Breast Surgery

Front 1

What is the main blood supply to the breast?

Back 1

second perforating branch of the internal mammary and lateral thoracic branches of the axillary artery

Front 2

What is the pathophysiology of mammary paget's disease

Back 2

underlying ductal carcinoma of the breast with retrograde extension into the overlying epidermis through mammary duct epithelium
Paget cells proliferate in the epidermis causing thickening of the nipple and the areolar skin.
Cells derived from the luminal lactiferous duct epithelium of breast tissue

Front 3

What is the flowchart of investigations when a breast lump is found?

Back 3

Clinical examination, mammorgraphy, US
If probably benign --> needle aspiration --> cyst or solid - if solid --> FNAC or excision biopsy
If uncertain or probably malignant --> establish diagnosis by FNAC, core biopsy or open surgical biopsy

Front 4

Epidemiology of Pagets disease

Back 4

1-4% of breast Ca- almost exclusively in female
Average age 5-10 years older than ductal breast Ca
90% infiltratind ductal ca associated- 10% DCIS
>50% with Pagets and palpable mass have axillary LN mets- worst survival

Front 5

What is a fibroadenoma?

Back 5

Benign breast tumour consisting of a fibrous connective tissue stroma and epitheileal proliferation: arises from a single lobule and composed of epithelial and fibrous components

Hint 5

Most common breast tumour in women <30
Most common b/w 15 and 30 years

Front 6

Management of Paget's disease

Back 6

Mastectomy (radical or modified) + lymph node clearance
2/3 positive LN

Front 7

What is the most common benign breast tumour in women under age 30?

Back 7

fibroadenoma
incidence of this falls after menopause when the breast lobule undergoes involution

Front 8

Diagnosis of Pagets disease of the breast

Back 8

Punch or full thickness wedge biopsy of the nipple- also need to biopsy any underlying mass or mammographic abnormality

Front 9

Is the risk of breast cancer increased with fibroadenomas?

Back 9

I'm not sure - TN says - only if the fibroadenoma is complex, there is adjacent atypia, or a strong family history of breast cancer
Other notes say NO

Front 10

What is the triple test for breast Ca

Back 10

1. clinical findings
2. Imaging
3. Non-surgical biopsy

Front 11

Clinical features breast of fibroadenoma?

Back 11

Breast mouse (very mobile)
Smooth, rubbery, non-tender, well-circumscribed
hormone dependent - so will grow during pregnancy and usually spontaneously involutes at menopause
2-3cm in diameter
needle aspiration yields NO fluid

Front 12

What investigations are required in a suspect fibroadenoma?

Back 12

A clinical examination is usually adequate in young women < 25 years
Core or exicisional biopsy
US and FNA alone cannot differentiate fibroadenoma from phyloodes tumour (mesenchymal tumour arising from breast lobular tissues - most are benign)
NO place for mammorgraphy

Front 13

Management of fibroadenomas?

Very occasionally seen in association with lobular carcinoma

Back 13

In women under 25 years the lump may be left alone unless the pt wants it removed
Consider surgical removal or cryoablation if > 2-3 cm or rapidly growing on serial US

Hint 13

If giant (occurs in <16y/o/perimenopausal): surgical enucleation

Front 14

What is a phyllodes tumour?

Back 14

Is an uncommon breast tumour that ranges from benign to locally invasive
Occurs in premenopausal women and clinicall resembles a fibroadenoma but grows quite rapidly: smooth, multinodular painless breast lump
Requires surgical excision (wide local excision with margin of 1cm) - recurrence common may require total mastectomy
Axillary involvement rare
RT for morderline/malignant to decrease recurrence
chemo for high risk: cystosarcoma phylloides

Hint 14

Mesenchymal tumour arising from breast lobular tissue
smooth, polylobulated mass mass of CT + cysts
tumours may have leaf-like projections
dx with core biopsy

Front 15

What does a breast cyst feel like?

Back 15

smooth, firm
NOT as mobile as a fibroadenoma
usually situated deep in the breast, may feel quite nodular

Front 16

How do you diagnose a breast cyst?

Back 16

confirmed by cyst aspiration and cytological examination of the cyst fluid but usually well shown on US and imaging

Front 17

Why do cysts develop in breast tissue?

Back 17

normal proliferative and regressive changes within the breast parenchyma including distortion and overgrowth of the main structural components (ducts, lobules, fibrous tissue)

Hint 17

Very common- up 10% of women get breast cysts in their lifetime
More common >40
size varies with menstrual cycle

Front 18

How do you manage breast cysts?

Back 18

If palpable treat with simple aspiration - if mass persists - further Ix
Surgical excision if non-traumatic aspirate is blood staine or cyst continually recurs

Front 19

What are the surgical indications for removal of a breast cyst?

Back 19

if non-traumatic aspirate is blood stained
if cyst continually recurs

Front 20

What are the clinical features of fat necrosis of the breast?

Back 20

firm, ill-defined mass with skin or nipple retraction +/- tenderness
(often indistinguishable from carcinoma even with imaging)

Front 21

What is often the cause of fat necrosis of the breast?

Back 21

Trauma (may be minor, +ve history in only 50%)

Front 22

What investigations should be done if you suspect fat necrosis?

Back 22

It will usually regress spontaneously but you must get complete imaging (may have calcification) + a biopsy to rule out carcinoma

Front 23

Where does breast cancer usually spread to?

Back 23

Axillary lymph nodes
> 4 nodes = bad prognosis/also internal mammary, axillary, supraclavicular
Can also spread to internal mammary nodes (usually inner quadrant) and supraclavicular nodes
Bone
Liver
Lung
Less common: brain, skin, peritoneum

Hint 23

30% false pos/neg on sampling
Tumours <2cm: 20% node positive
>2cm: 50% node positive

Front 24

What findings on mammogram suggest malignancy?

Back 24

poorly defined mass
spiculated border
microcalcifications
architectural distortion

Front 25

Which genetic mutations have been implicated in breast cancer?

Back 25

BRCA-1 gene
Li-Fraumeni syndrome (mutations in p53 tumour-suppressor gene)
Increased expression of a dominant oncogene - erbB2

Front 26

Which in situ breast cancer is pre-malignant?

Back 26

DCIS

LCIS is a RF for later development of breast cancer not necessarily in that breast

Front 27

Are invasive or in situ breast cancers more likely to be palpable?

Back 27

invasive
Most in situ are not palpable

Front 28

Management of LCIS

Back 28

almost always expresses ER and PR - tamoxifen
Clinical follow-up
Surgery is uncommon

Front 29

management of DCIS

Back 29

lumpectomy with wide excision margins + radiation (5-10% risk of invasive ca)
mastectomy if large area of disease, high grade or multifocal
possibly tamoxifen as adjuvant treatment

Front 30

What is the most common type of invasive breast cancer?

Back 30

invasive ductal carcinoma

Front 31

which type of breast cancer is most likely to be bilateral?

Back 31

lobular invasive - 20% are

Front 32

which type of breast cancer is most commonly seen in men?

Back 32

invasive ductal(因為男生沒有lobular)

Front 33

which type of breast cancer is harder to detect on mammorgaphy?

Back 33

Invasive lobular - it doesn't form microcalficiations
May benefit from MRI

Front 34

What is paget's disease of the nipple?

Back 34

ductal carcinoma that invades nipple with scaling, eczematoid lesion

Front 35

Stage breast cancer

Back 35

1: < 2cm, no nodes
2: 2-5 cm and/or movable axillary nodes
3: chest wall or skin fixation and/or fixed axillary nodes
4: mets

Front 36

What % if breast cancer is hireditary?

Back 36

5-10%

Front 37

What is the lymphatic drainage of the breast?

Back 37

75% drain to LN above and below the axillary vein
1. below pec minor
2. behind pec minor
3. above pec minor
Usually drain 1-->2-->3 but small proportion drains to subscapular/intercostal
sup aspect of breast--> straight to 3
25% (in medial 1/3) --> internal mammary nodes

Front 38

Does benign proliferative disease of the breast increase risk of breast Ca?

Back 38

yes, esp if cellular atypia, multiple pappilomatosis, atypical ductal/lobular hyperplasia, LCIS

Front 39

IS OCP associated with breast Ca?

Back 39

No but >5yrs HRT use is

Front 40

prognostic determinators in breast cancer?

Back 40

axillary node size
tumour size
histological grade
hormone receptor status
others (vascular invasion, menopausal status, HER2)

Front 41

Epidemiology of breast cancer

Back 41

1/13 in australia- lower in asian countries
1/18 sill die
progressive rise in incidence from age 25- steepest 40-55
Mean age at diagnosis = 60

Front 42

Pathology of breast cancers?

Back 42

almost all are adenocarcinomas and arise from terminal duct or lbular unit
70% invasive ductal ca: firm, fibrous mass, worst and most invasive
10% invasive lobular Ca: often multiple, bilateral. Linear arrangement of cells "indian filling"
0.5-2% inflammatory
12-15% special types- better prognosis because well differentiated

Front 43

What is "inflammatory" breast Ca?

Back 43

lymphatic invasion: very poor prognosis, tumor emboli in dermal lymphatics, increased vascularity --> red skin

Front 44

Is DCIS seen on a mammogram?

Back 44

Now 20-25% of breast Ca with screening
High grade DCIS is seen as areas of microcalcificatiom

Front 45

What is the likelyhood of DCIS progressive to an invasive breast Ca?

Back 45

25% in 5-10y

Front 46

Is LCIS pre-malignant?

Back 46

asymptomatic and mammography occult- often bilateral and multifocal
RR of BCA x 10 but NOT premalignant in itself
does not require radical excison- rather careful followup
atypical lobular hyperplasia = the low grade version: 4x BCA

Front 47

Pathogenesis of mastalgia?

Back 47

usually due to benign breast disease
poorly understood - median age of presentation is 35
poorly understoof pathogenesis: increased caffeine intake, fluid retention, abnormal prolactin secretion etc.

Front 48

Management of mastalgia

Back 48

decrease caffeine, OCP, evening primrose oil (FA)
for refractory: tamoxifen, danazol, bromocriptine

Front 49

When do you aspirate a breast mass?

Back 49

when the triple test says "probably benign"

Front 50

When do you FNAB a breast mass?

Back 50

when triple test is uncertain/prob malignant or when needle asp of a "probably benign mass" shows that it is solid
core biopsy/excision biopsy is appropriate and may be better: discrete solid lump in a woman >30 is better removed esp. if strong FHx.

Front 51

What is the incidence of micrometastases in BM in breast cancer?

Back 51

1/3 of lesions apparently confined to breast

Front 52

What % of abnormalities detected on mammographic screening are benign?

Back 52

>90%

Front 53

How often do you do mammography after breast Ca?

Back 53

annually, as 1%/year have a new cancer

Front 54

In which situations is breast ultrasound useful?

Back 54

dense parenchyma, equivocal mammogram, palpable lump, guide to biopsy

Front 55

Local recurrence after mastectomy and lumpectomy

Back 55

mastectomy: 0.5%/yr
lumpectomy: 1-2%/yr
These days perform breast conservation surgery on >70% of all pts

Front 56

Relative c/i to RT?

Back 56

multicentric, recurrent, pregnancy, CT diseases

Front 57

Incidence for mastectomy over lumpectomy?

Back 57

Involves complete excision of breast + nipple with preservation of underlying pectoral muscle- usually remove pectoralis fascia.
large cancer, nipple/skin invasion, multifocal disease, DCIS in margin, patient's choice, prior breast irradiation

Front 58

Complications of mastectomy?

Back 58

breast haematoma, wound infecrion, seroma of skin flap, psych

Front 59

What % of aust women have a breast recon after mastetomy?

Back 59

10%

Front 60

Complication of axillary dissection?

Back 60

seroma of axilla, pain + numbness on media; and upper aspect of arm
decreased abduction and elevation of shoulder
5% lymphoedema of arm- greatly increased risk if RT also given

Front 61

T3 breast Ca

Back 61

>5cm

Front 62

T4 breast Ca?

Back 62

any size if fixed to skin/chest wall

Front 63

N- staging of breasr Ca?

Back 63

N1- mobile ipsi axillary mets
N2- fixed ipsi axillary mets
N3: ipsi internal mammary/supraclav mets

Front 64

Incidence of endometrial Ca in women on tamoxifen?

Back 64

1/1000
need yearly gynae review

Front 65

Indications for chemo post surgery for breast Ca

Back 65

All node positiv women aged 70 or younger
Node neg: poor prognostic features, tumour >2cm, ER/PR neg, poor differentiation, lymphovascular invasion

Front 66

Average survival of stage 4 breast Ca?

Back 66

16m: worse if mets occur sooner after initial diagnosis
liver/cerebral worse prognosis
tumour burden is also a prognostic indicator
50% respond to hormonal rx, 60% responds to chemo for approx 1 year

Front 67

Incidence of nodal mets in BCA by size

Back 67

>5cm- 60% nodal mets
<1cm: 8% nodal mets

Front 68

Indications for radiation therapy in breast cancer?

Back 68

most get RT after breast conserving surgery
May be omitted if >70, tumour <10mm, low histo grade + lots of hormonal receptors
after mastectomy if tumour was v. large

Front 69

complications of breast RT?

Back 69

local (2-6 weeks): redness, soreness, ulceration of skin
discomfort and swelling of breast (few yrs)
cardiac damage
lymphoedema

Front 70

Standard chemorx for node +ve breast Ca

Back 70

node + premopasual: 4 cycles of doxo + cyclophosphamide +/- ovarian abalation if receptor positive

node + postmen: 5 yrs tamoxifen )R.pos) if poor prog feat do chemo before tamoxifen

Front 71

Chemorx for node -ve bca

Back 71

premenopausal: cytotoxic chemo if poor prognostic feat
postmen: tamoxifen/chemo

Front 72

Pathogenesis of fat nectosis

Back 72

necrotic adipose tissue promotes chronic fibrotic reaction- hard irreg lump which may be assoc with skin dimpling

Front 73

diagnosis of fat necrosis

Back 73

mammography: stellate area with calcifications
distinguish from Ca on biopsy