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ABSITE > 24 Breast > Flashcards

24 Breast Flashcards

1
Q

Embryologic origins of breast tissue

A

Ectoderm milk streak

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2
Q

Effect of estrogen on the breast

A

Development - duct development (double layer of columnar cells)
Cyclic - breast swelling, growth of glandular tissue

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3
Q

Effect of progesterone on the breast

A

Development - lobular development

Cyclic - maturation of glandular tissue, withdrawal cause menses

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4
Q

Effect of prolactin on breast development

A

Synergizes with estrogen and progesterone

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5
Q

Effect of FSH and LH surge on cyclical changes

A

Ovum release

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6
Q

What leads to atrophy of the breast after menopause?

A

Lack of estrogen and progesterone

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7
Q

Injury results in winged scapula

A

Long thoracic nerve
Serratus anterior
Lateral thoracic artery

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8
Q

Injury results in weak arm pull-ups and adduction

A

Thoracodorsal nerve
Latissimus dorsi
Thoracodorsal artery

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9
Q

Medial pectoral nerve

A

Pectoralis major and pectoralis minor

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10
Q

Lateral pectoral nerve

A

Pectoralis major only

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11
Q

Intercostobrachial nerve

A

Lateral cutaneous branch of the 2nd intercostal nerve
Sensation to medial arm and axilla
Just below axillary vein

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12
Q

Arterial supply to breast

A

Branches of:

  • Internal thoracic artery
  • Intercostal arteries
  • Thoracoacromial artery
  • Lateral thoracic artery
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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
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14
Q

Baston’s plexus

A

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

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15
Q

Lymphatic drainage of the breast

A

97% to axillary nodes
2% to internal mammary node

Supraclavicular nodes - N3 disease

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16
Q

What is the MCC primary axillary adenopathy?

A

Lymphoma

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17
Q

Cooper’s ligament

A

Suspensory ligaments, divides the breast into segments

Breast cancer invasion can cause dimpling

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18
Q

Breast abscess

A

Breastfeeding
S. aureus
Tx: percutneous or incision and drainage; stop breast feeding, breast pump; antibiotics

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19
Q

Infectious mastitis

A

Breastfeeding
S. aureus
Non-lactating - chronic inflammatory disease or autoimmune disease
Biopsy - r/o necrotic cancer

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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)

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21
Q

Galactocele

A

Breast feeding
Breast cyst filled with milk
Tx: aspiration or I&D

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22
Q

Galactorrhea

A

Increased prolactin, OCP, TCA, pneothiazines, metocloprmide, alpha-methyl dopa, reserpine
Associated with amenorrhea

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23
Q

Gynecomastia

A

2cm pinch
Cimetidine, spironolactone, THC
Tx: resect if doesn’t regress

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24
Q

Neonatal breast enlargement

A

Circulating maternal estrogens

Will regress

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25
Q

Accessory breast tissue

A

Polythelia

MCL axilla

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26
Q

Accessory nipples

A

From axilla to groin

Most common breast anomaly

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27
Q

Hypoplasia of chest wall
Amastia
Hypoplastic shoulder
No pectoralis muscle

A

Poland’s syndrome

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28
Q

Mastodynia

A

Pain in breast
Tx: Danazol, OCPs, NSAIDs, primrose oil, bromocriptin
Stop: carffeine, nicotine, methylxanthines

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29
Q

Mondor’s disease

A 
Superficial vein thrombophlebitis of breast 
Feels cordlike, painful
Trauma, strenuous exercise
MCL lower outer quadrant
Tx: NSAIDs
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30
Q

FIbrocystic disease

A

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)

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31
Q

Intraductal papilloma

A

MCC bloody nipple discharge
Small, nonpalpable, close to nipple
Dx: contrast ductogram
Tx: subareolar resection

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32
Q

Management of fibroadenoma in patients <40yo

A 
If:
- Feels clinically benign
- US/Mammo consistent with fibroadenoma
- FNA/core needle biopsy shows fibroadenoma
Than observe
If continues to grow - excisional biopsy
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33
Q

Management of fibroadenoma in patients >40yo

A

Excisional biopsy

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34
Q

Large, coarse calcification (popcorn lesions) on mammo?

A

Fibroadenoma

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35
Q

Prominent fibrous tissue compressing epithelial cells on pathology

A

Fibroadenoma

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36
Q

Green nipple discharge

A

Fibrocystic disease

If cyclical and nonspontaneous - reassure patient

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37
Q

Bloody nipple discharge

A 
Intraductal papilloma (poss ductal CA)
Tx: ductogram and excision of ductal area
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38
Q

Serous nipple discharge

A

Worrisome for cancer

Tx: excisional biopsy

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39
Q

Spontaneous nipple discharge

A

Worrisome for cancer

Excisional biopsy

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40
Q

Ductal carcinoma in situ

A

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)

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41
Q

When do you do a SLNB in DCIS?

A

Mastectomy
Comedo pattern
Palpable
>2cm

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42
Q

Lobular carcinoma in situa

A

40% CA in either breast, 5% synchronous lesion
Marker for development of breast cancer
Tx: excisional biopsy or BL subcutaneous mastectomy + tamoxifen

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43
Q

Indications for surgical biopsy after core needle biopsy?

A 
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
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44
Q

Symptomatic breast mass work up < 40yo

A

Ultrasound
Core needle biopsy (of FNA)
Mammo if clinical exam or US is indeterminant or suspicious

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45
Q

Symptomatic breast mass work up > 40yo

A

Bilateral mammo, ultrasound and core needle biopsy

Excisional biopsy if indicated

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46
Q

Cystic fluid

A

Bloody - excisional biopsy
Clear and recurs - excisional biopsy
Complex cyst - excisional biopsy

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47
Q

Core needle biopsy gives you:

A

architecture

48
Q

Fine needle aspiration gives you:

A

just cytology

49
Q

FNA or core needle biopsy result - next step?

Malignant

A

Definitive therapy

50
Q

FNA or core needle biopsy result - next step?

Suspicious

A

Surgical biopsy

51
Q

FNA or core needle biopsy result - next step?

Atypia

A

Surgical biopsy

52
Q

FNA or core needle biopsy result - next step?

Nondiagnostic

A

Repeat FNA or CNBx
OR
Surgical biopsy

53
Q

Benign

A

Possible observation

Unless results don’t match imaging - then surgical biopsy

54
Q

Sensitivity and specificity of mammo?

A

95%

55
Q

How large does a mass need to be to be detectable on mammo?

A

> 5mm

56
Q

On mammo - features suggestive of CA?

A 
Irregular borders
Spiculated
Multiple clustered, small, thin, linear, crushed-like and/or branching calcifications
Ductal asymmetry
Distortion of architecture
57
Q

BI-RADS 1

A

Negative

Routine screening

58
Q

BI-RADS 2

A

Benign finding

Routine screening

59
Q

BI-RADS 3

A

Probably benignt

Short-interval f/u mammo

60
Q

BI-RADS 4

A

Suspicious abnormality

Definite probability of cancer - CNBx

61
Q

BI-RADS 5

A

Highly suggestive of CA

High probability of cancer - CNBx

62
Q

BI-RADS 4 lesion CNBx shows:

  • Malignancy
  • Non-diagnostic
  • Benign and concordant
A
  • Follow appropriate treatment
  • Needle localization excisional biopsy
  • 6mo f/u mammo
63
Q

BI-RADS 5 lesion CNBx shows:

  • Malignancy
  • Anything else
A
  • Follow appropriate treatment

- Needle localization excisional biopsy

64
Q

Breast cancer screening

A

Mammo every 2-3 years after 40yo, yearly after 50yo

High-risk - start 10 years prior to familial breast CA

65
Q

Axillary nodes I

A

lateral to pectoralis minor muscle

66
Q

Axillary nodes II

A

Posterior to pectoralis minor muscle

67
Q

Axillary nodes III

A

Medial to pectoralis minor muscle

68
Q

Rotter’s nodes

A

Between pectoralis major and minor msucles

69
Q

Axillary node dissection

A

Levels I and II

70
Q

Prognostic staging factors for breast cancer

A

Nodes
Tumor size
Tumor grade
PR/ER status

71
Q

Most common site for distant mets

A

Bone

Lung, liver, brain

72
Q

T staging breast cancer

A

T1 <2cm
T2 >2cm but <5cm
T3 >5cm
T4 direct extension into chest wall, skin edema, skin ulceration, satelite skin nodules, inflammatory carcinoma

73
Q

N staging breast cancer

A

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
Q

Greatly increased risk for breast cancer (RR>4)

A

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
Q

Moderately increased risk for breast cancer (RR 2-4)

A

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

76
Q

Lower increased risk for breast cancer (RR<2)

A 
Early menarche
Late menopause
Nulliparity
Proliferative benign disease
Obesity
Alcohol use
Hormone replacement therapy
77
Q

BRCA I (lifetime risk)

A

Female breast CA 60%
Ovarian CA 40%
Male breast CA 1%

78
Q

BRCA II (lifetime risk)

A

Female breast CA 60%
Ovarian CA 10%
Male breast cancer 10%

79
Q

Patient with history of breast CA and BRCA?

A

Consider total abdominal hysterectomy and bilateral salpingo-oophorectomy

80
Q

Consideration for prophylactic mastectomy?

A 
Family history + BRCA gene
LCIS
PLUS:
- High anxiety patient
- poor access to care
- Difficult lesion
- Patient preference
81
Q

Male breast cancer

A 
<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
Q

Types of ductal carcinoma

A

Medullary (smooth borders, lymphocytes, bizarre cells)
Tubular
Mucinous (colloid)
Scirrhotic (worst prognosis)

83
Q

Characteristics of lobular cancer

A

Does not form calcifications
Extensively infiltrates
More likely to be bilateral, multifolcal and multicentric
Signet ring cells - worse prognosis

84
Q

Inflammatory breast cancer

A

Considered T4
Very aggressive
Dermal lymphatic invasion
Tx: neoadjuvant chemo, then MRM, then adjuvant chemo-XRT

85
Q

Treatment of breast cancer?

A

MRM
OR
BCT with XRT

86
Q

Simple mastectomy

A

Leaves 1-2% breast tissue, preserves the nipple
NOT for breast CA
For DCIS/LCIS

87
Q

Breast-conserving therapy

A

Lumpectomy + ALND or SLNB
Combined with post-op XRT
1cm margins

88
Q

Modified radical mastectomy

A

Remove all breast tissue including nipple areolar complex
Axillary node dissection (level I nodes)
Keep drains until <40cc/24hrs

89
Q

Absolute contraindications to breast-conserving therapy in invasive carcinoma?

A
  • 2+ primary tumors in separate quadrants
  • Persistent positive margins after reasonable surgical attempts
  • Pregnancy (CI to radiation)
  • Previous radiation
  • Diffuse, malignant-appearing microcalcifications
90
Q

Relative contraindications to breast-conserving therapy in invasive carcinoma?

A
  • History of scleroderma or active SLE
  • Large tumor in small breast (poor cosmesis)
  • Large/pendulous breast (poor cosmesis)
91
Q

Indications for SLNB?

A

Malignant tumors >1cm

NOT: clinically positive nodes

92
Q

Reaction to Lymphazurin blue dye?

A

Type I hypersensitivity reaction

93
Q

If during SLNB, no radiotracer or dye is found?

A

Do a formal ALND

94
Q

Contraindications to SLNB?

A

Clinically positive nodes
Prior axillary surgery
Inflammatory or locally advanced disease

95
Q

ALND

A

Talk level I and level II nodes

96
Q

Complications of MRM

A

Infection
Flap necrosis
Seroma
Hematoma

97
Q

Complications of ALND

A

Infection
Lymphedema
Lymphangiosarcoma
Axillary vein thrombosis (early, post-op swelling)
Lymphatic fibrosis (over 18mo)
Intercostal brachiocutaneous nerve injury

98
Q

Sudden, early, post-op swelling after ALND

A

Axillary vein thrombosis

99
Q

Hyperesthesia of inner arm and lateral chest wall after RMR?

A

Intercostal brachiocutaneous nerve injury
Most commonly injured nerve after mastectomy
No significant sequalea

100
Q

Radiotherapy for breast cancer

A

5000 rad for BCT and XRT

101
Q

Complications of XRT for breast cancer

A 
Edema
Erythema
Rib fractures
Pneumonitis
Ulceration
Sarcoma
Contralateral breast CA
102
Q

Contraindications to XRT

A

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

103
Q

Indication for XRT after mastectomy?

A 
>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
Q

Breast conservatory therapy with XRT?

A

Need negative margins before starting XRT
10% chance local recurrence - within 2 years, re-stage
Need salvage MRM for local recurrence

105
Q

Chemotherapy for breast cancer?

A 
TAC
Taxanes (docetaxel, paclitaxel), Adriamycin, clyclophosphamide (6-12 weeks)
106
Q

Chemotherapy - Breast cancer >1cm and negative nodes?

A

Everyone gets chemo, EXCEPT ER+ (aromatase inhibitor or tamoxifen only)

107
Q

Chemotherapy - breast cancer with positive nodes?

A

Everyone gets chemo, EXCEPT post-menopausal with ER+ (aromatase inhibitor only)

108
Q

Chemotherapy - Breast cancer <1cm with negative nodes?

A

NO chemo

Hormonal therapy

109
Q

Tamoxifen

A

Decreases risk of breast CA by 50%
1% risk blood clots
0.1% risk of endometrial CA

110
Q

Breast cancer - risk for increased recurrence and metastases?

A

Positive nodes
Large tumor
Negative receptors
Unfavorable subtype

111
Q

Pain, swelling, erythema in areas of metastatic breast cancer?

A

Metastatic flare
XRT can help
Particularly good for bone mets

112
Q

Axillary breast metastases with unknown primary?

A

Occult breast CA

Tx: MRM (70% have invasive cancer)

113
Q

Scaly skin lesion on nipple, biopsy shows Paget’s cells?

A 
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
Q

Cystosarcoma phyllodes

A 
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
Q

Patient presents with dark purple nodule or lesion on arm 5-10 years after surgery

A

Stewart-Treves syndrome

Lymphagiosarcoma from chronic lymphedema following axillary dissection

116
Q

Treatment of breast cancer in pregnancy?

A

1, 2nd trimester MRM

3rd trimester: lumpectomy with radiotracer slnb and postpartum XRT (no breastfeeding)

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