24 Breast Flashcards
Embryologic origins of breast tissue
Ectoderm milk streak
Effect of estrogen on the breast
Development - duct development (double layer of columnar cells)
Cyclic - breast swelling, growth of glandular tissue
Effect of progesterone on the breast
Development - lobular development
Cyclic - maturation of glandular tissue, withdrawal cause menses
Effect of prolactin on breast development
Synergizes with estrogen and progesterone
Effect of FSH and LH surge on cyclical changes
Ovum release
What leads to atrophy of the breast after menopause?
Lack of estrogen and progesterone
Injury results in winged scapula
Long thoracic nerve
Serratus anterior
Lateral thoracic artery
Injury results in weak arm pull-ups and adduction
Thoracodorsal nerve
Latissimus dorsi
Thoracodorsal artery
Medial pectoral nerve
Pectoralis major and pectoralis minor
Lateral pectoral nerve
Pectoralis major only
Intercostobrachial nerve
Lateral cutaneous branch of the 2nd intercostal nerve
Sensation to medial arm and axilla
Just below axillary vein
Arterial supply to breast
Branches of:
- Internal thoracic artery
- Intercostal arteries
- Thoracoacromial artery
- Lateral thoracic artery
What neurovascular structures need to be preserved in an axillary dissection?
Long thoracic nerve Thoracodorsal vessels and nerve Medial pectoral nerve Pectorails minor muscle Intercostal brachial nerve Axillary vein
Baston’s plexus
Valveless vein plexus that allows direct hematogenous metastasis of breast cancer to spine
Lymphatic drainage of the breast
97% to axillary nodes
2% to internal mammary node
Supraclavicular nodes - N3 disease
What is the MCC primary axillary adenopathy?
Lymphoma
Cooper’s ligament
Suspensory ligaments, divides the breast into segments
Breast cancer invasion can cause dimpling
Breast abscess
Breastfeeding
S. aureus
Tx: percutneous or incision and drainage; stop breast feeding, breast pump; antibiotics
Infectious mastitis
Breastfeeding
S. aureus
Non-lactating - chronic inflammatory disease or autoimmune disease
Biopsy - r/o necrotic cancer
Periductal mastitis
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)
Galactocele
Breast feeding
Breast cyst filled with milk
Tx: aspiration or I&D
Galactorrhea
Increased prolactin, OCP, TCA, pneothiazines, metocloprmide, alpha-methyl dopa, reserpine
Associated with amenorrhea
Gynecomastia
2cm pinch
Cimetidine, spironolactone, THC
Tx: resect if doesn’t regress
Neonatal breast enlargement
Circulating maternal estrogens
Will regress
Accessory breast tissue
Polythelia
MCL axilla
Accessory nipples
From axilla to groin
Most common breast anomaly
Hypoplasia of chest wall
Amastia
Hypoplastic shoulder
No pectoralis muscle
Poland’s syndrome
Mastodynia
Pain in breast
Tx: Danazol, OCPs, NSAIDs, primrose oil, bromocriptin
Stop: carffeine, nicotine, methylxanthines
Mondor’s disease
Superficial vein thrombophlebitis of breast Feels cordlike, painful Trauma, strenuous exercise MCL lower outer quadrant Tx: NSAIDs
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)
Intraductal papilloma
MCC bloody nipple discharge
Small, nonpalpable, close to nipple
Dx: contrast ductogram
Tx: subareolar resection
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
Management of fibroadenoma in patients >40yo
Excisional biopsy
Large, coarse calcification (popcorn lesions) on mammo?
Fibroadenoma
Prominent fibrous tissue compressing epithelial cells on pathology
Fibroadenoma
Green nipple discharge
Fibrocystic disease
If cyclical and nonspontaneous - reassure patient
Bloody nipple discharge
Intraductal papilloma (poss ductal CA) Tx: ductogram and excision of ductal area
Serous nipple discharge
Worrisome for cancer
Tx: excisional biopsy
Spontaneous nipple discharge
Worrisome for cancer
Excisional biopsy
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)
When do you do a SLNB in DCIS?
Mastectomy
Comedo pattern
Palpable
>2cm
Lobular carcinoma in situa
40% CA in either breast, 5% synchronous lesion
Marker for development of breast cancer
Tx: nothing, tamoxifen or BL subcutaneous mastectomy
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
Symptomatic breast mass work up < 40yo
Ultrasound
Core needle biopsy (of FNA)
Mammo if clinical exam or US is indeterminant or suspicious
Symptomatic breast mass work up > 40yo
Bilateral mammo, ultrasound and core needle biopsy
Excisional biopsy if indicated
Cystic fluid
Bloody - excisional biopsy
Clear and recurs - excisional biopsy
Complex cyst - excisional biopsy
Core needle biopsy gives you:
architecture
Fine needle aspiration gives you:
just cytology
FNA or core needle biopsy result - next step?
Malignant
Definitive therapy
FNA or core needle biopsy result - next step?
Suspicious
Surgical biopsy
FNA or core needle biopsy result - next step?
Atypia
Surgical biopsy
FNA or core needle biopsy result - next step?
Nondiagnostic
Repeat FNA or CNBx
OR
Surgical biopsy
Benign
Possible observation
Unless results don’t match imaging - then surgical biopsy
Sensitivity and specificity of mammo?
95%
How large does a mass need to be to be detectable on mammo?
> 5mm
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
BI-RADS 1
Negative
Routine screening
BI-RADS 2
Benign finding
Routine screening
BI-RADS 3
Probably benignt
Short-interval f/u mammo
BI-RADS 4
Suspicious abnormality
Definite probability of cancer - CNBx
BI-RADS 5
Highly suggestive of CA
High probability of cancer - CNBx
BI-RADS 4 lesion CNBx shows:
- Malignancy
- Non-diagnostic
- Benign and concordant
- Follow appropriate treatment
- Needle localization excisional biopsy
- 6mo f/u mammo
BI-RADS 5 lesion CNBx shows:
- Malignancy
- Anything else
- Follow appropriate treatment
- Needle localization excisional biopsy
Breast cancer screening
Mammo every 2-3 years after 40yo, yearly after 50yo
High-risk - start 10 years prior to familial breast CA
Axillary nodes I
lateral to pectoralis minor muscle
Axillary nodes II
Posterior to pectoralis minor muscle
Axillary nodes III
Medial to pectoralis minor muscle
Rotter’s nodes
Between pectoralis major and minor msucles
Axillary node dissection
Levels I and II
Prognostic staging factors for breast cancer
Nodes
Tumor size
Tumor grade
PR/ER status
Most common site for distant mets
Bone
Lung, liver, brain
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
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
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
Moderately increased risk for breast cancer (RR 2-4)
Prior breast cancer
Radiation exposure
First-degree relative with breast cancer
Age >35 first birth
Lower increased risk for breast cancer (RR<2)
Early menarche Late menopause Nulliparity Proliferative benign disease Obesity Alcohol use Hormone replacement therapy
BRCA I (lifetime risk)
Female breast CA 60%
Ovarian CA 40%
Male breast CA 1%
BRCA II (lifetime risk)
Female breast CA 60%
Ovarian CA 10%
Male breast cancer 10%
Patient with history of breast CA and BRCA?
Consider total abdominal hysterectomy and bilateral salpingo-oophorectomy
Consideration for prophylactic mastectomy?
Family history + BRCA gene LCIS PLUS: - High anxiety patient - poor access to care - Difficult lesion - Patient preference
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
Types of ductal carcinoma
Medullary (smooth borders, lymphocytes, bizarre cells)
Tubular
Mucinous (colloid)
Scirrhotic (worst prognosis)
Characteristics of lobular cancer
Does not form calcifications
Extensively infiltrates
More likely to be bilateral, multifolcal and multicentric
Signet ring cells - worse prognosis
Inflammatory breast cancer
Considered T4
Very aggressive
Dermal lymphatic invasion
Tx: neoadjuvant chemo, then MRM, then adjuvant chemo-XRT
Treatment of breast cancer?
MRM
OR
BCT with XRT
Simple mastectomy
Leaves 1-2% breast tissue, preserves the nipple
NOT for breast CA
For DCIS/LCIS
Breast-conserving therapy
Lumpectomy + ALND or SLNB
Combined with post-op XRT
1cm margins
Modified radical mastectomy
Remove all breast tissue including nipple areolar complex
Axillary node dissection (level I nodes)
Keep drains until <40cc/24hrs
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
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)
Indications for SLNB?
Malignant tumors >1cm
NOT: clinically positive nodes
Reaction to Lymphazurin blue dye?
Type I hypersensitivity reaction
If during SLNB, no radiotracer or dye is found?
Do a formal ALND
Contraindications to SLNB?
Pregnancy Multicentric disease Neoadjuvant therapy Clinically positive nodes Prior axillary surgery Inflammatory or locally advanced disease
ALND
Talk level I and level II nodes
Complications of MRM
Infection
Flap necrosis
Seroma
Hematoma
Complications of ALND
Infection
Lymphedema
Lymphangiosarcoma
Axillary vein thrombosis (early, post-op swelling)
Lymphatic fibrosis (over 18mo)
Intercostal brachiocutaneous nerve injury
Sudden, early, post-op swelling after ALND
Axillary vein thrombosis
Hyperesthesia of inner arm and lateral chest wall after RMR?
Intercostal brachiocutaneous nerve injury
Most commonly injured nerve after mastectomy
No significant sequalea
Radiotherapy for breast cancer
5000 rad for BCT and XRT
Complications of XRT for breast cancer
Edema Erythema Rib fractures Pneumonitis Ulceration Sarcoma Contralateral breast CA
Contraindications to XRT
Scleroderma (severe fibrosis and necrosis)
Previous XRT and would exceed recommended dose
SLE
Active rheumatoid arthritis
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)
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
Chemotherapy for breast cancer?
TAC Taxanes (docetaxel, paclitaxel), Adriamycin, clyclophosphamide (6-12 weeks)
Chemotherapy - Breast cancer >1cm and negative nodes?
Everyone gets chemo, EXCEPT ER+ (aromatase inhibitor or tamoxifen only)
Chemotherapy - breast cancer with positive nodes?
Everyone gets chemo, EXCEPT post-menopausal with ER+ (aromatase inhibitor only)
Chemotherapy - Breast cancer <1cm with negative nodes?
NO chemo
Hormonal therapy
Tamoxifen
Decreases risk of breast CA by 50%
1% risk blood clots
0.1% risk of endometrial CA
Breast cancer - risk for increased recurrence and metastases?
Positive nodes
Large tumor
Negative receptors
Unfavorable subtype
Pain, swelling, erythema in areas of metastatic breast cancer?
Metastatic flare
XRT can help
Particularly good for bone mets
Axillary breast metastases with unknown primary?
Occult breast CA
Tx: MRM (70% have invasive cancer)
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)
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
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
Treatment of breast cancer in pregnancy?
MRM
Unless late 3rd trimester - lumpectomy with ALND and postpartum XRT (no breastfeeding)
