24 Breast Flashcards
1
Q
Embryologic origins of breast tissue
A
Ectoderm milk streak
2
Q
Effect of estrogen on the breast
A
Development - duct development (double layer of columnar cells)
Cyclic - breast swelling, growth of glandular tissue
3
Q
Effect of progesterone on the breast
A
Development - lobular development
Cyclic - maturation of glandular tissue, withdrawal cause menses
4
Q
Effect of prolactin on breast development
A
Synergizes with estrogen and progesterone
5
Q
Effect of FSH and LH surge on cyclical changes
A
Ovum release
6
Q
What leads to atrophy of the breast after menopause?
A
Lack of estrogen and progesterone
7
Q
Injury results in winged scapula
A
Long thoracic nerve
Serratus anterior
Lateral thoracic artery
8
Q
Injury results in weak arm pull-ups and adduction
A
Thoracodorsal nerve
Latissimus dorsi
Thoracodorsal artery
9
Q
Medial pectoral nerve
A
Pectoralis major and pectoralis minor
10
Q
Lateral pectoral nerve
A
Pectoralis major only
11
Q
Intercostobrachial nerve
A
Lateral cutaneous branch of the 2nd intercostal nerve
Sensation to medial arm and axilla
Just below axillary vein
12
Q
Arterial supply to breast
A
Branches of:
- Internal thoracic artery
- Intercostal arteries
- Thoracoacromial artery
- Lateral thoracic artery
13
Q
What neurovascular structures need to be preserved in an axillary dissection?
A
Long thoracic nerve Thoracodorsal vessels and nerve Medial pectoral nerve Pectorails minor muscle Intercostal brachial nerve Axillary vein
14
Q
Baston’s plexus
A
Valveless vein plexus that allows direct hematogenous metastasis of breast cancer to spine
15
Q
Lymphatic drainage of the breast
A
97% to axillary nodes
2% to internal mammary node
Supraclavicular nodes - N3 disease
16
Q
What is the MCC primary axillary adenopathy?
A
Lymphoma
17
Q
Cooper’s ligament
A
Suspensory ligaments, divides the breast into segments
Breast cancer invasion can cause dimpling
18
Q
Breast abscess
A
Breastfeeding
S. aureus
Tx: percutneous or incision and drainage; stop breast feeding, breast pump; antibiotics
19
Q
Infectious mastitis
A
Breastfeeding
S. aureus
Non-lactating - chronic inflammatory disease or autoimmune disease
Biopsy - r/o necrotic cancer
20
Q
Periductal mastitis
A
Sx: noncyclical mastodynia, erythema, nipple retraction, creamy discharge from nipple, subareolar abscess
Risk: smoking, nipple piercing
Biopsy: dilated mammary ducts, inspissated secretions, marked periductal inflammation
Tx: abx and reassure (unless - bloody, nipple retraction or recurrent - biopsy to r/o inflammatory CA)
21
Q
Galactocele
A
Breast feeding
Breast cyst filled with milk
Tx: aspiration or I&D
22
Q
Galactorrhea
A
Increased prolactin, OCP, TCA, pneothiazines, metocloprmide, alpha-methyl dopa, reserpine
Associated with amenorrhea
23
Q
Gynecomastia
A
2cm pinch
Cimetidine, spironolactone, THC
Tx: resect if doesn’t regress
24
Q
Neonatal breast enlargement
A
Circulating maternal estrogens
Will regress
25
Accessory breast tissue
Polythelia
| MCL axilla
26
Accessory nipples
From axilla to groin
| Most common breast anomaly
27
Hypoplasia of chest wall
Amastia
Hypoplastic shoulder
No pectoralis muscle
Poland's syndrome
28
Mastodynia
Pain in breast
Tx: Danazol, OCPs, NSAIDs, primrose oil, bromocriptin
Stop: carffeine, nicotine, methylxanthines
29
Mondor's disease
```
Superficial vein thrombophlebitis of breast
Feels cordlike, painful
Trauma, strenuous exercise
MCL lower outer quadrant
Tx: NSAIDs
```
30
FIbrocystic disease
Papillomatosis, sclerosing adenosis, aprocrine metaplasia, duct adenosis, epithelial hyperplasia, ductal hyperplasia, lobular hyperplasia
Cancer risk ONLY with atypical ductal or lobular hyperplasia (resect all suspicious areas on mammo)
31
Intraductal papilloma
MCC bloody nipple discharge
Small, nonpalpable, close to nipple
Dx: contrast ductogram
Tx: subareolar resection
32
Management of fibroadenoma in patients <40yo
```
If:
- Feels clinically benign
- US/Mammo consistent with fibroadenoma
- FNA/core needle biopsy shows fibroadenoma
Than observe
If continues to grow - excisional biopsy
```
33
Management of fibroadenoma in patients >40yo
Excisional biopsy
34
Large, coarse calcification (popcorn lesions) on mammo?
Fibroadenoma
35
Prominent fibrous tissue compressing epithelial cells on pathology
Fibroadenoma
36
Green nipple discharge
Fibrocystic disease
| If cyclical and nonspontaneous - reassure patient
37
Bloody nipple discharge
```
Intraductal papilloma (poss ductal CA)
Tx: ductogram and excision of ductal area
```
38
Serous nipple discharge
Worrisome for cancer
| Tx: excisional biopsy
39
Spontaneous nipple discharge
Worrisome for cancer
| Excisional biopsy
40
Ductal carcinoma in situ
50% will develop ipsilateral CA, 5% contralateral CA
Cluster of calcifications
Premalignant lesion
Increased risk for recurrence with comedo type and >2.5cm
Tx:
- Lumpectomy and XRT, 1cm margin, tamoxifen
- Simple mastectomy (high grade, multifocal, large tumor)
41
When do you do a SLNB in DCIS?
Mastectomy
Comedo pattern
Palpable
>2cm
42
Lobular carcinoma in situa
40% CA in either breast, 5% synchronous lesion
Marker for development of breast cancer
Tx: excisional biopsy or BL subcutaneous mastectomy + tamoxifen
43
Indications for surgical biopsy after core needle biopsy?
```
Atypical ductal hyperplasia
Atypical lobular hyperplasia
Radial scar
Lobular carcinoma in situ
Columnar cell hyperplasia with atypia
Papillary lesions
Lack of concordance b/t mammo and histology
Non-diagnostic specimen
```
44
Symptomatic breast mass work up < 40yo
Ultrasound
Core needle biopsy (of FNA)
Mammo if clinical exam or US is indeterminant or suspicious
45
Symptomatic breast mass work up > 40yo
Bilateral mammo, ultrasound and core needle biopsy
| Excisional biopsy if indicated
46
Cystic fluid
Bloody - excisional biopsy
Clear and recurs - excisional biopsy
Complex cyst - excisional biopsy
47
Core needle biopsy gives you:
architecture
48
Fine needle aspiration gives you:
just cytology
49
FNA or core needle biopsy result - next step?
| Malignant
Definitive therapy
50
FNA or core needle biopsy result - next step?
| Suspicious
Surgical biopsy
51
FNA or core needle biopsy result - next step?
| Atypia
Surgical biopsy
52
FNA or core needle biopsy result - next step?
| Nondiagnostic
Repeat FNA or CNBx
OR
Surgical biopsy
53
Benign
Possible observation
| Unless results don't match imaging - then surgical biopsy
54
Sensitivity and specificity of mammo?
95%
55
How large does a mass need to be to be detectable on mammo?
>5mm
56
On mammo - features suggestive of CA?
```
Irregular borders
Spiculated
Multiple clustered, small, thin, linear, crushed-like and/or branching calcifications
Ductal asymmetry
Distortion of architecture
```
57
BI-RADS 1
Negative
| Routine screening
58
BI-RADS 2
Benign finding
| Routine screening
59
BI-RADS 3
Probably benignt
| Short-interval f/u mammo
60
BI-RADS 4
Suspicious abnormality
| Definite probability of cancer - CNBx
61
BI-RADS 5
Highly suggestive of CA
| High probability of cancer - CNBx
62
BI-RADS 4 lesion CNBx shows:
- Malignancy
- Non-diagnostic
- Benign and concordant
- Follow appropriate treatment
- Needle localization excisional biopsy
- 6mo f/u mammo
63
BI-RADS 5 lesion CNBx shows:
- Malignancy
- Anything else
- Follow appropriate treatment
| - Needle localization excisional biopsy
64
Breast cancer screening
Mammo every 2-3 years after 40yo, yearly after 50yo
| High-risk - start 10 years prior to familial breast CA
65
Axillary nodes I
lateral to pectoralis minor muscle
66
Axillary nodes II
Posterior to pectoralis minor muscle
67
Axillary nodes III
Medial to pectoralis minor muscle
68
Rotter's nodes
Between pectoralis major and minor msucles
69
Axillary node dissection
Levels I and II
70
Prognostic staging factors for breast cancer
Nodes
Tumor size
Tumor grade
PR/ER status
71
Most common site for distant mets
Bone
| Lung, liver, brain
72
T staging breast cancer
T1 <2cm
T2 >2cm but <5cm
T3 >5cm
T4 direct extension into chest wall, skin edema, skin ulceration, satelite skin nodules, inflammatory carcinoma
73
N staging breast cancer
N1 - 1-3 axillary nodes OR internal mammary node
N2 - 4-9 axillary nodes OR clinically apparent IM nodes
N3 - 10+ axillary nodes, infraclavicular nodes or IM nodes and suprclavicular nodes
74
Greatly increased risk for breast cancer (RR>4)
BRCA gene in patient with family hx of breast CA
>2 primary relatives with bilateral or premenopausal breast CA
DCIS (ipsilateral breast at risk)
LCIS (bilateral breast risk)
Fibrocystic disease with atypical hyperplasia
75
Moderately increased risk for breast cancer (RR 2-4)
Prior breast cancer
Radiation exposure
First-degree relative with breast cancer
Age >35 first birth
76
Lower increased risk for breast cancer (RR<2)
```
Early menarche
Late menopause
Nulliparity
Proliferative benign disease
Obesity
Alcohol use
Hormone replacement therapy
```
77
BRCA I (lifetime risk)
Female breast CA 60%
Ovarian CA 40%
Male breast CA 1%
78
BRCA II (lifetime risk)
Female breast CA 60%
Ovarian CA 10%
Male breast cancer 10%
79
Patient with history of breast CA and BRCA?
Consider total abdominal hysterectomy and bilateral salpingo-oophorectomy
80
Consideration for prophylactic mastectomy?
```
Family history + BRCA gene
LCIS
PLUS:
- High anxiety patient
- poor access to care
- Difficult lesion
- Patient preference
```
81
Male breast cancer
```
<1% of breast CA
Usually ductal
Late presentation - tend to involve PEC
Risks: steroids, previous XRT, family history, Klinefelter's syndrome
Tx: Modified radical mastectomy
```
82
Types of ductal carcinoma
Medullary (smooth borders, lymphocytes, bizarre cells)
Tubular
Mucinous (colloid)
Scirrhotic (worst prognosis)
83
Characteristics of lobular cancer
Does not form calcifications
Extensively infiltrates
More likely to be bilateral, multifolcal and multicentric
Signet ring cells - worse prognosis
84
Inflammatory breast cancer
Considered T4
Very aggressive
Dermal lymphatic invasion
Tx: neoadjuvant chemo, then MRM, then adjuvant chemo-XRT
85
Treatment of breast cancer?
MRM
OR
BCT with XRT
86
Simple mastectomy
Leaves 1-2% breast tissue, preserves the nipple
NOT for breast CA
For DCIS/LCIS
87
Breast-conserving therapy
Lumpectomy + ALND or SLNB
Combined with post-op XRT
1cm margins
88
Modified radical mastectomy
Remove all breast tissue including nipple areolar complex
Axillary node dissection (level I nodes)
Keep drains until <40cc/24hrs
89
Absolute contraindications to breast-conserving therapy in invasive carcinoma?
- 2+ primary tumors in separate quadrants
- Persistent positive margins after reasonable surgical attempts
- Pregnancy (CI to radiation)
- Previous radiation
- Diffuse, malignant-appearing microcalcifications
90
Relative contraindications to breast-conserving therapy in invasive carcinoma?
- History of scleroderma or active SLE
- Large tumor in small breast (poor cosmesis)
- Large/pendulous breast (poor cosmesis)
91
Indications for SLNB?
Malignant tumors >1cm
| NOT: clinically positive nodes
92
Reaction to Lymphazurin blue dye?
Type I hypersensitivity reaction
93
If during SLNB, no radiotracer or dye is found?
Do a formal ALND
94
Contraindications to SLNB?
Clinically positive nodes
Prior axillary surgery
Inflammatory or locally advanced disease
95
ALND
Talk level I and level II nodes
96
Complications of MRM
Infection
Flap necrosis
Seroma
Hematoma
97
Complications of ALND
Infection
Lymphedema
Lymphangiosarcoma
Axillary vein thrombosis (early, post-op swelling)
Lymphatic fibrosis (over 18mo)
Intercostal brachiocutaneous nerve injury
98
Sudden, early, post-op swelling after ALND
Axillary vein thrombosis
99
Hyperesthesia of inner arm and lateral chest wall after RMR?
Intercostal brachiocutaneous nerve injury
Most commonly injured nerve after mastectomy
No significant sequalea
100
Radiotherapy for breast cancer
5000 rad for BCT and XRT
101
Complications of XRT for breast cancer
```
Edema
Erythema
Rib fractures
Pneumonitis
Ulceration
Sarcoma
Contralateral breast CA
```
102
Contraindications to XRT
Scleroderma (severe fibrosis and necrosis)
Previous XRT and would exceed recommended dose
SLE
Active rheumatoid arthritis
103
Indication for XRT after mastectomy?
```
>4 nodes
Skin or chest wall involvement
Positive margins
Tumor >5cm (T3)
Extracapsular nodal invasion
Inflammatory CA
Fixed axillary node (N2) or internal mammary nodes (N3)
```
104
Breast conservatory therapy with XRT?
Need negative margins before starting XRT
10% chance local recurrence - within 2 years, re-stage
Need salvage MRM for local recurrence
105
Chemotherapy for breast cancer?
```
TAC
Taxanes (docetaxel, paclitaxel), Adriamycin, clyclophosphamide (6-12 weeks)
```
106
Chemotherapy - Breast cancer >1cm and negative nodes?
Everyone gets chemo, EXCEPT ER+ (aromatase inhibitor or tamoxifen only)
107
Chemotherapy - breast cancer with positive nodes?
Everyone gets chemo, EXCEPT post-menopausal with ER+ (aromatase inhibitor only)
108
Chemotherapy - Breast cancer <1cm with negative nodes?
NO chemo
| Hormonal therapy
109
Tamoxifen
Decreases risk of breast CA by 50%
1% risk blood clots
0.1% risk of endometrial CA
110
Breast cancer - risk for increased recurrence and metastases?
Positive nodes
Large tumor
Negative receptors
Unfavorable subtype
111
Pain, swelling, erythema in areas of metastatic breast cancer?
Metastatic flare
XRT can help
Particularly good for bone mets
112
Axillary breast metastases with unknown primary?
Occult breast CA
| Tx: MRM (70% have invasive cancer)
113
Scaly skin lesion on nipple, biopsy shows Paget's cells?
```
Paget's disease
Patient has DCIS or ductal CA in breast
Tx:
- If CA present - MRM
- NO cancer - simple mastectomy, including nipple-areolar complex)
```
114
Cystosarcoma phyllodes
```
10% malignant (>5-10 mitoses HPF)
NO nodal metastases, rarely hematologenous
Stromal and epithelial elements
Can be large
Tx: WLE with negative margins, no ALND
```
115
Patient presents with dark purple nodule or lesion on arm 5-10 years after surgery
Stewart-Treves syndrome
| Lymphagiosarcoma from chronic lymphedema following axillary dissection
116
Treatment of breast cancer in pregnancy?
1, 2nd trimester MRM
| 3rd trimester: lumpectomy with radiotracer slnb and postpartum XRT (no breastfeeding)
