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Flashcards in Chapter 24: Breast Deck (368):
1

Embryology: breast

Formed from the ectoderm milk streak

2

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

3

Cyclic change: increases breast swelling, growth of glandular tissue

Estrogen

4

Cyclic change: increase maturation of glandular tissue; withdrawal causes menses

Progesterone

5

Cyclic change: cause ovum release

FSH, LH surge

6

What causes atrophy of breast tissue after menopause?

After menopause, lack of estrogen and progesterone results in atrophy of breast tissue.

7

Innervates serratus anterior, injury results in winged scapula

Long thoracic nerve

8

Artery: supplies serratus anterior

Lateral thoracic artery

9

Innervates latissmus dorsi; injury results in weak arm pull-ups and adduction

Thoracodorsal nerve

10

Artery: supplies latissimus dorsi

Thoracodorsal artery

11

Innervates pectoralis major and pectorals minor

Medial pectoral nerve

12

Nerve: pectorals major only

Lacteral pectoral nerve

13

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.

Intercostobrachial nerve

14

Arteries that supply the breast

Internal thoracic artery, intercostal arteries, thoracoacromial artery, and lateral thoracic artery

15

Valveless vein plexus that allows direct hematogenous metastasis of breast CA to spine

Batson's plexus

16

Lymphatic drainage of the breast

- 97% to axillary nodes
- 2% to internal mamillary nodes
- Any quadrant can drain to the internal mammary nodes.

17

Considered N3 disease

Mets to supraclavicular nodes

18

Dx: primary axillary adenopathy

#1 is lymphoma

19

Suspensory ligaments of the breast. Divide breast into segments.

Cooper's ligaments

20

What does skin dimpling of the breast suggest?

Breast CA involving Cooper's ligaments dimpling the skin.

21

What are breast abscesses usually caused by?
MCC?

Usually a/w breast feeding.
MCC: Staph aureus

22

TX: breast abscess

Percutaneous or incision and drainage; discontinue breastfeeding; breast pump; antibiotics.

23

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)

24

What is infectious mastitis usually associated with?

Breastfeeding

25

Mammary duct ectasia or plasma cell mastitis

Periductal mastitis

26

S/S: noncyclical mastodynia, erythema, nipple retraction, creamy discharge from nipple; can have sterile or infected subareolar abscess

Periductal mastitis

27

Risk factors: periductal mastitis

Smoking, nipple piercings

28

Biopsy: Periductal mastitis

Dilated mammary ducts, inspissated secretions, marked periductal inflammation

29

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)

30

Breast cysts filled with milk; occurs with breastfeeding
Tx: ranges from aspiration to incision and drainage.

Galactocele

31

Can be caused by increased prolactin (pituitary prolactinoma), OCPs, TCAs, phenothiazines, metoclopramide, alpha-methyl dopa, reserpine.
- Is often a/w amenorrhea

Galactorrhea

32

2-cm pinch of breast tissue.
Tx: will likely regress; may need to resect if cosmetically deforming or causing social problems.

Gynecomastia

33

What is gynecomastia associated with?

Cimetidine. Spironolactone. Marijuana. Idiopathic in most.

34

Due to circulating maternal estrogens; will regress.

Neonatal breast enlargement.

35

MC location of polythelia (accessory breast tissue)

Axilla

36

MC breast anomaly.
Location?

Accessory nipples
- Found form axilla to groin

37

What is compromised with breast reduction?

Ability to lactate frequently compromised.

38

Hypoplasia of chest wall.
Amastia.
Hypoplastic shoulder.
No pectoralis muscle.

Poland's Syndrome

39

Pain in breast; rarely represents breast cancer.
Dx: history, breast exam, BL mammogram.

Mastodynia

40

Tx: Mastodynia

Danazol.
OCPs
NSAIDs.
Evening primrose oil.
Bromocriptine.
D/C: caffeine, nicotine, methylxanthines.

41

Pain before menstrual period, most commonly represents acute or subacute.

Cyclic mastodynia.

42

Continuous pain. MC'ly represents acute or subacute infection; continuous mastodynia is more refractory to treatment than cyclic mastodynia.

Continuous mastodynia.

43

Superficial vein thrombophlebitis of breast, feels cordlike, can be painful.

Mondor's disease

44

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.

45

Tx: Mondor's disease

NSAIDs

46

Dx: breast pain, nipple discharge (usually yellow to brown), lumpy breast tissue that varies with hormonal cycle.

Fibrocystic change.

47

Types of fibrocystic change.

Papillomatosis. Sclerosing adenosis. Apocrine metaplasia. Duct adenosis. Epithelial hyperplasia. Ductal hyperplasia. Lobular hyperplasia.

48

What type of fibrocystic disease is associated with risk of CA?

Atypical ductal or lobular hyperplasia.

49

Tx: atypical ductal / lobular hyperplasia subtypes of fibrocystic change?

Resect.
- Do not need to get negative margins with atypical hyperplasia; just remove all suspicious areas (i.e., calcifications that appear on mammogram).

50

MCC bloody nipple discharge

Intraductal papilloma

51

- Usually small, non palpable, close to nipple.
- Not premalignant

Intraductal papilloma

52

Intraductal papilloma
- Dx?
- Tx?

Dx: contrast ductogram to find papilloma, then needle localization
Tx: Subareolar resection of the involved duct and papilloma.

53

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.

Fibroadenoma

54

Path: fibroadenoma

prominent fibrous tissue compressing epithelial cells

55

Mammography: fibroadenoma

Large, coarse calcifications (popcorn lesions) from degeneration.

56

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.

57

Tx: enlarging fibroadenoma

Excisional biopsy

58

Why avoid resection of fibroadenoma in teenagers / younger children?

Resection can affect breast development.

59

Fibroadenoma: pts > 40

Excisional biopsy to ensure dx

60

Tx: fibroadenoma

- Pts Observe. No?ex bx.
- Pts > 40: Ex bx to ensure diagnosis

61

Most nipple discharge is...

Benign

62

Dx: nipple discharge

History, breast exam, BL mammogram. Try to find the trigger point on exam.

63

Nipple discharge: green
Tx?

Usually due to fibrocystic disease.
Tx: if cyclical and non spontaneous, reassure pt.

64

Nipple discharge: bloody
Tx?

MC intraductal papilloma; occasionally ductal CA.
Tx: Need ductogram and excision of that ductal area.

65

Nipple: serous discharge

Worrisome for cancer. Especially if coming form only 1 duct or spontaneous.
Tx: Excisional biopsy of that ductal area

66

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.

67

Discharge:
- Occurs only with pressure, tight garments, exercise, etc.
- Not as worrisome but may still need excisional biopsy (e.g., if bloody)

Nonspontaneous discharge

68

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).

69

Malignant cell of the ductal epithelium without invasion of basement membrane

Ductal carcinoma in situ.

70

DCIS Risk Ca:
Ipsilateral Breast
Contralateral Breast

Ipsilateral breast: 50%
Contralateral breast: 5%

71

DCIS: premalignant lesion

Yes.

72

- Usually not palpable and presents as a cluster of calcifications on mammography.
- Can have solid, cribriform, papillary, comedy patterns

DCIS

73

Most aggressive subtype DCIS
- Necrotic areas
- High risk for multi centricity, micro invasion, recurrence.
Tx?

Comedo pattern DCIS
- Tx: simple mastectomy.

74

Increased risk of cancer in DCIS?

Comedo type and lesions > 2.5cm

75

Tx: DICS (not high grade)

Lumpectomy and XRT.
Need 1cm margins.
No ALND or SLNB.
Possibly tamoxifen.

76

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.

77

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.

78

Patient who develop breast CA are more likely to develop a..

Ductal CA (70%)

79

Possibility of synchronous breast cancer at time of LCIS diagnosis?

5% (most likely ductal CA)

80

Do you need negative margins for LCIS?

No.

81

Treatment for LCIS

Nothing. Tamoxifen. BL subcutaneous mastectomy (no ALND).

82

Indications for Surgical Biopsy after core biopsy

Atypical ductal hyperplasia.
Atypical lobular hyperplasia.
Radial scar.
LCIS
Columnar cell hyperplasia with atypia.
Papillary lesion.
Lack of concordance between appearance of mammography lesion and histologic diagnosis.
Nondiagnostic specimen.

83

Country: lowest risk of breast CA worldwide

Japan

84

United States breast cancer risk

1 in 8 women (12%); 5% in women with no risk factors.

85

Breast cancer screening decreases mortality by..

25%

86

Years survival: untreated breast cancer

2-3 years

87

%: Beast CA with negative mammogram and negative ultrasound

10%

88

Clinical features of breast CA

Distortion of normal architecture.
Skin / nipple distortion or retraction.
Hard.
Tethered. Indistinct borders.

89

Symptomatic breast mass work up

Ultrasound & Core needle biopsy. (consider FNA).
- Need mammo in pts

90

Symptomatic breast mass work up > 40 years old

Need bilateral mammograms.
Ultrasound.
Core needle biopsy.

91

If core needle biopsy or FNA is indeterminate, non-diagnostic, non-concordant with exam findings / imaging studies..

Will need excisional biopsy.

92

Clinically indeterminate or suspect solid masses will eventually need..

Excisional biopsy unless CA diagnosis is made prior to that.

93

Tx: cyst fluid

Bloody: cyst excisional biopsy
Clear/recurs: excisional biopsy.
Complex: excisional biopsy

94

Test: gives architecture

CNBx

95

Test: Gives cytology (just the cells)

FNA

96

Mgmt: malignant breast mass (FNA/CNBx)

Definitive therapy

97

Mgmt: suspicious breast mass (FNA/CNBx)

Surgical biopsy

98

Mgmt: atypia breast mass (FNA/CNBx)

Surgical biopsy

99

Mgmt: non diagnostic breast mass (FNA/CNBx)

Repeated FNA/CNBx or surgical biopsy

100

Mgmt: benign breast mass (FNA/CNBx)

Possible observation - exam and imaging studies need to concordant with benign disease, otherwise need excisional biopsy.

101

Sensitivity / specificity: mammography

90%

102

How does mammography increase with age?

Sensitivity increases with age as the dense parenchymal tissue is replaced with fat.

103

Size breast mass to be detected by mammography

> 5 mm

104

Mammography: suggestive of Cancer

Irregular borders. Speculated. Multiple clustered. Small. Thin. Linear. Crushed-like and/or branching calcifications. Ductal asymmetry. Distortion of architecture.

105

BI-RAD 1.

Negative
Tx: Routine screening

106

BI-RADs 2

Benign finding
Tx: Routine screening

107

BI-RADs 3

Probably benign finding
Tx: Routine screening

108

BI-RADs 4

Suspicious abnormality (eg, indeterminate calcifications or architecture)
Tx: definite probability of CA; get CNBx

109

BI-RADs 5

Highly suggestive of CA (suspicious calcifications or architecture)
Tx: high probability of CA; get CNBx.

110

Tx: BI-RADs 4 lesion CNBx
- Malignancy?
- Non-determinate?
- 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

111

Tx: BI-RADs 5 lesion CNBx shows
- Malignancy?
- Any other finding?

- Malignancy: follow appropriate tx
- Any other finding (non diagnostic, indeterminate, or benign) -> all need needle localization excisional biopsy.

112

What allows appropriate staging with SLNBx (mass is still present) and one-step surgery for patients diagnosed with breast cancer?

CNBx without excisional biopsy.

113

Recommendations: mammogram screening?

Q 2-3 years after age 40, then yearly after 50.

114

Recommendations: high-risk mammogram screening

10 years before the youngest age of diagnosis of breast CA in first-degree relative.

115

Why aren't mammograms generally recommended in patients

Hard to interpret because of dense parenchyma.

116

How does mammogram radiation dose change in younger patients?

Dose decreases

117

Node levels:
I?
II?
III?

I: lateral to pectoralis minor muscle
II: beneath pectoralis minor muscle.
III: medial to pectorlis minor muscle

118

LN: between the pectoralis major and pectoralis minor muscles.

Rotter's nodes

119

What nodes do you generally take?

Level I and II. Take level III nodes only if grossly involved.

120

Most important prognostic staging factor

Nodes

121

Factors including in prognostic staging

Nodes (most important). Size. Grade. Progesterone / Estrogen receptor status.

122

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

123

Most common site for distant metastasis

Bone

124

Time: Single malignant cell to 1-cm tumor.

Approximately 5-7 years

125

Location: increased risk of multicentricity

Central and subareolar tumors

126

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.

127

Breast CA: moderately increased risk (relative risk 2-4)

- Prior breast cancer
- Radiation exposure
- First degree relative with breast cancer
- Age > 35 first birth

128

Breast CA: lower increased risk (relative risk

- Early menarche / late menopause
- Nulliparity
- Proliferative benign disease
- Obesity, alcohol, hormone replacement therapy.

129

BRCA I Cancer Risk
- Female breast CA
- Ovarian CA
- Male breast CA

Lifetime risk..
- Female breast: 60%
- Ovarian: 40%
- Male breast: 1%

130

BRCA II Cancer Risk
- Female breast CA
- Ovarian CA
- Male breast CA

Lifetime risk..
- Female breast: 60%
- Ovarian: 10%
- Male breast: 10%

131

Sx Considerations: BRCA families with history of breast cancer

Total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO)

132

Breast Cancer risk: first degree relative with bilateral, premenopausal breast cancer

50%

133

Considerations for prophylactic mastectomy

- Family history + BRCA gene
- LCIS
- 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

134

Why are positive receptors good?

Better response to hormones, chemotherapy, surgery, and better overall prognosis.

135

Receptor-positive tumors are more common in...

Postmenopausal women

136

What receptor do you want positive: estrogen or progesterone?

Progesterone receptor-positive tumors have better prognosis than estrogen receptor-positive tumors.

137

What happens with positive estrogen AND progesterone receptors?

Both positive? Has the best prognosis.

138

%: Breast cancer negative for both receptors.

10%

139

-

Male breast cancer

140

What is male breast cancer associated with?

Steroid use.
Previous XRT.
Family history.
Klinefelter's syndrome

141

Tx: male breast cancer

Tx: Modified Radical Mastectomy (MRM)

142

- 85% of all breast cancer.
Tx?

Ductal CA
Tx: MRM or BCT (breast conserving therapy) with post XRT

143

Ductal CA: Subtypes

Medullary.
Tubular.
Mucinous.
Scirrhotic.

144

Ductal CA: smooth borders, increased lymphocytes, bizarre cells, more favorable prognosis.

Medullary ductal CA

145

Ductal CA: small tubule formations, more favorable prognosis.

Tubular ductal CA

146

Ductal CA: produces an abdundance of mucin, more favorable prognosis

Mucinous (colloid) ductal CA

147

Ductal CA: worse prognosis

Schirrhotic

148

- 10% of all breast CA
- Does not form calcifications, extensively infiltrative, increased bilateral, multifocal and multi centric disease.
- signet ring cells confer worse prognosis

Lobular cancer

149

Tx: lobular cancer

MRM or BCT with post op XRT

150

Path: confers worse prognosis in lobular CA

Signet ring cells

151

- 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

152

Tx: inflammatory breast CA

Neoadjuvant chemo, then MRM, then adjuvant chemo-XRT (most common method)

153

- Leaves 1%-2% of breast tissue, preserves the nipple
- Not indicated for breast CA treatment
- Used for DCIS and LCIS

Subcutaneous mastectomy
(simple mastectomy)

154

- Removes all breast tissue, including the nipple areolar complex
- Includes axillary node dissection (level 1 nodes)

Modified radical mastectomy

155

Surgical options for breast cancer

Subcutaneous mastectomy.
Breast-conserving therapy.
Modified radical mastectomy.
SLNB.
ALND.

156

Combined with postop XRT; need 1cm margin

Breast-conserving therapy.

157

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

158

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.

159

- Indicated only for malignant tumors > 1cm
- Not indicated in pts with clinically positive nodes (need ALND).

Sentinel lymph node biopsy (SLB)

160

When is accuracy best for sentinel lymph node biopsy?

When primary tumor is present (finds the right lymphatic channels)

161

Dye used for sentinel lymph node biopsy

Lymphazurin blue dye or radio tracer is injected directly into the tumor area.

162

What to do: no radio tracer dye is found during sentinel lymph node biopsy

Do a formal ALND

163

Contraindications: SLNB (sentinel lymph node biopsy)

Pregnancy.
Multi centric disease.
Neoadjuvant therapy.
Clinically positive nodes.
Prior axillary surgery.
Inflammatory or locally advanced disease.

164

When level nodes do you take for axillary lymph node dissection?

Level 1 and 2 nodes

165

Complications of MRM

Infection.
Flap necrosis.
Seromas.

166

Complications of ALND

- Infection, lymphedema, lymphangiosarcoma.
- Axillary vein thrombosis (sudden early post swelling)
- Lymphatic fibrosis (slow swelling over 18 months)
- Intercostal brachiocutaneous nerve injury

167

ALND: sudden, early, post op swelling

Axillary vein thrombosis

168

ALND: slow swelling over 18 months

Lymphatic fibrosis

169

ALND: hypesthesia of inner arm and lateral chest wall; most commonly injured nerve after mastectomy, no significant sequelae

Intercostal brachiocutaneous nerve injury

170

MC'ly injured nerve after mastectomy

Intercostal brachiocutaneous nerve injury.

171

How long do you leave in drains after ALND?

Drainage

172

Radiation dose of radiotherapy

5,000 rad for BCT and XRT

173

Complications: XRT

Edema. Erythema. Rib fratures. Pneumonitis. Ulceration. Sarcoma. Contralateral breast CA.

174

Contraindications: XRT

Scleroderma (results in severe fibrosis and necrosis). Previous XRT and would exceed recommended dose. SLE (relative). Active rheumatoid arthritis (relative).

175

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)

176

When can you start XRT after BCT?

When you have 1cm negative margins following BCT

177

%: Chance of local recurrence after BCT with XRT

10%
- Usually within 2 years of first operation.
- Need to re-stage with recurrence.
- Need salvage MRM for local recurrence.

178

Chemotherapy regimen

TAC
(taxanes, Adriamycin, cyclophosphamide for 6-12 weeks)

179

Who gets chemotherapy with positive nodes?

Everyone EXCEPT postmenopausal women with positive estrogen receptors (they get hormonal therapy only aromatase inhibitor (anastrozole))

180

Tx: postmenopausal, positive nodes, estrogen receptor positive

Hormonal therapy only with aromatase inhibitor (anastrozole)

181

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.

182

No chemo.
Hormonal therapy as above if positive estrogen receptors.

183

Tx after chemo: pts positive for estrogen receptors

Appropriate hormonal therapy

184

Have been shown to decrease recurrence and improve survival

Both chemotherapy and hormonal

185

Taxanes

Docetaxel, paclitaxel

186

- Decreases risk of breast cancer by 50%
- 1% risk of blood clots; 0.1% risk of endometrial cancer

Tamoxifen

187

What happens to women with breast cancer recurrence?

Almost all women with recurrence die of disease.

188

Increased recurrences and metastases occurs with..

Positive nodes.
Large tumors.
Negative receptors.
Unfavorable subtype.

189

- Pain, swelling, erythema is metastatic areas.
Tx?

Metastatic flare
- Tx: XRT can help
XRT is good for bone metastasis

190

Breast CA that presents as axillary metastases with unknown primary.
Tx?

Occult breast CA
- Tx: MRM (70% are found to have breast CA)

191

- Scaly skin lesion on nipple
- Have DCIS or ductal CA in breast
Tx?

Paget's disease
Tx: need MRM if cancer present; otherwise simple mastectomy (need to include the nipple-areolar complex with Paget's)

192

Bx: Paget's disease

Paget's cells

193

Tx: Paget's disease

Need MRM if cancer present; otherwise simple mastectomy (need to include the nipple-areolar complex with Paget's)

194

- 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?

Cystosarcoma phyllodes
- Tx: WLE with negative margins; no ALND

195

Tx: Cystosarcoma phyllodes

WLE with negative margins; no ALND

196

- Lymphangiosarcoma from chronic lymphedema following axillary dissection
- Pts present with dark purple nodule or lesion on arm 5-10 years after surgery

Stewart-Treves syndrome

197

- 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

198

Tx: pregnant with mass - cyst

Drain it and send FNA for cytology

199

Tx: pregnant with mass - solid

Perform core needle biopsy or FNA

200

Pregnancy with mass: core needle and FNA equivocal

Need to go to excisional biopsy.

201

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

202

Radiation in pregnancy with breast cancer.

No XRT while pregnant, no breastfeeding after delivery.

203

Boundaries of the axilla:
- Superior
- Posterior
- Lateral
- Medial

- 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.

204

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

205

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

Long thoracic nerve

206

Courses lateral to long thoracic nerve on latissimus doors muscle; innervates latissimus dorsi muscle

Thoracodorsal nerve

207

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

208

Runs medial to the medial pectoral nerve (names describe orientation from the brachial plexus!); innervates the pectoral major.

Lateral pectoral nerve

209

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

"Winged scapula"

210

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

Intercostobrachial nerve

211

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

Axillary vein

212

What is the lymphatic drainage of the breast?

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

213

What are the suspensory breast ligaments called?

Cooper's ligaments

214

What is the mammary "milk line"?

Embryological line from should to thigh where "supernumerary" breast areolar and / or nipple can be found

215

What is the "tail of Spence"?

"Tail" of breast tissue that tapers into the axilla.

216

Which hormone is mainly responsible for breast milk production?

Prolactin

217

What is the incidence of breast cancer?

12% lifetime risk

218

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

75%

219

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

~ 2%

220

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

33%

221

What are the major breast cancer suspeptibility genes?

BRCA1/2

222

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

Prophylactic bilateral mastectomy

223

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

Failure to diagnose a breast carcinoma.

224

What is the train of error for misdiagnosed breast cancer?

1. Age 75% of cases of misdiagnosed breast cancer have these three characteristics.

225

What are the history risk factors for breast cancer?

NAACP
- Nulliparity
- 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)

226

What are physical / anatomic risk factors for breast cancer?

CHAFED LIPS
- Cancer in the breast (3% synchronous contralateral cancer)
- Hyperplasia, Atypical hyperplasia, Female, Elderly, DCIS
- LCIS, Inferited genes, Papilloma, Sclerosing adenosis

227

What is the relative risk of hormone replacement therapy?

1 - 1.5

228

Is "run of the mill" fibrocystic disease a risk factor for breast cancer?

No

229

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.

230

Why does the skin retraction occur?

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

231

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.

232

What is the most common site of breast cancer?

Approximately one half of cancers develop in the upper outer quadrants.

233

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%)

234

What is the MC type of breast cancer?

Infiltrating ductal ca

235

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.

236

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.

237

When is the best time for breast self-exam?

1 week after menstrual period

238

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.

239

What are the radiographic tests for breast cancer?

Mammography and breast ultrasound, MRI

240

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

Breast ultrasound

241

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)

242

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.

243

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

Stereotactic (mammotome) biopsy or needle localization therapy

244

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.

245

What is a mammotome biopsy?

Mammogram-guided computerized stereotactic core biopsies

246

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).

247

What would be suspicious mammographic findings?

Mass, microcalcifications, stellate / spiculated mass

248

What is a "radial scar" seen on mammogram?

Spiculated mass with central lucency, +/- microcalcifications

249

What tumor is a/w a radial scar?

Tubular carcinoma, thus, biopsy is indicated.

250

What is the "workup" for a breast mass?

1. Clinical breast exam
2. Mammogram on breast ultrasound.
3. FNA, core biopsy, or open biopsy

251

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

Aspirate it with a needle

252

Is the fluid from a breast cyst sent for cytology?

Not routinely, bloody fluid should be sent for cytology.

253

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.

254

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

255

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

Estrogen and progesterone receptors

256

What staging system is used for breast cancer?

TMN

257

Stage: tumor

Stage 1

258

Stage: tumor

Stage 2A

259

Stage: Tumor 2-5 cm in diameter with mobile axillary nodes
- or -
Tumor > 5cm with no nodes

Stage 2B

260

Stage: Tumor > 5cm with mobile axillary nodes
- or -
Any size tumor with fixed axillary nodes, no metastases

Stage 3A

261

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 3B

262

Stage: Any size tumor, no distant mets.
Positive: supraclavicular, infraclavicular, or internal mammary lymph nodes

Stage 3C

263

Stage: distant mets (including ipsilateral supraclavicular nodes)

Stage 4

264

What are the sites of metastases?

Lymph nodes (MC). Lung / pleura. Liver. Bones. Brain.

265

What are the major treatments of breast cancer?

Modified radical mastectomy.
Lumpectomy and radiation + SLND.
(Both: either +/- post op chemo / tamoxifen)

266

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.

267

What breast carcinomas are candidates for lumpectomy and radiation (breast-conserving therapy)?

Stage 1 and 2 (tumors

268

What approach may allow a patients with stage 3A cancer to have breast-conserving surgery?

Neoadjuvant chemotherapy - if the prep chemo shrinks the tumor.

269

What is the treatment of inflammatory carcinoma of the breast?

Chemotherapy first! Then often followed by radiation, mastectomy, or both.

270

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.

271

What is the major absolute contraindication to lumpectomy and radiation?

Pregnancy

272

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.

273

Where are the drains placed with an MRM?

1. Axilla
2. Chest wall (breast bed)

274

When should the drains be removed s/p MRM?

275

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.

276

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.

277

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)

278

When do you remove the drains after an axillary dissection?

When there is

279

What is a sentinel node biopsy?

Instead of removing all the axillary lymph nodes, the primary draining or "sentinel" lymph node is removed.

280

How is the sentinel lymph node found?

Inject blue dye and/or technetium-labeled sulfur colloid (best results with both)

281

What follows a positive sentinel node biopsy?

Removal of the rest of the axillary lymph nodes

282

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

283

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

284

How does tamoxifen work?

It binds estrogen receptors

285

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

"Salvage" mastectomy

286

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.

287

What are common options for breast reconstruction?

TRAM flap, implant, latissimus dorsi flap

288

What is a TRAM flap?

Transverse Rectus Abdominis Myocutaneous flap

289

What are the side effects of tamoxifen?

Endometrial cancer (2.5 x relative risk), DVT, PE, cataracts, hot flashes, mood swings

290

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

291

What type of chemotherapy is usually used for breast cancer?

CMF (cyclophosphamide, methotrexate, 5-fluorouracil) or CAF (cyclophosphamide, adriamycin, 5-fluorouracil)

292

What makes a tumor high risk?

> 1 cm in size
Lymphatic / vascular invasion
Nuclear grade (high)
S phase (high)
ER negative
HER-2/neu overexpression

293

What is DCIS also known as?

Intraductal carcinoma.

294

Describe DCIS.

Cancer cells in the duct without invasion. (Cells do not penetrate the basement membrane).

295

s/s: DCIS

Usually none; usually nonpalpable

296

DCIS: mammographic findings

Microcalcifications

297

DX: DCIS

Core or open biopsy

298

DCIS: most aggressive subtype

Comedo

299

Risk: lymph node mets DCIS

300

What is the major risk with DCIS?

Subsequent development of infiltrating ductal carcinoma in the same breast

301

Tx: DCIS Tumor

Remove with 1 cm margins +/- XRT

302

Tx: DCIS Tumor > 1cm

Perform lumpectomy with 1 cm margins and radiation or total mastectomy (no axillary dissection)

303

What is a total (simple) mastectomy?

Removal of the breast and nipple without removal of the axillary nodes (always remove nodes with invasive cancer)

304

When must a simple mastectomy be performed for DCIS?

Diffuse breast involvement (e.g., diffuse micro calcifications), > 1cm and contraindication to radiation

305

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

306

What is adjuvant for DCIS?

1. Tamoxifen
2. Postlumpectomy XRT

307

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.

308

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

Cancer arises in the same breast as DCIS.

309

What is LCIS?

Lobular Carcinoma in Situ (Carcinoma cells in the lobules of the breast without invasion)

310

s/s: LCIS

None

311

Mammographic findings: LCIS

None

312

Dx: LCIS

LCIS is found incidentally on biopsy

313

LCIS: major risk

Carcinoma of either breast

314

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)

315

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

~ 30% in the 20 years after diagnosis of LCIS

316

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

317

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.

318

What is the treatment of LCIS?

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

319

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.

320

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

LCIS: liberally in either breast

321

MCC bloody nipple discharge in young women

Intraductal papilloma

322

MC breast tumor

Fibroadenoma

323

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

324

What are the common options for breast reconstruction after a mastectomy?

Saline implant
TRAM flap

325

What is the incidence of breast cancer in men?

326

What is the average age at diagnosis?

65 years of age

327

What are the risk factors?

Increased estrogen. Radiation. Gynecomastia from increased estrogen. Estrogen therapy. Klinefelter's syndrome (XXY). BRCA2 carriers.

328

Is benign gynecomastia a risk factor for male breast cancer?

No

329

What type of breast cancer do men develop?

Nearly 100% of cases are ductal carcinoma (men do not usually have breast lobules)

330

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)

331

MC presentation: breast cancer in main

Painless breast mass

332

Dx: breast cancer in men

Biopsy and mammogram

333

Tx: breast cancer in men

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

334

MCC green, straw-colored or brown nipple discharge

Fibrocystic disease

335

MCC breast mass after breast trauma

Fat necrosis

336

Thrombophlebitis of superficial breast veins

Mondor's disease

337

What must be ruled out with spontaneous galactorrhea (+/- amenorrhea)

Prolactinoma (check pregnancy test and prolactin level)

338

Mesenchymal tumor arising from breast lobular tissue; most are benign

Cystosarcoma phyllodes

339

Phyllodes tumor: age

25-55 years (usually older than pt with fibroadenoma)

340

s/s: phyllodes tumor

Mobile, smooth breast mass that resembles a fibroadenoma on exam, mammogram / ultrasound findings

341

Dx: Phyllodes tumor

Core biopsy / excision

342

Tx: Phyllodes tumor

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

343

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)

344

Is there a role for chemotherapy with cystosarcoma phyllodes?

Consider chemotherapy if large tumor > 5 cm and "stromal overgrowth"

345

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

Fibroadenoma

346

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

Fibroadenoma

347

Dx: fibroadenoma

Negative needle aspiration looking for fluid; ultrasound, core biopsy

348

Tx: fibroadenoma

Surgical resection for large or growing lesions; small fibroadenomas can be observed closely.

349

MC breast tumor in women

Fibroadenoma

350

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

Fibrocystic disease

351

S/S Breast pain or tenderness that varies with the menstrual cycle; cysts; and fibrous ("nodular") fullness

Fibrocystic disease

352

Dx: fibrocystic disease

Breast exam, history, and aspirated cysts (usually straw-colored or green fluid)

353

Tx: fibrocystic disease

Stop caffeine.
Pain meds (NSAIDS)
Vitamin E, evening primrose oil (danazol and OCP as last resort)

354

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

355

Superficial infection of the breast (cellulitis)

Mastitis

356

MCC mastitis

Breast-feeding

357

MCC mastitis - bacteria

S. aureus

358

Tx: mastitis

Stop breast-feeding and use a breast pump instead; apply heat; administer antibiotics

359

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

To make sure that she does not have inflammatory breast cancer!

360

Causes of breast abscesses

Mammary ductal ectasia (stenosis of breast duct) and mastitis

361

Breast abscess: MC bacteria

Nursing - S. aureus
Nonlatating: mixed infection

362

Tx: Breast abscess

Antibiotics (eg, dicloxacillin)
Needle or open drainage with cultures taken.
Resection of involved ducts if recurrent.
Breast pump if breast-feeding.

363

Infection of the breast during breast feeding - most commonly caused by S. aureus; treat with antibiotics and follow for abscess formation

Lactational mastitis

364

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

Breast cancer

365

Enlargement of the male breast

Male Gynecomastia

366

Causes of male gynecomastia

Medications.
Illicit drugs (marijuana)
Liver failure
Increased estrogen
Decreased testosterone

367

Major DDX male gynecomastia in the older patient

Male breast cancer

368

Tx: male gynecomastia

Stop or change medications; correct underlying cause if there is a hormonal imbalance; and perform biopsy or subcutaneous mastectomy (i.e., leave nipple) if refractory to conservative measures and time.