Surgery - Breast

Question 1

What are the risk factors for the development of breast cancer?

Answer 1

Smoking
FHx
BRCA mutations
Early menarche/late menopause
HRT
Older first pregnancy

Breast feeding is protective

Question 2

Describe the screening programme for breast cancer

Answer 2

Females 50-70yrs get mammography every 3 yrs

Question 3

How might a symptomatic breast lump present?

Answer 3

Pain
New lump
Skin changes
Nipple discharge
Redness/inflammation

Question 4

Name the pre-malignancy breast conditions

Answer 4

DCIS (80%)

LCIS (20%)

Question 5

What are the malignant types of breast cancer

Answer 5

Ductal 
Lobular
Tubular
Medullary
Mucinous
Papillary

Can also be described by hormone receptor status:
- ER, HER2, PR…

Question 6

How are breast lumps investigated?

Answer 6

Triple assessment:

• history and examination
• imaging (USS/mammography)
• biopsy (FNA/core)

Question 7

What are the surgical options for breast cancer?

Answer 7

(all +/- sentinel node biopsy or axillary lymph node clearance)

• WLE
• Mammoplasty (breast conserving)
• Mastectomy +/- reconstruction
• > TRAM (transverse rectus abdominus myocutaneous flap)
• > DIEP (deep inferior epigastric perforators)

RTx always given after WLE/mastectomy

Question 8

What are the hormonal treatment options for breast cancer?

Answer 8

Tamoxifen (oestrogen receptor antagonist) = for pre/perimenopausal women
DO NOT USE POST-MENOPAUSE AS INCREASE ENDOMETRIAL CANCER RISK

Letrazole/anostrazole - stop conversion of adrenal androgens into oestrogens = for post-menopausal women

Question 9

What is the Nottingham prognostic index?

Answer 9

Predicts pt survival and risk of relapse

grade + stage + tumour size (cm) / 5

Question 10

Describe male breast cancer

Answer 10

• Uncommon <1% of all breast cancers
  
  • Usually presents in older men
  • Usually presents at a later stage than in females
  • Treatment very similar to female breast cancer
  • Is linked to family history in female relatives

Question 11

Describe non-infectious benign breast disease

Answer 11

fat necrosis
pagets disease
fibroadenoma
cyst
fibrocystic change
breast abscess

Question 12

Describe infectious benign breast disease

Answer 12

lactational mastitis
mammary duct ectasia
periductal mastitis

Question 13

Describe fibroadenomas

Answer 13

• benign overgrowth of one lobule
• younger women <30yrs
• normally a firm, discrete, very mobile lump which does not need removed

Question 14

Describe benign breast cyst

Answer 14

associated with fibrocystic disease

• usually multiple/bilateral cystic lumps filled with yellow/green fluid
• common in pre-perimenopausal women on HRT
• identify on USS and aspirate

Question 15

Describe breast abscess

Answer 15

• usually caused by skin commensals (staph) and has systemic symptoms
• common in post-partum women
• painful, red hot skin
• treat by USS guided aspiration and Abx

Question 16

Describe fibrocystic breast disease

Answer 16

• 15-55yrs
• cyclical lumpy breasts
• hormonal pain
• very common in pre-menopausal women
• diffuse lumpiness

Treatment = OCP/aspiration

Question 17

Describe fat necrosis

Answer 17

• post-traumatic (often traumatic incident forgotten)
• trauma causes fibrosis, local haematoma and calcification
• may present with a lump and overlying bruising which resolves over time

Question 18

Describe Paget’s disease of the nipple

Answer 18

• pre-cancerous, eczema like changes of the nipple skin
• common in ELDERLY
• take a punch biopsy to diagnose

Question 19

Describe lactational mastitis

Answer 19

• an acute staph infection of mammary ducts
• may form an abscess
• no need to stop lactating
• treat with aspiration and antibiotics

Question 20

Describe mammary duct ectasia

Answer 20

• benign nipple retraction presenting with a slit-like nipple
• underlying inflamed mammary ducts
• associated with smoking
• recurrent green discharge/abscesses

Treat with antibiotics and abscess drainage

Question 21

Describe periductal mastitis

Answer 21

• inflammation and abscess formation around the nipple
• ASSOCIATED with smoking
• common in 40yr olds
• treatment:
• > stop smoking
• > antibiotics
• > drainage

Question 22

What is a Phyllodes tumour?

Answer 22

Malignant
Tear drop breast appearance
Not tender, mobile lump
Increased breast size

Question 23

List the 4 indications for mastectomy

Answer 23

1) Large tumours >5cm
2) Multifocal breast tumours
3) Diffuse DCIS
4) Large tumour relative to the patients breast size