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Surgery Two > 6 - Breast > Flashcards

6 - Breast Flashcards

1
Q

Workup for breast CA

A

Focused H/P
Dx MMG with f/u U/S
Bx (FNA, Core Bx, incisional vs excisional Bx)
MRI prior to surgery

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2
Q

Purpose of ducts?

A

Stores milk and connects the nipple

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3
Q

SE’s of XRT

A 
Lethargy
N/V
Dry skin
Breast TTP
Lymphedema of arm
Lung scarring
Cardiomyopathy
Myalgias
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4
Q

What is BI-RADS?

A

Breast Imaging Reporting and Data System

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5
Q

All patients receive what prior to surgery?

A

MRI (Eval tumor size, lesion quanity, guides TXT plan)

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6
Q

Fibrocystic changes will present with:

A

Bilateral breast pain
Nipple d/c
Correlate w/ menses (TTP peaks during luteal phase)

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7
Q

Workup for fibrocystic changes:

A

CBE during phases of menstrual cycle
MMG
Bx (FNA, core needle, or open)

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8
Q

Not necessarily risk factors for breast CA: 6

A 
Nursing
2nd degree relative fam hx
OCP’s
Boob job
Hx of mastitis
Fibrocystic breast
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9
Q

BI-RADS - Biopsy proven malignancy

A

6

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10
Q

Is breast US useful in screening?

A

No

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11
Q

Sentinel node bx and lumpectomy

A

Inject radio-nucleatide dye (uptake into mass/lymph)
Preop - scan ID’s sentinel node for excise (axillary)
Surgeon - ID’s node w/ gamma probe and excised
If 1st node NEG - likely no spread or axillary dissect

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12
Q

BI-RADS - 2

A

2 - benign findings (vascular Ca++, stable lesions, etc…)

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13
Q

Pathology - Human epidermal growth factor receptor (HER2) treated with: 2

A

Anticlonal antibodies

Poor prognosis 2/2 rapid metastasis

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14
Q

Pathology - progesterone receptor (PR) treated with:

A

Antiprogesterones

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15
Q

When is breast US normally used?

A

If mass found on MMG
Differs - cystic vs solid mass or (Guides FNA/Bx)
-smooth walled = likely benign
-irregularly shaped = req W/U

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16
Q

Radical mastectomy

A

Breast, skin, pectoralis, lymph nodes removed
Usually major blood loss
Decreased arm fx due to muscle gone (lymphedema)

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17
Q

Adjuvant chemo/xrt

A

Txt after surgery

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18
Q

Txt for fibrocystic changes (NbNv-F)

A 
No caffeine 
Bra support
NSAIDs (Rarely - tamoxifen, danasol)
Vit E / Primrose oil
Failure - SubQ mastectomy
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19
Q

What is the most important prognostic variable concerning breast CA txt?

A

tumor mets to axillary lymph nodes

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20
Q

Features of a BI-RADS 2? (WLC-S)

A

Well-circumscribed homogenous mass
Large or Dense / macrocalcifications
Calcified blood vessels
Stable benign findings havent changed form prev MMG

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21
Q

Txt for fibroadenoma

A

Observe (Benign Exam, MMG, FNA)

>35yo, elective excise per pt

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22
Q

Describe XRT

A

Radiation therapy - targeted (tangential)

Start XRT 2-6 wks POST surgery, 5x/wk, for 6-8 wks

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23
Q

Breast cancer pain is often?

A 
Often painless (hence the importance of screening) 
(some painful however)
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24
Q

W/U nipple d/c?

A 
Inspection / palpation (mass)
Dx MMG
Peri-areolar U/S
Cytology
HCG, prolactin, FSH, LH thyroid fx
Refer to surgery
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25
Q

BI-RADS - Highly suggestive of malig (definitely Bx)

A

5

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26
Q

Limitations of MMG?

A

Dense breasts -> difficult to image
Breast implants can obscure findings
Uses ionizing radiation

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27
Q

Other reconstruction / cosmetic option (besides TRAM)

A

Tissue expander

Gradually increase saline volume to stretch skin, then permanent implant is placed at desired size.

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28
Q

BI-RADS - 6

A

6 - Biopsy proven malignancy

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29
Q

Risk factors for breast CA: 5

A 
Females and >age
1st degree relative fam hx
High dietary fat
BRCA1 - 60% lifetime risk
BRCA 2 - 30% lifetime risk
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30
Q

BI-RADS - negative or normal

A

1

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31
Q

Patient positions for clinical breast exam

A

Supine and Sitting

  • lean forward
  • arms raised
  • pectoralis flex
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32
Q

Probably causes of breast pain: (MF-PIC)

A 
Mondor’s Dz
Fibrocystic breasts
Pregnancy
Infection
Costochondritis
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33
Q

What happens if you injure the thoracodorsal nerve?

A

Latissimus dorsi

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34
Q

What is Mondor’s Dz?

A

Trauma to chest wall vein after trauma / surgery

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35
Q

Breast abscess

A

Raised TTP mass near nipple

  • Fever/chills
  • Sweats/WBC^
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36
Q

Paget’s dz of the breast? 5

A

Ductal carcinoma involving the nipple
+/- palpable mass
Nipple itch/burn
Eczematoid / crusted lesion on nipple/areola
Any refrac lesion (top) abx or CCS >1 week > refer surg

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37
Q

Acute breast abscess usually due to?

A

Lactating breast

Chronic? Normally duct ectasia (thick, green black sticky discharge, older women)

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38
Q

Pathology - estrogen receptor (ER) treated with:

A

Antiestrogens

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39
Q

Incisional and excisional Bx

A

Both for palpable mass - Performed in OR
-Incisional - piece taken - PVT seratoma/good cosmetic
OR
-Excisional - entire mass removed with “clean margins” > sent to pathologist - can remove in-situ or non-metastisized mass in one surgery

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40
Q

BI-RADS - probably benign (repeat in 6 mos)

A

3

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41
Q

Common breast complaints (DAMP-G)

A 
D/C
ABNL MMG 
Mass
Pain
Gynecomastia (dudes)
42
Q

What is galactorrhea? W/U?

A

Bilateral milky d/c in non-lactating women
Not ass/w breast CA
Check for hyperprolactinemia or hypothyroidism
Dx MMG and F/U U/S PRN

43
Q

BI-RADS - 0

A

0 - additional imaging needed

44
Q

BI-RADS - 1

A

1 - negative or normal

45
Q

Core Bx

A

Local anesth
Spring-loaded
w/w/out U/S-guidance
“Fired” through mass, slide > pathology

46
Q

Is MMG a substitute for CBE/SBE?

A

No

47
Q

MC presentation of breast CA:

A

Found lump during SBE
Painless, unilateral, w/out nipple d/c
Hard mass w/ irregular margins

48
Q

Fibroadenoma presents how?

A

Young-F w/ decreased incidence closer to menopause
Smooth or slightly lobulated
1-3cm diameter

49
Q

TRAM

A

Transverse Rectus Abdominus Muscle

-Flap used to reproduce breast mound after mastectomy

50
Q

BI-RADS - 5

A

5 - Highly suggestive of malignancy (definitely Bx)

51
Q

Inflammatory breast CA presents with:

A

Breast erythema/edema w/out palpable mass usually
-confused with mastitis - does NOT respond to ABX
Non-lactating women (High DDx)
Highly malignant

52
Q

Screening MMG

A

Prelim- Not as detailed as a dx MMG

Pt has no S/S and has a NL PE

53
Q

What is Macromastia? Presents

A

Breast hypertrophy

  • Bra staps dig into shoulders
  • Upper back pain, poor posture
  • Chronic dermatitis under breasts
  • Difficult to find fitting clothes
54
Q

Male breast CA:

A

Usually older men
BRCA2 oncogene ass/w
Often involves the nipple

55
Q

MC palpable breast masses?

A

FA- Fibroadenoma
FC- Fibrocystic changes
FN- Fat necrosis
Gyn- Gynecomastia

56
Q

Bilateral gynecomastia causes?

A
  1. Increased Estrg
    - Testicular tumors, lung cancer, starved, thyrotoxicosis
  2. Decreased Test
    - Klinefelters, 2/2 testicular failure
  3. Rx causes
    - ESTG, Anabolic steroid, Cimetidine, Digoxin, Bud, INH
57
Q

BI-RADS - 3

A

3 - probably benign (repeat in 6 mos)

58
Q

Imaging for breast complaints

A

1st - Dx MMG

2nd - U/S

59
Q

What is the ratio of lobes:ducts

A

10-20:1

60
Q

Needle localized Bx

A

For non-palpable mass seen on MMG or U/S
Two parts:
1- in clinic (local anesth) - wire insert w/ US or CT guide
THEN
2 - taken to OR for excision of tissue > pathology

61
Q

What are the two standard views for MMG?

A

Craniocaudal (CC)
Mediolateral (CL)
(Spot compressions w/ specific site magnification)

62
Q

Goal of MMG’s

A

Detect breast CA before it becomes palpable

63
Q

What normally left in place after major breast removal?

A

Drains, to prevent seromas

64
Q

Rx causing Nipple d/c: (A-SCAN)

A 
A-Antipsychotics
S-Sedatives
C-Cimetidine
A-Anti-HTN
N-Narcotics
65
Q

MC breast CA type:

A

Infiltrating ductal carcinoma

66
Q

What are the fx unit of the breast and its purpose?

A

Lobes are the fx unit

produce milk

67
Q

Most nipple d/c are:

A

Benign- (MC) intraduct papilloma/mammary duct ectasia

Malig - <15% - ductal carcinoma in situ

68
Q

MC type of breast CA?

A

Ductal carcinoma

Lobular carcinoma is rare

69
Q

Management for breast pain (O-DEAD)

A 
OCP (stabilize hormones)
Dx MMG w/ f/u US 
Exercise
Avoid narc, diuretics, iodine, tamoxifen, danazol
Decreased caffeine
70
Q

Difference between incisional vs excisional Bx?

A

Inc - take a piece of the mass

Exc - take whole mass (lumpectomy)

71
Q

Complications of breast reduction mammoplasty (Mostly all surgeries) (I-BUN)

A 
(Dreaded four)
Infection
Bleeding
Undesired cosmetic outcome 
Numbness
72
Q

Triple negative breast CA: and TXT? 4

A

Most are BRCA1 (+)
Negative for ER, PR, and HER2 (hence “triple negative)
Most aggressive breast CA, worst prognosis
Mainstay txt with chemotherapy

73
Q

What is ductal carcinoma in situ?

A

Cancerous lesion and must be removed

After excision, XRT remaining breast tissue

74
Q

Fibrocystic changes MC population?

A

Women during childbearing ages

75
Q

Txt for breast abscess

A

Stop nursing
Admit
IV ABX
I/D or Bx

76
Q

What to examine with CBE?

A

4 quads and tail of Spence (pt point to complaint)

77
Q

Drains are no longer needed when drainage is

A

<30mL/D

78
Q

Modified radical mastectomy: MRM

A
  • Tissue, nipple, axillary nodes removed
  • Muscle spared
    Retains some skin for reconstruction
79
Q

Diagnostic MMG

A

Follow-up on lesion found during screening or abnormal exam

80
Q

BI-RADS - additional imaging needed

A

0

81
Q

BI-RADS - Suspicious (consider Bx)

A

4

82
Q

What Rx/substances to avoid if CC is breast pain?

(TIDD-N) and?

A 
T- Tamoxifen
I- Iodine
D- Diuretics
D- Danazol
N- Narcotics
and Caffeine
83
Q

Bilateral gynecomastia points - 7

A

Decreased androgen production as dudes age
-Estg increased
-Test decreased
- due to Rx
No nipple d/c
MMG and U/S PRN
Reassurance and routine consult with general surgery

84
Q

Txt for acute mastitis

A

ABX (staph and strep coverage)
Moist heat
Continue pump/nursing

85
Q

BI-RADS - 4

A

4 - Suspicious (consider Bx)

86
Q

MRI is helpful for: (EGD-G)

A

Eval tumor size
Guide txt plan
Doesn’t req breast compression
Good for dense tissue/implants

87
Q

Invasive testing for breast complaints?

A

Bx > Tissue dx > path report

88
Q

Are most breast masses serious?

A

No - 80% are benign (i.e. fibroadenoma)

89
Q

Tumor marker/tissue Dx findings?

A

ER - Estg receptor
PR - Prog receptor
HER2 - Human epidermal growth factor receptor
x3 NEG breast cancer (MC BRCA-1)

90
Q

FNA procedure basics

A

W/ local anesth - create negative pressure w/ needle/syringe > slide to pathology

91
Q

Features of benign breast pain?

A

NL PE and pain is
Cyclical
Bilateral
Diffuse (non-focal)

92
Q

Unilateral gynecomastia points - 4

A

Normally young dudes
Benign (No nipple d/c)
Usually goes away but teenagers are impatient
-sub-q mastectomy (Nipple/skin spared)

93
Q

What is lobular carcinoma in situ?

A

Marker for CA
Still encapsulated in the lobe
30% chance of developing CA

94
Q

BI-RADS categories

A

0 - additional imaging needed
1 - negative or normal
2 - benign findings (vascular Ca++, stable lesions, etc…)
3 - probably benign (repeat in 6 mos)
4 - Suspicious (consider Bx)
5 - Highly suggestive of malignancy (definitely Bx)
6 - Biopsy proven malignancy

95
Q

Name 2 pre-invasive breast cancers?

A

Lobular Carcinoma In-Situ

Ductal Carcinoma In-Situ

96
Q

Presentation of acute mastitis

A

Lactating women
Cellulitis around nipple w/out mass
Grows staph or strep

97
Q

Neoadjuvant chemo/XRT

A

Txt prior to surgery to debulk tumors

98
Q

What happens if you injure the long thoracic nerve?

A

Winged scapula

99
Q

Chronic breast abscess usually due to?

A

Duct ectasia (widen duct)

  • Thick/Sticky green /lack D/C
  • 40-60YOF
100
Q

Extra nipples called? Noticed when? TXT?

A

Supranumerary nipple
Noticed during preggo - occurs along milk ducts
Benign -excise

101
Q

BI-RADS - benign findings (vascular Ca++, stable lesions, etc…)

A

2

102
Q

Later signs of breast CA:

A 
Skin dimpling
Nipple retraction
Fixation to chest 
Axillary LAD
Peau d’ orange

Surgery Two (9 decks)

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