Chapter 24: Breast Flashcards
(283 cards)
1
Q
Embryology: breast
A
Formed from the ectoderm milk streak
2
Q
Hormones that cause.. 1. Duct development (double layer of columnar cells) 2. Lobular development 3. Synergizes estrogen and progesterone
A
- Estrogen: duct development (double layer of columnar cells) 2. Progesterone: lobular development 3. Prolactin: synergizes estrogen and progesterone
3
Q
Cyclic change: increases breast swelling, growth of glandular tissue
A
Estrogen
4
Q
Cyclic change: increase maturation of glandular tissue; withdrawal causes menses
A
Progesterone
5
Q
Cyclic change: cause ovum release
A
FSH, LH surge
6
Q
What causes atrophy of breast tissue after menopause?
A
After menopause, lack of estrogen and progesterone results in atrophy of breast tissue.
7
Q
Innervates serratus anterior, injury results in winged scapula
A
Long thoracic nerve
8
Q
Artery: supplies serratus anterior
A
Lateral thoracic artery
9
Q
Innervates latissmus dorsi; injury results in weak arm pull-ups and adduction
A
Thoracodorsal nerve
10
Q
Artery: supplies latissimus dorsi
A
Thoracodorsal artery
11
Q
Innervates pectoralis major and pectorals minor
A
Medial pectoral nerve
12
Q
Nerve: pectorals major only
A
Lacteral pectoral nerve
13
Q
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.
A
Intercostobrachial nerve
14
Q
Arteries that supply the breast
A
Internal thoracic artery, intercostal arteries, thoracoacromial artery, and lateral thoracic artery
15
Q
Valveless vein plexus that allows direct hematogenous metastasis of breast CA to spine
A
Batson’s plexus
16
Q
Lymphatic drainage of the breast
A
- 97% to axillary nodes - 2% to internal mamillary nodes - Any quadrant can drain to the internal mammary nodes.
17
Q
Considered N3 disease
A
Mets to supraclavicular nodes
18
Q
Dx: primary axillary adenopathy
A
1 is lymphoma
19
Q
Suspensory ligaments of the breast. Divide breast into segments.
A
Cooper’s ligaments
20
Q
What does skin dimpling of the breast suggest?
A
Breast CA involving Cooper’s ligaments dimpling the skin.
21
Q
What are breast abscesses usually caused by? MCC?
A
Usually a/w breast feeding. MCC: Staph aureus
22
Q
TX: breast abscess
A
Percutaneous or incision and drainage; discontinue breastfeeding; breast pump; antibiotics.
23
Q
MCC infectious mastitis in nonlactating women
A
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
Q
What is infectious mastitis usually associated with?
A
Breastfeeding
25
Mammary duct ectasia or plasma cell mastitis
Periductal mastitis
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S/S: noncyclical mastodynia, erythema, nipple retraction, creamy discharge from nipple; can have sterile or infected subareolar abscess
Periductal mastitis
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Risk factors: periductal mastitis
Smoking, nipple piercings
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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
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Can be caused by increased prolactin (pituitary prolactinoma), OCPs, TCAs, phenothiazines, metoclopramide, alpha-methyl dopa, reserpine. - Is often a/w amenorrhea
Galactorrhea
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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
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MC breast anomaly. Location?
Accessory nipples - Found form axilla to groin
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What is compromised with breast reduction?
Ability to lactate frequently compromised.
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Hypoplasia of chest wall. Amastia. Hypoplastic shoulder. No pectoralis muscle.
Poland's Syndrome
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Pain in breast; rarely represents breast cancer. Dx: history, breast exam, BL mammogram.
Mastodynia
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Tx: Mastodynia
Danazol. OCPs NSAIDs. Evening primrose oil. Bromocriptine. D/C: caffeine, nicotine, methylxanthines.
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Pain before menstrual period, most commonly represents acute or subacute.
Cyclic mastodynia.
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Continuous pain. MC'ly represents acute or subacute infection; continuous mastodynia is more refractory to treatment than cyclic mastodynia.
Continuous mastodynia.
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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.
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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
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Mammography: fibroadenoma
Large, coarse calcifications (popcorn lesions) from degeneration.
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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.
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Tx: enlarging fibroadenoma
Excisional biopsy
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Why avoid resection of fibroadenoma in teenagers / younger children?
Resection can affect breast development.
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Fibroadenoma: pts > 40
Excisional biopsy to ensure dx
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Tx: fibroadenoma
Pts < 40 Observe. No ex bx.
| Pts > 40: Ex bx to ensure diagnosis
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Most nipple discharge is...
Benign
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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.
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Nipple discharge: bloody Tx?
MC intraductal papilloma; occasionally ductal CA. Tx: Need ductogram and excision of that ductal area.
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Nipple: serous discharge
Worrisome for cancer. Especially if coming form only 1 duct or spontaneous. Tx: Excisional biopsy of that ductal area
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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.
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Discharge: - Occurs only with pressure, tight garments, exercise, etc. - Not as worrisome but may still need excisional biopsy (e.g., if bloody)
Nonspontaneous discharge
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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).
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Malignant cell of the ductal epithelium without invasion of basement membrane
Ductal carcinoma in situ.
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DCIS Risk Ca: Ipsilateral Breast Contralateral Breast
Ipsilateral breast: 50% Contralateral breast: 5%
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DCIS: premalignant lesion
Yes.
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Usually not palpable and presents as a cluster of calcifications on mammography. - Can have solid, cribriform, papillary, comedy patterns
DCIS
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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
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Tx: DICS (not high grade)
Lumpectomy and XRT. Need 1cm margins. No ALND or SLNB. Possibly tamoxifen.
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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.
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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.
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Patient who develop breast CA are more likely to develop a..
Ductal CA (70%)
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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.
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BI-RAD 1.
Negative Tx: Routine screening
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BI-RADs 2
Benign finding Tx: Routine screening
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BI-RADs 3
Probably benign finding Tx: Routine screening
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BI-RADs 4
Suspicious abnormality (eg, indeterminate calcifications or architecture) Tx: definite probability of CA; get CNBx
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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
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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.
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Why aren't mammograms generally recommended in young patients
Hard to interpret because of dense parenchyma.
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How does mammogram radiation dose change in younger patients?
Dose decreases
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Node levels: I? II? III?
I: lateral to pectoralis minor muscle II: beneath pectoralis minor muscle. III: medial to pectorlis minor muscle
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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.
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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
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Most common site for distant metastasis
Bone
124
Time: Single malignant cell to 1-cm tumor.
Approximately 5-7 years
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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
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Breast CA: lower increased risk (relative risk
- Early menarche / late menopause - Nulliparity - Proliferative benign disease - Obesity, alcohol, hormone replacement therapy.
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BRCA I Cancer Risk - Female breast CA - Ovarian CA - Male breast CA
Lifetime risk.. - Female breast: 60% - Ovarian: 40% - Male breast: 1%
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BRCA II Cancer Risk - Female breast CA - Ovarian CA - Male breast CA
Lifetime risk.. - Female breast: 60% - Ovarian: 10% - Male breast: 10%
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Sx Considerations: BRCA families with history of breast cancer
Total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO)
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Breast Cancer risk: first degree relative with bilateral, premenopausal breast cancer
50%
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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
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What receptor do you want positive: estrogen or progesterone?
Progesterone receptor-positive tumors have better prognosis than estrogen receptor-positive tumors.
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What happens with positive estrogen AND progesterone receptors?
Both positive? Has the best prognosis.
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%: Breast cancer negative for both receptors.
10%
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What is male breast cancer associated with?
Steroid use. Previous XRT. Family history. Klinefelter's syndrome
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Tx: male breast cancer
Tx: Modified Radical Mastectomy (MRM)
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85% of all breast cancer. Tx?
Ductal CA Tx: MRM or BCT (breast conserving therapy) with post XRT
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Ductal CA: Subtypes
Medullary. Tubular. Mucinous. Scirrhotic.
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Ductal CA: smooth borders, increased lymphocytes, bizarre cells, more favorable prognosis.
Medullary ductal CA
144
Ductal CA: small tubule formations, more favorable prognosis.
Tubular ductal CA
145
Ductal CA: produces an abdundance of mucin, more favorable prognosis
Mucinous (colloid) ductal CA
146
Ductal CA: worse prognosis
Schirrhotic
147
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
148
Tx: lobular cancer
MRM or BCT with post op XRT
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Path: confers worse prognosis in lobular CA
Signet ring cells
150
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
151
Tx: inflammatory breast CA
Neoadjuvant chemo, then MRM, then adjuvant chemo-XRT (most common method)
152
Leaves 1%-2% of breast tissue, preserves the nipple - Not indicated for breast CA treatment - Used for DCIS and LCIS
Subcutaneous mastectomy (simple mastectomy)
153
Removes all breast tissue, including the nipple areolar complex - Includes axillary node dissection (level 1 nodes)
Modified radical mastectomy
154
Surgical options for breast cancer
Subcutaneous mastectomy. Breast-conserving therapy. Modified radical mastectomy. SLNB. ALND.
155
Combined with postop XRT; need 1cm margin
Breast-conserving therapy.
156
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
157
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.
158
Indicated only for malignant tumors > 1cm - Not indicated in pts with clinically positive nodes (need ALND).
Sentinel lymph node biopsy (SLB)
159
When is accuracy best for sentinel lymph node biopsy?
When primary tumor is present (finds the right lymphatic channels)
160
Dye used for sentinel lymph node biopsy
Lymphazurin blue dye or radio tracer is injected directly into the tumor area.
161
What to do: no radio tracer dye is found during sentinel lymph node biopsy
Do a formal ALND
162
Contraindications: SLNB (sentinel lymph node biopsy)
Pregnancy. Multi centric disease. Neoadjuvant therapy. Clinically positive nodes. Prior axillary surgery. Inflammatory or locally advanced disease.
163
When level nodes do you take for axillary lymph node dissection?
Level 1 and 2 nodes
164
Complications of MRM
Infection. Flap necrosis. Seromas.
165
Complications of ALND
- Infection, lymphedema, lymphangiosarcoma. - Axillary vein thrombosis (sudden early post swelling) - Lymphatic fibrosis (slow swelling over 18 months) - Intercostal brachiocutaneous nerve injury
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ALND: sudden, early, post op swelling
Axillary vein thrombosis
167
ALND: slow swelling over 18 months
Lymphatic fibrosis
168
ALND: hypesthesia of inner arm and lateral chest wall; most commonly injured nerve after mastectomy, no significant sequelae
Intercostal brachiocutaneous nerve injury
169
MC'ly injured nerve after mastectomy
Intercostal brachiocutaneous nerve injury.
170
How long do you leave in drains after ALND?
Drainage
171
Radiation dose of radiotherapy
5,000 rad for BCT and XRT
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Complications: XRT
Edema. Erythema. Rib fratures. Pneumonitis. Ulceration. Sarcoma. Contralateral breast CA.
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Contraindications: XRT
Scleroderma (results in severe fibrosis and necrosis). Previous XRT and would exceed recommended dose. SLE (relative). Active rheumatoid arthritis (relative).
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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)
175
When can you start XRT after BCT?
When you have negative margins following BCT
176
%: 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.
177
Chemotherapy regimen
TAC (taxanes, Adriamycin, cyclophosphamide for 6-12 weeks)
178
Who gets chemotherapy with positive nodes?
Everyone EXCEPT postmenopausal women with positive estrogen receptors (they get hormonal therapy only aromatase inhibitor (anastrozole))
179
Tx: postmenopausal, positive nodes, estrogen receptor positive
Hormonal therapy only with aromatase inhibitor (anastrozole)
180
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.
181
Tx after chemo: pts positive for estrogen receptors
Appropriate hormonal therapy
182
Have been shown to decrease recurrence and improve survival
Both chemotherapy and hormonal
183
Taxanes
Docetaxel, paclitaxel
184
Decreases risk of breast cancer by 50% - 1% risk of blood clots; 0.1% risk of endometrial cancer
Tamoxifen
185
What happens to women with breast cancer recurrence?
Almost all women with recurrence die of disease.
186
Increased recurrences and metastases occurs with..
Positive nodes. Large tumors. Negative receptors. Unfavorable subtype.
187
Pain, swelling, erythema is metastatic areas. Tx?
Metastatic flare - Tx: XRT can help XRT is good for bone metastasis
188
Breast CA that presents as axillary metastases with unknown primary. Tx?
Occult breast CA - Tx: MRM (70% are found to have breast CA)
189
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)
190
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
191
Tx: Cystosarcoma phyllodes
WLE with negative margins; no ALND
192
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
193
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
194
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
195
Radiation in pregnancy with breast cancer.
No XRT while pregnant, no breastfeeding after delivery.
196
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.
197
Courses along lateral chest wall in midaxillary line on serratus anterior muscle; innervates serratus anterior muscle
Long thoracic nerve
198
Courses lateral to long thoracic nerve on latissimus doors muscle; innervates latissimus dorsi muscle
Thoracodorsal nerve
199
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
200
Runs medial to the medial pectoral nerve (names describe orientation from the brachial plexus!); innervates the pectoral major.
Lateral pectoral nerve
201
What is the name of the cutaneous nerve that crosses the axillary in a transverse fashion?
Intercostobrachial nerve
202
What is the lymphatic drainage of the breast?
Lateral: axillary lymph nodes Medial: parasternal nodes that run with internal mammary artery.
203
What is the mammary "milk line"?
Embryological line from should to thigh where "supernumerary" breast areolar and / or nipple can be found
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What is the "tail of Spence"?
"Tail" of breast tissue that tapers into the axilla.
205
What percentage of women with breast cancer have no known risk factor?
75%
206
What percentage of all breast cancers occur in women younger than 30 years?
~ 2%
207
What percentage of all breast cancers occur in women older than 70 years?
33%
208
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)
209
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
210
What is the relative risk of hormone replacement therapy?
1 - 1.5
211
Is "run of the mill" fibrocystic disease a risk factor for breast cancer?
No
212
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.
213
What is the most common site of breast cancer?
Approximately one half of cancers develop in the upper outer quadrants.
214
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%)
215
What is the MC type of breast cancer?
Infiltrating ductal ca
216
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.
217
When is the best time for breast self-exam?
1 week after menstrual period
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What option is best to evaluate a breast mass in a woman younger than 30 years?
Breast ultrasound
219
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.
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What is the process for performing a biopsy when a non palpable mass is seen on mammo?
Stereotactic (mammotome) biopsy or needle localization therapy
221
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).
222
What would be suspicious mammographic findings?
Mass, microcalcifications, stellate / spiculated mass
223
What is a "radial scar" seen on mammogram?
Spiculated mass with central lucency, +/- microcalcifications
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What tumor is a/w a radial scar?
Tubular carcinoma, thus, biopsy is indicated.
225
What is the "workup" for a breast mass?
1. Clinical breast exam 2. Mammogram on breast ultrasound. 3. FNA, core biopsy, or open biopsy
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Is the fluid from a breast cyst sent for cytology?
Not routinely, bloody fluid should be sent for cytology.
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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.
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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
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What are the sites of metastases?
Lymph nodes (MC). Lung / pleura. Liver. Bones. Brain.
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What are the major treatments of breast cancer?
Modified radical mastectomy. Lumpectomy and radiation + SLND. (Both: either +/- post op chemo / tamoxifen)
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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.
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What breast carcinomas are candidates for lumpectomy and radiation (breast-conserving therapy)?
Stage 1 and 2
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What approach may allow a patients with stage 3A cancer to have breast-conserving surgery?
Neoadjuvant chemotherapy - if the preo chemo shrinks the tumor.
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What is the treatment of inflammatory carcinoma of the breast?
Chemotherapy first! Then often followed by radiation, mastectomy, or both.
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What is the major absolute contraindication to lumpectomy and radiation?
Pregnancy
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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.
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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.
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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.
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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)
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How is the sentinel lymph node found?
Inject blue dye and/or technetium-labeled sulfur colloid (best results with both)
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What follows a positive sentinel node biopsy?
Removal of the rest of the axillary lymph nodes
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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
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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
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What is the treatment for local recurrence in breast after lumpectomy and radiation?
"Salvage" mastectomy
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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.
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What are common options for breast reconstruction?
TRAM flap, implant, latissimus dorsi flap
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What is a TRAM flap?
Transverse Rectus Abdominis Myocutaneous flap
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What are the side effects of tamoxifen?
Endometrial cancer (2.5 x relative risk), DVT, PE, cataracts, hot flashes, mood swings
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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
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What type of chemotherapy is usually used for breast cancer?
CMF (cyclophosphamide, methotrexate, 5-fluorouracil) or CAF (cyclophosphamide, adriamycin, 5-fluorouracil)
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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
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Describe DCIS.
Cancer cells in the duct without invasion. (Cells do not penetrate the basement membrane).
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s/s: DCIS
Usually none; usually nonpalpable
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DCIS: mammographic findings
Microcalcifications
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DCIS: most aggressive subtype
Comedo
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What is the major risk with DCIS?
Subsequent development of infiltrating ductal carcinoma in the same breast
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Tx: DCIS Tumor
Remove with (-) margins +/- XRT
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Tx: DCIS Tumor > 1cm
Perform lumpectomy with (-) margins and radiation or total mastectomy (no axillary dissection)
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What is a total (simple) mastectomy?
Removal of the breast and nipple without removal of the axillary nodes (always remove nodes with invasive cancer)
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When must a simple mastectomy be performed for DCIS?
Diffuse breast involvement (e.g., diffuse micro calcifications), > 1cm and contraindication to radiation
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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
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What is adjuvant for DCIS?
1. Tamoxifen 2. Postlumpectomy XRT
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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.
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Mammographic findings: LCIS
None
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Dx: LCIS
LCIS is found incidentally on biopsy
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What percentage of women with LCIS develop an invasive breast carcinoma?
~ 30% in the 20 years after diagnosis of LCIS
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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.
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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
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What are the risk factors of male breast cancer?
Increased estrogen. Radiation. Gynecomastia from increased estrogen. Estrogen therapy. Klinefelter's syndrome (XXY). BRCA2 carriers.
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Is benign gynecomastia a risk factor for male breast cancer?
No
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What type of breast cancer do men develop?
Nearly 100% of cases are ductal carcinoma (men do not usually have breast lobules)
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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)
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MCC green, straw-colored or brown nipple discharge
Fibrocystic disease
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Mesenchymal tumor arising from breast lobular tissue; most are benign
Cystosarcoma phyllodes
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Phyllodes tumor: age
25-55 years (usually older than pt with fibroadenoma)
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s/s: phyllodes tumor
Mobile, smooth breast mass that resembles a fibroadenoma on exam, mammogram / ultrasound findings
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Tx: Phyllodes tumor
If benign, wide local excision; if malignant, simple total mastectomy.
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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)
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Is there a role for chemotherapy with cystosarcoma phyllodes?
Consider chemotherapy if large tumor > 5 cm and "stromal overgrowth"
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Benign tumor of the breast consisting of streams overgrowth, collagen arranged in "swirls"
Fibroadenoma
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S/S Breast pain or tenderness that varies with the menstrual cycle; cysts; and fibrous ("nodular") fullness
Fibrocystic disease
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Tx: fibrocystic disease
Stop caffeine. Pain meds (NSAIDS) Vitamin E, evening primrose oil (danazol and OCP as last resort)
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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
