Breast Flashcards
DCIS
Involves ducts. Risk of invasive cancer in ipsilateral breast
Often unilateral and unicentric
Local tx w/ mastectomy or breast-conserving therapy (BCT; lumpectomy) + adjuvant rads
2mm margin
LCIS
Involves lobules
Cancer can be ductal or lobular
Marker of elevated risk of invasive cancer, up to 40% in either breast
Often bilateral and multi centric
Tx: excisional biopsy Tamoxifen/antiestrogen modulators reduce risk of subsequent invasive, hormone-positive breast cancer
Inflammatory breast CA
edema, erythema, dimpling (Peau d’orange)
rapid onset without underlying breast mass
Bx: dermal lymphovascular invasion
Paget disease of breast
scaly, eczematous, raw, vesicular, ulcerated lesion. begins on nipple, spreads to areola
Bx: malignant, intraepithelial adenocarcinoma cells (Paget cells) single or in small groups within epidermis of nipple. Cells have pale/clear cytoplasm, oval nuclei, prominent nucleoli b/w normal keratinocytes
assoc w/ underlying carcinoma (DCIS or IDC)
tx: total mastectomy w/ wide excision of nipple-areolar complex and SLNBx
Fat necrosis
Benign
2/2 breast trauma/surgery
Bx: lipid-laden MPs
Infiltrating lobular carcinoma
No mass
Lack of E-cadherin staining
Bx: small cells, infiltrate mammary stroma & adipose individually and in single-file pattern, grow in target-like configuration, around normal breast ducts
Phyllodes tumor
Breast mass/abnormal mammo findings, smooth, multinodular, well-defined, firm, mobile, painless mass, rapidly growing.
similar to fibroadenomas but phyllodes have malignant potential 2/2 increased cellularity, invasive margins
Bx: leaf-like architecture, elongated ductal elements & cleft-like spaces, papillary projections of epithelial-lined stroma
Tx: wide local surgical excision w/ 1cm tumor free margins. rarely mets to LNs. recurrence -> resect.
Mastitis
lactating or nonlactating
lactating - caused by staph aureus. MC in first 4-6 weeks of breastfeeding or during weaning. Tx: Abx, cont breast feeding.
Epidemic puerperal mastitis - caused by MRSA. purulent nipple drainage. Tx: Abx, stop breastfeeding
RFs for Breast Cancer
Low risk: age monarche <12, age menopause >55, nulliparity, obesity, hormone replacement therapy
mod risk: age at first birth >30, mother or sis w/ breast CA, previous breast CA, radiation exposure
high risk: BRCA1/2 mutation, age >70
What explains why upper outer quadrant is most frequent site of both benign and malignant breast disease?
Most of epithelial tissue in upper outer quadrant
MC site of both benign and malignant breast disease
Most benign and malignant breast lesions are derived from epithelial tissue
Inflammatory breast cancer recon options
Following surgery these patients need post mastectomy radiation.
Delayed autologous recon is preferred to prevent delay of adjuvant radiation and avoid complications w/ irradiating reconstructed breast
Radial scar
Nonpalpable lesion, benign
Histo: central fibroelastosis w/ radiating ducts & lobules w/ atypia, micro cysts, epithelial hyperplasia, adenosis
Tx: excisional bx (r/o cancer)
Breast lesions that require excisional bx following CNBx
Atypical lobular hyperplasia LCIS Radial scar Papillary lesions Phyllodes tumor
Breast lesions that require mastectomy following CNBx
DCIS
invasive cancer
Intraductal papilloma
MCC pathological nipple discharge
Tx: surgical excision
BRCA 1/2 mutation cancer risks
BRCA 1
- tumor suppressor gene mutation on chrom 17
- Breast cancer risk: 55-70%
- Ovarian 40%
- Male breast cancer 1%
- Prostate 15-20%
- Pancreatic 2-4%
BRCA 2
- tumor suppressor gene mutation on chrom 13
- Breast CA 45-70%
- Ovarian 15%
- Male breast 8%
- Prostate 30-40%
- Pancreatic 5%
Hereditary breast cancer syndrome
mutation TSG located on chrom 17 or 13
pt w/ mutation has 70% chance of breast cancer
PPx bilateral mastectomy offered (decreases risk of breast CA ~90% for pts w/ BRCA1/2 mutations)
Surveillance if nonop desired:
- Monthly self-breast exams at 18
- MRI at 25
- Annual mammograms at 30
- Ovarian CA screen w/ transvag US & CA 125 q6 mo at 30
RFs for Male breast cancer
Klinefelter syndrome Obesity Gynecomastia Exogenous estrogen exposure BRCA 2 mutation
Same prognosis for Male vs Female breast CA stage-for-stage. Male usually have pectoral involvement at time of Dx
Risk of atypical ductal hyperplasia for cancer
3- to 5- fold increase risk of cancer in both breasts
Excisional biopsy is recommended when CNBx shows ADH due to 20% rate of DCIS
Breast Angiosarcoma
Dark, violaceous mass, vascular tumors
Histo: distorted vessels (endothelial cells), pleomorphism, mitoses
Hx of radiation (breast-conserving therapy)
Primarily in breast parenchyma
Secondarily in dermis of breast after radiation - fatal w/ medial survival of 2 years (dark, purple nodule in field of prior radiation); 2nd MC etiology of secondary angiosarcoma is chronic lymphedema (Stewart-Treves syndrome)
Route of spread: hematogenous to lung/bone
tx: total mastectomy + adjuvant chemo (extends survival)
Long thoracic nerve injury
Winged scapula
Innervates serratus
Thoracodorsal nerve injury
Weakness of extension, adduction, internal rotation of arm at shoulder
Innervates lattisimus
Medial pectoral nerve injury
Weakness of extension, adduction, internal rotation of arm at shoulder
Innervates pec major & minor
Lateral pectoral nerve injury
Weakness of flexion of arm at shoulder
Innervates pec major
Intercostobrachial nerve injury
Hypoesthesia of upper inner arm
Innervates skin
