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Flashcards in Breast Deck (172):
1

What are the 4 boundaries of the axilla for dissection?

Superior: axillary vein
Posterior: long thoracic nerve
Lateral: latissimus dorsi
Medial: pectoralis minor

2

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

3

Where is the long thoracic nerve?

Courses along lateral chest wall in midaxillary line on serratus anterior muscle

4

Which muscles does the long thoracic nerve innervate?

Serratus anterior muscle

5

Where is the thoracodorsal nerve?

Courses lateral to the long thoracic nerve on latissimus dorsi muscle

6

Which muscles does the thoracodorsal nerve innervate?

Latissimus dorsi muscle

7

Where is the medial pectoral nerve?

Runs lateral to or through the pectoral minor muscle, laterally to the lateral pectoral nerve

8

Which muscles does the medial pectoral nerve innervate?

Pectoral minor and major muscles

9

Where is the lateral pectoral nerve?

Runs medial to the medial pectoral nerve

10

Which muscles does the lateral pectoral nerve innervate?

Pectoral major muscle

11

What is the name of the deformity if you cut the long thoracic nerve?

Winged scapula

12

What is the name of the cutaneous nerve that crosses the axilla in a transverse fashion?

Intercostobrachial nerve

13

What is the name of the large vein that marks the upper limit of the axilla?

Axillary vein

14

What is the lymphatic drainage of the breast?

Lateral: axillary lymph nodes
Medial: parasternal nodes that run with internal thoracic artery

15

Where are the level I axillary lymph nodes?

Lateral to the pectoral minor muscle

16

Where are the level II axillary lymph nodes?

Deep to the pectoral minor muscle

17

Where are the level III axillary lymph nodes?

Medial to the pectoral minor muscle

18

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

19

What are the suspensory breast ligaments called?

Cooper's ligaments

20

What is the mammary "milk line"?

Embryological line from shoulder to thigh where supernumerary breast areolar and/or nipples can be found

21

What is the tail of Spence?

Tail of breast tissue that tapers into the axilla

22

Which hormone is mainly responsible for breast milk production?

Prolactin

23

What is the incidence of breast cancer?

12%

24

What percentage of women with breast cancer have no known risk factor?

75%

25

What percentage of all breast cancers occur in women younger than 30 years?

2%

26

What percentage of all breast cancers occur in women older than 70 years?

33%

27

What are the major breast cancer susceptibility genes?

BRCA1 and BRCA2

28

What option exists to decrease the risk of breast cancer in women with BRCA?

Prophylactic bilateral mastectomy

29

What is the most common motivation for legal cases involving the breast?

Failure to diagnose a breast carcinoma

30

What is the triad of error for misdiagnosed breast cancer?

1. Age

31

What are the history risk factors for breast cancer?

NAACP:
Nulliparity
Age at menarche ( 55)
Cancer of the breast (in self or family)
Pregnancy with first child (> 30 years)

32

What are the physical/anatomic risk factors for breast cancer?

CHAFED LIPS:
Cancer of the breast, Hyperplasia, Atypical hyperplasia, Female, Elderly, DCIS, LCIS, Inherited genes, Papilloma, Sclerosing adenosis

33

What is the relative risk for breast cancer with HRT?

1-1.5

34

Is typical fibrocystic disease a risk factor for breast cancer?

No

35

What are the possible symptoms of breast cancer?

Asymptomatic, breast mass, pain (most painless), nipple discharge, local edema, nipple retraction, dimple, nipple rash

36

Why does skin retraction occur in some breast cancers?

Tumor involvement of Cooper's ligaments and subsequent traction on ligaments pull skin inward

37

What are the signs of breast cancer?

Mass (> 1cm), dimple, nipple rash, edema, axillary or supraclavicular nodes

38

What is the most common site of breast cancer?

Approximately 50% develop in the UOQ

39

What are the different types of invasive breast cancer?

Infiltrating ductal carcinoma, medullary carcinoma, infiltrating lobular carcinoma, tubular carcinoma, mucinous carcinoma, inflammatory breast cancer

40

What is the most common type of breast cancer?

Infiltrating ductal carcinoma

41

What is the differential diagnosis for breast cancer?

Fibrocystic disease, fibroadenoma, intraductal papilloma, duct ectasia, fat necrosis, abscess, radial scar, simple cyst

42

Describe the appearance of the edema of the dermis in inflammatory breast cancer.

Peau d'orange

43

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

44

What are the recommendations for mammograms?

35-40 yo: baseline mammogram
40-50 yo: mammogram every or every other year
> 50 yo: annual mammogram

45

When is the best time for breast self-exam?

1 week after menstrual period

46

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.

47

What are the radiographic tests for breast cancer?

Mammography, breast U/S, MRI

48

What is the classic picture of breast cancer on mammogram?

Spiculated mass

49

Which option is best to evaluate a breast mass in a woman younger than 30 years?

Breast U/S

50

What are the methods for obtaining breast tissue for pathologic examination?

FNA, core biopsy, mammotome stereotactic biopsy, open biopsy

51

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

52

What is the process for performing a biopsy when a non-palpable mass is seen on mammogram?

Stereotactic (mammotome) biopsy or needle localization biopsy

53

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

54

What is a mammotome biopsy?

Mammogram-guided computerized stereotactic core biopsy

55

What is obtained first, the mammogram or the biopsy?

Mammogram is obtained first; otherwise, tissue extraction may alter the mammographic findings

56

What would be suspicious mammographic findings?

Mass, microcalcifications, stellate/spiculated mass

57

What is a radial scar seen on mammogram?

Spiculated mass with central lucency +/- microcalcifications

58

What tumor is associated with a radial scar?

Tubular carcinoma

59

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

60

How do you proceed if the mass appears to be a cyst?

Aspirate it with a needle

61

Is the fluid from a breast cyst sent for cytology?

Not routinely; bloody fluid should be sent

62

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

63

What is the preoperative staging workup in a patient with breast cancer?

Bilateral mammogram
CXR: lung mets
LFTs: liver mets
Serum Ca, alkaline phosphatase: bone mets
Other: head CT

64

What hormone receptors must be checked for in the biopsy specimen?

Estrogen and progesterone (guides adjuvant treatment)

65

What staging system is used for breast cancer?

TMN

66

What is stage I breast cancer?

Tumor

67

What is stage IIA breast cancer?

Tumor

68

What is stage IIB breast cancer?

Tumor 2-5 cm with mobile axillary nodes, or
Tumor > 5 cm with no nodes

69

What is stage IIIA breast cancer?

Tumor > 5 cm with mobile axillary nodes, or
Fixed axillary nodes, no mets

70

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

71

What is stage IIIC breast cancer?

Positive supraclavicular, infraclavicular, or internal mammary lymph nodes

72

What is stage IV breast cancer?

Distant metastases (including ipsilateral supraclavicular nodes)

73

What are the sites of breast cancer metastases?

Lymph nodes, lung/pleura, liver, bones, brain

74

What are the major treatments of breast cancer?

Modified radical mastectomy; lumpectomy with radiation and sentinel node dissection

75

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

76

What breast cancers are candidates for lumpectomy and radiation?

Stage I and II

77

What approach may allow a patient with stage IIIA cancer to have breast-conserving surgery?

Neoadjuvant chemotherapy (provided the preop chemo shrinks the tumor)

78

What is the treatment of inflammatory breast cancer?

Chemo first; followed by radiation, mastectomy, or both

79

What is done in a lumpectomy with radiation?

Segmental mastectomy, axillary node dissection, and course of radiation therapy after operation (several weeks)

80

What is the major absolute contraindication to lumpectomy and radiation?

Pregnancy

81

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

82

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.

83

Where are the drains placed with a modified radical mastectomy?

1. Axilla
2. Chest wall (breast bed)

84

When should the drains be removed after axillary dissection?

85

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

86

During an axillary dissection, should the patient be paralyzed?

No, because the nerves are stimulated with resultant muscle contraction to help identify them

87

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

88

What is a sentinel node biopsy?

Instead of removing all the axillary lymph nodes, the primary draining node is removed

89

How is the sentinel lymph node found?

Inject blue dye and/or technetium-labelled sulfur colloid

90

What follows a positive sentinel node biopsy?

Removal of rest of axillary lymph nodes

91

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

92

What do you do with a mammotome biopsy that returns as "atypical hyperplasia"?

Open needle loc biopsy

93

How does tamoxifen work?

It binds estrogen receptors

94

What is the treatment for local recurrence in breast after lumpectomy and radiation?

Salvage mastectomy

95

Can tamoxifen prevent breast cancer?

Yes

96

What are common options for breast reconstruction?

TRAM flap, implant, latissimus dorsi flap

97

What is a TRAM flap?

Transverse Rectus Abdominis Myocutaneous flap

98

What are the side effects of tamoxifen?

Endometrial cancer (2.5 fold), DVT, PE, cataracts, hot flashes, mood swings

99

In high-risk women, is there a way to reduce the risk of developing breast cancer?

Yes, tamoxifen

100

What type of chemotherapy is usually used for breast cancer?

CMF (Cyclophosphamide, Methotrexate, 5-Fluorouracil), or
CAF (Cyclophosphamide, Adriamycin, 5-Fluorouracil)

101

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

102

What is DCIS?

Ductal Carcinoma In Situ
A.K.A. intraductal carcinoma

103

What are the signs and symptoms of DCIS?

Usually none

104

What are the mammographic findings of DCIS?

Microcalcifications

105

How is the diagnosis of DCIS made?

Core or open biopsy

106

What is the most aggressive histologic type of DCIS?

Comedo

107

What is the risk of lymph node metastasis with DCIS?

108

What is the major risk factor with DCIS?

Subsequent development of infiltrating ductal carcinoma in same breast

109

What is the treatment for DCIS tumor

Lumpectomy with 1 cm margins +/- XRT

110

What is the treatment for DCIS tumor > 1 cm?

Lumpectomy with 1 cm margins and XRT, or
Total mastectomy

111

What is a total mastectomy?

Removal of the breast and nipple without removal of the axillary nodes

112

When must a simple mastectomy be performed for DCIS?

Diffuse breast involvement; > 1 cm; and contraindication to radiation

113

What is the role of axillary node dissection with DCIS?

None

114

What is the role of tamoxifen in DCIS?

5 years will lower risk up to 50%

115

What is a memory aid for the breast in which DCIS breast cancer arises?

DCIS = Directly in same breast

116

What is LCIS?

Lobular Carcinoma In Situ

117

What are the signs and symptoms of LCIS?

None

118

What are the mammographic findings for LCIS?

None

119

How is the diagnosis of LCIS made?

Found incidentally on biopsy

120

What is the major risk with LCIS?

Carcinoma of either breast

121

Which breast is most at risk for developing an invasive carcinoma in LCIS?

Equal risk

122

What percentage of women with LCIS develop an invasive breast cancer?

30% in 20 years

123

What type of invasive breast cancer do patients with LCIS develop?

Usually infiltrating ductal carcinoma

124

What medication may lower the risk of developing breast cancer in LCIS?

Tamoxifen

125

What is the treatment for LCIS?

Close follow-up (or bilateral simple mastectomy in high-risk patients)

126

What is the major difference in the subsequent development of invasive breast cancer with DCIS and LCIS?

LCIS cancer develops in either breast

127

How do you remember which breast is at risk for invasive cancers in patients with LCIS?

LCIS = Liberally in either breast

128

What is the most common cause of bloody nipple discharge in a young woman?

Intraductal papilloma

129

What is the most common breast tumor in patients younger than 30 years?

Fibroadenoma

130

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

131

What is the incidence of breast cancer in men?

132

What is the average age of diagnosis of breast cancer in men?

65 years

133

What are the risk factors for breast cancer in men?

Increased estrogen, radiation, estrogen therapy, Klinefelter's syndrome, BRCA2

134

Is benign gynecomastia a risk factor for male breast cancer?

No

135

What type of breast cancer do men develop?

Ductal carcinoma (men do not have lobules)

136

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)

137

What is the most common presentation of breast cancer in men?

Painless breast mass

138

How is breast cancer in men diagnosed?

Biopsy and mammogram

139

What is the treatment for breast cancer in men?

1. Mastectomy
2. Sentinel LN dissection of clinically negative axilla
3. Axillary dissection if clinically positive axillary LN

140

What is the most common cause of green, straw-colored, or brown nipple discharge?

Fibrocystic disease

141

What is the most common cause of breast mass after breast trauma?

Fat necrosis

142

What is Mondor's disease?

Thrombophlebitis of superficial breast veins

143

What must be ruled out with spontaneous galactorrhea?

Prolactinoma

144

What is cystosarcoma phyllodes?

Mesenchymal tumor arising from breast lobular tissue.
Most are benign.

145

What is the usual age of the patient with cystosarcoma phyllodes?

35-55 years

146

What are the signs and symptoms of cystosarcoma phyllodes?

Mobile, smooth breast mass that resembles a fibroadenoma on exam, mammogram and U/S findings

147

How is cystosarcoma phyllodes diagnosed?

Core biopsy or excision

148

What is the treatment for cystosarcoma phyllodes?

If benign, wide local excision.
If malignant, simple total mastectomy.

149

What is the role of axillary dissection with cystosarcoma phyllodes?

Only if clinically palpable axillary nodes

150

Is there a role for chemotherapy with cystosarcoma phyllodes?

Consider if large tumor (> 5cm) and stromal overgrowth

151

What is fibroadenoma?

Benign tumor of the breast consisting of stromal overgrowth, collagen arranged in swirls

152

What is the clinical presentation of a fibroadenoma?

Solid, mobile, well-circumscribed round breast mass, usually

153

How is fibroadenoma diagnosed?

Negative FNA, U/S, core biopsy

154

What is the treatment for fibroadenoma?

Surgical resection for large or growing lesions.
Small fibroadenomas can be observed.

155

What is fibrocystic disease?

Common benign breast condition consisting of fibrous and cystic changes in the breast

156

What are the signs and symptoms of fibrocystic disease?

Breast pain or tenderness that varies with the menstrual cycles, cysts, fibrous or nodular fullness

157

How is fibrocystic disease diagnosed?

Breast exam, history, FNA

158

What is the treatment for symptomatic fibrocystic disease?

NSAIDs, vitamin E, evening primrose oil, stop caffeine

159

What is done if a patient has a breast cyst?

Needle drainage:
If bloody or palpable mass after aspiration: open biopsy.
If straw-colored or green: follow closely

160

What is mastitis?

Superficial infection of the breast (cellulitis)

161

When does mastitis occur most often?

Breast-feeding

162

What bacteria are most commonly the cause of mastitis?

Staph aureus

163

How is mastitis treated?

Stop breast-feeding and use a breast pump, apply heat, antibiotics

164

Why must a patient with mastitis have close follow-up?

To make sure that she does not have inflammatory breast cancer

165

What are the causes of breast abscesses?

Mammary ductal ectasia, mastitis

166

What is the most common bacteria in breast abscesses?

Nursing: Staph aureus
Non-lactating: mixed

167

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

168

What must be ruled out with a breast abscess in a non-lactating woman?

Breast cancer

169

What is male gynecomastia?

Enlargement of the male breast

170

What are the causes of gynecomastia?

Medications, illicit drugs (marijuana), liver failure, increased estrogen, decreased testosterone

171

What is the major differential diagnosis of the older patient with gynecomastia?

Male breast cancer

172

What is the treatment for gynecomastia?

Stop or change medications; correct underlying cause if hormonal; perform biopsy or subcutaneous mastectomy if refractory to conservative measures and time