O slideshow foi denunciado.
Utilizamos seu perfil e dados de atividades no LinkedIn para personalizar e exibir anúncios mais relevantes. Altere suas preferências de anúncios quando desejar.

34

Compartilhar

Baixar para ler offline

Breast Surgery for Medical Finals

Baixar para ler offline

Notes on breast surgery for medical finals.

Audiolivros relacionados

Gratuito durante 30 dias do Scribd

Ver tudo

Breast Surgery for Medical Finals

  1. 1. Breast Surgery Christiane Riedinger, September 2014 Resources: Path notes, Surgical Talk, Lecture Notes in Clin Surgery
  2. 2. TOC ● Clinical Assessment ● Pathology ● Management
  3. 3. Clinical Assessment
  4. 4. History ● Symptoms of breast disease ○ Pain ■ Cyclical? => Bilat. can depend on diet (caffeine) Drug Mx: change contraceptive method, danazol, tamoxifen, LHRH analogues ■ Non-cyclical? => Abscess, CA, Tietze’s syndrome*, Herpes Zoster and other chest wall lesions. ○ Discharge ■ Clear Intraductal papilloma (benign) ■ Milky Galactorrhoea ■ Purulent Abscess ■ Multi-coloured Duct ectasia (inflammatory) ■ Blood Intraductal papilloma, CA, Paget’s ○ Lump
  5. 5. Breast Tumours: How to describe a lump ● she cuts the fish 3x + PER ○ site, size, surface ○ colour, contour, consistency, compressability/fluctuancy ○ tenderness, temperature, transillumination ○ fluid-filled, fixed (tethering vs. fixation, depth), fields (lymphatic drainage) ○ pulsatile (e.g. aneurysm) ○ expansile ○ reducible/relation to skin, muscle, other structures (hernia/breast lesion) ● Difference between tethering (lesion near fibrous septum or ligaments of Astley Cooper, evident upon elevation of the arms or tension of pec major - dimpling) and fixation (tumour attached to muscle and skin? implies more advanced disease) ● ??????
  6. 6. Breast Examination (1) ● Ask about pain ● Be ruthless but polite in terms of exposure for inspection ● General observation ○ General appearance - cachexia, pallor, SOB ○ Signs of previous surgery - wide local excision, mastectomy, reconstruction ○ Signs of infection ○ Nipples ■ Discharge, e.g. lactation, blood (duct ectasia, intraductal papilloma) ■ Rash (e.g. in Paget’s, DCIS underlying nipple, peau d’orange) ■ Inversion/retraction of nipples ■ Accessory nipples (usually below breast), accessory breast tissue (usually in axilla) ○ Supraclavicular area and axilla - swollen, nodes, veins, muscle wasting ● Continue with patient sitting at 45* ● Inspect breasts ○ Ask if pain when moving arms ○ Watch breasts as arms behind head – T4 skin, Astley Cooper* => Tethering? arms behind back – T4 chest wall pec. major => Fixation? ○ = check for invading masses of stage T4 ○ Ask about discharge and ask patient to demonstrate it
  7. 7. Breast Examination (2) ● Continue with patient lying flat with hands behind the head ● Cover patient and expose body parts needed ● Check inframammary fold with back of hand ○ Say: “I am now examining under the breast” ○ Most common finding: intertrigo – chronic thrush under breast ● Palpate 5 areas of the breast and axilla and nodes ○ Upper outer quadrant + axilla (most common site of lesions) Hold pt’s R arm with your R arm then palpate axilla with the other hand. Ask patient to lift arm up, place hand in axilla, lift arm down to rest on yours, then roll fingers down axilla 4 times. Examine the left axilla with the left hand and vice versa. If you feel a lump, feel if it is fixed or not. ○ Upper inner quadrant ○ Lower inner quadrant ○ Lower outer quadrant ○ Areolar complex ○ Palpate normal breast first ■ During palpation don’t lift up hand ■ Move all around breast ○ Lymph nodes: Axillary (already done), infraclavicular, supraclavicular, neck ● Cover patient
  8. 8. Breast Examination (3) ● PRESENTATION ○ To complete my examination, I’d like to ■ Send off potential discharge for cytology ■ Palpate the liver and ausculate the chest for suspected mestastases ■ Perform a triple assessment ■ Clinical Hx and Ex => done ■ Radiological Mammography and US +/- MRI ■ Pathological Fine needle aspiration => cytology and core biopsy ■ MRI if younger patient or discrepancy between clinical assessment and mammography or when planning breast conserving surgery ○ This lady has a non-tender/tender Xcm lump in the X quadrant of the X breast. It has a XX surface and a XX edge, is mobile/immobile and not/attached to XX. There are XXX palpable in the axilla, continue description as above. There are XXX nodes palpable in the supraclavicular fossa / other sites. My differential diagnosis is XXXX based on the age of the patient, the most likely diagnosis is XXXX.
  9. 9. Breast Examination (4) ● Note main DD has 4 choices (Mannequin does not have inflammatory lesion and 2 lumps to palpate, the benign diagnosis depends on age of patient) ○ Fibrocystic lesion ■ Women >30-40 ■ Changes with cycle ○ Benign neoplasm, e.g. fibroadenoma ■ Women <30-40 ■ Changes with cycle ○ Malignant lesion: Peau d’orange, nipple retraction, tethering, fixation, change in breast size, ulceration, Paget’s ■ Painless lump ■ More likely in upper outer quadrant? ○ Inflammatory lesion ■ Usually painful ● DD of breast discharge ○ Ask if spontaneous or on squeezing ○ Orange watery fluid from single duct Intraductal papilloma ○ Bright red blood from single duct Papilloma or malignancy ○ White or green discharge from multiple ducts Benign ○ Bilateral milky discharge Galactorrhoea ● Note on axillary nodes ○ 25% of palpable node will not contain metastases ○ 25% of nodes containing metastases are not palpable
  10. 10. Aids to DD ● Have 4 main options for lump (note for exam: mannequin does not have inflammatory option, has 1 palpable benign or malignant lump. Need to distinguish 2 benign conditions by age of the patient) ○ Benign fibroCYSTIC lesion in older women, terminal ducts undergo apoptosis and terminal lobuloaveolar unit produces fluid => cyst ■ Change with cycle ■ Most likely if >>30y and up to menopause ○ Benign FIBROADENOMA = STROMA, “breast mice” ■ Change with cycle ■ Most likely if <~30y!!! Young!!! ○ MALIGNANT tumour ■ Painless lump ○ INFLAMMATORY lesion ■ PAINFUL, potential purulent discharge
  11. 11. Pathology
  12. 12. Breast Tumours: Risk factors ● Age ● Gender - only 15% of breast CA patients have other risk factors ● Inherited trait ● Oe exposure: early menarche, late menopause, no children, children at age of >35y ● OCP (risk returns back to normal) ● HRT (beyond the age of 55), risk returns to normal 5y post stopping, combined Oe/P HRT is worse than Oe only ● Previous benign breast disease: atypical epithelial hyperplasia (fibrocystic lesion) ● Obesity, alcohol intake, NOT smoking!?! (Acc. to surgical talk) ● Radiation exposure, esp. post lymphoma (mantle radiotherapy)
  13. 13. Breast Tumours: Overview ● While listing the different pathological types of tumours, think of the different tissues it can originate from ○ Types of breast tissue epithelium (duct vs. lobule) ○ Fibroblasts (stroma) ○ Types of skin epithelium (keratinocytes vs. glands etc..)
  14. 14. Benign Breast Tumours/Lesions ● General: Lipoma, sebaceous cyst, hamartoma, sarcoma (rare), 2* mets ● Fibrocystic >>35, perimenopausal, remodelling of breast tissue causing fluid entrapment ○ Non-proliferating cystic changes => cyclical, ASPIRATION AND CYTOLOGY ○ Proliferating: ■ Epithelial hypertrophy ■ Sclerosing adenosis => ● Inflammatory ○ Mastitis (lactating) => ABX, ABSCESS ASPIRATION AND IV ABX, BREASTFEEDING CONTINUATION ○ Non-lactating: piercings => periductal mastitis, fungal in immunosuppressed, granulomatous in sarcoidosis or TB, infective in T2DM, RA => TREAT UNDERLYING CAUSE AND CAUSATIVE AGENT ● Benign ○ Fibroadenoma <<35 (Breast mice) => EXCISION OR NO Rx ○ Phylloides: WLE OR MASTECOMY AS 15% MALIGNANT ○ Intraductal papilloma => EXCISION OR NO Rx
  15. 15. Malignant Breast Tumours ● DCIS ● DCIS near nipple = Paget’s disease ● DCIS subtype: comedone ● LCIS ● Invasive ductal NST ● Invasive ductal ○ Lobular ○ Medullary ○ Colloid/Mucinous ○ Tubular ○ Inflammatory ○ Cibriform ○ Micropapillary ○ Apocrine ○ Adenoid ○ Metaplastic ● Invasive LCIS
  16. 16. Breast Tumours: Organisation by site ● 50% upper outer quadrant ● 20% central ● 4% bilateral 1* or >1 1* lobular carcinoma invasive ductal carcinoma mucinous carcinoma medullary carcinoma intraductal papillomaPaget’s, DCIS lipoma sebaceous cyst stroma: fibrocystic fibroadenoma phylloides
  17. 17. Breast Tumours: Genetic Changes A HER2 -ve slow growing, responds to tamoxifen but not well to chemo OeR +ve = luminal B HER2 +ve double +ve, worse, often node involvement basal-like HER2 -ve, triple -ve, highly aggressive, medullary, BRCA1/2 involved OeR -ve PR -ve HER2+ve HER2 +ve highly proliferative ● 10% genetic predisposition of which 30% BRCA1/2 ● RECEPTORS ○ 30% HER2 upregulated (human epidermal GF = Y kinase) => worse prognosis ○ Oe R present/absent => if present better prognosis ● PROTEINS ○ Ras/Myc upregulated ○ pRb/p53 downregulated ● Classification according to receptor involvement:
  18. 18. Management
  19. 19. Screening of Breast Cancer ● 47-73 (after 70 voluntary) ● Every 3y ● 2 view mammogram looking for calcification ● Procedure ○ +ve (abnormal) => core biopsy ■ B1: Normal => return to screening (if biopsy from wrong area rebiopsy) ■ B2: Benign => reassure, return to screening ■ B3: Uncertain malignant potential => excision ■ B4: Suspicion of malignancy => rebiopsy or excision ■ B5: Malignant => surgical excision (WLE or mastectomy) ● B5a - DCIS ● B5b - invasive ○ -ve (normal) => return to screening programme
  20. 20. Ix of Breast Disease ● Referral from GP or screening of suspicious lumps or mamogram findings: ● Triple assessment (diagnostic tests) ○ Clinical Hx and Ex ○ Radiological Mammography and US (useful for Ix of lesions already diagnosed, not useful for ab initio identification, also US axilla) ○ Pathological Fine-needle aspiration FNA cytology and core biopsy ■ FNA: cystic lesion disappears on aspiration => diagnosis ■ Core biopsy only performed if suspicion of cancer after FNA ○ MRI if younger patient (high tissue density on mammobraphy) or discrepancy between clinical assessment and mammography or when planning breast conserving surgery ● Other Ix: ○ FBC (potential marrow involvement), LFTs, U&E/CA, CXR, Isotope bone scan, liver US.
  21. 21. Ix of Breast Disease: Mammography ● Views ○ Mediolateral-oblique view MLO ○ Craniocaudal view CC ○ Lateromedial/mediolateral view? ● Result suspicious of cancer ○ White asymmetrical spiculated lesion containing microcalcification ○ DCIS: cluster of microcalcification ● Efficiency ○ Misses 7% of palpable cancers and 20% in pre-menopausal women ○ Lobular carcinoma not well detected ● ADD
  22. 22. Ix of Breast Disease: Staging ● Staging informs on state of progression and guides treatment ● Assessment for staging ○ Lymph node biopsy ○ CT for metastases ○ Bone scan for metastases ○ CXR for metastases ○ Liver US for metastases ○ Blood tests as before: FBC, LFTs, serum calcium, U&E ● TNM ○ Tx 1* cannot be assessed ○ T0 No evidence of 1* ○ Tis In situ ○ T1 <2cm ○ T2 2-5cm ○ T3 >5cm ○ T4 Chest wall or skin involvement ● Nx Lymph nodes cannot be assessed e.g. if removed ● N0 no involvement ● N1 Movable axillary ● N2 Fixed axillary ● N3 Ipsilateral thoracic nodes ● Mx Cannot be assessed ● M0 No distant mets ● M1 Distant mets
  23. 23. Why Stage and Grade ● Grade = biology/histology differentiation ● Stage = anatomy infiltration ● Prognosis guided by ○ grade (incl. node biopsies) ○ stage i
  24. 24. Treatment Overview ● Management by MDT: surgeon, oncologist, nurse, radiologist, histopathologist, cytologist, coordinator, +/- plastic surgery, genetics, palliative care Breast care nurse from 1st visit for SUPPORT AND EDUCATION ● Medical ○ Tyrosine kinase inhibitors: HER2 antagonists Herceptin ○ Endocrine treatment: Oe antagonist Tamoxifen pre-menopausal, Arimidex post ● Surgical ○ Excision of the tumour ○ Surgery to axilla ○ +/- Breast reconstruction ● Radiological ● +/- Adjuvant therapy: hormonal, biological or chemotherapy, neo-adjuvant means prior to surgery ● Know local policies and national guidelines ● Consider social circumstances of patient ● Breast care nurse from 1st visit for SUPPORT AND EDUCATION
  25. 25. Surgical Treatment of the 1* Tumour ● <4cm ○ Breast-conserving surgery: WLE wide local excision and radiotherapy ○ OR mastectomy ○ Depends on patient choice, 75% chose WLE ● For impalpable tumours ○ Stereotactic localisation under mammographic control ○ Needle is placed in place of microcalcification ○ Area surrounding the needle is excised ○ Excised area X-rayed to confirm it contains the calcifications ● If margins of local excision not clear, re-excision is required ● Treatment of axilla is not normally done in DCIS
  26. 26. Treatment of the Axilla ● Aim: Prevent cancer spread and establish prognosis (axillary nodes most important prognostic indicator!) ● Procedures: Sentinel lymph node biopsy SNL 1. Pre-op US with FNA 2. Sentinel node biopsy ● Pre-op intradermal injection of technetium and methylene blue into tumour / periareolar ● Wait 2h ● Find first axillary node draining the cancer, excise and examine. ● Find hot and blue nodes and excise just these 3. If sentinel node +ve for tumour => axillary clearance Axillary sampling 1. Remove >4 nodes and analyse histologically, if any +ve then axillary clearance ● Grades of axillary clearance ○ Axillary sampling Lower part of axillary fatpad, obsolete ○ Level 1 Nodes up to axillary vein ○ Level 2 Nodes up to pec minor ○ Level 3 Nodes up to 1st rib ○ The more, the higher the risk of nerve damage and lymphoedema ● Do NOT perform radiotherapy to a cleared axilla => inc. risk of lymphoedema
  27. 27. Surgical Treatment of Breast CA ● Conservation surgery (usually <4cm) ○ Wide local excision WLE, removal of cylinder of breast tissue down to the pectoral muscle ○ Limited axillary surgery ○ Post-operative radiotherapy ● Total simple mastectomy (usually >4cm or too large in small breast or nipple) ○ Removal of breast tissue, nipple and areola +/- axillary surgery ● Skin sparing mastectomy ○ Circular incision around nipple and removal of breast tissue with nipple by diathermy excision through incision, followed by insertion of drainage tubes +/- implants and closure ● Nipple sparing mastectomy with simultaneous reconstruction ● Nipple and areola sparing mastectomy ● Most radical treatment - but no increased survival ○ Radical mastectomy with axillary clearance ○ Post-operative radiotherapy (if >5cm or close to chest wall) ● +/- chemotherapy, endocrine and antibody therapy
  28. 28. Breast Reconstruction ● Immediate ● Delayed ○ If significant comorbidity ○ or post-operative radiotherapy ● Becker prosthesis ○ Prosthesis placed under the pectoralis muscle / implant with potential port ○ Simplest procedure ● Autologous reconstruction / tissue flaps, when skin replacement needed ○ Latissimus dorsi ○ DIEP ■ Deep inferior epigastric perforator (a, anastomosed onto inf. mammary a) ■ Only skin and fat flap ○ previously TRAB (now replaced by DIEP) ■ Transverse abdominus, ■ Muscle sacrificed
  29. 29. Chemotherapy ● Overall reduces the risk of (distal) recurrence by 20% ● Greatest success in young node + xx ● In each case, assess potential benefits against toxicity (RISK Management!) ● Combination more effective than single agent (single more palliative) ● Six cycles of cytotoxic chemo given 1/m for 6m ● FEC: 5-fluorouracil, epirubicin and cyclophosphamide ● Scoring of toxicity 0-4, 1 can still work, from 2 on cannot continue work ● Side-effects ○ Alopecia (can prevent with scalp cooling) ○ Mouth ulcers ○ Sterility ○ Myelosuppression ○ Extravasation: stop infusion don’t remove! ○ Lethargy ○ Nausea and vomiting ○ Teratogenicity ○ Specific to individual drugs
  30. 30. Radiotherapy ● Reduces (local) recurrence but not mortality ● Usually combined with WLE ● 50Gy external beam radiotherapy 5d/w for 3w ● Side-effects ○ Tiredness ○ Skin irritation (~sunburn) from ~week3 ○ Shrinkage of the irradiated breast ● Reduces risk of recurrence from 30% to 5% in 10y
  31. 31. Adjuvant Therapy ● Improves survival by 5-10% over 10y ● Oe antagonists / endocrine therapy ○ Usually for 5y if OeR +ve, especially if nodal spread. +/- ovarian ablation ○ Also reduce risk of contralateral breast CA, recurrence, death rate, 5%/10% benefit if node -ve/+ve at 10y ○ Side effects: menopausal-type symptoms (less so with arimidex) ○ Tamoxifen - actually a mixed agonist/antagonist = SERM selective OeR modulator ○ Arimidex = anastrozole - an aromatase inhibitor that blocks peripheral oe production in fat tissues in post-menopausal women where ovaries no longer produce Oe ● Herceptin = Trastuzumab ○ HER2 antibody ○ 25% of breast CA HER2 +ve (i.e. with HER2 overexpression?) ○ Side-effects: cardiomyopathy and congestive cardiac failure ○ Given every 3w for 1y as long as no cardiac problems ○ 3-monthly echocardiograms to monitor (see NICE) ● Neo-adjuvant therapy*** ○ Treat with endocrine and/or cytotoxic drugs prior to surgery to allow shrinkage of the tumour, followed by radiotherapy post-operatively
  32. 32. Prognosis ● Predictive factors ○ Node involvement single best predictor of survival! Nr of nodes ~ p of distant mets! ○ Also: size, grade (differentiation), Nottingham Prognostic Index (size, grade and nodes), vascular invasion, hormone R, HER2 R, histo type. ● DCIS >90% 5y ● if recurrence 50% invasive ● <1% death risk ● <2cm 90% 5y ● node -ve 80% 5y ● 16 nodes 50% 5y ● distant mets 15% 5y, life expectancy 2-3y ● metastases to: (LCIS different: CSF, serosal surfaces, GI, ovaries, uterus, bone marrow)
  33. 33. Advanced Disease ● Tumour >5cm initial Mx non-surgical: chemotherapy with subsequent surgery +/- radiotherapy ● Sole radiotherapy only if unfit for surgery or very elderly +/- adjuvant ● Metastatic disease: systemic therapy = hormonal, chemotherapy for advanced visceral disease ● Treatment of bone mets ○ Radiotherapy ○ Bisphosphonates ● Treatment of hypercalcaemia due to bone mets ○ Hydration with IV saline ○ Diuretics ○ Bisphosphonates (inhibit Ras farnesylation and osteoclast proliferation) ● Palliative care ○ Treat pain and other symptoms of advanced disease
  34. 34. Additional Info https://www.adjuvantonline.com/index.jsp ● Treatment of discharge of the breast ○ Hadfield’s procedure: duct excision ○ Microdochectomy: removal of the duct by a probe passed into it
  • IrshadAhmad177

    Feb. 26, 2021
  • RiteshVishwakarma26

    Jan. 16, 2021
  • ShikhaJorwal

    Jan. 11, 2021
  • ManishaPerika1

    Dec. 15, 2020
  • collinooi

    Oct. 17, 2020
  • ManavSoni7

    Aug. 11, 2020
  • SALMANPP1

    Aug. 1, 2020
  • NilamNalawade1

    Jul. 9, 2020
  • RaymanAdnan2

    Jan. 13, 2020
  • AliQorbanee

    Dec. 14, 2019
  • KimSunGo2

    Dec. 11, 2019
  • gerasiusnegumbo

    Nov. 8, 2019
  • JagadeeshYadav9

    Sep. 21, 2019
  • AzimMuhammed

    May. 17, 2019
  • WajeehaSaeed

    Apr. 16, 2019
  • drpramodj

    Apr. 8, 2019
  • VishnuVishnu41

    Mar. 17, 2019
  • BahredinBekri1

    Feb. 24, 2019
  • SubratKumarSahoo23

    Aug. 25, 2018
  • KritikaPahadia

    Jul. 3, 2018

Notes on breast surgery for medical finals.

Vistos

Vistos totais

5.447

No Slideshare

0

De incorporações

0

Número de incorporações

379

Ações

Baixados

222

Compartilhados

0

Comentários

0

Curtir

34

×