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Venous disease 57
If an atypical ulcer, consider a biopsy (vasculitic, Marjolin’s ulcer).
Assess oedema.
A6: What treatment options are appropriate?
Initial treatment will involve compression of the lower limb with four-layer compression bandages. Leg
elevation is recommended when sitting or lying. Surgery should be considered in those with a patent deep
venous system who have incompetence of the saphenofemoral, saphenopopliteal and or perforators.
Patients are best managed by specialist nurse-led ulcer clinics in the community, unless there are
concerns of infection or rapid deterioration which may require hospital intervention.
Nutritional and vitamin supplementation may be required as well as optimization of medical
problems. Patient education is essential to reduce recurrence.
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58 General surgery
BREAST
Questions
Clinical cases
For each of the clinical case scenarios given
Q1: What is the likely differential diagnosis?
Q2: What features of the given history support the diagnosis?
Q3: What additional features in the history would you seek to support a particular
diagnosis?
Q4: What clinical examination would you perform and why?
Q5: What investigations would be most useful and why?
Q6: What treatment options are appropriate?
CASE 1.23 –
‘I’ve found a breast lump’
You are asked to see a 24-year-old marketing manager who noticed a lump in her left breast 6 weeks
ago. She has not had breast lumps previously, and has no family history of breast cancer. Examination
reveals a 2-cm-diameter rm mass lateral to her left nipple.
CASE 1.24 –
‘Something has shown up on my screening mammogram’
A 50-year-old woman is recalled for further assessment after her rst-round screening mammograms
show some ‘calcications’. Physical examination is unremarkable, with no lump palpable. A
mammographic-guided stereotactic core biopsy is performed, and histology shows ductal carcinoma in
situ (DCIS). Appropriate treatment needs to be arranged.
CASE 1.25 –
‘I’ve found a lump under my armpit’
This 62-year-old woman sees her GP after noticing a hard lump under her right arm, and is referred
urgently to a symptomatic breast clinic. The nding is conrmed, and also a hard 4-cm mass is felt in
the right breast deep to the nipple. The clinical impression is one of breast cancer. Mammographic and
ultrasound images support the diagnosis, and image-guided core biopsy of the breast mass and ne-
needle aspiration of the axillary mass conrms malignant cells. Treatment options are discussed.
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Breast 59
OSCE Counselling cases
OSCE COUNSELLING CASE 1.11 –
‘What can I do about this breast pain?’
OSCE COUNSELLING CASE 1.12 –
‘I’m confused about my surgical
options for breast cancer. Which
should I choose?’
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60 General surgery
Key concepts
In order to work through the core clinical cases in this section you will need to understand the following
key concepts.
HOW COMMON IS BREAST CANCER?
Breast cancer accounts for approximately 25 per cent of all female malignancies in the United Kingdom.
Young women are much less likely to develop it, with the risk slowly increasing with age. The incidence
is approximately 1 in 100 000 at age 40, rising to 400 in 100 000 at age 80. You may read that 1 in 8 to
12 women will get breast cancer. This is the cumulative, lifetime risk, which is age dependent.
‘MY GRANDMOTHER HAD BREAST CANCER – WILL I GET IT TOO?’
There are a number of factors which will increase any given individual’s risk of developing breast cancer.
Hereditary breast cancers, caused by genetic abnormalities (e.g. the BRCA 1 or 2 genes) are responsible
for only 10 per cent of all breast cancers. Other risk factors are much more common, but variable.
Family history is important when it is a rst-degree relative (mother or sister) and when the cancer
was diagnosed pre-menopause, or has been diagnosed in multiple relatives. With a relatively common
disease such as breast cancer, having more distant relatives with breast cancer is usually just chance.
HOW IS BREAST CANCER MANAGED?
Options for the diagnosis and treatment for breast cancer have expanded hugely over recent years.
Management should occur within a multidisciplinary setting, involving radiologists, surgeons,
pathologists, oncologists, specialist breast care nurses, and reconstructive surgeons in order to ensure
the best outcomes for patients.
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Breast 61
Answers
Clinical cases
CASE 1.23 –
‘I’ve found a breast lump’
A1: What is the likely differential diagnosis?
Fibroadenoma
Fat necrosis
Breast abscess
Phyllodes tumour
Breast cancer – less likely, but needs to be excluded
A2: What features of the given history support the diagnosis?
The young age of the patient makes the diagnosis of broadenoma the most likely, with other benign
lesions also possible. Breast cancer in this age group is extremely rare, but needs to be considered; a
strong family history would increase one’s concern.
A3: What additional features in the history would you seek to support a
particular diagnosis?
Ask about trauma to the breast, a history of which may support a diagnosis of fat necrosis. Also ask about
breastfeeding, and medical conditions that would make infection more likely, including smoking.
A4: What clinical examination would you perform and why?
Clinical examination of both breasts, axillae and supraclavicular fossae should be performed with a
chaperone present.
A5: What investigations would be most useful and why?
To complete the ‘triple assessment’, imaging and biopsy would normally be performed. Mammography
is difcult to interpret in the dense breasts of women under the age of 40, and is only performed if a
cancer is diagnosed. Ultrasound has greater diagnostic accuracy and is the imaging modality of choice
in this age group. In the case of this 24-year-old woman, most breast surgeons would not biopsy this
lesion if it felt typical of a broadenoma, and had the typical ultrasound appearances. Image-guided
core biopsy could be performed if she was over 25, or there were any atypical features on examination
or ultrasound.
A6: What treatment options are appropriate?
The natural history of broadenomas is that about a third spontaneously regress over time, one-third
remain unchanged and one-third continue to grow. Women should understand this in order to make
treatment choices.
Non-operative: a signicant proportion of women are adequately reassured by a benign diagnosis,
and prefer to avoid an operation.
Operative: removal of a broadenoma is usually possible with a small incision at the areolar margin,
which normally results in a small, cosmetically acceptable scar.
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62 General surgery
CASE 1.24 –
‘Something has shown up on my screening mammogram’
A1: What is the likely differential diagnosis?
Small ecks of calcium, seen on mammograms, are relatively common. Their likely diagnosis depends upon
their shape, size and number. Large calcications are usually not associated with cancer. Some congurations
of calcium deposition are considered pathognomonic, such as cup-shaped dependent calcium in cysts. In
contrast, groups of small calcications (‘clustered microcalcications’) may be associated with extra breast cell
activity, usually benign, but sometimes in areas of early invasive cancer or DCIS.
A2: What features of the given history support the diagnosis?
Roughly 50 per cent of breast cancers in the United Kingdom are diagnosed before they have formed
a lump through the mammographic screening programme. Screening is designed to identify DCIS
or invasive breast cancer early to allow earlier, less radical treatments. Despite current controversies
regarding the possible overtreatment of some women with subclinical disease which would have never
caused symptoms, most large studies have shown screening is effective on a population basis.
A3: What additional features in the history would you seek to support a
particular diagnosis?
Family history should again be determined for both breast and ovarian cancer. Although this will make
no difference for this patient, it may have implications for her children.
A4: What clinical examination would you perform and why?
Examination of both breasts is required, in addition to complete physical examination.
A5: What investigations would be most useful and why?
The screening mammograms should be reviewed in the multidisciplinary meeting, and further views
performed if required. Any previous screening lms should be reviewed and audited to assess whether
the lesion was visible earlier. An ultrasound scan of the axilla should be performed to assess for any
abnormal looking lymph nodes.
As the lesion is not palpable, a mammographic stereotactic or ultrasound-guided core biopsy should
be obtained.
Subsequent histological analysis of the stereotactic core biopsy shows DCIS.
A6: What treatment options are appropriate?
Treatment options for most women with DCIS are wide local excision and radiotherapy (breast-
conserving therapy) if well localized and small, or if extensive or multifocal, mastectomy. To aid
excision of an impalpable lesion, a wire is placed under mammographic or ultrasound guidance so
that the tip lies adjacent to the area needing removal. Axillary staging with sentinel lymph node (SLN)
biopsy is not performed for DCIS treated by breast-conserving therapy as the risk of axillary nodal
spread is very small. If a mastectomy is being performed to treat DCIS, most surgeons would ‘stage’
the axilla with SLN biopsy. This is because there is a small risk of there being undiagnosed invasive
breast cancer within a large area of DCIS, and also because SLN biopsy cannot be performed after
mastectomy if an invasive breast cancer is found within the mastectomy specimen.
If a wide local excision is performed, the surgical margins need to be carefully assessed to ensure
complete excision. Further excisions may be required to achieve this. In high-grade or extensive
DCIS there is good evidence from large randomized trials that radiotherapy reduces the rate of local
recurrence. Because 50 per cent of local recurrences after treatment for DCIS are invasive, initial optimal
treatment is vital. Immediate reconstruction should be offered to any undergoing a mastectomy to treat
DCIS.
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Breast 63
CASE 1.25 –
‘I’ve found a lump under my armpit’
A1: What is the likely differential diagnosis?
The diagnosis is secure – breast cancer with axillary lymph node metastasis. Attention should now be
directed towards the presence of symptoms or signs of distant metastatic spread.
A2: What features of the given history support the diagnosis?
See above.
A3: What additional features in the history would you seek to support a
particular diagnosis?
See above.
A4: What clinical examination would you perform and why?
Complete physical examination should search for metastases.
A5: What investigations would be most useful and why?
Investigations should be focussed on staging the disease and determining risk factors for anaesthesia
and surgery. A CT scan of the thorax, abdomen and pelvis, and whole skeleton bone scan would be
routine in this clinical setting.
A6: What treatment options are appropriate?
Unless the patient chooses a non-operative approach, surgery is required and is usually supplemented
by chemotherapy, radiotherapy and hormonal manipulation. In women presenting with proven nodal
disease and a tumour unsuitable for wide local excision, chemotherapy is increasingly being given
prior to surgery (neo-adjuvant chemotherapy). This has the benet of demonstrating the efcacy of
the chemotherapy, treats systemic disease (which has the greatest impact on long-term survival) and
may reduce the size of the primary tumour to such an extent that breast-conserving surgery becomes
possible. In a number of women there is a complete clinical and radiological response to chemotherapy,
and therefore it is advisable to insert a small titanium clip into the tumour before starting chemotherapy,
so that it can be localized when surgery takes place. In patients with extensive co-morbidities that
prevent surgery, neo-adjuvant endocrine (primary hormone treatment) can be used.
Surgical: breast surgery is performed to achieve local control of disease, and reduce disease burden
to a level that adjuvant treatments can control. In addition, it allows prognostic information to be
gained that will guide the choices of subsequent adjuvant treatments. The main choice to be made is
between WLE and radiotherapy to the remaining breast, and mastectomy, either of which is combined
with axillary lymph node dissection. These two treatment options offer equivalent long-term survival,
and should usually be the choice of the patient. If there were no pre-operative evidence of axillary nodal
spread, then SLN biopsy would be performed at the time of WLE or mastectomy in order to ‘stage’
the axilla. This procedure avoids much of the morbidity associated with axillary lymph node dissection
(seroma, lymphoedema, shoulder pain and stiffness).
Reconstructive surgery should ideally be offered to the patient considering mastectomy, and options
include immediate or delayed reconstruction. There are many options available to a woman wanting
a breast reconstruction. A reconstructed breast can be formed using implants and tissue expanders
alone, endogenous tissues (e.g. latissimus dorsi ap, DIEP ap, TRAM ap etc.) either on their own
(autologous) or combined with an implant.
Radiotherapy: there is very good evidence from large randomized controlled trials that radiotherapy
reduces local recurrence and improves survival after WLE, making breast-conserving therapy equivalent
to mastectomy in terms of long-term survival. Radiotherapy may also be used after mastectomy for
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64 General surgery
large, aggressive tumours with axillary node metastasis, directed towards the chest wall, axilla and
supraclavicular fossa.
Chemotherapy: this is offered to women with aggressive tumours in order to reduce the risk
of distant metastatic disease. Most women with involved axillary lymph nodes are considered for
chemotherapy, women with large, high-grade tumours, or younger women also benet.
Hormonal manipulation: approximately 70 to 80 per cent of women have oestrogen/progesterone
receptor–rich tumours, which makes them sensitive to hormone manipulation. Tamoxifen (a selective
estrogen receptor modulator) binds to the oestrogen receptor in breast cells, blocking its action. It
is used in pre-menopausal women with oestrogen receptor–positive breast cancer. The Aromatase
inhibitor group of drugs prevents androgens from being converted into oestradiol, and is used in post-
menopausal women with oestrogen receptor–positive breast cancer. These treatments greatly reduce
the risk of breast cancer recurrence, and are generally well tolerated.
Biological therapy: approximately 15 to 20 per cent of breast cancers over-express the epidermal
growth factor receptor HER-2/neu, which is an important part of the pathway stimulating tumour
growth and preventing cell death. Women with HER-2 positive breast cancers can benet from
treatment with trastuzumab (Herceptin) or similar agents. Trastuzumab is a monoclonal antibody
directed against the HER-2 receptor. It is currently given weekly for a year.
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Breast 65
OSCE Counselling cases
OSCE COUNSELLING CASE 1.11 –
‘What can I do about this breast pain?’
Breast pain is surprisingly common amongst women. It may be cyclical or non-cyclical, and a careful
history will determine the timing and any trigger factors. It is important to consider ‘non-breast’
causes, such as chest wall, neck, back and shoulder pain. After history and examination has excluded
any other aetiology, options for managing breast pain can be discussed. Most women will cope with
the discomfort once they have been re-assured that there is nothing sinister causing the pain.
The importance of a correctly tting bra should be emphasized, and specialized sports bras may
be useful for periods of vigorous exercise. Reducing caffeine intake, stopping smoking, taking part in
regular exercise and reducing dietary fat intake are the most important lifestyle modications of benet
in women with true breast pain.
Simple analgesics may be appropriate if the pain is only present for a few days during a particular
part of the menstrual cycle. Some women nd benet from taking evening primrose oil, which is rich
in vitamin E and some essential fatty acids. It needs to be taken at relatively high doses, and for at least
2 months before the peak benet is obtained, but has relatively few side effects, and can be bought
without prescription.
OSCE COUNSELLING CASE 1.12 –
‘I’m confused about my surgical
options for breast cancer. Which
should I choose?’
For most women (except those with very advanced tumours) it has been shown by a number of well-
performed studies that breast-conserving therapy (i.e. WLE followed by radiotherapy to the remaining
breast) results in the same overall survival rates as mastectomy, and a similarly low rate of local
recurrence. Accordingly, the choice of surgery should be the patient’s. Whatever approach is used, it
should be made clear to the woman that she will be supported with as much information she feels she
needs in order to make the decision.
Many women feel that time is critical, and they want to have their operation as soon as possible. It
is worth emphasizing that breast cancer is usually very slow growing, and that at the time of diagnosis
it may already have been present for many months or even years. Allowing some days, or even a week
or two to make a decision will not jeopardize the outcome, but may allow unpressured choices to be
made.
Mastectomy has a major impact on the body image of most women. For women who choose
mastectomy, or for whom WLE is not appropriate (e.g. previous radiotherapy to that breast, or large or
multifocal disease), reconstructive surgery should usually be discussed and offered.
Axillary staging provides prognostic information that inuences adjuvant treatment. Sentinel lymph
node biopsy is a technique of identifying the rst node(s) that drains the breast. This is performed using
a dual technique of injected radio-active colloid and blue dye. It has the signicant benet of reduced
post-operative morbidity when compared with axillary lymph node dissection. If the sentinel node is
clear, the presumption is that the rest of the axillary nodes are also clear. Unfortunately its sensitivity is
not 100 per cent, plus if the sentinel node is positive it usually requires further axillary surgery to ‘clear’
the axilla, or axillary radiotherapy.
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66 General surgery
REVISION PANEL
Breast cancer is one of the most common malignancies. The risk of developing breast cancer
increases with age.
Triple assessment – clinical examination, radiological imaging, and cytology and/or histology –
underlies the diagnosis of breast lumps. Optimal investigation and treatment is obtained through
a multidisciplinary approach.
Imaging options for the breast include ultrasound, mammography and MRI. Screening
mammography programmes are an important means of detecting breast cancer at an earlier
point than when clinically apparent, with the hope of improving both individual and population
outcomes.
Surgical treatment of breast cancer continues to evolve, with techniques including breast-
conserving treatment, reconstructive and oncoplastic approaches and sentinel node biopsy to
minimally assess draining lymph node basins.
Adjuvant treatment after surgery has an important role in reducing recurrence rates and mortality.
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