Chapter 24 - Breast Flashcards Preview

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Flashcards in Chapter 24 - Breast Deck (152):
1

Estrogen leads to what part of breast development?

Duct (double layer of columnar cells)

2

Progesterone leads to what part of breast development?

Lobular development

3

Prolactin has what effect on breast development?

Synergizes esterogen and progesterone

4

Estrogen causes what cyclic change in the breast?

Increased breast swelling, growth of glandular tissue

5

Progesterone causes what cyclic change in the breast?

Increased maturation of glandular tissue; withdrawal causes menses

6

What cyclic change is caused by LH, FHS surge?

Causes ovum release

7

Long thoracic nerve innervates what? Injury results in what?

Serratus anterior; winged scapula

8

Thoracodorsal nerve innervates what? Injury causes what?

Latissimus dorsi; weak arm pull-ups and adduction

9

What artery goes to the serratus anterior?

Lateral thoracic artery

10

What artery goes to latissimus dorsi?

Thoracodorsal artery

11

Medial pectoral nerve innervates what?

Pectoralis major and minor

12

Lateral pectoral nerve innervates what?

Pectoralis major only

13

Intercostobrachial nerve comes from where? Innervates what?

From lateral cutaneous branch of the 2nd intercostal nerve; sensation to medial arm and axilla

14

Branches of what arteries supply the breast?

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

15

Batson's plexus allows what to happen in breast cancer?

Valveless vein plexus that allows direct hematogenous mets to spine

16

What does primary axillary adenopathy indicate?

#1 lymphoma

17

Positive supraclavicular nodes indicate what stage disease?

M1

18

Most common bacteria in breast abscess?

S. aureus, strep; associated with breast feeding

19

Treatment for abscesses?

I&D, d/c breast feeding; ice, heat, pump, antibiotics

20

Most common bacteria in infectious mastitis?

S. aureus; in nonlactating women can be due to chronic inflammatory diseases (actinomyces, TB, syphilis)

21

Workup for infectious mastitis?

Need to rule out necrotic cancer; incisional biopsy including skin

22

What is periductal mastitis?

Mammary duct ectasia or plasma cell mastitis; dilated mammary ducts, inspissated secretions, marked periductal inflammation

23

Symptoms of periductal mastitis?

Noncyclical mastodynia, nipple retraction, creamy discharge from nipple; can have sterile subareolar abscess; pts with difficulty breast feeding

24

Treatment for periductal mastitis?

Reassure if discharge is creamy, non bloody and not associated with nipple retraction; otherwise r/o cancer

25

What is a galactocele?

Breast cysts filled with milk; occurs with breast feeding

26

Treatment for galactocele?

Aspiration to I&D

27

What is galactorrhea caused by?

High prolactin (pituitary prolactinoma), OCPs, TCAs, phenothiazines, metoclopramide, alpha-methyl dopa, reserpine

28

What is gynecomastia? Caused by?

2cm pinch (ouch); cimetidine, spironolactone, marijuana, idiopathic

29

What is the cause of neonatal breast enlargement?

Due to circulating maternal estrogens; will regress

30

Most common location for accessory breast tissue?

Axilla

31

What is the most common breast abnormality?

Accessory nipples

32

What is Poland's syndrome?

Hypoplasia of chest wall, amastia, hypoplastic shoulder, no pectoralis muscle

33

Workup for mastodynia?

Pain in breast; rarely represents breast CA; H&P and bilateral mammogram

34

Treatment for mastodynia?

Danazol, OCPs, NSAIDs, evening primrose oil, bromocriptine

35

What is cyclic mastodynia most commonly caused by?

Fibrocystic diseased

36

What is continuous mastodynia caused by?

Most commonly acute or subacute infection

37

What is Mondor's disease?

Superficial vein thrombophlebitis of breast; cordlike, can be painful

38

What is Mondor's associated with? Treatment?

Trauma and strenuous exercise; NSAIDs

39

Symptoms of fibrocystic disease?

Breast pain, nipple discharge (uncommon, yellow to brown), masses, lumpy breast tissue that varies with hormonal cycle

40

How can sclerosing adenosis present?

Cluster of calcifications on mammogram without mass or pain

41

How is sclerosing adenosis differentiated from breast CA?

By regularity of nuclei and absence of mitoses

42

Risk factors for benign breast disease?

Early menarche, late menopause, small breast size, normal or low body weight, h/o cyclic breast discomfort, irregular menses, h/o spontaneous abortions, postmenopausal status

43

Most common cause of bloody discharge from nipple?

Intraductal papilloma

44

Malignancy risk with intraductal papilloma?

NOT premalignant

45

Treatment of intraductal papilloma?

Resection (subareolar resection curative)

46

What is the most common breast lesion in adolescents and young women?

Fibroadenoma

47

Characteristics of fibroadenoma?

Painless, slow growing, well cicumscribed, firm and rubbery; change size in pregnancy; grows to several cm in size then stop

48

Pathology of fibroadenoma? Mammography findings?

Prominent fibrous tissue compressing epithelial cells; popcorn lesions (large, coarse calcifications)

49

Work up of nipple discharge?

H&P, bilateral mammogram

50

What is green discharge due to? What is the treatment?

Fibrocystic disease; if cyclical and nonspontaneous, reassure patient

51

What is bloody discharge due to? Treatment?

Most commonly intraductal papilloma, occasionally ductal CA; galactogram and excision of that ductal area

52

What is serous discharge due to? Treatment?

Worrisome for cancer; excisional biopsy of that ductal area

53

What is spontaneous discharge due to? Treatment?

Worrisome for cancer no matter what color or consistency; biopsy in area of duct

54

What is nonspontaneous discharge due to? Treatment

Pressure, tight garments, exercise; not as worrisome, however still need biopsy

55

Characteristics of diffuse papillomatosis? Risk of cancer?

Multiple ducts of both breasts, larger when solitary, serous discharge; increased risk of cancer (40%)

56

Mammogram findings of diffuse papillomatosis?

Swiss cheese appearance

57

Definition of ductal carcinoma in situ?

Malignant cells of ductal epithelium without invasion of the basement membrane

58

% risk of cancer with DCIS?

50-60% get cancer if not resected; 5-10% will get cancer in contralateral breast

59

Mammogram findings with DICS?

Usually not palpable; cluster of calcifications on mammography

60

Margins needed with excision of DCIS?

2-3mm

61

Patterns of DCIS?

Solid, cribriform, papillary, comedo

62

What is the most aggressive subtype of DCIS?

Comedo pattern; with necrotic areas; high risk fro multicentricity, microinvasion, recurrence

63

What characteristics increase the recurrence risk following excision of DCIS?

Comedo type, lesions >2.5cm

64

Treatment for DCIS?

Lumpectomy and XRT, ?tamoxifen; simple mastectomy if high grade, if large tumor not amenable to lumpectomy or not able to et good margins; NO ALND

65

Cancer risk with lobular carcinoma in situ?

40% get cancer (either breast)

66

Is LCIS premalignant?

NO, considered a marker for the development of breast CA; do NOT need negative margins

67

What type of breast CA do patients with LCIS develop?

More likely to develop ductal CA (70%)

68

% risk of having synchronous breast CA at the time of diagnosis of LCIS?

5%

69

Treatment for LCIS?

Nothing, tamoxifen, bilateral subutaneous mastectomy (NO ALND)

70

What country has the lowest rate of breast cancer worldwide?

Japan

71

Lifetime risk of breast cancer?

1 in 8 women (12%); 4-5% in women with no risk factors

72

What % will screening decrease mortality of breast cancer by?

25%

73

Median survival of untreated breast cancer?

2-3y

74

Clinical features of breast CA?

Distortion of normal breast architecture, skin/nipple distortion or retraction, hard, tethered, indistinct borders

75

Workup for symptomatic breast mass in pt <30y?

US: if solid - FNA; excisional biopsy if FNA is nondiagnostic

76

Workup of symptomatic breast mass in patient 30-50y?

Bilateral mammograms and FNA; excisional biopsy if FNA nondiagnostic

77

Workup of symptomatic breast mass in pt >50y?

Bilateral mammograms and excisional or core needle biopsy

78

Workup for cyst?

If fluid bloody: cyst excisional biopsy; clear and recurs, cyst excisional biopsy; complex, cyst excisional biopsy

79

What is the sensitivity/specificity of mammography?

90%; sensitivity increases with age as the dense parenchymal tissue is replaced with fat

80

Size of tumor that is able to be detected by mammography?

>5mm

81

General screening guidelines?

Mammogram Q2-3y after 40y, yearly after 50y; high risk screening: 10y prior to youngest age of diagnosis of breast CA in 1st degree relative

82

What are the node levels of the breast?

I: lateral to pec minor, II: beneath pec minor, III: medial to pec minor; Rotter's nodes - between the pec major and minor

83

What level node needs to be sampled?

Level I

84

What is the most important prognostic factor in breast cancer?

Nodal status; also tumor size, grade, progesterone/estrogen receptor status

85

5 year survival is 0 positive nodes?

75%

86

% of nonpalpable nodes that are positive at surgery?

30%

87

5 year survival if 1-3 nodes are positive?

60%

88

5 year survival if 4-10 nodes are positive?

40%

89

What is the most common location of distant mets?

Bone

90

What characteristics of tumor have increased multicentricity?

Central and subareolar tumors

91

T staging for breast cancer?

T1: 5cm, T4: skin or chest wall involvement, peau du'orange, inflammatory cancer

92

N staging for breast cancer?

N1: ipsilateral axillary nodes, N2: fixed ipsilateral axiallary nodes, N3: ipsilateral internal mammary nodes

93

Factors that will greatly increase breast cancer risk?

BRCA gene, >2 primary relatives with bilateral or premenopausal breast CA, DCIS and LCIS, fibrocystic disease with atypical hyperplasia

94

Factors that will moderately increase risk of breast cancer?

FH of breast cancer, early menarche, late menopause, nulliparity, radiation, previous breast CA, environmental risk factor (high-fat diet, obesity)

95

How much does a 1st degree relative with bilateral, premenopausal breast cancer increase breast cancer risk?

50%

96

Other cancers associated with BRCA I?

Ovarian (50%), endometrial CA; consider TAH, bilateral oophrectomies

97

Other cancers associated with BRCA II?

Male breast cancer

98

Requisites for prophylactic mastectomy?

FH + BRCA gene, LCIS, plus one of the following: anxiety, poor access to follow up exams, difficult lesion to follow, patient preference

99

Receptor positive tumors lead to what prognosis?

Better response to hormones, chemo, surgery, and better overall prognosis

100

Which receptor-positive tumors have best prognosis?

Progesterone > estrogen; both positive with best prognosis

101

What % of breast cancers are negative for both receptors?

10%

102

What type of cancer do males usually have?

Ductal

103

Male breast cancer is associated with what?

Steroid use, previous XRT, FH, Klinefelter's syndrome, prolonged hyperestrogenic state

104

Treatment of male breast cancer?

Modified radical mastectomy

105

What % of breast CAs are ductal?

85%

106

What are the subtypes of ductal CA?

Medullary, tubular, mucinous, scirrhotic

107

Characteristics of medullary breast CA?

Smooth borders, high lymphocytes, ductal type cancer with bizarre cells; majority E+/P+, more favorable prognosis

108

Characteristics of tubular CA?

Small tubule formations, nodes + in 10%, more favorable prognosis

109

Characteristics of mucinous CA?

Colloid, produces an abundance of mucin, more favorable prognosis

110

Characteristics of scirrhotic CA?

Worse prognosis

111

Treatment for ductal CA?

MRM or lumpectomy with ALND (or SNLB); post op XRT

112

What % of breast cancers are lobular?

10%

113

Characteristics of lobular CA?

Does not form calcifications, infiltrative, inc. bilateral, multifocal and multicentric

114

Lobular cancer with signet ring cells have what prognosis?

Worse

115

Treatment for lobular CA?

MRM or lumpectomy with ALND (or SLNB); postop XRT

116

Treatment for inflammatory cancer?

May need chemo and XRT 1st, then mastectomy

117

Stage of inflammatory cancer?

Considered T4

118

Median survival of inflammatory cancer?

Very aggressive; 36mo

119

What causes the peau d'orange lymphedema of inflammatory cancer?

Dermal lymphatic invasion; erythematous and warm

120

Preoperative studies needed before breast surgery?

CXR, bilateral mammorgrams, CBC, LFTs; abdominal CT if LFTs elevated; head CT if headaches; bone scan if bone pain or inc. alk phos

121

Subcutaneous (simple) mastectomy indications?

DCIS, LCIS; NOT indicated for breast CA; leaves 1-2% of breast tissue, preserves teh nipple

122

Margins necessary with simple mastectomy?

1cm; with SLNB

123

Indications for SLNB?

Malignant tumors >1cm; NOT indicated for pts with clincallly positive nodes

124

Complications of lymphazurin blue?

Type I hypersensitivity reactions

125

What next if no SLN found during SLND?

Formal ALND

126

The sentinal node is found in what % of the time?

95%

127

Contraindications to SNLB?

Pregnancy, multicenteric disease, neoadjuvant, clinically positive nodes, prior axillary surgery, inflammatory or locally adcanced disease

128

Modified radical mastectomy includes what?

All breast tissue including the nipple areolar complex; axillary node dissection (level I)

129

Radical mastectomy includes what?

MRM and overlyting skin, pectoralis major and minor, level I, II, III lymph nodes

130

Complications of axillary lymph node dissection?

Infection, lymphedema, lymphangiosarcoma, axillary vein thrombosis, lympatic fibrosis, intercostal brachiocutaneous nerve injury

131

Signs of axillary vein thrombosis?

Sudden, early, postop swelling

132

Most commonly injured nerve after mastecomy?

Intercostal brachiocutaneous nerve; hypersthesia of inner arm and lateral chest wall

133

Radiotherapy dose for breast cancer?

5000 rad for lumpectomy and XRT

134

Complications of XRT?

Edema, erythema, rib fractures, pneumonitis, ulceration, sarcoma, contralateral breast CA

135

Contraindications of XRT?

Scleroderma, previous XRT, SLE, active RA

136

What is the chance of recurrence following lumpectomy with XRT?

10%; usually within first 2 years

137

Treatment with local recurrence?

Salvage MRM

138

Which patients get chemo?

Positive nodes (except postmenopausal women with positive estrogen receptors (tamoxifen), >1cm and negative nodes

139

By what percent does tamoxifen decrease short-term risk of breast cancer by?

50-60%

140

What is the risk of blood clots on tamoxifen?

1%

141

What is the risk of endometrial cancer in patients that are on tamoxifen?

0.1%

142

What are the symptoms of a metastatic flare? What is the treatment?

Pain, swelling, erythema in metastatic areas; XRT

143

What is occult breast cancer?

Breast-cancer that presents as axillary metastases with unknown primary

144

What percent of occult breast-cancer are found to have breast cancer at mastectomy?

70%

145

What are benign conditions that mimic breast cancer?

Radial scar, fibromatosis, granular cell tumors, fat necrosis

146

Which malignant tumors have a benign appearance; smooth rounded masses?

Mucinous cancer, medullary cancer, cystosarcoma phyllodes

147

How does Paget's disease present? What is the treatment?

Presents with scaly skin lesion on nipple; biopsy shows Paget's cells. Need modified radical mastectomy if cancer present, otherwise simple mastectomy

148

What percent of cystosarcoma phyllodes are malignant? How is the diagnosis made?

10%; based on mitoses per high-power field, resemble giant fibroadenoma, has stromal and epithelial elements

149

What is the treatment for cystosarcoma phyllodes?

Wide local excision with negative margins, no ALND

150

What is Stuart-Treves syndrome?

Lymphangiosarcoma from chronic lymphedema following axillary dissection, presents with dark purple nodule on the arm 5 to 10 years after surgery

151

What is the prognosis for a mass that presents during pregnancy?

Worse prognosis because it tends to present late

152

Treatment for breast cancer that presents during pregnancy?

First trimester: MRM; second trimester: MRM; third trimester: MRM or if late can perform lumpectomy with ALND and postpartum XRT; no chemo or radiation while pregnant, no breast-feeding after delivery