Boobies Flashcards
What are the 3 major structures of the breast?
skin, subcutaneous tissue, and breast tissue
What comprises breast tissue?
parenchyma and stroma
How many collecting milk ducts open to the nipple?
5-10
What lies beneath the breast tissue?
pectoral fascia
What acts as a suspensory system for the breast?
Cooper’s ligaments
Where does 60% of the breasts blood supply come from?
internal mammary (internal thoracic)
Where does 30% of the breasts blood supply come from?
lateral thoracic
Which nodes drain 97% of the breast?
Axillary nodes
Which nodes drain 3% of the breast?
Internal mammary chain
What musculature is under the breast?
Pectoralis major and minor, serratus anterior, latissimus dorsi
What nerves innervate the pecs?
Medial and lateral pectoral nerves innervate pecs
What nerves run through the axilla?
lateral thoracic and thoracodorsal nerves
What nerve is sensory to the posterior upper arm and runs through the axilla?
Intercostal-brachial cutaneous nerve
What genetic mutations cause pts to have a lifetime risk of breast cancer between 50-90%?
BRCA 1 or 2
What are non-genetic risk factors for breast cancer?
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
What are genetic risk factors for breast cancer?
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
What is the Gail model for determining breast cancer risk?
Combines age, age at 1st MP, age at 1st live birth, number of primary relatives affected, breast bx hx, ethnicity
What other cancers is a BRCA positive patient also at risk for?
ovarian ca(25-45%)
pancreatic ca
melanoma
prostate ca
How is surveillance conducted on BRCA positive patients?
exam
mammo
U/S
MRI q 6 mo
How is breast cancer prevented in BRCA positive patients?
Bilateral prophylactic mastectomy
Bilat salpingo-oophorectomy
tamoxifen
Mammography reduces breast cancer mortality by 30% in what age group?
50-69
At what age should screening mammography begin and how often?
Yearly at 40 years
Do self breast exams or clinical breasts exams prevent more cancers?
Clinical. Studies suggest no improvement in survival for self breast exam
What is captured on the mediolateraloblique mammogram?
chest wall
tail of Spence
axilla
What type of mammograms are ordered for asymptomatic patients yearly after 40?
Screening
What type of mammograms are ordered for patients with symptoms?
Diagnostic
How do densities show on mammography?
White
How does fat show on mammography?
Grey
What do microcalcifications indicate on mammography?
Ductal carcinoma in situ
What is a BI-RAD lesion staged at 0?
Needs further evaluation
What is a BI-RAD lesion staged at 1?
Negative
What is a BI-RAD lesion staged at 5?
Highly suggestive of malignancy
What is a BI-RAD lesion staged at 6?
Known biopsy proven malignancy
What views are included in a screening mammogram?
Cranio-caudal (CC)
Mediolateraloblique (MLO)
What views are included in a diagnostic mammogram?
Anything the radiologist wants, including U/S
What is the triad of error for delayed breast cancer diagnosis?
Young age (<45)
Negative mammogram
Self-discovered breast mass
When should you order a breast ultrasound?
Any time you order a diagnostic mammogram
What are the two phases of the breast exam?
Inspection
Palpation
How should the patient sit for inspection?
Upright with arms relaxed, then raised, pecs contracted with hands on hips
What are signs of breast cancer you can find with inspection?
Skin- edema, lesions, retraction, dimpling
Nipple areolar complex for retraction and discharge
How should the patient be positioned for the palpation phase of the breast exam?
Upright and supine
What anatomy should be palpated during the clinical breast exam?
Breasts and lymph node basins
How much of the breast should be palpated
from clavicle to beyond inframammary crease, and from sternum through axilla
What imaging is ordered to diagnose a breast mass?
US and diagnostic mammo
What information will FNA not give about a mass?
Invasion
What is the usual type of biopsy to diagnose malignancy?
Core needle bx
What is an excisional bx?
removal of the entire palpable or imaged abnormality
What are characteristic of fibrocystic breasts?
common cause of breast pain, often cyclic
What are three benign conditions that could be mistaken for breast cancer?
Fibrocystic breast
Cysts
Fibroadenoma
What is a Phyllodes tumor?
usually benign, can enlarge, needs excision with clear margins
How is breast pain managed?
Decrease caffeine
Vitamin E
Evening primrose oil
What are three prescriptions for breast pain?
danocrine, tamoxifen, bromocriptine
When are breast infections most common?
During lactation
How are breast infections managed?
Management include emptying breast (nurse or pump)
antibiotics
drainage if there is an abscess
It is safe to continue to feed the infant
What causes breast infections in non-lactating women?
Smoking
What condition must be ruled out with breast infections?
Inflammatory breast cancer (f/u with patient to ensure resolution of sx)
How are cysts diagnosed?
Exam, US, FNA
What diagnostic procedure is required for solid masses?
Biopsy
What do skin changes (peau d’orange, erythema) indicate?
Inflammatory breast cancer
What do micro calcifications on mammogram indicate?
Ductal carcinoma in situ
fibrocystic breast disease (more common)
What is a spiculated mass on mammogram indicative of?
Invasive cancer
What will be found on ultrasound for breast cancer?
Irregular solid mass
Taller than wide
Shadowing
Diagnosis of breast cancer requires what?
Biopsy
What type of biopsy will give adequate information for initial treatment decisions?
Image guided core needle bx
What are the three disciplines of breast cancer treatment?
Surgery
Radiation
Systemic tx (Chemo or hormone blockade)
Surgical options include _________ but not _________.
Radiation, not chemo
Breast conserving therapy requires_______.
postoperative radiation
What are the goals of breast cancer surgery?
Clear margins
Adequate staging of the cancer (lymph node status, tumor size)
What are the two surgical options for breast cancer?
Breast conserving therapy
Mastectomy
What is included in a lumpectomy?
Lumpectomy and sentinel node
When is axillary node dissection necessary?
If more than 2 sentinel nodes are positive
What always follows a lumpectomy?
Radiation therapy
When is radiation therapy necessary with mastectomy?
Only if tumor >5cm, margins positive, or lymph node is positive (4)
Which surgical option has a higher survival rate?
Neither. Both have same survival rates
What are the contraindications of breast conservation therapy?
- 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
What is the schedule for whole breast radiation?
5 days per week for six weeks
What are the side effects of whole breast radiation?
Fatigue, skin changes, low risk of cardiac or pulmonary effects
How is mammosite (partial breast irradiation) conducted?
Placement of a balloon catheter into lumpectomy cavity and twice daily radiation for 5 days
What is lumpectomy and sentinel node biopsy?
Usually an outpatient procedure Takes 1-2 hours Requires general anesthetic Usually leaves 2 separate incisions Recovery is fairly rapid
What happens intraoperatively if 3 SNLs are found to be positive?
axillary LN dissection
What can be used for reconstruction following mastectomy?
Implants (often by way of tissue expanders)
TRAM flap or latissimus flap using pts own tissue
DIEP flaps (deep inferior epigastric perforators)
Describe mastectomy
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
How is chemo used as adjuvant therapy?
In combination with breast conserving therapy in the absence of detectable disease or spread to prevent or delay recurrence
How is chemo used as neo-adjuvant therapy?
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
What is the usual order of tx for breast cancer?
surgery, chemo (if indicated), followed by radiation, then hormone blockade
When is neo-adjuvant chemo given?
for inflammatory breast cancer, always followed by postop radiation
What drugs are used in hormone blockade?
Tamoxifen and Aromatase inhibitors
What is tamoxifen?
Estrogen receptor blocker
What are armatase inhibitors
block production of estrogen
Who gets adjuvant chemo?
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
What are the risks and side effects of tamoxifen?
uterine cancer, blood clots
hot flashes
What are the benefits of tamoxifen?
Increase bone density and lower cholesterol
What types of tumors is tamoxifen used for?
ER positive
What is the efficacy of tamoxifen?
Prevents 1 of 2 recurrences
Prevents 1 of 3 deaths
What is irreversible ovarian ablation?
Surgical removal (worthwhile for BRCA +)
What is reversible ovarian ablation?
GNRH agonist (Zoladex)
What affect does menopause (often chemo-induced) have on breast cancer?
Higher survival
What are the sources of estrogen in post-menopausal women?
adrenals and subQ fat
What enzyme converts precursors into estrogen?
aromatase
What are the names of aromatase inhibitors?
Anastrozole (arimidex), Letrozole (femara), and exemestane (aromasin)
What is Her2-neu?
Oncogene that is over expressed in 30% of breast cancers
What medication is an antibody to Her2-neu?
Trastuzumab (herceptin)
What is herceptin used in combination with?
Chemo
What is the risk with herceptin and how is it monitiored?
Heart failure; MUGA scans
