Flashcards in Chapter 24: Breast Deck (368):
Formed from the ectoderm milk streak
Hormones that cause..
1. Duct development (double layer of columnar cells)
2. Lobular development
3. Synergizes estrogen and progesterone
1. Estrogen: duct development (double layer of columnar cells)
2. Progesterone: lobular development
3. Prolactin: synergizes estrogen and progesterone
Cyclic change: increases breast swelling, growth of glandular tissue
Cyclic change: increase maturation of glandular tissue; withdrawal causes menses
Cyclic change: cause ovum release
FSH, LH surge
What causes atrophy of breast tissue after menopause?
After menopause, lack of estrogen and progesterone results in atrophy of breast tissue.
Innervates serratus anterior, injury results in winged scapula
Long thoracic nerve
Artery: supplies serratus anterior
Lateral thoracic artery
Innervates latissmus dorsi; injury results in weak arm pull-ups and adduction
Artery: supplies latissimus dorsi
Innervates pectoralis major and pectorals minor
Medial pectoral nerve
Nerve: pectorals major only
Lacteral pectoral nerve
Lateral cutaneous branch of the 2nd intercostal nerve; provides sensation to medial arm and axilla; encountered just below axillary vein when performing axillary dissection. Can transect without serious consequences.
Arteries that supply the breast
Internal thoracic artery, intercostal arteries, thoracoacromial artery, and lateral thoracic artery
Valveless vein plexus that allows direct hematogenous metastasis of breast CA to spine
Lymphatic drainage of the breast
- 97% to axillary nodes
- 2% to internal mamillary nodes
- Any quadrant can drain to the internal mammary nodes.
Considered N3 disease
Mets to supraclavicular nodes
Dx: primary axillary adenopathy
#1 is lymphoma
Suspensory ligaments of the breast. Divide breast into segments.
What does skin dimpling of the breast suggest?
Breast CA involving Cooper's ligaments dimpling the skin.
What are breast abscesses usually caused by?
Usually a/w breast feeding.
MCC: Staph aureus
TX: breast abscess
Percutaneous or incision and drainage; discontinue breastfeeding; breast pump; antibiotics.
MCC infectious mastitis in nonlactating women
S. aureus MC in non lactating women can be due to chronic inflammatory diseases (e.g., actinomyces) or autoimmune disease (e.g., SLE) -> may need to r/o necrotic cancer (need incisional biopsy including the skin)
What is infectious mastitis usually associated with?
Mammary duct ectasia or plasma cell mastitis
S/S: noncyclical mastodynia, erythema, nipple retraction, creamy discharge from nipple; can have sterile or infected subareolar abscess
Risk factors: periductal mastitis
Smoking, nipple piercings
Biopsy: Periductal mastitis
Dilated mammary ducts, inspissated secretions, marked periductal inflammation
Tx: periductal mastitis
If typical creamy discharge is present that is not bloody and not associated with nipple retraction, give antibiotics and reassure; if not or it recurs, need to r/o inflammatory CA (incisional biopsy including the skin)
Breast cysts filled with milk; occurs with breastfeeding
Tx: ranges from aspiration to incision and drainage.
Can be caused by increased prolactin (pituitary prolactinoma), OCPs, TCAs, phenothiazines, metoclopramide, alpha-methyl dopa, reserpine.
- Is often a/w amenorrhea
2-cm pinch of breast tissue.
Tx: will likely regress; may need to resect if cosmetically deforming or causing social problems.
What is gynecomastia associated with?
Cimetidine. Spironolactone. Marijuana. Idiopathic in most.
Due to circulating maternal estrogens; will regress.
Neonatal breast enlargement.
MC location of polythelia (accessory breast tissue)
MC breast anomaly.
- Found form axilla to groin
What is compromised with breast reduction?
Ability to lactate frequently compromised.
Hypoplasia of chest wall.
No pectoralis muscle.
Pain in breast; rarely represents breast cancer.
Dx: history, breast exam, BL mammogram.
Evening primrose oil.
D/C: caffeine, nicotine, methylxanthines.
Pain before menstrual period, most commonly represents acute or subacute.
Continuous pain. MC'ly represents acute or subacute infection; continuous mastodynia is more refractory to treatment than cyclic mastodynia.
Superficial vein thrombophlebitis of breast, feels cordlike, can be painful.
What is Mondor's disease associated with?
Def: superficial vein thrombophlebitis of breast
- Associated with trauma and strenuous exercise.
- Usually occurs in lower outer quadrant.
Tx: Mondor's disease
Dx: breast pain, nipple discharge (usually yellow to brown), lumpy breast tissue that varies with hormonal cycle.
Types of fibrocystic change.
Papillomatosis. Sclerosing adenosis. Apocrine metaplasia. Duct adenosis. Epithelial hyperplasia. Ductal hyperplasia. Lobular hyperplasia.
What type of fibrocystic disease is associated with risk of CA?
Atypical ductal or lobular hyperplasia.
Tx: atypical ductal / lobular hyperplasia subtypes of fibrocystic change?
- Do not need to get negative margins with atypical hyperplasia; just remove all suspicious areas (i.e., calcifications that appear on mammogram).
MCC bloody nipple discharge
- Usually small, non palpable, close to nipple.
- Not premalignant
Dx: contrast ductogram to find papilloma, then needle localization
Tx: Subareolar resection of the involved duct and papilloma.
MC breast lesion in adolescents and young women; 10% multiple.
- Usually painless, slow growing, well circumscribed, firm, and rubbery.
- Often grows to several cm in size and then stops.
- Can change in size with menstrual cycle. Can enlarge in pregnancy.
prominent fibrous tissue compressing epithelial cells
Large, coarse calcifications (popcorn lesions) from degeneration.
Criteria for observation of fibroadenoma.
In patients less than 40 years old:
1. Mass needs to feel clinically benign (firm, rubbery, rolls, not fixed).
2. US or mammogram needs to be consistent with fibroadenoma.
3. Need FNA or core needle biopsy to show fibroadenoma.
Tx: enlarging fibroadenoma
Why avoid resection of fibroadenoma in teenagers / younger children?
Resection can affect breast development.
Fibroadenoma: pts > 40
Excisional biopsy to ensure dx
- Pts Observe. No?ex bx.
- Pts > 40: Ex bx to ensure diagnosis
Most nipple discharge is...
Dx: nipple discharge
History, breast exam, BL mammogram. Try to find the trigger point on exam.
Nipple discharge: green
Usually due to fibrocystic disease.
Tx: if cyclical and non spontaneous, reassure pt.
Nipple discharge: bloody
MC intraductal papilloma; occasionally ductal CA.
Tx: Need ductogram and excision of that ductal area.
Nipple: serous discharge
Worrisome for cancer. Especially if coming form only 1 duct or spontaneous.
Tx: Excisional biopsy of that ductal area
Nipple: spontaneous discharge
No matter what the color or consistency is, this is for worrisome for CA -> all these patients need excisional biopsy of duct area causing the discharge.
- Occurs only with pressure, tight garments, exercise, etc.
- Not as worrisome but may still need excisional biopsy (e.g., if bloody)
Sx: nipple discharge
May have to do a complete subareolar resection if the area above cannot be properly identified (no trigger point or mass felt).
Malignant cell of the ductal epithelium without invasion of basement membrane
Ductal carcinoma in situ.
DCIS Risk Ca:
Ipsilateral breast: 50%
Contralateral breast: 5%
DCIS: premalignant lesion
- Usually not palpable and presents as a cluster of calcifications on mammography.
- Can have solid, cribriform, papillary, comedy patterns
Most aggressive subtype DCIS
- Necrotic areas
- High risk for multi centricity, micro invasion, recurrence.
Comedo pattern DCIS
- Tx: simple mastectomy.
Increased risk of cancer in DCIS?
Comedo type and lesions > 2.5cm
Tx: DICS (not high grade)
Lumpectomy and XRT.
Need 1cm margins.
No ALND or SLNB.
Tx: High grade DCIS
Simple mastectomy if high grade (e.g., comedo type, multi centric, multifocal), if a large tumor not amenable to lumpectomy, or if not able to get good margins. No ALND.
Considered a marker for the development of breast CA, not premalignant itself.
- 40% get cancer (either breast)
- No calcifications, is not palpable.
- Primarily found in premenopausal women.
Lobular carcionma in situ - LCIS.
Patient who develop breast CA are more likely to develop a..
Ductal CA (70%)
Possibility of synchronous breast cancer at time of LCIS diagnosis?
5% (most likely ductal CA)
Do you need negative margins for LCIS?
Treatment for LCIS
Nothing. Tamoxifen. BL subcutaneous mastectomy (no ALND).
Indications for Surgical Biopsy after core biopsy
Atypical ductal hyperplasia.
Atypical lobular hyperplasia.
Columnar cell hyperplasia with atypia.
Lack of concordance between appearance of mammography lesion and histologic diagnosis.
Country: lowest risk of breast CA worldwide
United States breast cancer risk
1 in 8 women (12%); 5% in women with no risk factors.
Breast cancer screening decreases mortality by..
Years survival: untreated breast cancer
%: Beast CA with negative mammogram and negative ultrasound
Clinical features of breast CA
Distortion of normal architecture.
Skin / nipple distortion or retraction.
Tethered. Indistinct borders.
Symptomatic breast mass work up
Ultrasound & Core needle biopsy. (consider FNA).
- Need mammo in pts
Symptomatic breast mass work up > 40 years old
Need bilateral mammograms.
Core needle biopsy.
If core needle biopsy or FNA is indeterminate, non-diagnostic, non-concordant with exam findings / imaging studies..
Will need excisional biopsy.
Clinically indeterminate or suspect solid masses will eventually need..
Excisional biopsy unless CA diagnosis is made prior to that.
Tx: cyst fluid
Bloody: cyst excisional biopsy
Clear/recurs: excisional biopsy.
Complex: excisional biopsy
Test: gives architecture
Test: Gives cytology (just the cells)
Mgmt: malignant breast mass (FNA/CNBx)
Mgmt: suspicious breast mass (FNA/CNBx)
Mgmt: atypia breast mass (FNA/CNBx)
Mgmt: non diagnostic breast mass (FNA/CNBx)
Repeated FNA/CNBx or surgical biopsy
Mgmt: benign breast mass (FNA/CNBx)
Possible observation - exam and imaging studies need to concordant with benign disease, otherwise need excisional biopsy.
Sensitivity / specificity: mammography
How does mammography increase with age?
Sensitivity increases with age as the dense parenchymal tissue is replaced with fat.
Size breast mass to be detected by mammography
> 5 mm
Mammography: suggestive of Cancer
Irregular borders. Speculated. Multiple clustered. Small. Thin. Linear. Crushed-like and/or branching calcifications. Ductal asymmetry. Distortion of architecture.
Tx: Routine screening
Tx: Routine screening
Probably benign finding
Tx: Routine screening
Suspicious abnormality (eg, indeterminate calcifications or architecture)
Tx: definite probability of CA; get CNBx
Highly suggestive of CA (suspicious calcifications or architecture)
Tx: high probability of CA; get CNBx.
Tx: BI-RADs 4 lesion CNBx
- Benign and concordant with mammogram?
- Malignancy: follow appropriate treatment
- Non-diagnostic, interdeterminate, or benign and non-concordant with mammogram -> need needle localization excisional biopsy
- Benign and concordant with mammogram -> 6 month follow-up
Tx: BI-RADs 5 lesion CNBx shows
- Any other finding?
- Malignancy: follow appropriate tx
- Any other finding (non diagnostic, indeterminate, or benign) -> all need needle localization excisional biopsy.
What allows appropriate staging with SLNBx (mass is still present) and one-step surgery for patients diagnosed with breast cancer?
CNBx without excisional biopsy.
Recommendations: mammogram screening?
Q 2-3 years after age 40, then yearly after 50.
Recommendations: high-risk mammogram screening
10 years before the youngest age of diagnosis of breast CA in first-degree relative.
Why aren't mammograms generally recommended in patients
Hard to interpret because of dense parenchyma.
How does mammogram radiation dose change in younger patients?
I: lateral to pectoralis minor muscle
II: beneath pectoralis minor muscle.
III: medial to pectorlis minor muscle
LN: between the pectoralis major and pectoralis minor muscles.
What nodes do you generally take?
Level I and II. Take level III nodes only if grossly involved.
Most important prognostic staging factor
Factors including in prognostic staging
Nodes (most important). Size. Grade. Progesterone / Estrogen receptor status.
What is survival directly related to in breast cancer?
Number of positive nodes.
- 0: 75% 5-year survival
- 1-3: 60% 5-year survival
- 4-10: 04% 5-year survival
Most common site for distant metastasis
Time: Single malignant cell to 1-cm tumor.
Approximately 5-7 years
Location: increased risk of multicentricity
Central and subareolar tumors
Breast CA: greatly increased risk (relative risk > 4)
- BRCA gene in pt with +fam hx
- > 2 primary relatives with BL or premenopausal breast CA
- DCIS (ipsilateral breast at risk) and LCIS (both breasts have same high risk)
- Fibrocystic disease with atypical hyperplasia.
Breast CA: moderately increased risk (relative risk 2-4)
- Prior breast cancer
- Radiation exposure
- First degree relative with breast cancer
- Age > 35 first birth
Breast CA: lower increased risk (relative risk
- Early menarche / late menopause
- Proliferative benign disease
- Obesity, alcohol, hormone replacement therapy.
BRCA I Cancer Risk
- Female breast CA
- Ovarian CA
- Male breast CA
- Female breast: 60%
- Ovarian: 40%
- Male breast: 1%
BRCA II Cancer Risk
- Female breast CA
- Ovarian CA
- Male breast CA
- Female breast: 60%
- Ovarian: 10%
- Male breast: 10%
Sx Considerations: BRCA families with history of breast cancer
Total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO)
Breast Cancer risk: first degree relative with bilateral, premenopausal breast cancer
Considerations for prophylactic mastectomy
- Family history + BRCA gene
- Also need one of the following: high patient anxiety, poor patient access for follow-up exams and mammograms, difficult lesion to follow on exam or with mammograms, or patient with preference for mastectomy
Why are positive receptors good?
Better response to hormones, chemotherapy, surgery, and better overall prognosis.
Receptor-positive tumors are more common in...
What receptor do you want positive: estrogen or progesterone?
Progesterone receptor-positive tumors have better prognosis than estrogen receptor-positive tumors.
What happens with positive estrogen AND progesterone receptors?
Both positive? Has the best prognosis.
%: Breast cancer negative for both receptors.
Male breast cancer
What is male breast cancer associated with?
Tx: male breast cancer
Tx: Modified Radical Mastectomy (MRM)
- 85% of all breast cancer.
Tx: MRM or BCT (breast conserving therapy) with post XRT
Ductal CA: Subtypes
Ductal CA: smooth borders, increased lymphocytes, bizarre cells, more favorable prognosis.
Medullary ductal CA
Ductal CA: small tubule formations, more favorable prognosis.
Tubular ductal CA
Ductal CA: produces an abdundance of mucin, more favorable prognosis
Mucinous (colloid) ductal CA
Ductal CA: worse prognosis
- 10% of all breast CA
- Does not form calcifications, extensively infiltrative, increased bilateral, multifocal and multi centric disease.
- signet ring cells confer worse prognosis
Tx: lobular cancer
MRM or BCT with post op XRT
Path: confers worse prognosis in lobular CA
Signet ring cells
- Considered T4 disease
- Very aggressive -> median survival of 36 months
- Has dermal lymphatic invasion, which causes peau d'orange lymphedema appearance on breast, erythematous and warm
Inflammatory breast cancer
Tx: inflammatory breast CA
Neoadjuvant chemo, then MRM, then adjuvant chemo-XRT (most common method)
- Leaves 1%-2% of breast tissue, preserves the nipple
- Not indicated for breast CA treatment
- Used for DCIS and LCIS
- Removes all breast tissue, including the nipple areolar complex
- Includes axillary node dissection (level 1 nodes)
Modified radical mastectomy
Surgical options for breast cancer
Modified radical mastectomy.
Combined with postop XRT; need 1cm margin
Absolute contraindications to Breast-Conserving Therapy in invasive CA
- Two or more primary tumors in separate quadrants of the breast.
- Persistant + margins after reasonable surgical attempts
- Pregnancy: BCT with radiation after delivery.
- h/o prior therapeutic radiation to breast region that would result in re-treatment with excessively high radiation dose.
- Diffuse malignant appearing microcalcifications
Relative contraindications to breast-conserving therapy in invasive carcinoma
- h/o scleroderma or active SLE
- Large tumor in a small breast that would result in cosmoses unacceptable to pt.
- Very large of pendulous breasts if reproducibility of patient setup and adequate dose homogeneity cannot be ensured.
- Indicated only for malignant tumors > 1cm
- Not indicated in pts with clinically positive nodes (need ALND).
Sentinel lymph node biopsy (SLB)
When is accuracy best for sentinel lymph node biopsy?
When primary tumor is present (finds the right lymphatic channels)
Dye used for sentinel lymph node biopsy
Lymphazurin blue dye or radio tracer is injected directly into the tumor area.
What to do: no radio tracer dye is found during sentinel lymph node biopsy
Do a formal ALND
Contraindications: SLNB (sentinel lymph node biopsy)
Multi centric disease.
Clinically positive nodes.
Prior axillary surgery.
Inflammatory or locally advanced disease.
When level nodes do you take for axillary lymph node dissection?
Level 1 and 2 nodes
Complications of MRM
Complications of ALND
- Infection, lymphedema, lymphangiosarcoma.
- Axillary vein thrombosis (sudden early post swelling)
- Lymphatic fibrosis (slow swelling over 18 months)
- Intercostal brachiocutaneous nerve injury
ALND: sudden, early, post op swelling
Axillary vein thrombosis
ALND: slow swelling over 18 months
ALND: hypesthesia of inner arm and lateral chest wall; most commonly injured nerve after mastectomy, no significant sequelae
Intercostal brachiocutaneous nerve injury
MC'ly injured nerve after mastectomy
Intercostal brachiocutaneous nerve injury.
How long do you leave in drains after ALND?
Radiation dose of radiotherapy
5,000 rad for BCT and XRT
Edema. Erythema. Rib fratures. Pneumonitis. Ulceration. Sarcoma. Contralateral breast CA.
Scleroderma (results in severe fibrosis and necrosis). Previous XRT and would exceed recommended dose. SLE (relative). Active rheumatoid arthritis (relative).
Indications for XRT after mastectomy.
- > 4 nodes
- Skin or chest wall involvement
- Positive margins
- Tumor > 5 cm (T3)
- Extracapsular nodal invasion.
- Inflammatory CA
- Fixed axillary nodes (N2) or internal mammary nodes (N3)
When can you start XRT after BCT?
When you have 1cm negative margins following BCT
%: Chance of local recurrence after BCT with XRT
- Usually within 2 years of first operation.
- Need to re-stage with recurrence.
- Need salvage MRM for local recurrence.
(taxanes, Adriamycin, cyclophosphamide for 6-12 weeks)
Who gets chemotherapy with positive nodes?
Everyone EXCEPT postmenopausal women with positive estrogen receptors (they get hormonal therapy only aromatase inhibitor (anastrozole))
Tx: postmenopausal, positive nodes, estrogen receptor positive
Hormonal therapy only with aromatase inhibitor (anastrozole)
Chemo: > 1cm and negative nodes
Everyone gets chemo except patients with positive estrogen receptors - > they can get hormonal therapy only with tamoxifen if they are premenopausal or aromatase inhibitor (anastrozole) if they are postmenopausal.
Hormonal therapy as above if positive estrogen receptors.
Tx after chemo: pts positive for estrogen receptors
Appropriate hormonal therapy
Have been shown to decrease recurrence and improve survival
Both chemotherapy and hormonal
- Decreases risk of breast cancer by 50%
- 1% risk of blood clots; 0.1% risk of endometrial cancer
What happens to women with breast cancer recurrence?
Almost all women with recurrence die of disease.
Increased recurrences and metastases occurs with..
- Pain, swelling, erythema is metastatic areas.
- Tx: XRT can help
XRT is good for bone metastasis
Breast CA that presents as axillary metastases with unknown primary.
Occult breast CA
- Tx: MRM (70% are found to have breast CA)
- Scaly skin lesion on nipple
- Have DCIS or ductal CA in breast
Tx: need MRM if cancer present; otherwise simple mastectomy (need to include the nipple-areolar complex with Paget's)
Bx: Paget's disease
Tx: Paget's disease
Need MRM if cancer present; otherwise simple mastectomy (need to include the nipple-areolar complex with Paget's)
- 10% malignant, based on mitoses per high-power field (>5-10)
- No nodal metastases, hematogenous spread if any (rare)
- Resembles giant fibroadenoma; his stromal and epithelial elements (mesencymal tissue)
- Can often be large tumors
- Tx: WLE with negative margins; no ALND
Tx: Cystosarcoma phyllodes
WLE with negative margins; no ALND
- Lymphangiosarcoma from chronic lymphedema following axillary dissection
- Pts present with dark purple nodule or lesion on arm 5-10 years after surgery
- Tends to present late, leading to worse prognosis.
- Mammography and US do not work as well during pregnancy.
- Try to use ultrasound to avoid radiation
Pregnancy with mass
Tx: pregnant with mass - cyst
Drain it and send FNA for cytology
Tx: pregnant with mass - solid
Perform core needle biopsy or FNA
Pregnancy with mass: core needle and FNA equivocal
Need to go to excisional biopsy.
If breast CA
- 1st trimester?
- 2nd trimester?
- 3rd trimester?
- 1st: MRM
- 2nd: MRM
- 3rd: MRM or if late can perform lumpectomy with ALND and postpartum XRT
Radiation in pregnancy with breast cancer.
No XRT while pregnant, no breastfeeding after delivery.
Boundaries of the axilla:
- Superior: axillary vein
- Posterior: long thoracic nerve
- Lateral: latissimus dorsi
- Medial: lateral to, deep to, or medial to pectoral minor muscle, depending on the level of nodes taken.
What four nerves must the surgeon be aware of during an axillary dissection?
1. Long thoracic nerve
2. Thoracodorsal nerve
3. Medial pectoral nerve
4. Lateral pectoral nerve
Courses along lateral chest wall in midaxillary line on serratus anterior muscle; innervates serratus anterior muscle
Long thoracic nerve
Courses lateral to long thoracic nerve on latissimus doors muscle; innervates latissimus dorsi muscle
Runs lateral to or through the pectoral minor muscle, actually lateral to the lateral pectoral nerve, innervates the pectoral minor and pectoral major muscles
Medial pectoral nerve
Runs medial to the medial pectoral nerve (names describe orientation from the brachial plexus!); innervates the pectoral major.
Lateral pectoral nerve
What is the name of the deformity if you cut the long thoracic nerve in this area?
What is the name of the cutaneous nerve that crosses the axillary 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 mammary artery.
What are the suspensory breast ligaments called?
What is the mammary "milk line"?
Embryological line from should to thigh where "supernumerary" breast areolar and / or nipple 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?
12% lifetime risk
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 suspeptibility genes?
What option exists to decrease the risk of breast cancer in women with BRCA?
Prophylactic bilateral mastectomy
What is the most common motivation for medicolwegal cases involving the breast?
Failure to diagnose a breast carcinoma.
What is the train of error for misdiagnosed breast cancer?
1. Age 75% of cases of misdiagnosed breast cancer have these three characteristics.
What are the history risk factors for breast cancer?
- Age at menarche (younger than 13 years)
- Age at menopause (> 55 years)
- Cancer of the breast (in self or family)
- Pregnancy with first child (> 30 yrs)
What are physical / anatomic risk factors for breast cancer?
- Cancer in the breast (3% synchronous contralateral cancer)
- Hyperplasia, Atypical hyperplasia, Female, Elderly, DCIS
- LCIS, Inferited genes, Papilloma, Sclerosing adenosis
What is the relative risk of hormone replacement therapy?
1 - 1.5
Is "run of the mill" fibrocystic disease a risk factor for breast cancer?
What are the possible symptoms of breast cancer?
No symptoms. Mass in the breast. Pain (most painless). Nipple discharge. Local edema. Nipple retraction. Dimple. Nipple rash.
Why does the skin retraction occur?
Tumor involvement of Cooper's ligaments and subsequent traction on ligaments pull skin inward.
What are the signs of breast cancer?
Mass (1 cm is usually the smallest lesion that can be palpated on examination).
Dimple. Nipple rash. Edema. Axillary / supraclavicular nodes.
What is the most common site of breast cancer?
Approximately one half of cancers develop in the upper outer quadrants.
What are the different types of invasive breast cancer?
Infiltrating ductal ca (75%)
Medullary ca (15%)
Infiltrating lobular CA (2%)
Tubular ca (2%)
Mucinous ca (colloid) (1%)
Inflammatory breast ca (1%)
What is the MC type of breast cancer?
Infiltrating ductal ca
What is the differential diagnosis of breast cancer?
Fibrocystic disease of the breast. Fibroadenoma. Intraductal papilloma. Duct ectasia. Fat necrosis. Abscess. Radial scar. Simple cyst.
Breast exam recommendations?
Self-exam of breasts monthly.
Ages 20-40 years: breast exam every 2-3 years by a physician.
> 40 years: annual breast exam by physician.
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; younger women have more fibrous tissue, which makes mammograms harder to interpret.
What are the radiographic tests for breast cancer?
Mammography and breast ultrasound, MRI
What option is best to evaluate a breast mass in a woman younger than 30 years?
What are the methods for obtaining tissue for pathologic examination?
FNA, core biopsy (larger needle core sample), mammotome sterotactic biopsy, and open biopsy which can be incisional (cutting a piece of the mass) or excisional (cutting out the entire mass)
What are the indications for biopsy of breast mass?
?Persistent mass after aspiration.
solid Mass. Blood in cyst aspirate. Suspicious lesion by mammo/US/MRI. Ulcer or dermatitis of nipple. Patient's concern of persistent breast abnormality.
What is the process for performing a biopsy when a non palpable mass is seen on mammo?
Stereotactic (mammotome) biopsy or needle localization therapy
What is needle loc biopsy (NLB)?
Needle localization by radiologist, followed by biopsy; removed breast tissue must be checked by mammo to ensure al of the suspicious lesion has been excised.
What is a mammotome biopsy?
Mammogram-guided computerized stereotactic core biopsies
What is obtained first, the mammogram or the biopsy?
Mammogram is obtained first; otherwise, tissue extraction (core or open) may alter the mammography findings (FNA may be done prior to the mammo because the fine needle will not affect the mammography 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 a/w a radial scar?
Tubular carcinoma, thus, biopsy is indicated.
What is the "workup" for a breast mass?
1. Clinical breast exam
2. Mammogram on breast ultrasound.
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 for cytology.
When do you proceed to open biopsy for a breast cyst?
1. In the case of a second cyst recurrence.
2. Bloody fluid in the cyst.
3. Palpable mass after aspiration.
What is the preoperative staging workup in a patient with breast cancer?
1. Bilateral mammo (CA in one breast is a risk for cancer in 2)
2. CXR (lung mets)
3. LFT (liver mets)
4. Serum calcium level, alkaline phosphatase (if these tests indicate bone mets/bone pain, proceed to bone scan)
5. Other: depending s/s
What hormone receptors must be checked for in the biopsy specimen?
Estrogen and progesterone receptors
What staging system is used for breast cancer?
Stage: Tumor 2-5 cm in diameter with mobile axillary nodes
- or -
Tumor > 5cm with no nodes
Stage: Tumor > 5cm with mobile axillary nodes
- or -
Any size tumor with fixed axillary nodes, no metastases
Stage: Peau d'orange (skin edema) or Chest wall invasion / fixation or Inflammatory cancer or breast skin ulceration or breast skin satellite metastases or any tumor and + ipsilateral internal mammary lymph nodes.
Stage: Any size tumor, no distant mets.
Positive: supraclavicular, infraclavicular, or internal mammary lymph nodes
Stage: distant mets (including ipsilateral supraclavicular nodes)
What are the sites of metastases?
Lymph nodes (MC). Lung / pleura. Liver. Bones. Brain.
What are the major treatments of breast cancer?
Modified radical mastectomy.
Lumpectomy and radiation + SLND.
(Both: either +/- post op chemo / tamoxifen)
What are the indications for radiation therapy after a modified radical mastectomy?
Stage 3A, Stage 3B, Pectoral muscle / fascia invasion.
Positive internal mammary LN.
Positive surgical margins.
> 4 positive axillary LN's postmenopausal.
What breast carcinomas are candidates for lumpectomy and radiation (breast-conserving therapy)?
Stage 1 and 2 (tumors
What approach may allow a patients with stage 3A cancer to have breast-conserving surgery?
Neoadjuvant chemotherapy - if the prep chemo shrinks the tumor.
What is the treatment of inflammatory carcinoma of the breast?
Chemotherapy first! Then often followed by radiation, mastectomy, or both.
What is a "lumpectomy and radiation"?
Lumpectomy (segmental mastectomy: removal of a part of the breast); axillary node dissection; and a course of radiation therapy after operation, over a period of several weeks.
What is the major absolute contraindication to lumpectomy and radiation?
What is a modified radical mastectomy?
Breast, axillary nodes (level I and 2) and nipple-areolar complex are removed. Pectoralis major and minor muscles are not removed (Auchincloss modification). Drains are placed to drain lymph fluid.
Where are the drains placed with an MRM?
2. Chest wall (breast bed)
When should the drains be removed s/p MRM?
What are the potential complications after a modified radical mastectomy?
Ipsilateral arm lymphedema. Infection. Injury to nerves, skin flap necrosis, hematoma / serum, phantom breast syndrome.
During an axillary dissection, should the patient be paralyzed?
No, because the nerves (long thoracic / thoracodorsal) are stimulated with resultant muscle contraction to help identify them.
How can the long thoracic and thoracodorsal nerves be identified during an axillary dissection?
Nerves can be stimulated with a forceps, which results in contraction of the latissimus dorsi (thoracodorsal nerve) or anterior serratus (long thoracic nerve)
When do you remove the drains after an axillary dissection?
When there is
What is a sentinel node biopsy?
Instead of removing all the axillary lymph nodes, the primary draining or "sentinel" lymph node is removed.
How is the sentinel lymph node found?
Inject blue dye and/or technetium-labeled sulfur colloid (best results with both)
What follows a positive sentinel node biopsy?
Removal of the rest of the axillary lymph nodes
What is now considered the standard of care for lymph node evaluation in women with T1 or T2 tumors (stages 1 and 2A) and clinically negative axillary lymph nodes?
Sentinel lymph node dissection
What do you do with a mammotome biopsy that returns as "atypical" hyperplasia?
Open needle loc biopsy as many will have DCIS or invasive cancer
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?
Yes. In the breast cancer prevention trial of 13,000 women at increased risk, tamoxifen reduces risk by ~ 50% across all ages.
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 x relative risk), DVT, PE, cataracts, hot flashes, mood swings
In high-risk women, is there a way to reduce the risk of developing breast cancer?
Yes, tamoxifen for 5 yr will lower the risk ~ 5%, but with an increased risk of endometrial cancer and clots, it must be an individual patient determination
What type of chemotherapy is usually used for breast cancer?
CMF (cyclophosphamide, methotrexate, 5-fluorouracil) or CAF (cyclophosphamide, adriamycin, 5-fluorouracil)
What makes a tumor high risk?
> 1 cm in size
Lymphatic / vascular invasion
Nuclear grade (high)
S phase (high)
What is DCIS also known as?
Cancer cells in the duct without invasion. (Cells do not penetrate the basement membrane).
Usually none; usually nonpalpable
DCIS: mammographic findings
Core or open biopsy
DCIS: most aggressive subtype
Risk: lymph node mets DCIS
What is the major risk with DCIS?
Subsequent development of infiltrating ductal carcinoma in the same breast
Tx: DCIS Tumor
Remove with 1 cm margins +/- XRT
Tx: DCIS Tumor > 1cm
Perform lumpectomy with 1 cm margins and radiation or total mastectomy (no axillary dissection)
What is a total (simple) mastectomy?
Removal of the breast and nipple without removal of the axillary nodes (always remove nodes with invasive cancer)
When must a simple mastectomy be performed for DCIS?
Diffuse breast involvement (e.g., diffuse micro calcifications), > 1cm and contraindication to radiation
What is the role of axillary node dissection with DCIS?
No role in true DCIS (i.e., without micro invasion); some perform a sentinel lymph node dissection for high-grade DCIS
What is adjuvant for DCIS?
2. Postlumpectomy XRT
What is the role of tamoxifen in DCIS?
Tamoxifen for 5 years will lower the risk up to 50%, but with increased risk of endometrial cancer and clots; it must be an individual patient determination.
What is a memory aid for the breast in which DCIS breast cancer arises?
Cancer arises in the same breast as DCIS.
What is LCIS?
Lobular Carcinoma in Situ (Carcinoma cells in the lobules of the breast without invasion)
Mammographic findings: LCIS
LCIS is found incidentally on biopsy
LCIS: major risk
Carcinoma of either breast
Which breast is more at risk for developing an invasive carcinoma?
Equal risk in both breasts! (think of LCIS as a risk marker for future development of cancer in either breast)
What percentage of women with LCIS develop an invasive breast carcinoma?
~ 30% in the 20 years after diagnosis of LCIS
What type of invasive breast cancer do patients with LCIS develop?
Most commonly, infiltrating ductal carcinoma with equal distribution in the contralateral and ipsilateral breast
What medication may lower the risk of developing breast cancer in LCIS?
Tamoxifen for 5 yrs will lower the risk up to 50%, but with an increased risk of endometrial cancer and clots; it must be an individual patient determination.
What is the treatment of 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; DCIS cancer develops in the ipsilateral breast.
How do you remember which breast is at risk for invasive cancers in patients with LCIS?
LCIS: liberally in either breast
MCC bloody nipple discharge in young women
MC breast tumor
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 are the common options for breast reconstruction after a mastectomy?
What is the incidence of breast cancer in men?
What is the average age at diagnosis?
65 years of age
What are the risk factors?
Increased estrogen. Radiation. Gynecomastia from increased estrogen. Estrogen therapy. Klinefelter's syndrome (XXY). BRCA2 carriers.
Is benign gynecomastia a risk factor for male breast cancer?
What type of breast cancer do men develop?
Nearly 100% of cases are ductal carcinoma (men do not usually have breast lobules)
S/S: Breast cancer in men
Breast mass (most are painless), breast skin changes (ulcers, retraction), and nipple discharge (usually blood or a blood-tinged discharge)
MC presentation: breast cancer in main
Painless breast mass
Dx: breast cancer in men
Biopsy and mammogram
Tx: breast cancer in men
2. Sentinel LN dissection of clinically negative axilla
3. Axillary dissection if clinically positive axillary LN
MCC green, straw-colored or brown nipple discharge
MCC breast mass after breast trauma
Thrombophlebitis of superficial breast veins
What must be ruled out with spontaneous galactorrhea (+/- amenorrhea)
Prolactinoma (check pregnancy test and prolactin level)
Mesenchymal tumor arising from breast lobular tissue; most are benign
Phyllodes tumor: age
25-55 years (usually older than pt with fibroadenoma)
s/s: phyllodes tumor
Mobile, smooth breast mass that resembles a fibroadenoma on exam, mammogram / ultrasound findings
Dx: Phyllodes tumor
Core biopsy / excision
Tx: Phyllodes tumor
If benign, wide local excision; if malignant, simple total mastectomy.
What is the role of axillary dissection with cystosarcoma phyllodes tumor?
Only if clinically palpable axillary nodes, as the malignant form rarely spreads to nodes (MC site of mets is the lung)
Is there a role for chemotherapy with cystosarcoma phyllodes?
Consider chemotherapy if large tumor > 5 cm and "stromal overgrowth"
Benign tumor of the breast consisting of streams overgrowth, collagen arranged in "swirls"
Solid, mobile, well-circumscribed round breast mass, usually
Negative needle aspiration looking for fluid; ultrasound, core biopsy
Surgical resection for large or growing lesions; small fibroadenomas can be observed closely.
MC breast tumor in women
Common benign breast condition consisting of fibrous (rubbery) and cystic changes in the breast
S/S Breast pain or tenderness that varies with the menstrual cycle; cysts; and fibrous ("nodular") fullness
Dx: fibrocystic disease
Breast exam, history, and aspirated cysts (usually straw-colored or green fluid)
Tx: fibrocystic disease
Pain meds (NSAIDS)
Vitamin E, evening primrose oil (danazol and OCP as last resort)
What is done if the patient has a breast cyst?
Aspirate s/t needle drainage:
- Bloody / palpable mass: open bx
- Straw / green color: follow closely, 2nd? needle aspirate
- Re-recurrence usually requires open biopsy
Superficial infection of the breast (cellulitis)
MCC mastitis - bacteria
Stop breast-feeding and use a breast pump instead; apply heat; administer antibiotics
Why must the patient with mastitis have close follow-up?
To make sure that she does not have inflammatory breast cancer!
Causes of breast abscesses
Mammary ductal ectasia (stenosis of breast duct) and mastitis
Breast abscess: MC bacteria
Nursing - S. aureus
Nonlatating: mixed infection
Tx: Breast abscess
Antibiotics (eg, dicloxacillin)
Needle or open drainage with cultures taken.
Resection of involved ducts if recurrent.
Breast pump if breast-feeding.
Infection of the breast during breast feeding - most commonly caused by S. aureus; treat with antibiotics and follow for abscess formation
What must be ruled out with a breast abscess in a non lactating woman?
Enlargement of the male breast
Causes of male gynecomastia
Illicit drugs (marijuana)
Major DDX male gynecomastia in the older patient
Male breast cancer