Breast surgery

Q1: Fibroadenoma vs Phyllodes:

Fibroadenoma Phyllodes
Age Young (20-30) ≥ 40
Tumor Benign (Most common benign Benign or malignant
breast tumor)
Features Mouse-like (freely mobile),
oval mass that moves very
easily
Menstruation Affected by menses NOT related to menses
Spread Never (benign) Malignant phyllodes spreads
Hematogenously (CT chest is
always the next step after
diagnosing malignant
phyllodes)
Main Management reassurance Excision always (benign &
malignant)
Indications for surgery Symptomatic Always excision
More than 3 cm
Increasing in size
Unsure diagnosis (age > 40)
Patient distress
Type of surgery Excision of the mass Benign = Excision
Malignant1 = Mastectomy OR
WLE + radiotherapy

1Malignant phyllodes  Always do CT after diagnosing malignant phyllodes (for staging).

Do mastectomy for large phyllodes and for small phyllodes do wide local excision (WLE) +
radiation. Malignant phyllodes is called cystosarcoma phyllodes  sarcomas metastasize
through the blood
*Small malignant phyllodes = WLE + radiation
*Large malignant (≥ 5 cm) phyllodes = Mastectomy
*Malignant phyllodes = hematogenous spread = forget about the axillary lymph nodes and
do CT prior to any intervention (for staging)
*Benign phyllodes = just do excision (No need for staging/CT)
*Asymptomatic, < 3 cm fibroadenoma + incidental finding = always reassurance is the best
answer
*Painful fibroadenoma = Always excisional biopsy is the best answer

Cord-like painful lesion in the breast + redness and tenderness = Mondors

disease
Mondors is a self-limited disease  analgesia is enough
Mondor is a really good guy (self-limited)
 Catchy point:
Q: Paget disease of the nipple:
C U In Summer (see you in summer)
 Presentation: Paget
-Scaling itching with crusts and ulceration
Crusting
-There is almost always an underlying malignancy
-It is an extension to the nipple  Bloody discharge Ulceration

Itching

Scaling
 Management:
-Mastectomy + SLNB (if you don’t know the status of the lymph nodes)
-Modified Radical mastectomy (Mastectomy + Axillary dissection)  if you know
there is metastasis to Axillary LNs
Catchy point:
Carcinoma in situ Scaly pruritic rash on the vagina =
Paget disease of the vagina
Q: LCIS vs DCIS:
 Lobular carcinoma in situ (LCIS):
-Types  Classic and pleomorphic
-Classic LCIS is NOT a premalignant condition, but it might indicate associated
malignancy
-Pleomorphic LCIS is equivalent to DCIS  May transform into invasive cancer
-Pleomorphic LCIS is Managed as DCIS (see below)
-Management of classic LCIS is excisional biopsy to Rule Out associated (another)
malignancy followed by mammogram in 1 year

DCIS and pleomorphic LCIS

Q: Management of DCIS (ductal carcinoma in situ):
 Diffuse microcalcification  Mastectomy
 Large DCIS (> 5 cm)  Mastectomy
 Discrete small (< 5 cm) microcalcification (mass)  Lumpectomy + SLNB + radiation
(to achieve clear margins)  this triad is called breast conserving surgery
 Pleomorphic LCIS  excisional biopsy
 Pleomorphic LCIS + large or diffuse  Mastectomy
 SLNB: usually NOT required
 Indications for SLNB:
-Large (> 5 cm) DCIS
-DCIS with Comedo necrosis (The necrosis breaks the basement membrane and
allows the cancerous cells to spread beyond the basement membrane)
-Recurrent DCIS
Nipple discharge
Catchy point:
Q: Nipple discharge: Breast lump after trauma  Fat necrosis  benign

 Bilateral: Breast lump + radical scar on histopathology 

-Physiologic excision (might be pre-malignant)
-Rule out hyperprolactinemia *Eradicate the radical scar = Excision
 Unilateral:
-Bloody  intraductal papilloma  excision
-Green and cord-like on palpation  Mammary duct ectasia  Excision
-Straw/hay colored nipple discharge + Bilateral breast tenderness that is increased
with menses  Fibrocystic change disease  OCP or NSAIDs (conservative)

Mastitis
Q: Mastitis vs inflammatory breast cancer:
 Mastitis types:
-In lactating women  S Aureus is the MCC
-In non-lactating women  diabetic + smoker (smoking damages the ducts  debris
in the duct  duct gets closed  bacteria reproduce/accumulate behind the block
 infection)
 Management of mastitis:
-Mastitis + No fluctuation (No abscess/lump to be drained) = Antibiotics alone
-Mastitis + Fluctuation (Abscess) = Incision & drainage (NOT US-guided drainage)
 Inflammatory carcinoma of the breast:
-Elderly female with axillary LAP, skin changes (Orange peel appearance), and fever
-Lymphadenopathy (LAP) is a must in inflammatory carcinoma of the breast

Breast cysts Catchy point:

Q: Management of breast cyst: Screening for breast CA starts at the age of

40 till 75 with annual mammogram
 Simple cyst:
-Aspiration
-If bloody content  send for cytology Catchy point:
 Recurrent simple cyst for second time: The confirmatory test for mondors
-Aspirate again disease is US
-If bloody, send for cytology Mondors is self-limited (2-6 weeks)
 Complex cyst: Warm compressors + NSAIDs are enough
-Always rule out malignancy
-History and P/E  US  complex cyst  mammogram  Core-needle biopsy  if
benign (follow-up), if malignant (treat accordingly)
  25-year-old woman presents to your clinic with left-sided breast mass. She visited
the hospital 2 months ago for the same complaint and she was diagnosed with a
simple breast cyst. Aspiration was done for her previous complaint. What is the
best next step NOW?
-The best step now is to do US to know what are you dealing with, is it a simple cyst
again or is it a complex cyst or is it fibroadenoma

BRCA-2 screening
Q: When and how to screen people with BRCA-2 mutation?
 At the age of 18 years- 25: physical examination by the patient
 At the age of 25: physical exam by the doctor (twice/year) + annual MRI
 At the age of 30: Annual mammogram + Ovarian cancer screening1
1Ovarian cancer screening: Pelvic exam + Pelvic US + CA-125
*MRI for BRCA-2 starts at 25 years till 30 (annually)
*Mammogram for BRCA-2 starts at 30 (annually)
*Mammogram for the General population starts at 40 till 75 years of age (done every 2
years starting at 40)

Q: When NOT to do mammogram?

 Breast implants
 Age < 30 (Because the mamo at this age is Useless)
 Pregnancy and breastfeeding
*If any of the above is present and you suspect malignancy, the next step as an imaging of
choice is US.

Q: A lady with fibrocystic disease, what is the food that she should avoid?
Foods that contain xanthine

 Caffeine
 Cola
 Tobacco

Catchy point:
Fibroids of uterus and fibrocystic change disease of
breast  Both are hormone-sensitive, benign, and
treated with NSAIDs and OCPs
Q: Breast lesions and the corresponding age: MDE = mammary duct
ectasia
 Fibrocystic change disease: < 40 (20-40)
 Fibroadenoma: < 40 (20-30)
 Phyllodes (cystosarcoma phyllodes): > 40
 Intraductal papilloma and MDE: Perimenopause (30-55)
 Invasive carcinoma and Paget disease of breast: > 40
 Inflammatory carcinoma of breast: < 40 (this is a unique exception, know it !!)
 Radical scar and fat necrosis: any age
 Breast cysts: any age
 Mondors disease: Any age because it is a superficial thrombophlebitis (30-60)

Q: Causes of nipple retraction:

 Nipple retraction + nipple discharge  MDE
 Nipple retraction + history of trauma  fat necrosis
 Nipple retraction + elderly + risks for breast cancer  invasive carcinoma causing
traction of Cooper’s ligament
 Nipple retraction + signs of inflammation  inflammatory breast carcinoma

Q: Traction of Cooper’s ligament by invasive cancer causes:

 Dimpling of the SKIN
 Retraction of the Nipples

Q: What is the contraception of choice in a lactating lady?

 Progesterone-based contraception

Q: What is the most common invasive breast cancer?

 Invasive ductal carcinoma
 Remember that the letter ‘’D’’ comes before the letter ‘’L’’ in the alphabet, thus
invasive ductal carcinoma is more common than invasive lobular carcinoma

Q: Breast lesions that are benign:

 Fibrocystic  OCP and NSAIDs
 Fibroadenoma  Reassure unless symptomatic or causing patient anxiety or
enlarging mass
 Benign phyllodes  excision (excisional biopsy)
 Fat necrosis
 Intraductal papilloma  Always excision
 Simple cyst (well-circumscribed + jet black on US)  Aspirate
 Mondors disease  superficial thrombophlebitis  NSAIDs + warm compressors
  Mastitis  Antibiotic (if NO fluctuant mass to be drained) and incisional drainage (if
there is mass to be drained)

Q: The most common cancer death in females is due to:

The most common cancer in female
 Number 1  lung CA (this is a deadly CA) is breast

The most common cancer cause of

 Number 2  Breast CA hypercalcemia is breast cancer

Q: The most common cancer in females (excluding basal and squamous

carcinoma of skin) is:
 Breast CA Catchy point:
 However, the most common CA in females is skin cancer Sentinel lymph node is the first
node that drains the breast tissue
Q: Risk factors for breast CA:
 ↑ Estrogen exposure:
-Early menarche (< 12) and late menopause (> 55)
-Late first pregnancy (> 30)
 Old age (the most important risk factor after BRCA mutation)
 Personal or family history of breast CA
 Atypical ductal hyperplasia and DCIS
 Estrogen replacement post-menopause
 Radiation exposure to the chest (for lymphoma for instance)

Q: BIRADS scoring system for breast mass on mammogram:

 BIRADS 0: incomplete assessment  repeat or choose another modality
 BIRADS 1: Negative  mammogram every 2 years (if the lady is ≥ 40 years of age)
 BIRADS 2: Benign  mammogram every 2 years (if the lady is ≥ 40 years of age)
 BIRADS 3: Maybe benign  Mammogram in 6 months
 BIRADS 4: Suspicious  requires biopsy (core-needle)
 BIRADS 5: likely malignant  excisional Biopsy
 BIRADS 6: Already proven by biopsy to be malignant  breast CA management
 BIRADS 5 and 6: deal with them as malignancy
*Fibroadenoma in elderly is BIRAD 3  follow-up mammogram in 6 months

Q: Diagnosing breast CA depends on:

Triple assessment (consultants want you to know this term)

 History and physical True cut biopsy = core needle biopsy

 Imaging: mammogram and US
 Invasive testing: Biopsy and FNA
Q: Receptor positivity and prognosis:
 ER & PR positive cancers have better prognosis than HER2-neu positive cancers
 Triple negative cancers have the worst prognosis  always give neoadjuvant
(Pre-op) chemotherapy
 Best prognosis  ER and PR positive > HER2 neu positive

Q: Prognosis in breast cancer:

 The stage is important
 Lymph node status is the most important factor affecting the prognosis

Q: Types of breast surgery:

 Mastectomy: removal of breast ONLY
 Radical mastectomy: Removal of breast + axillary node + pectoralis muscles  Not
done anymore
 Modified radical mastectomy = Radical mastectomy – pectoralis muscles removal
 Modified radical mastectomy = Mastectomy + axillary lymph node dissection

Q: When to say ‘’locally advanced breast cancer’’?

 Inflammatory carcinoma of the breast Inflammatory CA of breast
 Large cancer > 5 cm management:
 Skin/nipple/chest wall invasion: Neoadjuvant chemo  surgery 
-Invading pectoralis muscle radiation
-Skin/Nipple ulceration
 Large-fixed axillary lymph nodes

Q: Breast cancer staging and management:

 Early1 (stage 1-2):
-Breast conserving surgery for all  Lumpectomy + SLNB + radiation
-Positive nodes  Always adjuvant (Post-op) chemotherapy
- ER positive + > 1 cm  Tamoxifen
 Locally Advanced (stage 3):
-Neoadjuvant chemo  Modified radical mastectomy or Mastectomy + SLNB
 Advanced breast CA (stage 4):
-Distal metastasis
-Palliative management
1Early means  Not locally advanced CA and NOT metastasized
Q: Management of breast CA in a nutshell:
 Early  Breast conserving surgery  Lumpectomy + SLNB + Radiation
 Early + nodes positive  add neoadjuvant chemo
 Locally advanced  Neoadjuvant  Mastectomy + SLNB or modified radical
mastectomy
 Metastasis/stage 4  Palliation

Q: You are the surgeon and you removed a 6 mm DCIS. LCIS was found on the
margins of the pathology report. What is the best option?
A- Re-operate to remove the LCIS from the margins
B- Adjuvant chemotherapy
C- Tamoxifen
D- Radiation
*The correct ANSWER is radiation (D). DCIS is managed with breast conserving surgery 
Lumpectomy + SNLB + Radiation
*LCIS at the margin is NOT scarry but the DCIS management is incomplete if the patient
does NOT receive radiation

Catchy point:
Tamoxifen for premenopausal women

Aromatase inhibitors for post-menopausal women. Why? I will let

you think

Q: When to consider adjuvant chemotherapy?

 Early invasive cancer + LNs are positive

Done By Dr.Ali Almajid

YouTube Channel: Medicine With Alis