Flashcards in Breast Deck (172):
What are the 4 boundaries of the axilla for dissection?
Superior: axillary vein
Posterior: long thoracic nerve
Lateral: latissimus dorsi
Medial: pectoralis minor
What 4 nerves must a surgeon be aware of during an axillary dissection?
1. Long thoracic nerve
2. Thoracodorsal nerve
3. Medial pectoral nerve
4. Lateral pectoral nerve
Where is the long thoracic nerve?
Courses along lateral chest wall in midaxillary line on serratus anterior muscle
Which muscles does the long thoracic nerve innervate?
Serratus anterior muscle
Where is the thoracodorsal nerve?
Courses lateral to the long thoracic nerve on latissimus dorsi muscle
Which muscles does the thoracodorsal nerve innervate?
Latissimus dorsi muscle
Where is the medial pectoral nerve?
Runs lateral to or through the pectoral minor muscle, laterally to the lateral pectoral nerve
Which muscles does the medial pectoral nerve innervate?
Pectoral minor and major muscles
Where is the lateral pectoral nerve?
Runs medial to the medial pectoral nerve
Which muscles does the lateral pectoral nerve innervate?
Pectoral major muscle
What is the name of the deformity if you cut the long thoracic nerve?
What is the name of the cutaneous nerve that crosses the axilla in a transverse fashion?
What is the name of the large vein that marks the upper limit of the axilla?
What is the lymphatic drainage of the breast?
Lateral: axillary lymph nodes
Medial: parasternal nodes that run with internal thoracic artery
Where are the level I axillary lymph nodes?
Lateral to the pectoral minor muscle
Where are the level II axillary lymph nodes?
Deep to the pectoral minor muscle
Where are the level III axillary lymph nodes?
Medial to the pectoral minor muscle
What are Rotter's nodes?
Nodes between the pectoral major and minor muscles.
Not usually removed unless they are enlarged or feel suspicious intra-operatively
What are the suspensory breast ligaments called?
What is the mammary "milk line"?
Embryological line from shoulder to thigh where supernumerary breast areolar and/or nipples can be found
What is the tail of Spence?
Tail of breast tissue that tapers into the axilla
Which hormone is mainly responsible for breast milk production?
What is the incidence of breast cancer?
What percentage of women with breast cancer have no known risk factor?
What percentage of all breast cancers occur in women younger than 30 years?
What percentage of all breast cancers occur in women older than 70 years?
What are the major breast cancer susceptibility genes?
BRCA1 and BRCA2
What option exists to decrease the risk of breast cancer in women with BRCA?
Prophylactic bilateral mastectomy
What is the most common motivation for legal cases involving the breast?
Failure to diagnose a breast carcinoma
What is the triad of error for misdiagnosed breast cancer?
1. Age < 45
2. Self-diagnosed mass
3. Negative mammogram
What are the history risk factors for breast cancer?
Age at menarche (< 13)
Age at menopause (> 55)
Cancer of the breast (in self or family)
Pregnancy with first child (> 30 years)
What are the physical/anatomic risk factors for breast cancer?
Cancer of the breast, Hyperplasia, Atypical hyperplasia, Female, Elderly, DCIS, LCIS, Inherited genes, Papilloma, Sclerosing adenosis
What is the relative risk for breast cancer with HRT?
Is typical fibrocystic disease a risk factor for breast cancer?
What are the possible symptoms of breast cancer?
Asymptomatic, breast mass, pain (most painless), nipple discharge, local edema, nipple retraction, dimple, nipple rash
Why does skin retraction occur in some breast cancers?
Tumor involvement of Cooper's ligaments and subsequent traction on ligaments pull skin inward
What are the signs of breast cancer?
Mass (> 1cm), dimple, nipple rash, edema, axillary or supraclavicular nodes
What is the most common site of breast cancer?
Approximately 50% develop in the UOQ
What are the different types of invasive breast cancer?
Infiltrating ductal carcinoma, medullary carcinoma, infiltrating lobular carcinoma, tubular carcinoma, mucinous carcinoma, inflammatory breast cancer
What is the most common type of breast cancer?
Infiltrating ductal carcinoma
What is the differential diagnosis for breast cancer?
Fibrocystic disease, fibroadenoma, intraductal papilloma, duct ectasia, fat necrosis, abscess, radial scar, simple cyst
Describe the appearance of the edema of the dermis in inflammatory breast cancer.
What are the recommendations for breast exams?
Self-exam of breasts monthly
20-40 yo: breast exam every 2-3 years
> 40 yo: annual breast exam
What are the recommendations for mammograms?
35-40 yo: baseline mammogram
40-50 yo: mammogram every or every other year
> 50 yo: annual mammogram
When is the best time for breast self-exam?
1 week after menstrual period
Why is mammography a more useful diagnostic tool in older women than in younger?
Breast tissue undergoes fatty replacement with age, making masses more visible.
Young women have more fibrous tissue.
What are the radiographic tests for breast cancer?
Mammography, breast U/S, MRI
What is the classic picture of breast cancer on mammogram?
Which option is best to evaluate a breast mass in a woman younger than 30 years?
What are the methods for obtaining breast tissue for pathologic examination?
FNA, core biopsy, mammotome stereotactic biopsy, open biopsy
What are the indications for breast biopsy?
Persistant mass after aspiration, solid mass, blood in cyst aspirate, suspicious lesion by mammography/U/S/MRI, bloody nipple discharge, ulcer or dermatitis of nipple, patient concern
What is the process for performing a biopsy when a non-palpable mass is seen on mammogram?
Stereotactic (mammotome) biopsy or needle localization biopsy
What is needle loc biopsy?
Needle localization by radiologist, followed by biopsy; removed breast tissue must be checked by mammogram to ensure all of the suspicious lesion has been excised
What is a mammotome biopsy?
Mammogram-guided computerized stereotactic core biopsy
What is obtained first, the mammogram or the biopsy?
Mammogram is obtained first; otherwise, tissue extraction may alter the mammographic findings
What would be suspicious mammographic findings?
Mass, microcalcifications, stellate/spiculated mass
What is a radial scar seen on mammogram?
Spiculated mass with central lucency +/- microcalcifications
What tumor is associated with a radial scar?
What is the workup for a breast mass?
1. Clinical breast exam
2. Mammogram or breast U/S
3. FNA, core biopsy, or open biopsy
How do you proceed if the mass appears to be a cyst?
Aspirate it with a needle
Is the fluid from a breast cyst sent for cytology?
Not routinely; bloody fluid should be sent
When do you proceed to open biopsy for a breast cyst?
1. Recurrence of second cyst
2. Bloody fluid in cyst
3. Palpable mass after aspiration
What is the preoperative staging workup in a patient with breast cancer?
CXR: lung mets
LFTs: liver mets
Serum Ca, alkaline phosphatase: bone mets
Other: head CT
What hormone receptors must be checked for in the biopsy specimen?
Estrogen and progesterone (guides adjuvant treatment)
What staging system is used for breast cancer?
What is stage I breast cancer?
Tumor < 2 cm
What is stage IIA breast cancer?
Tumor < 2 cm with mobile axillary nodes, or
Tumor 2-5 cm with no nodes
What is stage IIB breast cancer?
Tumor 2-5 cm with mobile axillary nodes, or
Tumor > 5 cm with no nodes
What is stage IIIA breast cancer?
Tumor > 5 cm with mobile axillary nodes, or
Fixed axillary nodes, no mets
What is stage IIIB breast cancer?
Peau d'orange skin, or
Chest wall invasion/fixation, or
Inflammatory cancer, or
Breast skin ulceration, or
Breast skin satellite metastases
What is stage IIIC breast cancer?
Positive supraclavicular, infraclavicular, or internal mammary lymph nodes
What is stage IV breast cancer?
Distant metastases (including ipsilateral supraclavicular nodes)
What are the sites of breast cancer metastases?
Lymph nodes, lung/pleura, liver, bones, brain
What are the major treatments of breast cancer?
Modified radical mastectomy; lumpectomy with radiation and sentinel node dissection
What are the indications for radiation therapy after a modified radical mastectomy?
Stage IIIA-B, pectoral muscle/fascia invasion, positive internal mammary LN, positive surgical margins, > 3 positive axillary LNs post-menopausal
What breast cancers are candidates for lumpectomy and radiation?
Stage I and II
What approach may allow a patient with stage IIIA cancer to have breast-conserving surgery?
Neoadjuvant chemotherapy (provided the preop chemo shrinks the tumor)
What is the treatment of inflammatory breast cancer?
Chemo first; followed by radiation, mastectomy, or both
What is done in a lumpectomy with radiation?
Segmental mastectomy, axillary node dissection, and course of radiation therapy after operation (several weeks)
What is the major absolute contraindication to lumpectomy and radiation?
Other than pregnancy, what are other contraindications to lumpectomy and radiation?
Previous radiation to chest, positive margins, collagen vascular disease (e.g. scleroderma), extensive DCIS
What is a modified radical mastectomy?
Removal of breast, axillary nodes (levels I and II), nipple-areolar complex.
Drains are placed to drain lymph fluid.
Pectoral major and minor muscles are NOT removed.
Where are the drains placed with a modified radical mastectomy?
2. Chest wall (breast bed)
When should the drains be removed after axillary dissection?
< 30 cc/day drainage or on POD #14 (whichever is first)
What are the potential complications after a modified radical mastectomy?
Ipsilateral arm lymphedema, infection, injury to nerves, skin flap necrosis, hematoma/seroma, phantom breast syndrome
During an axillary dissection, should the patient be paralyzed?
No, because the nerves are stimulated with resultant muscle contraction to help identify them
How can the long thoracic and thoracodorsal nerves be identified during an axillary dissection?
Stimulate with forceps, resulting in contraction of anterior serratus or latissimus dorsi
What is a sentinel node biopsy?
Instead of removing all the axillary lymph nodes, the primary draining node is removed
How is the sentinel lymph node found?
Inject blue dye and/or technetium-labelled sulfur colloid
What follows a positive sentinel node biopsy?
Removal of rest of axillary lymph nodes
What is now considered the standard of care for lymph node evaluation in women with stage I or IIA breast cancer?
Sentinel lymph node dissection
What do you do with a mammotome biopsy that returns as "atypical hyperplasia"?
Open needle loc biopsy
How does tamoxifen work?
It binds estrogen receptors
What is the treatment for local recurrence in breast after lumpectomy and radiation?
Can tamoxifen prevent breast cancer?
What are common options for breast reconstruction?
TRAM flap, implant, latissimus dorsi flap
What is a TRAM flap?
Transverse Rectus Abdominis Myocutaneous flap
What are the side effects of tamoxifen?
Endometrial cancer (2.5 fold), DVT, PE, cataracts, hot flashes, mood swings
In high-risk women, is there a way to reduce the risk of developing breast cancer?
What type of chemotherapy is usually used for breast cancer?
CMF (Cyclophosphamide, Methotrexate, 5-Fluorouracil), or
CAF (Cyclophosphamide, Adriamycin, 5-Fluorouracil)
What is a high-risk tumor in the breast?
> 1 cm, lymphatic/vascular invasion, high nuclear grade, high S phase, ER negative, HER-2/neu overexpression
What is DCIS?
Ductal Carcinoma In Situ
A.K.A. intraductal carcinoma
What are the signs and symptoms of DCIS?
What are the mammographic findings of DCIS?
How is the diagnosis of DCIS made?
Core or open biopsy
What is the most aggressive histologic type of DCIS?
What is the risk of lymph node metastasis with DCIS?
What is the major risk factor with DCIS?
Subsequent development of infiltrating ductal carcinoma in same breast
What is the treatment for DCIS tumor < 1 cm?
Lumpectomy with 1 cm margins +/- XRT
What is the treatment for DCIS tumor > 1 cm?
Lumpectomy with 1 cm margins and XRT, or
What is a total mastectomy?
Removal of the breast and nipple without removal of the axillary nodes
When must a simple mastectomy be performed for DCIS?
Diffuse breast involvement; > 1 cm; and contraindication to radiation
What is the role of axillary node dissection with DCIS?
What is the role of tamoxifen in DCIS?
5 years will lower risk up to 50%
What is a memory aid for the breast in which DCIS breast cancer arises?
DCIS = Directly in same breast
What is LCIS?
Lobular Carcinoma In Situ
What are the signs and symptoms of LCIS?
What are the mammographic findings for LCIS?
How is the diagnosis of LCIS made?
Found incidentally on biopsy
What is the major risk with LCIS?
Carcinoma of either breast
Which breast is most at risk for developing an invasive carcinoma in LCIS?
What percentage of women with LCIS develop an invasive breast cancer?
30% in 20 years
What type of invasive breast cancer do patients with LCIS develop?
Usually infiltrating ductal carcinoma
What medication may lower the risk of developing breast cancer in LCIS?
What is the treatment for LCIS?
Close follow-up (or bilateral simple mastectomy in high-risk patients)
What is the major difference in the subsequent development of invasive breast cancer with DCIS and LCIS?
LCIS cancer develops in either breast
How do you remember which breast is at risk for invasive cancers in patients with LCIS?
LCIS = Liberally in either breast
What is the most common cause of bloody nipple discharge in a young woman?
What is the most common breast tumor in patients younger than 30 years?
What is Paget's disease of the breast?
Scaling rash/dermatitis of the nipple caused by invasion of skin by cells from a ductal carcinoma
What is the incidence of breast cancer in men?
What is the average age of diagnosis of breast cancer in men?
What are the risk factors for breast cancer in men?
Increased estrogen, radiation, estrogen therapy, Klinefelter's syndrome, BRCA2
Is benign gynecomastia a risk factor for male breast cancer?
What type of breast cancer do men develop?
Ductal carcinoma (men do not have lobules)
What are the signs and symptoms of breast cancer in men?
Breast mass (usually painless), breast skin changes (ulcers, retractions), nipple discharge (usually blood-tinged)
What is the most common presentation of breast cancer in men?
Painless breast mass
How is breast cancer in men diagnosed?
Biopsy and mammogram
What is the treatment for breast cancer in men?
2. Sentinel LN dissection of clinically negative axilla
3. Axillary dissection if clinically positive axillary LN
What is the most common cause of green, straw-colored, or brown nipple discharge?
What is the most common cause of breast mass after breast trauma?
What is Mondor's disease?
Thrombophlebitis of superficial breast veins
What must be ruled out with spontaneous galactorrhea?
What is cystosarcoma phyllodes?
Mesenchymal tumor arising from breast lobular tissue.
Most are benign.
What is the usual age of the patient with cystosarcoma phyllodes?
What are the signs and symptoms of cystosarcoma phyllodes?
Mobile, smooth breast mass that resembles a fibroadenoma on exam, mammogram and U/S findings
How is cystosarcoma phyllodes diagnosed?
Core biopsy or excision
What is the treatment for cystosarcoma phyllodes?
If benign, wide local excision.
If malignant, simple total mastectomy.
What is the role of axillary dissection with cystosarcoma phyllodes?
Only if clinically palpable axillary nodes
Is there a role for chemotherapy with cystosarcoma phyllodes?
Consider if large tumor (> 5cm) and stromal overgrowth
What is fibroadenoma?
Benign tumor of the breast consisting of stromal overgrowth, collagen arranged in swirls
What is the clinical presentation of a fibroadenoma?
Solid, mobile, well-circumscribed round breast mass, usually < 40 years
How is fibroadenoma diagnosed?
Negative FNA, U/S, core biopsy
What is the treatment for fibroadenoma?
Surgical resection for large or growing lesions.
Small fibroadenomas can be observed.
What is fibrocystic disease?
Common benign breast condition consisting of fibrous and cystic changes in the breast
What are the signs and symptoms of fibrocystic disease?
Breast pain or tenderness that varies with the menstrual cycles, cysts, fibrous or nodular fullness
How is fibrocystic disease diagnosed?
Breast exam, history, FNA
What is the treatment for symptomatic fibrocystic disease?
NSAIDs, vitamin E, evening primrose oil, stop caffeine
What is done if a patient has a breast cyst?
If bloody or palpable mass after aspiration: open biopsy.
If straw-colored or green: follow closely
What is mastitis?
Superficial infection of the breast (cellulitis)
When does mastitis occur most often?
What bacteria are most commonly the cause of mastitis?
How is mastitis treated?
Stop breast-feeding and use a breast pump, apply heat, antibiotics
Why must a patient with mastitis have close follow-up?
To make sure that she does not have inflammatory breast cancer
What are the causes of breast abscesses?
Mammary ductal ectasia, mastitis
What is the most common bacteria in breast abscesses?
Nursing: Staph aureus
What is the treatment of breast abscesses?
Antibiotics (dicloxacillin); needle or open drainage with cultures; resection of involved ducts if recurrent; breast pump if feeding
What must be ruled out with a breast abscess in a non-lactating woman?
What is male gynecomastia?
Enlargement of the male breast
What are the causes of gynecomastia?
Medications, illicit drugs (marijuana), liver failure, increased estrogen, decreased testosterone
What is the major differential diagnosis of the older patient with gynecomastia?
Male breast cancer