ABSITE Review - Breast Flashcards
What is the main hormone needed for duct development?
Estrogen
What is the main hormone needed for duct development?
Progesterone
What are the functions of estrogen in the breast?
increase breast swelling, GROWTH of glandular tissue
What are the functions of progesterone in the breast?
increase MATURATION of glandular tissue; withdrawal causes menses
What is the function of the long thoracic nerve? What happens when it is injured?
Innervates serratus anterior; injury results in winged scapula
What is the function of the thoracodorsal nerve? What happens when it is injured?
Innervates latissimus dorsi; injury results in weak arm pullups and adduction
What is the function of the medial pectoral nerve?
Innervates pectoralis major only
What is the function of the lateral pectoral nerve?
Innervates pectoralis major only
What is the function of the intercostobrachial nerve?
Lateral cutaneous branch of the 2nd intercostal nerve; provides sensation to medial arm and axilla
What is the Batson’s plexus?
Valveless vein plexus that allows direct hematogenous metastasis of breast to spine
Where goes the lymphatic drainage of the breast?
97% to the axillary nodes
1-2% to the internal mammary nodes
What is the MCC of primary axillary adenopathy?
1 lymphoma
What are the Cooper’s ligaments?
Suspensory ligaments, dive the breast into segments
Breast CA involving these strands can dimple the skin
What is the MCC and bacteria in breast abscess?
MCC - breastfeeding
MC bacteria - S. Aureus
Mention some causes of gynecomastia.
Cimetidine, spironolactone, marijuana; idiopathic in most
What is the cause of neonatal breast enlargement?
Due to circulating maternal estrogens; will regress
What is the MC breast anomaly?
Accessory nipples which can be found from axilla to groin
What is the Poland’s syndrome?
Hypoplasia of chest wall, amastia, hypoplastic shoulder, no pectoralis muscle
What is Mondor’s Disease? What is the treatment?
Superficial vein thrombophlebitis of breast. Associated with trauma and strenous exercise. Usually occurs in lower outer quadrant.
Tx - NSAIDs
What are the usual symptoms of fibrocystic disease?
Breast pain, nipple discharge (yellow to brown), masses, lumpy breast tissue that varies with hormonal cycle
When fibrocystic disease has cancer risk?
Only cancer risk is in atypical ductal or lobular hyperplasia.
What is the MCC of bloody discharge from nipple?
Intraductal papilloma
What is the study of choice to fing the papilloma?
Contrast ductogram
What is the MC breast lesion in adolescents? How it is described?
Fibroadenoma - painless, slow-growing, well circumscribed, firm and rubbery
What are some mammogram findings for a fibroadenoma?
Can have large, coarse calcifications (popcorn lesions) on mammography from degeneration
What is the treatment for a fibroadenoma in women 30yrs?
Women < 30 yrs - benign on physical exam, US or mammogram, FNA showing the lesion
Women > 30 yrs - excisional biopsy
Is nipple discharge likely benign? What color is associated with each lesion?
Most nipple discharge is benign.
Green - fibrocystic disease -> reassure patient
Bloody - intraductal papilloma, occassionally ductal CA –> need galactogram and excision of that ductal area
Serous - worrisome for cancer –> excisional biopsy
What is the usual mammogram finding and risk of CA in diffuse papillomatosis?
Mammogram - swiss cheese appereance
40% get breast CA
What is DCIS? What is the risk of CA? What is the treatment?
DCIS - Ductal carcinoma in situ - malignant cells of the ductal epithelium without invasion of the basement membrane
Considered a premalignant lesion.
50-60% get cancer if not resected (ipsilateral breast); 5-10% in contralateral breast
Dx - mammogram with cluster of calcifications
Tx - lumpectomy and XRT; possibly tamoxifen - NEED negative margins but no ALND
What is the most aggressive subtype of DCIS?
Comedo type - has necrotic areas, high risk for multicentricity, microinvasion, and recurrence
Tx - simple mastectomy
What is LCIS? What is the risk of CA? What is the treatment?
LCIS - Lobular carcinoma in situ
NOT premalignant lesion.
40% get cancer EITHER breast
Tx - nothing, tamoxifen or BL SQ mastectomy (no ALND) - DO NOT need negative margins
What is the breast CA risk?
1 in 8 women (12%)
What is the symptomatic breast mass workup?
Ultrasound –> if solid, FNA; excisional bx if FNA nondiagnostic
30-50 yrs –> BL mammograms and FNA; excisional bx if FNA nondiagnostic
> 50yrs –> BL mammogram and excisional or core needle bx
What is the minimum size for a breast mass to be detected by mammogram?
5mm
What is the current recommendation for screening mmmograms?
Every 2-3 yrs after age 40, yearly after age 50
High-risk - mammogram 10 yrs before the youngest age of diagnosis of breast CA in first-degree relative
What is the BI-RADS classification?
1 - Negative - Routine screening
2 - Benign finding - Routine screening
3 - Probably benign finding - Short interval follow up
4 - Suspicious abnormality consider biopsy - Definite probability of malignancy
5 - Highly suggestive of malignancy - High probability of cancer; appropiate action should be taken.
What are the 3 node levels in the breast?
Level 1 - Lateral to pectoralis minor muscle
Level 2 - Beneath pectoralis minor muscle
Level 3 - Medial to pectoralis minor muscle
Rotter’s nodes - between pectoralis major and minor muscles
What is the most important prognostic staging factor in breast cancer?
Lymph node status
What is the MC distant metastasis in breast CA?
Bone
What is the TNM staging system for breast CA?
T1: 5cm, T4: skin or chest wall involvement, peau d’orange, inflammatory cancer
N1: ipsilateral axillary nodes, N2: fixed ipsilateral axillary nodes, N3: ipsilateral internal mammary nodes
M1: distant metastasis (includes supraclavicular nodes)
Which BRCA mutation has higher risk of male breast cancer and ovarian cancer?
Male breast CA - BRCA2 5-10%
Ovarian CA - BRCA1 30-45% - consider TAH and BSO
What breast cancers have better overall prognosis?
Receptor positive tumors - ER +, PR +
PR + > ER+
How common is ductal breast cancer and what is the treatment?
85% of all breast cancer
Tx - MRM or lumpectomy with ALND (or SLNB); postop XRT
How common is lobular breast cancer and what is the treatment?
10% of all breast CAs
Signet-ring cells confer worse prognosis
Tx - MRM or lumpectomy with ALND (or SLNB); postop XRT
What the pathology of the peau d’orange?
Dermal lymphatic invasion
What are the ABSOLUTE contraindications to breast conserving therapy?
2 or more primary tumors in separate quadrants
Persistent + margins after reasonable attempts
Pregnancy - cannot receive radiation
Hx of prior therapeutic irradiation - due to high dose of radiation
Diffuse malignant-appearing microcalcifications
What are the RELATIVE contraindications to breast conserving therapy?
Hx of scleroderma or active SLE
Extensive gross, multifocal disease in same quadrant
Large tumor in a small breast
Very large or pendulous breast
When is a SLNB indicated?
Indicated only for malignant tumors >1cm
During a SLNB, if no radiotracer or dye is found, what is the next step?
Formal ALND
What are some contraindications for SLNB?
Pregnancy, multicentric disease, neoadjuvant, clinically positive nodes, prior axillary surgery, inflammatory or locally advanced disease
What is a modified radical mastectomy?
Removes all breast tissue including the nipple aereolar complex, includes axillary node dissection (Level 1)
What are the indications for radiation after mastectomy?
> 4 nodes Skin or chest wall involvement Positive margins Tumor > 5cm (T3) Extracapsular nodal invasion Inflammatory CA Fixed axillary nodes (N2) or internal mammary nodes (N3)
Who gets chemotherapy?
Positive nodes - everyone gets chemo except postmenopausal women with positive estrogen receptors –> tamoxifen
>1cm and negative nodes - everyone get chemo except pts with positive ER –> tamoxifen
<1cm and negative nodes - no further treatment
What are the side effects of tamoxifen?
1% risk of DVTs; 0.1% risk of endometrial cancer
What is Paget’s disease of the breast?
Scaly skin lesion on nipple; biopsy shows Paget’s cells
Pts have DCIS or ductal CA in breast
Tx - need MRM if cancer present; otherwise simple mastectomy
What is Cystosarcoma phyllodes? What is the treatment?
10% malignant; no nodal metastases
Resembles giant fibroadenoma; has stromal and epithelial elements
Tx - WLE with negative margins; no ALND
What is Stewart-Treves syndrome?
Lymphangiosarcoma from chronic lymphedema following axillary dissection (MRM)
