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Flashcards in Fiser Chapter 24 BREAST Deck (105):
1

Breast develops from what

Ectoderm milk streak

2

Estrogen, progesterone, and prolactin in breast development

Estrogen -> duct development (double layer of columnar cells)

Progesterone -> lobular development

Prolactin -> synergizes estrogen and progesterone

3

Cyclic hormone changes in breast

Estrogen -> increases breast swelling and growth of glandular tissue

Progesterone -> increases maturation of glandular tissue, withdrawal causes menses

FSH, LH surge -> ovum release

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

4

Long thoracic nerve

Serratus anterior; injury causes winged scapula

5

Blood and nerve supply to serratus anterior

Long thoracic nerve

Lateral thoracic artery

6

Thoracodorsal nerve

Latissimus dorsi; injury causes weak arm pull-ups and adduction

7

Blood and nerve supply to latissimus dorsi

Thoracodorsal nerve

Thoracodorsal artery

8

Pectoralis muscle nerves

Pectoralis major: medial pectoral nerve, lateral pectoral nerve

Pectoralis minor: medial pectoral nerve

9

Intercostobrachial nerve

Lateral cutaneous branch of 2nd intercostal nerve

Provides sensation to medial arm and axilla; encountered just below axillary vein when performing ax dissection; can transect without serious consequences

10

Breast blood supply

Branches of internal thoracic artery, intercostal arteries, thoracoacromial artery, and lateral thoracic artery

11

Batson's plexus

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

12

Breast lymphatic drainage

97% to axillary nodes

2% to internal mammary nodes (any quadrant can drain to internal mammary nodes)

13

Primary axillary adenopathy

#1 is lymphoma

14

Breast cancer with positive supraclavicular nodes

N3 disease

15

Cooper's ligaments

Suspensory ligaments; divide breast into segments

Breast CA involving these strands can dimple the skin

16

Breast abscess most common bacteria

Staph aureus; strep

Usually associated with breastfeeding

17

Breast abscess tx

Perc or I&D; discontinue breast feeding; breast pump, antibiotics

18

Infectious mastitis most common bacteria

S aureus most common in nonlactating women, can be due to chronic inflammatory diseases (actinomyces) or autimmune disease (SLE) -> may need to r/o necrotic cancer (need incision biopsy including skin)

Most commonly associated with breastfeeding though

19

Smoker with nipple piercing, presents with noncyclical mastodynia, erythema, nipple retraction, creamy discharge from nipple. On biopsy has dilated mammary ducts, inspissated secretions, marked periductal inflammation

Periductal mastitis: mammary duct ectasisa or plasma cell mastitis

-can have sterile or infected subareolar abscess

-Tx: ABX and reassurance, if typical creamy discharge is present that is not bloody and not associated with nipple retraction
-If bloody or nipple retraction or recurs, INCISIONAL BIOPSY WITH SKIN to r/o inflammatory breast CA

20

Lactating woman with breast cyst filled with milk

Glactocele

Tx: Aspiration or I&D

21

Causes of galactorrhea

-Increased prolactin (pituitary prolactinoma)
-OCPs
-TCAs
-Phenothiazines
-Metoclopramide
-Alpha-methyl dopa
-Reserpine

-Often associated with amenorrhea

22

Gynecomastia causes

-Cimetidine
-Spironolactone
-Marijuana
-Most are idiopathic
-2-cm pinch
-Tx: will likely regress; may need to resect if cosmetically deforming or causing social problems

23

Neonatal breast enlargement due to what

Circulating maternal estrogens; will regress

24

Accessory breast tissue (most common in axilla)

Polythelia

25

Most common breast anomaly

Accessory nipples (can be found from axilla to groin)

26

Side effect of breast reduction

Compromised lactation

27

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

Poland's syndrome

28

Mastodynia workup, tx

Cyclic mastodynia: pain before menstrual period, most commonly from fibrocystic disease

Continuous mastodynia: most commonly represents acute or subacute infection; continuous mastodynia is more refractory to treatment than cyclic mastodynia

Dx: H&P, bilateral mammogram

Tx: danazol, OCPs, NSAIDs, evening primrose oild, bromocriptine, stop caffeine/nicotine/methylxanthines

29

Superficial vein thrombophlebitis of breast; feels cordlike; can be painful

Mondor's disease

-Associated with trauma and strenuous exercise

-Usually in lower outer quadrant

Tx: NSAIDs

30

Breast pain, nipple discharge (yellow-to-brown), lumpy breast tissue, varies with hormonal cycle; dx and cancer risk?

Fibrocystic disease (many types- papillomatosis, sclerosing adenosis, apocrine metaplasia, duct adenosis, epithelial hyperplasia, ductal hyperplasia, lobular hyperplasia)

-Only cancer risk is in ATYPICAL DUCTAL OR LOBULAR HYPERPLASIA. Resect these lesions
-Do NOT need negative margins with atypical hyperplasia, just remove all suspicious areas (ie calcifications) that appear on mammogram

31

Most common cause of bloody nipple discharge; dx; cancer risk?

Intraductal papilloma: usually small, nonpalpable, close to nipple

NOT premalignant

-Contrast ductogram to find papilloma then needle localization; tx subareolar resection of involved duct and papilloma

32

Most common breast lesion in adolescents and young women

Fibroadenoma

33

Young woman with painless, slow growing, well circumscribed, firm, rubbery lesion, changes in size with menstrual cycle

Fibroadenoma: 10% are multiple

Biopsy: fibrous tissue compressing epithelial cells

Mammo: can have large, course calcifications (popcorn lesions) on mammography from degeneration

<40yo: as long as clinically benign (firm, rubbery, rolls, mobile), US or mammo consistent with fibroadenoma, and RNA or core needle biopsy shows fibroadenoma, CAN OBSERVE; otherwise excisional biopsy (also excise if growing). Avoid resection in teens and children as can affect breast development

>40yo: excisional biopsy to ensure diagnosis

34

Nipple discharge

-Get H&P, bilateral mammo

-Usually benign

-Try to find trigger point of mass on exam, if cannot find then may need COMPLETE subareolar resection

35

Green nipple discharge

Fibrocystic disease: if cyclical and nonspontaneous, reassure patient.

36

Bloody nipple discharge

Most commonly intraductal papilloma, but occasionally ductal CA: need ductogram and EXCISION of that ductal area

37

Serous nipple discharge

Worrisome for cancer, especially if coming from only 1 duct or spontaneous: EXCISIONAL biopsy of that ductal area

38

Spontaneous nipple discharge

No matter what color or consistency, is worrisome for CA: EXCISIONAL biopsy of duct area causing the discharge

39

Nonspontaneous nipple discharge (only with pressure, tight garments, exercise, etc)

Not as worrisome but may still need excisional biopsy (eg if bloody)

40

Cluster of calcifications on mammography, pathology shows malignant cells of ductal epithelium without invasion of BM

DCIS:

-Premalignant: 50% get cancer of same breast if not resected; 5% get cancer of other breast

-Can have solid, cribriform, papillary, and comedo patterns.

-COMEDO MOST AGGRESSIVE SUBTYPE: necrotic areas, high risk for multicentricity, microinvasion, recurrence. Tx: Simple mastectomy

-Also higher recurrence if > 2.5 cm

41

DCIS treatment

Lumpectomy and XRT. Need 1 cm margins (?).

Simple mastectomy if high grade (eg comedo type, multicentric, multifocal), if large tumor not amenable to lumpectomy, or not able to get good margins; then maybe SLNB

NO ALND OR SLNB

Possibly tamoxifen

42

LCIS

Marker for development of breast ca (not premalignant itself): 40% get cancer (either breast, more likely ductal cancer); 5% risk of having synchronous breast CA at time of diagnosis

-Primarily found in premenopausal women

-NO calcifications, not palpable, usually incidental finding, multifocal disease common

-Tx: nothing, tamoxifen, or bilateral subcutaneous mastectomy (no ALND); do NOT need negative margins

43

Indications for surgical biopsy after core biopsy

-Atypical ductal hyperplasia
-Atypical lobular hyperplasia
-Radial scar
-LCIS
-Columnar cell hyperplasia with atypia
-Papillary lesions
-Lack of concordance between appearance of mammographic lesion and histologic diagnosis
-Nondiagnostic specimen (including absence of calcifications on specimen radiograph when biopsy performed for calcifications)

44

Breast cancer epidemiology

-Less in poor areas

-Japan lowest rate

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

-Screening decreases mortality by 25%

-Untreated: median survival 2-3 years

-10% of breast CAs have negative mammogram and US

45

Clinical features of breast CA

-Distortion of normal architecture

-Skin/nipple distortion or retraction

-Hard, tethered, indistinct borders

46

Symptomatic breast mass workup

<40yo: US and core needle bx (consider FNA), mammogram if exam or US indeterminate or suspicious for CA otherwise avoid radiation

>40yo: bilateral mammograms, US, core needle biopsy

-If CNBx or FNA indeterminate, non-diagnostic, or non-concordant with exam findings/imaging -> EXCISIONAL BIOPSY

-Cyst fluid: if bloody or complex, need excisional biopsy; if clear and recurs, need excisional biopsy

47

Difference between CNBx and FNA

CNBx gives architecture

FNA gives cytology (just the cells)

48

Mammography sensitivity, specificity, cancer features

90% sensitivity and specificity (sensitivity increases with age as dense parenchymal tissue replaced with fat)

Mass must be at least 5 mm to be detected

Cancer features: irregular borders; speculated; multiple clustered, small, thin, linear, crushed-like and/or branching calcifications; ductal asymmetry, distortion of architecture

49

BI-RADS classification of mammographic abnormalities

1. Negative -> routine screening

2. Benign finding -> routine screening

3. Probably benign finding -> short interval follow-up

4. Suspicious abnormality (eg indeterminate calcifications or architecture) -> Definite probability of CA; get CNBx

5. Highly suggestive of CA (suspicious calcifications or architecture) -> High probability of CA; get CNBx

50

CNBx shows non-diagnostic, indeterminate, or benign but non-cordinant with mammogram -> next step?

Needle localization excisional biopsy

Benign and concordant with BI-RADS 4 mammo, then 6 month follow-up

51

What's the point of CNBx in BI-RADS 4 and 5?

Allows appropriate staging with SLNBx (mass still present) and one-step surgery (avoids 2 surgeries) for patients diagnosed with breast Ca

52

Breast cancer screening

40yo: mammogram every 2-3 years

50yo: mammogram yearly

High-risk: mammogram 10 years before the youngest age of diagnosis of breast CA in first-degree relative

53

Node levels

I: lateral to pec minor

II: beneath pec minor

III: medial to pec minor

Rotter's nodes: between pec major and pec minor

ALND: take level I and II (and III only if grossly involved)

54

Most important prognostic staging factor in breast cancer?

Nodes: survival is directly related to the number of positive nodes
0: 75% 5-year survival
1-3: 60% 5-year survival
4-10: 40% 5-year survival

Other: size, grade, hormone receptor status

Central and subareolar tumors have increase risk of multicentricity

Takes about 5-7 years to go from single malignant cell to 1 cm tumor

55

Most common site for distant metastasis in breast disease

Bone

Other: lung, liver, brain

56

Breast cancer T staging

T1: up to 2 cm

T2: 2-5 cm in greatest dimension

T3: > 5 cm

T4: any size, but direct extension to chest wall (not including pec muscle), skin edema, ulceration, satellite skin nodules, or inflammatory carcinoma = stage IIIB

57

Breast cancer N staging

N0: none

N1: 1-3 axillary nodes or path positive IM nodes

N2: 4-9 axillary nodes or clinically apparent IM nodes

N3: 10 or more axillary nodes, or in infraclavicular nodes, or in axillary and IM nodes, or supraclavicular nodes

58

Breast cancer M staging

M1 distant metastasis = Stage IV

59

Who has greatly increased breast cancer risk (relative risk >4)?

-BRCA gene in patient with family history of breast cancer
-At least 2 primary relatives with bilateral or premenopausal breast cancer
-DCIS (ipsilateral breast at risk) or LCIS (both breasts have same high risk)
-Fibrocystic disease with ATYPICAL HYPERPLASIA

60

Who has moderately increased breast cancer risk (relative risk 2-4)?

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

61

Who has lower increased breast cancer risk (relative risk <2)?

-Early menarche
-Late menopausea
-Nulliparity
-Proliferative benign disease
-Obesity
-Alcohol use
-Hormone replacement therapy

62

BRCA I and II (+ family history of breast cancer) and lifetime cancer risk

BRCA I: breast (60%), ovarian ca (40%), and male (1%)

BRCA II: breast (60%), male breast ca (10%), and ovarian (10%)

-Higher breast ca risk if first degree relative with bilateral premenopausal breast cancer

63

BRCA families with history of breast cancer, what is treatment?

-Consider total abdominal hysterectomy and bilateral salpingooophorectomy

-Consider prophylactic mastectomy

64

Who should consider prophylactic mastectomy?

-Family history + BRCA

-LCIS

-But also need one of: high anxiety, poor access for follow-up and mammos, difficult lesion to follow on exam or with mammos, or patient preference for mastectomy

65

Breast cancer receptors

-Positive receptos have better response to hormones, chemotherapy, surgery, and better overall prognosis; receptor-positive tumors are more common in Postmenopausal women

-PR positive tumors have better prognosis than ER positive tumors

-Tumors that are both PR and ER positive have the best prognosis

-10% of all breast ca is negative for both receptors

66

Male breast cancer: what type is it? prognosis? associations? treatment?

-Usually ductal

<1% of all breast cancers

-Poorer prognosis d/t late presentation

-Increased pectoral muscle involvement

-Associated with steroid use, previous XRT, family history, Klinefelter's syndrome

Tx: MRM

67

What percentage of breast cancer is ductal versus lobular?

85% ductal, 10% lobular

68

Ductal breast cancer subtypes

-Medullary

-Tubular

-Mucinous

-Scirrhotic

69

What kind of breast cancer has smooth borders, increased lymphocytes, bizarre cells

-Medullary (ductal cancer)

70

What kind of breast cancer has small tubule formations?

-Tubular (ductal)

71

What kind of breast cancer produces an abundance of mucin?

-Mucinous/colloid (ductal)

72

What kind of breast cancer has a bad prognosis?

Scirrhotic (ductal)

73

Breast cancer tx

MRM or BCT with postop XRT

74

What kind of breast cancer does not form calcifications?

Lobular breast cancer: no calcs, extensively infiltrative, more often bilateral, multifocal and multicentric

-Signet ring cells confer worse prognosis

75

What kind of breast cancer has dermal lymphatic invasion?

Inflammatory breast cancer: considered T4 disease, very aggressive (median survival 36 months)

-Peau d'orange lymphedema appearance on breast; erythematous and warm

76

Tx of inflammatory breast cancer

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

77

Surgical options for breast cancer

1. Subcutaneous mastectomy (simple mastectomy): leaves 1-2% of breast tissue, preserves nipple; ONLY FOR DCIS AND LCIS (not breast cancer)

2. Breast-conserving therapy = lumpectomy, quadrectomy, etc. plus ALND or SLNB; combined with postop XRT; need 1 cm margin (?)

3. Modified radical mastectomy: removes all breast tissue including nipple areolar complex; includes ALND (level I nodes)

78

Contraindications to BCT in invasive carcinoma

ABSOLUTE:
-two or more primary tumors in separate quadrants
-positive margins after reasonable surgical attempts
-pregnancy (no XRT; but may be ok if in 3rd trimester and can do XRT postpartum)
-History of prior breast XRT that would result in retreatment to an excessively high radiation dose
-Diffuse malignant-appearing calcifications

RELATIVE:
-History of scleroderma or active SLE
-Large tumor in small breast that would have cosmetic result unacceptable to patient
-Very large or pendulous breasts if reproducibility of patient setup and adequate dose homogeneity cannot be ensured

79

Advantages of SLN over ALND

-Fewer complications

-Usually find 1-3 nodes; 95% of the time, the sentinel node is found



80

SLNB indications

-Only for malignant tumors > 1cm

-Accuracy best when primary tumor is present (finds right lymphatic channels)

-Well suited for small tumors with low risk of axillary metastases

81

SLNB contraindications

-Clinically positive nodes -> ALND

-If no radiotracer or dye is found during SLNB -> ALND

-Multicentric disease, neoadjuvent therapy, prior axillary surgery, inflammatory or locally advanced disease, pregnancy

82

SLNB procedure

Lymphazurin blue dye or radiotracer is injected directly into tumor area

-Lumphazurin blue dye has had Type I Hypersensitivity reactions reported

83

ALND procedure (what nodes are taken?)

Level I and II nodes

84

Complications of MRM

Infection

Flap necrosis

Seromas

85

Complications of ALND

-Infection

-Lymphedema

-Lymphangiosarcoma

-Axillary vein thrombosis

-Lymphatic fibrosis

-Intercostal brachiocutaneous nerve injury

86

Sudden, early, postop swelling after ALND

Axillary vein thrombosis

87

Slow swelling over 18 months after ALND

Lymphatic fibrosis

88

Hyperesthesia of inner arm and lateral chest wall after ALND

Intercostal brachiocutaneous nerve injury: most commonly injured nerve after mastectomy; no significant sequelae

89

Breast cancer XRT

-5,000 rad for BCT and XRT

90

Complications of XRT

-Edema

-Erythema

-Rib fractures

-Pneumonitis

-Ulceration

-Sarcoma

-Contralateral breast cancer

91

Contraindications to breast cancer XRT

-Scleroderma, SLE, active rheumatoid arthritis

-Previous XRT and would exceed recommended dose

92

Indications for XRT after mastectomy

> 4 nodes

Skin or chest wall involvement

Inflammatory cancer

Positive margins

Tumor > 5 cm (T3)

Fixed axillary nodes (N2) or internal mammary nodes (N3)

Extracapsular nodal invasion (?)

93

BCT with XRT methods

Need negative margins (1 cm) following BCT before starting XRT

10% chance of local recurrence, usually within 2 years of 1st operation, need to re-stage with recurrence

Need salvage MRM with local recurrence

94

Breast cancer recurrence (in same site) after BCT, what is treatment?

Salvage MRM (must also re-stage)

95

Breast cancer chemotherapy indications

-Positive nodes (unless postmenopausal with positive nodes -> then anastrozole)

>1 cm tumor (unless positive estrogen receptors -> tamoxifen or anastrozole)

After chemo, patients positive for ER should receive appropriate hormonal therapy

96

Chemotherapy used for breast cancer

TAC for 6-12 weeks

-Taxanes (docetaxel, paclitaxel)
-Adriamycin
-Cyclophosphamide

97

Tamoxifen effect on recurrence; side effects

Decreases by 50%

Side effects:
-blood clots (1%)
-endometrial cancer (0.1%)

98

Who has increased recurrences and metastases?

-Positive nodes

-Large tumors

-Negative receptors

-Unfavorable subtype

99

Woman with history of breast cancer has bone pain, swelling, erythema

Metastatic flare: XRT can help, and is good for bone mets

100

Woman presents with breast cancer in axilla but cannot find primary

Occult breast cancer

Tx: MRM (70% are found to have breast cancer)

101

Woman with scaly skin lesion on nipple; dx and tx

Paget's disease: biopsy shows paget cells

-Patients have DCIS or ductal CA in breast

Tx: MRM if cancer present, otherwise simple mastectomy (must include nipple areolar xomplex with Paget's)

102

Large tumor with stromal and epithelial elements (mesenchymal tissue)

Cystosarcoma phylloides

-10% malignant, based on mitoses per hpf (> 5-10)
-Hematogenous spread rare; NO nodal mets
-Resembles giant fibroadenoma; can be large

Tx: WLE with negative margins; NO ALND

103

Dark purple nodule or lesion on arm 5-10 years after ALND

Stewart-Treves syndrome: Lymphangiosarcoma from chronic lymphedema following axillary dissection

104

Breast mass in pregnancy

-US (although both mammogram and US do not work as well during pregnancy)

-If cyst -> drain, send FNA for cytology
-If solid -> core needle biopsy or FNA

-Equivocal biopsy -> excisional biopsy

105

Breast cancer in pregnancy

-Tends to present late -> worse prognosis
-No XRT while pregnant; no breastfeeding after delivery

1st trimester: MRM
2nd trimester: MRM
3rd trimester: MRM or if late can perform lumpectomy with ALND and postpartum XRT