Breast Flashcards
Breast is a modified
Sweat gland
Vertical extent of breast is
Between 2nd to 6th rib
Horizontal extent of breast is
Sternum to anterior/ mid Axillary line
What is Axillary tail of spence
Breast tissue that goes into the axilla.
ST the prominent Axillary tail of spence of mistaken as breast lump.
How many lactiferous duct open into the nipple
15-20
Dimpling of skin occurs due to
If a cancer involves the suspensory ligament of cooper , it pulls the ligament inside resulting in a dimpling in skin.
What leads to the retraction of a breast
If a cancer involves the lactiferous ducts , pulling the nipple inside leads to retraction of the nipple.
Retraction of nipples can be congenital or recent
Recent retraction can be slit (……) or circumferential (…….)
Ductal Ectasia OR Malignancy ..
What is Peau d’ orange
Skin resembles orange peel due to blockage of subdermal lymphatic.
If present in cancer it is a sign of skin involvement
In Peau d’ orange there is blockage of
Subdermal Lymphatics.
what is the most conspicuous sign of malignancy in breast cancer ?
Peau d’ orange
What is the functional unit of the breast
TDLU (Terminal Duct lobular unit)
Site of origin for major cancer
Lymphatic drainage of breast is by
Axillary, lymph node (90%)
internal mammary lymph node (10%)
- from upper and lower quadrant
Surgical division of axillary lymph node
By pectoralis minor muscle
Level I : lateral to pectoralis minor
level II : behind pectoralis minor
level III : medial to pectoralis minor
What is the Rotter lymph node?
Inter-pectoral lymph node
(between pectoralis major and pectoralis minor. It falls under level II)
Triple assessment of breast include
Clinical examination + history + radiological : <40 years : USG ; >40 years mammography
+ histopathology : FNAC , FNNAC , TRU-CUT biopsy
What is the best examination technique
Dial clock method
How much radiation is exposed in mammograms
(0.1-0.2) cGy radiation is exposed.
What is the latest form of mammography?
3D mammography / breast tomosynthesis
More sensitive , Best result in dense breast
Which patient need to start screening by the age of 35 years
Strong family history
risk of breast cancer > 20%
(GAIL index : BRCA pro score)
Which patient need to start screening by the age of 25 years
BRCA Mutation
First degree relative of patient with BRCA mutation.
MRI is done.
At 30 to 35 years it is switched to mammography. (if MRI is all clear) If breast density is high , MRI will be continued.
What are the mammography findings of benign breast tumor?
Well differentiated , hallo surrounding lesion ; macrocalcification
What are the mammography findings of malignant breast tumor?
Irregular spiculated lesion
Architectural distortion. lymph nodes Microcalcification
Popcorn, calcification in the breast indicates
Fibroadenoma
Lead pipe calcification / egg shell calcification in the breast indicate
Fat necrosis (mimics malignancy) secondary to trauma ; resolves with time
Broken needle calcification indicate
Duct Ectasia
Teacup calcification indicate
Fibrocystic Disease
Order of risk of calcification
Cluster > linear > segmental > diffuse
How does lymph node in malignant breast cancer seen on mammogram?
Rounded
Loss of hallo and fatty Hilum
How does lymph node in benign breast cancer seen on mammogram?
Kidney shaped
Fatty hilum present
What is the investigation of choice in breast implants
MRI
Which sign is seen in intracapsular rupture of implant
Linguini sign
In USG intracapsular rupture, Seen as
Stepladder pattern
In USG Extracapsular rupture, Seen as
Snowstorm appearance
Breast conservative surgery is contraindicated in
Multicentric malignancy
How many gauge needle is used for FNAC
23-30 G
It’s only cytology
FNNAC is done for
Superficial lesion(breast and thyroid)
How many gauge needle is used for Tru-Cut biopsy
14-16G needle (16G is best)
What is the gold standard investigation for breast lump?
Excisional Biopsy
Most common mutated gene in familial cases of breast cancer(10%)
BRCAI
Most common mutated gene in sporadic cases of breast cancer(90%)
p53
BRCA 1 and BRCA 2 are on chromosome
BRCA 1: 17q
BRCA 2 : 13q
BRCA mutation can predispose a patient to
HBOC (hereditary breast and ovarian cancer syndrome)
BRCA 1 breast tumor
More aggressive
Basal subtype
Poor prognosis
More common histology ; Medullary cx
BRCA 2 breast tumor
Luminal subtype
Better prognosis
Best Time to do RRSO
After completion of family But before 40 years
Which SERM reduces the risk of breast cancer by 47%
Tamoxifen
MC quadrant affected in breast cancer
Upper outer quadrant
Least common quadrant affected in breast cancer
Lower Inner quadrant
What is the most common type of breast cancer?
Invasive ductal carcinoma (IDC)
Not otherwise specific (NOS)
Which type of Ductal carcinoma has the best prognosis
Tubular
Which type of Ductal carcinoma has the worst prognosis
Medullary (BRCA1 mutation)
E-cadherin mutation is seen in
Invasive lobular Carcinoma (ILC)
Single file pattern
IOC for diagnosis of breast cancer
Tru-Cut biopsy
yTNM staging means
After neoadjuvant therapy
Lobular carcinoma in situ is considered as
Benign condition
Most common site of distant metastasis
Bone
Most common bone involved in distant metastasis
Vertebral column (Batson’s plexus)
Most common vertebrae involved in distant metastasis
Lumbar > Thoracic
Most common type of metastasis in breast cancer
Osteolytic > Osteoblastic
What is oncoplasty?
It combines principles of cancer surgery and plastic surgery
Most difficult area of breast , where oncoplasty is done is
Upper inner quadrant , as there very little breast tissue available here
AKA no Man’s zone
Upper inner quadrant is AKA
No man’s zone
During lumpectomy the mass is removed with the
Pectoral fascia
Radical mastectomy involves removal of
Breast plus nipple areoles complex/NAC + pectoralis major + pectoralis minor + level 1,2,3 Axillary lymph node
Which incision is made in MRM
Elliptical stewart incision
MRM involves
The removal of breast + NAC + Pectoralis fascia + level 1,2,3 Axillary lymph node ;;; (+—)pectoralis minor
In Auchincloss method pectoralis minor is
Only retracted
In Scanlon and Patey method P. Minor is
Cut
Simple, mastectomy involves
Removal of breast + NAC + pectoralis fascia, but lymph nodes not removed
Boundaries of axillary dissection
Axillary vein : superior boundary
Thoracodorsal pedicle supplying the latissimus dorsi muscle : lateral boundary
Angular vein : inferior boundary
Halsted ligament : medial boundary 
Structures save during MRM are
Axillary vein
Thoracodorsal pedicle
Long thoracic nerve
P.Major +- P. Minor
Lateral and medial pectoral nerve
Most common nerve injury during MRM is
ICBN / intercostobrachial nerve
Patient complains of altered sensation over axilla and arm
Which nerve injury during MRM will lead to winging of scapula
Long thoracic nerve / nerve of bell / nerve to serratus anterior
Which nerve injury can lead to weakness of latissimus dorsi muscle
Thoracodorsal nerve injury
Lateral and medial pectoral, nerve injury can lead to weakness of
Pectoralis major/pectoralis minor
What is the most common complication of MRM?
Seroma formation / collection of fluid beneath the flap
Management of lymphedema includes
Lymphedema exercises
Arm stalking
Arm Elevation
Pneumatic compression stocking/lymphopress
What is Stewart Trave’s syndrome?
It can develop in long-standing lymphedema, which last for more than 8 to 10 years. The patient presents with bluish/reddish nodules over the upper limb called angiosarcoma/ lymphangiosarcoma.
Management of angiosarcoma in Stewart Treve’s syndrome
Forequarter amputation/disarticulating upper limb with scapula.
Poor prognosis
What is cancer en cuirasse
In some cases, the recurrence will be scattered/diffuse all over the chest wall.
What is Phantom breast syndrome?
Occurs due to ICBN neuralgia
Patient complains of pain in the breast and sometimes feels as if the breast tissue is still there。
Best flap for reconstruction
DIEP flap/ deep inferior epigastric artery perforator flap
Which is the most commonly used flap
TRAM flap / transverse rectus abdominous myocutaneous flap
Which is the first draining lymph node from breast cancer
Sentinel/guardian lymph node 
What is the most common complication of blue dye technique?
Skin tattooing
What is the best technique for sentinel lymph node biopsy
Blue dye + radionucleotide
What is the most common nerve injury complication of sentinel lymph node biopsy?
ICBN injury
Chemotherapy indication in breast cancer are
Positive lymph nodes
locally advanced breast cancer
ER , PR negative tumor
HER 2 neu positive tumors
Chemotherapy regimes CAF is
Cyclophosphamide
Adriamycin
F 5- fluorouracil
Chemotherapy regimes CMF is
Cyclophosphamide
Methotrexate
F 5- fluorouracil
SE of Cyclophosphamide is
 Hemorrhagic cystitis
Which metabolic gives rise to hemorrhaging cystitis
Acrolin
The preventive agent of hemorrhaging cystitis is known as
Mesna
Adriamycin leads to do which side effect
Dilated cardiomyopathy
These days we follow which chemotherapy regimen
AC followed by T/EC followed by T
Adriamycin
Cyclophosphamide
Epirubicin
Taxanes: Docetaxel , Paclitaxel
What is the side effect of paclitaxel?
Neuropathy
What is Pertuzumab/perjecta?
Newer HER 2 neu directed medicine.
A combination of pertuzumab + trastuzumab gives a better response than only trastuzumab.
What are the indications of radiotherapy in breast cancer?
Positive lymph nodes
Tumor>5cm
Locally advanced breast carcinoma
After BCS 
What are the criteria for APBI?
50 years or more
T1 Disease.
No lymphovascular invasion / LVI
ER POSITIVE DISEASE
Unifocal tumors
Hormonal therapy used in patients with
ER , PR positive patients 
What are the two sources of estrogen in Peri menopausal woman?
Ovary and peripheral conversion
Which SERM is used as hormonal therapy in premenopausal women .
Tamoxifen (most common)
Dose : 20mg/day
What kind of agent used as hormonal therapy in postmenopausal woman?
Aromatase inhibitor
Letrozole
anastrozole
exemestane
If patient is HER2 neu positive……Will be added
Herceptin
Which investigation is made to confirm the diagnosis of pregnancy associated breast cancer
imaging investigation of choice is ultrasound, but and core needle biopsy /tru cut biopsy is done to confirm the diagnosis
What is Ductal carcinoma in situ type of breast cancer?
These are carcinoma, which have not invaded the basement membrane 
Most common type of DCIS
Papillary
Which is the most aggressive type of DCIS
Comedo
Which prognostic index is used in DCIS
Van Nyus Prognostic index
What to do if HER2neu is 2+
 We must do FISH/ fluorescent in situ hybridization before giving Herceptin (transtuzumab)
Most common organism responsible for lactational breast abscess
Staphylococcus aureus
Which surgery is performed in breast abscess associated with the duct ectasia
Hadfield’s procedure
Which antibiotics are given in lactarional breast abscess
Amoxycillin + Clavulinic Acid (or) Cloxacillin
Which drug is given to suppress lactation
Cabergolin
Most common ANDI in 15 to 25 years of patient
Fibroadenoma
Most common ANDI in 25 to 40 years of patient
Fibrocystic disease
Most common ANDI in >40 years of patient
Fibrocystic disease
What is the most common cause of breast lump?
Fibroadenoma
Age group (15-25) years
what is seen On the mammogram of Fibroadenoma
Pop corm calcification
Infra mammary incision is known as
Gillard Thomas incision
Which gauge needle is use in mammotome
8G needle
Phyllodes tumor is known as
Cystosarcoma phyllodes
(FNAC has no role)
Most common site of Metastasis of phyllodes tumor
Lungs
Recurrence is very common in which surgery of phyllodes
Lumpectomy ( wide local excision)
Cause of non cyclical mastalgia
Tietze syndrome(costochondritis)
Rx : intralesional triamcinolone
What is mondor’s structure
Superficial thrombophlebitis of chest vein
Most common vein involved in mondor’s disease Is
Lateral Thoracic vein
Treatment: Analgesics
Most common cause of bloody nipple discharge
Duct papilloma
Management of duct papilloma
Microdochectomy — Tennis Racquet incision. Single duct and lump excised.
What is the most common cause of pathological nipple discharge?
Multiple duct ectasia
Periductal mastitis is AKA
Zuska’s disease
What is the management of Duct ectasia ?
Antibiotics
If the conditions persist Hadfield procedure is done (cone excision of multiple ducts)
What is a common site of accessory breast tissue?
Egg Zila 
What is Poland syndrome ?
Anastia with Absence of breast tissue
Absence of unilateral pectoralis major and breast tissue
What is polythelia
Accessory nipples
What is Athelia
Absences of nipples
Distance between two nipples in breast reduction
19-21 cm
Why do we have to perform breast reduction surgery?
For breast hypertrophy
Drug induced cause of gynecomastia
DISCO
Digoxin
INH (isoniazid)
Spironolactone, steroids
Cimetidine , K = ketoconazole
Oestrogen
Most common cause of greenish nipple discharge
Duct Extasia
Which cancer in women is represented as bilateral and multicentric breast lumps
LCIS
What is the most common cause of blood stained nipple discharge from a single duct?
Ductal papilloma
What is the most common cause of blood stained nipple discharge from a multiple duct?
Carcinoma
Which gene mutation are associated with triple negative tumor
tP53
ER negative HER2 negative (triple negative) molecular subtype commonly involves the following hydrological subtype
Medullary
Adenoid cystic
Secretory
Metaplastic
Spindle cell
Squamous
Matrix producing
ER positive HER2-negative status on immunohistochemisty is suggestive of
Luminal Type of breast carcinoma
ER positive HER2-negative molecular subtype (luminal type) commonly includes the following histological subtype
Well and poorly differentiated lobular carcinoma
Tubular carcinoma
Mucinous carcinoma
Papillary carcinoma
BRCA 1 and BRCA 2 are
Tumor suppressor genes
BRCA 1 is located on chromosome
17
BRCA 2 is located on chromosome
13
Athelia and amastia refers to
Athelia : absence of nipples
Amastia : congenital absence of the breast and nipple.
Amazia is
Breast tissue is absent but NAC is present
Tietze’s syndrome
Is a benign inflammation of one or more costal cartilage
What is zuska disease
It is the subcutaneous abscess of the breast tissue beneath the areola of nipple. Aka subareolar accesses
Stewart Trevert syndrome
It is characterized by lymph angiosarcoma in chronic long-standing lymphedema following mastectomy
Most common variant of breast carcinoma
Invasive Ductal carcinoma AKA Infiltrating Ductal carcinoma
Which type of breast cancer is most common in males
Infiltrating, ductal carcinoma
Bilateral and multicentric breast lump are associated with
Lobular carcinoma, in situ
Most common, and most sensitive malignant finding on USG
Lump will be taller than wider
Most specific finding of malignancy on USG
Central Vascularity
Which signs are specific for intra capsular receptor of breast implants
Linguine sign ;on MRI
Stepladder sign : on USG
Tis classification is used for the staging off
Ductal carcinoma in situ(DCIS)
Paget’s disease
Indication for surgery in fibroadenoma
- Size >3 cm
- Multiple
- Giant type
- Recurrence
- Cosmesis
- Complex type
what do you know about breast mouse (Fibroadenoma)
• Fibroadenoma aka Breast mouse is the most common benign tumor of breast.
• It is MC seen in young age group females (15-30 yrs)
• Clinically, it is slow growing, painless solitary mass, which is mobile in nature (that’s why known as breast mouse).
• IOC: FNAC
• Upon mammography: Popcorn calcification
