Breast Flashcards
Extent of breast
Vertically - 2 to 6th ribs
Horizontally- sternum to midaxillary line
Extension of breast in axilla
Axillary tail of spence
Breasts are supported by
Suspensory ligament of Cooper
Breast lies over?
Pectoralis muscle
Dimpling of skin over breast is due to
Suspensory ligament of cooper pulls ligament inside
If a cancer involves lactiferous duct, it causes
Retraction of nipple
Retraction of nipple can be ?
Congenital
Acquired due to
Ductal ectasia - slit
Malignancy - circumferential
Most conspicuous of sign of malignancy involving skin of breast
It is seen due to?
Peau d orange
Blockade of subdermal lymphatics
Functional unit of breast?
TDLU
Terminal duct lobular unit
Lymphatic drainage of breast
Axillary 90%
Clinical division
Ant, central, apical, lateral, posterior
Surgical division by pectoralis minor Level 1 lateral to Level 2 behind Level 3 medial Internal mammary 10%
Rotters lymph node is seen in
It is interpectoral lymph node
Bw pectoralis major and minor
Level 2
Triple assessment in breast examination
Clinical examination+ history Radiological Less than 40 USG More than 40 MAMMOGRAPHY Histopathology FNAC, BIOPSY
Why mammography is not a screening tool in young female breast examination
Young increaaed glandular tissue, dense breast
Best clinical examination technique for breast lump
Dial clock method
Views for a mammogram
Craniocaudal
Mediolateral oblique
Screening indication of mammogram
Annual mammography should be started at 40yrs of age
If strong family history, Risk of breast cancer more than 20%
Start screening by 35 yrs of age
If BRCA mutation
First degree relative of pt with brca mutation
Start screening at 25 yrs mri is done
How to differentiate between benign or malignant tumor on mammography
Benign - well diff, halo surrounded, macrocalcification
Malignant- irregular, distorted, lymph node inv, microcalcification
What is BIRADS
Breast Imaging Reporting and Data System
Birads score 3 means
Probably benign
Short interval follow up (6months)
Risk of cancer 0-2%
Usg modality is used in
Differentiate bw solid and cystic mass
Pregnant lady with lump
Young female with dense Breast
Linguini sign is seen in
MRI
Intracapsular rupture of breast implants
Investigation of choice in breast implants
MRI
USG finding, intracapsular rupture of implant
Extracapsular rupture of implant
Intracapsular- Stepladder pattern
Extracapsular- snowstorm appearance
Uses of MRI IN BREAST
Ioc in breast implants Diff bw multifocal and multicentric Most sensitive investigation for DCIS IOC to identify local/scar recurrence after surgery Screening of young high risk pt
Popcorn calcification is seen in
Fibrodenoma
Lead pipe pattern is found in
Fat necrosis mimics malignancy
Secondary to trauma
Broken needle pattern
Tea cup pattern
Duct ectasia
Fibrocystic ds
Histopathology of breast cancer is done by
FNAC
FNNAC
TRU CUT BIOPSY
FNNAC is done for
Superficial lesion (breast & thyroid)
Tru cut biopsy is a type of
Needle used?
Incisional biopsy
16G is best for breast biopsy
IOc in breast cancer
Why?
Tru cut biopsy As tissue is obtained Diff bw in situ and invasive ca ER, PR, HER NEU stat can be obtained Less false negative rate
Tru cut biopsy is IOC in breast cancer
other example?
Prostatic cancer
Soft tissue sarcoma
Gold standard for breast lump
Excisional biopsy
Incidence of breast cancer in India
1 in every 21 indian women develops breast cancer
Imp risk factors for breast cancer
Age increase Early menarche Late menopause Family history Obesity Alcohol Smoking HRT Nulliparity Maternal age at first live birth
Most common gene mutation in breast cancer
P53 in 90% of sporadic cases
Most common gene mutation in familial breast cancer
BRCA 1
Location of brca gene
And which one is responsible for breast cancer
BRCA1 17q
BRCA 2 13q
BRCA 1> BRCA2
SUBTYPE OF BRCA1 breast tumor
Most common histology
Basal subtype
Medullary ca
SUBTYPE OF BRCA2 breast tumor
Luminal subtype
BRCA mutation predisposes a pt to which syndrome
Hereditary breast and ovarian cancer syndrome
Risk reduction technique if breast cancer
Bilateral prophylactic mastectomy
Bilateral salpingo-oophorectomy (Risk Reduction)
SERM - Tamoxifen
Most common quadrant affected in breast cancer
Upper outer
Single file pattern is seen in
Invasive lobular carcinoma
Types of invasive ductal carcinoma
Best and worst prognosis?
Tubular best prog
Mucinous
Medullary worst prog
Mutation in INVASIVE LOBULAR CARCINOMA
E cadherin
Molecular classification of breast cancer is based on
Gene expression profiling
Alred score is used for
Estrogen and progesterone receptor profiling in molecular classification of breast cancer
Proliferation index marker is
Ki67
Grading to measure HER2/NEU RECEPTOR
0 negative \+1 negative \+2 equivocal -FISH DONE IT CAN BE AMPLIFIED +3 NOT AMPLIFIED -NEGATIVE \+3 positive
Subtype of breast cancer with low proliferation index
High proliferation index
Low luminal A - best prognosis
High Basal type - triple negative - worst prognosis
TNBC Paradox
Good response to anthracycline chemotherapy initially, but relapse in 1.5-2 yrs
IOC for staging of breast cancer
Isotope used
PET CT
18-FDG
yTNM
cTNM
MEANS
After neoadjuvant therapy -yTNM
Clinical TNM -cTNM
pT1 staging is for
Pathological tumor staging
1 stage means tumor size more than 1 mm less than 20 mm
Involvement of chest wall includes following str…
This TStage is
T4A
Chest wall inv. Serratus anterior, ribs, intercostal muscle
Pectoralis inv not considered
T4B is involvement of
Skin -peau d’ orange, ulcer, satellite lesion
Dimpling retraction not considered
Stage of matted axillary lymph nodes
N2 A
Most common site of distance metastasis in breast cancer
Bone
Most common bone metastasis
Vertebral column (Batson plexus)
Most common vertebrae
lumbar> thoracic
Metastasis type in breast cancer
Osteolytic >Osteoblastic
Surgery for primary breast tumor
Breast conservation surgery
Mastectomy
Recurrence rate of BCS and mastectomy
LRR OF BCS -4%
MASTECTOMY LESS THAN 1%
Margin status of BCS
1mm of normal tissue along with lumpectony
Typed of BCS
Volume displacement - when less than 15% volume resected
Volume replacement-when more than 15% volume resected
Radiotherapy in mandate in BCS.
What are contraindications of BCS.
Pregnancy
Collagen vascular ds
Prior Radiotherapy exposure
Technical contraindications of BCS
Multicentric Multifocal Lobular cancer (tends to be multicentric) LABC Large tumor to breast ratio
Radical mastectomy was described by
It is removal of-
Halstead Removal of - Breast Nipple areolar complex Pectoralis major minor Level 1,2,3 axillary lymph nodes
Incision of modified radical mastectomy
It is removal of?
Elliptical Stewart incision Breast Nipple areolar complex Pectoralis fascia Level 1,2,3 axillary lymph nodes
Variant of MRM
Auchincloss pectoralis minor is retracted
Scanlon pectoralis minor is cut
Patey \
Variant of MRM
Auchincloss pectoralis minor is retracted
Scanlon pectoralis minor is cut
Patey \
What is simple mastectomy
Removal of breast NAC PECTORALIS fascia
Axillary lymph nodes not removed
Simple mastectomy is done in
Phyllodes
DCIS
Toilet mastectomy
Fungating cancer
What is axillary clearance
Minimum 10 axillary lymph nodes removal
Complications of axillary clearance
Bleeding Intercostobrachial nerve injury during mrm Flap necrosis Seroma lymphedema Scar recurrence Phantom breast syndrome
Winging of scapula is due to
Long thoracic nerve injury
Most common complications of MRM
Management
Prevention
Seroma - accumulation of fluid beneath flap
Mgt
Aspirate under aseptic conditions and do pressure
Dressing,
Prevention
Insert drain and remove if output less than 40cc/ day for 2 consecutive days
What is the cause of lymphedema Incidence Prevention Management Prognosis if not treated
If axillary clearance and radiotherapy are given to axilla - lymphedema of UL
2-5%
PREVENTION - Sentinel LN biopsy
Management- arm stocking, exercise,
Long standing cases can develop secondary malignancy - Stewart Treves Syndrome( angiosarcoma)
Management of Stewart treves syndrome
Forequarter amputation
Most common cause of upper limb lymphedema
Post mastectomy lymphedema
Cancer en curasse?
Nodules cover chest wall like an armor in local/scar recurrence
Most common cause of phantom breast syndrome
ICBN neuralgia
➡️Breast 4⬅️
Q lactation Breast abscess m c cause can be?
Source of infection?
Staph aureus
Oropharynx of child
Fluctuation as a late sign is seen in which abscess?
Breast Parotid Palmar Plantar Ischiorectal
Breast abscess occuring in peri menopausal women
Causative organism
Diagnosis can be made through?
Mgt
Breast abscess ass with duct ectasia Aerobic and anaerobic Diag by USG Mgt Antibiotics Surgery-Hadfield procedure
Management of lactational breast abscess
Antibiotics - co amoxiclav Analgesic In case of pus, Usg guided aspiration (at least 2 attempt) if fails I&D
In management of lactational breast abscess
After I & D next step would be to?
Suppress lactation by cabergoline to prevent fistula formation
In case of non healing abscess next step should be?
Suspect TB or inflammatory breast cancer
To confirm -Biopsy from wall of lesion
Aberration of normal development and involution (ANDI) conditions mc in
15-25 yrs of age
25 -40 yrs of age
>40 yrs of age
Fibroadenoma
Fibrocystic disease
Fibrocystic disease
Most common cause of breast lump
Incidence
C/F
Diagnosis
Fibroadenoma
15-25 yrs of age
Firm mobile lump
Painless
Usg ,
mammogram -popcorn calcification
Types of fibroadenoma
Pericanalicular- hard
Intracanalicular
Indication for surgery of fibroadenoma
. Painful . Cosmetic . Rapid increase in size . Fam hist of breast cancer . Giant fibroadenoma>5 cm
Types of incision used in fibroadenoma
Peri areolar incision ➡️ closure of incision by subcuticular suture
Gillard Thomas incision➡️ inframammary incision
Methods of scarless fibroadenoma surgery
RFA
Radio frequency ablation
MAMMOTOME
Vacuum assisted biopsy system
Needle used in mammotome
Limitations of scarless fibroadenoma surgery
8G needle
Limitation
Fibroadenoma more than equal to 2cm
Away from midline
Other name of phyllodes tumor
Incidence
Aka cytosarcoma phyllodes
Occurs in 3-4th decade
How to diagnose phyllodes tumor
Trucut and excisional biopsy
Number of mitotic figures and diff bw benign and malignant
Fnac finding of phyllodes
No role of FNAC
Clinical features of phyllodes
MC site of its hematogenous spread
Rapidly enlarging breast lump
Dilated veins
Lungs
Mgt of phyllodes tumor
Surgery-
Lumpectomy
Simple mastectomy
Indication of simple mastectomy in phyllodes tumor
Recurrence
Very large tumor
Malignant
Types of mastalgia
Cyclical and non cyclical
Cyclincal mastalgia is seen in
Incidence and clinical features
Fibroadenosis
Incidence-25-40yrs
Clinical features
Pain at beginning of cycle
Examination, diagnosis finding of fibro adenosis
Mgt
Lumpy breast Diag by usg Mgt Weight reduction Lowering of tea coffee
Vit e primrose oil capsule for 2 months
If pain persists
Low dose tamoxifen, danozol
Non cyclical mastalgia causes
Treatment
Tietze syndrome (costochondritis) Intralesional triamcinolone
Mondor disease (superficial thrombophlebitis of chest vein) T/t analgesic
Vein involved in mondors ds
Clinical presentation
Lateral thoracic vein
Cord like str, pain
Mgt of breast cyst
Diagnosis usg
If large complex, aspirate
Bloody Residual cyst,
send for cytology and excise
Non bloody
Cyst resolve completely
Monitor pt
No need to send for cytology
Serous nipple discharge from
single duct
Multiple duct
Surface of nipple
Single and multiple duct Pregnancy Puberty Cancer Duct ectasia
Surface of nipple
Pagets
Eczema
Greenish bluish nipple discharge
Multiple duct ectasia
Most common cause of pathological nipple discharge
Multiple duct ectasia
Bloody discharge
Single duct
Multiple duct
Single-
Duct papilloma
Multiple
Cancer
Duct ectasia
Most common cause of bloody nipple discharge
Duct papilloma
Diagnosis of duct papilloma can be done by?
Mgt
USG-ectatic duct
Cytology of nipple discharge
Ductoscopy
Mgt
Microdochetomy -tennis racket incision single duct and lump is excised
What leads to zuska’s disease
Duct ectasia, leads to stasis of secretion and periductal mastitis k/a Zuska’s Disease
Manifestation of Zuska’s disease
Diagnosis and management
Peri areolar abscess /sinus formation
Bluish greenish discharge (multiple ducts)
Diagnosis
USG-multiple dilated ducts
Mgt
Antibiotics
Hadfield procedure ie cone excision of multiple ducts
How to differentiate pagets from eczema
Pagets is U/L while eczema is bilateral
Nipple areola complex destroyed in pagets
Not destroyed in eczema
How to diagnose pagets ds
Punch biopsy -
Paget cells in epidermis
What is polymastia
Mc site
Mgt
Accesory breast tissue
Axilla
Excision
Poland syndrome
Absence of breast tissue and unilateral pectoralis major
Polythelia
Athelia
Accesory nipples
Absence of nipple
Breast reduction surgery is done for?
Pattern used?
Dist bw 2 nipples in breast reduction
Done for breast hypertrophy
Inverted T pattern
19-21cm
Gynecomastia and its causes
Enlargement of. Male breast tissue
Causes
Physiological
Puberty, newborn, senile
Pathological Idiopathic Drugs-digoxin isoniazid spironolactone cimetidine ketoconazole estrogen Mumps orchitis Others
Diagnosis of gynecomastia
Tumor causing gynecomastia
Usg - 3 cm diameter disc of breast tissue Tumors- Rcc Hcc Testicular ass c paraneoplastic syndrome
