/immobile * Irregular, hard, gritty/stony * Very dense scarring, no necrosis * Location: Upper outer quadrant (50%), central 20%. * Skin tethering * Fibrous tissue pulls the skin into the tumour * Dense central scar with bands pulling the overlying skin towards the cancer * Puckering * Nipple changes, discharge, retraction or distortion.   * Nipple retraction: If tumour is within the tubules * Painless lymphadenopathy * Rarely cancer can present with Paget disease of breast  (nipple eczema) or inflammatory breast cancer * Rarely it can present with bony secondaries * e.g. back pain, dyspnoea, weight loss, headache **Diagnosis** * Triple assessment * Clinical: History, examine * Imaging: Mammography, ultrasound, MRI * Biopsy: Fine needle aspirate (cytology), core needle biopsy (histology), excision (histology) * By the time you have reached CNB: 90% of BrCa is diagnosed _Limitations in diagnosis_ * Clinical * \<1cm * Other causes for thickening, lumps * Density * Imaging * Mammograms \<50 years of age * Ultrasound for screening: takes a long time for full US * Pathology * Representative sampling * Impalpable lesions * Surgery + ultrasound + Hookwire

Gen surgery Learning objectives: Flashcards

(84 cards)