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Surgery > Boobies > Flashcards

Boobies Flashcards

1
Q

What are the 3 major structures of the breast?

A

skin, subcutaneous tissue, and breast tissue

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2
Q

What comprises breast tissue?

A

parenchyma and stroma

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3
Q

How many collecting milk ducts open to the nipple?

A

5-10

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4
Q

What lies beneath the breast tissue?

A

pectoral fascia

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5
Q

What acts as a suspensory system for the breast?

A

Cooper’s ligaments

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6
Q

Where does 60% of the breasts blood supply come from?

A

internal mammary (internal thoracic)

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7
Q

Where does 30% of the breasts blood supply come from?

A

lateral thoracic

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8
Q

Which nodes drain 97% of the breast?

A

Axillary nodes

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9
Q

Which nodes drain 3% of the breast?

A

Internal mammary chain

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10
Q

What musculature is under the breast?

A

Pectoralis major and minor, serratus anterior, latissimus dorsi

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11
Q

What nerves innervate the pecs?

A

Medial and lateral pectoral nerves innervate pecs

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12
Q

What nerves run through the axilla?

A

lateral thoracic and thoracodorsal nerves

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13
Q

What nerve is sensory to the posterior upper arm and runs through the axilla?

A

Intercostal-brachial cutaneous nerve

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14
Q

What genetic mutations cause pts to have a lifetime risk of breast cancer between 50-90%?

A

BRCA 1 or 2

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15
Q

What are non-genetic risk factors for breast cancer?

A 
Age
Personal history of breast cancer
History of atypical hyperplasia on biopsy
Hx high dose radiation to chest
Alcohol and diet
Reproductive factors 
Late age at 1st full term pregnancy (>30), early menarche (55), no full term pregnancy, never breast fed
Factors affecting circulating hormones
OCP, HRT, obesity
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16
Q

What are genetic risk factors for breast cancer?

A

BRCA 1 and BRCA 2
2 or more 1st degree relatives diagnosed at an early age Relative risk > 4.0
One 1st degree relative with breast cancer
Relative risk between 2.1-4.0

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17
Q

What is the Gail model for determining breast cancer risk?

A

Combines age, age at 1st MP, age at 1st live birth, number of primary relatives affected, breast bx hx, ethnicity

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18
Q

What other cancers is a BRCA positive patient also at risk for?

A

ovarian ca(25-45%)
pancreatic ca
melanoma
prostate ca

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19
Q

How is surveillance conducted on BRCA positive patients?

A

exam
mammo
U/S
MRI q 6 mo

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20
Q

How is breast cancer prevented in BRCA positive patients?

A

Bilateral prophylactic mastectomy
Bilat salpingo-oophorectomy
tamoxifen

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21
Q

Mammography reduces breast cancer mortality by 30% in what age group?

A

50-69

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22
Q

At what age should screening mammography begin and how often?

A

Yearly at 40 years

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23
Q

Do self breast exams or clinical breasts exams prevent more cancers?

A

Clinical. Studies suggest no improvement in survival for self breast exam

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24
Q

What is captured on the mediolateraloblique mammogram?

A

chest wall
tail of Spence
axilla

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25
Q

What type of mammograms are ordered for asymptomatic patients yearly after 40?

A

Screening

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26
Q

What type of mammograms are ordered for patients with symptoms?

A

Diagnostic

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27
Q

How do densities show on mammography?

A

White

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28
Q

How does fat show on mammography?

A

Grey

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29
Q

What do microcalcifications indicate on mammography?

A

Ductal carcinoma in situ

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30
Q

What is a BI-RAD lesion staged at 0?

A

Needs further evaluation

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31
Q

What is a BI-RAD lesion staged at 1?

A

Negative

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32
Q

What is a BI-RAD lesion staged at 5?

A

Highly suggestive of malignancy

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33
Q

What is a BI-RAD lesion staged at 6?

A

Known biopsy proven malignancy

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34
Q

What views are included in a screening mammogram?

A

Cranio-caudal (CC)

Mediolateraloblique (MLO)

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35
Q

What views are included in a diagnostic mammogram?

A

Anything the radiologist wants, including U/S

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36
Q

What is the triad of error for delayed breast cancer diagnosis?

A

Young age (<45)
Negative mammogram
Self-discovered breast mass

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37
Q

When should you order a breast ultrasound?

A

Any time you order a diagnostic mammogram

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38
Q

What are the two phases of the breast exam?

A

Inspection

Palpation

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39
Q

How should the patient sit for inspection?

A

Upright with arms relaxed, then raised, pecs contracted with hands on hips

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40
Q

What are signs of breast cancer you can find with inspection?

A

Skin- edema, lesions, retraction, dimpling

Nipple areolar complex for retraction and discharge

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41
Q

How should the patient be positioned for the palpation phase of the breast exam?

A

Upright and supine

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42
Q

What anatomy should be palpated during the clinical breast exam?

A

Breasts and lymph node basins

43
Q

How much of the breast should be palpated

A

from clavicle to beyond inframammary crease, and from sternum through axilla

44
Q

What imaging is ordered to diagnose a breast mass?

A

US and diagnostic mammo

45
Q

What information will FNA not give about a mass?

A

Invasion

46
Q

What is the usual type of biopsy to diagnose malignancy?

A

Core needle bx

47
Q

What is an excisional bx?

A

removal of the entire palpable or imaged abnormality

48
Q

What are characteristic of fibrocystic breasts?

A

common cause of breast pain, often cyclic

49
Q

What are three benign conditions that could be mistaken for breast cancer?

A

Fibrocystic breast
Cysts
Fibroadenoma

50
Q

What is a Phyllodes tumor?

A

usually benign, can enlarge, needs excision with clear margins

51
Q

How is breast pain managed?

A

Decrease caffeine
Vitamin E
Evening primrose oil

52
Q

What are three prescriptions for breast pain?

A

danocrine, tamoxifen, bromocriptine

53
Q

When are breast infections most common?

A

During lactation

54
Q

How are breast infections managed?

A

Management include emptying breast (nurse or pump)
antibiotics
drainage if there is an abscess
It is safe to continue to feed the infant

55
Q

What causes breast infections in non-lactating women?

A

Smoking

56
Q

What condition must be ruled out with breast infections?

A

Inflammatory breast cancer (f/u with patient to ensure resolution of sx)

57
Q

How are cysts diagnosed?

A

Exam, US, FNA

58
Q

What diagnostic procedure is required for solid masses?

A

Biopsy

59
Q

What do skin changes (peau d’orange, erythema) indicate?

A

Inflammatory breast cancer

60
Q

What do micro calcifications on mammogram indicate?

A

Ductal carcinoma in situ

fibrocystic breast disease (more common)

61
Q

What is a spiculated mass on mammogram indicative of?

A

Invasive cancer

62
Q

What will be found on ultrasound for breast cancer?

A

Irregular solid mass
Taller than wide
Shadowing

63
Q

Diagnosis of breast cancer requires what?

A

Biopsy

64
Q

What type of biopsy will give adequate information for initial treatment decisions?

A

Image guided core needle bx

65
Q

What are the three disciplines of breast cancer treatment?

A

Surgery
Radiation
Systemic tx (Chemo or hormone blockade)

66
Q

Surgical options include _________ but not _________.

A

Radiation, not chemo

67
Q

Breast conserving therapy requires_______.

A

postoperative radiation

68
Q

What are the goals of breast cancer surgery?

A

Clear margins

Adequate staging of the cancer (lymph node status, tumor size)

69
Q

What are the two surgical options for breast cancer?

A

Breast conserving therapy

Mastectomy

70
Q

What is included in a lumpectomy?

A

Lumpectomy and sentinel node

71
Q

When is axillary node dissection necessary?

A

If more than 2 sentinel nodes are positive

72
Q

What always follows a lumpectomy?

A

Radiation therapy

73
Q

When is radiation therapy necessary with mastectomy?

A

Only if tumor >5cm, margins positive, or lymph node is positive (4)

74
Q

Which surgical option has a higher survival rate?

A

Neither. Both have same survival rates

75
Q

What are the contraindications of breast conservation therapy?

A
  • 2 or more tumors in separate quadrants or diffuse microcalcifications throughout breast or inflammatory breast cancer
  • Hx of previous radiation to the chest/breast
  • Pregnancy (can’t do radiation)
  • Inability to clear margins
  • Presence of active autoimmune diseases, esp scleroderma or lupus which can lead to complications from radiation
76
Q

What is the schedule for whole breast radiation?

A

5 days per week for six weeks

77
Q

What are the side effects of whole breast radiation?

A

Fatigue, skin changes, low risk of cardiac or pulmonary effects

78
Q

How is mammosite (partial breast irradiation) conducted?

A

Placement of a balloon catheter into lumpectomy cavity and twice daily radiation for 5 days

79
Q

What is lumpectomy and sentinel node biopsy?

A 
Usually an outpatient procedure
Takes 1-2 hours
Requires general anesthetic
Usually leaves 2 separate incisions
Recovery is fairly rapid
80
Q

What happens intraoperatively if 3 SNLs are found to be positive?

A

axillary LN dissection

81
Q

What can be used for reconstruction following mastectomy?

A

Implants (often by way of tissue expanders)
TRAM flap or latissimus flap using pts own tissue
DIEP flaps (deep inferior epigastric perforators)

82
Q

Describe mastectomy

A

Requires general anesthetic and overnight hospital stay
SLN bx is usually done in conjunction with mastectomy and will dictate amount of axillary dissection is completed
1-2 drains for 1-2 weeks
Slightly longer operation
Takes a bit longer to recover – more stiff and sore, especially with reconstruction

83
Q

How is chemo used as adjuvant therapy?

A

In combination with breast conserving therapy in the absence of detectable disease or spread to prevent or delay recurrence

84
Q

How is chemo used as neo-adjuvant therapy?

A

Treatment given in pre-op setting may shrink the tumor
Provides evidence of whether the chemo will work
May shrink large or fixed tumors to allow clearance of margins and makes BCT more feasible
Complete response found in pathology after neoadjuvant offers good prognosis

85
Q

What is the usual order of tx for breast cancer?

A

surgery, chemo (if indicated), followed by radiation, then hormone blockade

86
Q

When is neo-adjuvant chemo given?

A

for inflammatory breast cancer, always followed by postop radiation

87
Q

What drugs are used in hormone blockade?

A

Tamoxifen and Aromatase inhibitors

88
Q

What is tamoxifen?

A

Estrogen receptor blocker

89
Q

What are armatase inhibitors

A

block production of estrogen

90
Q

Who gets adjuvant chemo?

A

higher risk of recurrence
premenopausal
higher risk tumors (LN positive, larger tumor, ER negative)
Certain oncotypes (genetics of tumors) when uncertain if woman will benefit from chemo

91
Q

What are the risks and side effects of tamoxifen?

A

uterine cancer, blood clots

hot flashes

92
Q

What are the benefits of tamoxifen?

A

Increase bone density and lower cholesterol

93
Q

What types of tumors is tamoxifen used for?

A

ER positive

94
Q

What is the efficacy of tamoxifen?

A

Prevents 1 of 2 recurrences

Prevents 1 of 3 deaths

95
Q

What is irreversible ovarian ablation?

A

Surgical removal (worthwhile for BRCA +)

96
Q

What is reversible ovarian ablation?

A

GNRH agonist (Zoladex)

97
Q

What affect does menopause (often chemo-induced) have on breast cancer?

A

Higher survival

98
Q

What are the sources of estrogen in post-menopausal women?

A

adrenals and subQ fat

99
Q

What enzyme converts precursors into estrogen?

A

aromatase

100
Q

What are the names of aromatase inhibitors?

A

Anastrozole (arimidex), Letrozole (femara), and exemestane (aromasin)

101
Q

What is Her2-neu?

A

Oncogene that is over expressed in 30% of breast cancers

102
Q

What medication is an antibody to Her2-neu?

A

Trastuzumab (herceptin)

103
Q

What is herceptin used in combination with?

A

Chemo

104
Q

What is the risk with herceptin and how is it monitiored?

A

Heart failure; MUGA scans

Surgery (10 decks)

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