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Breast Flashcards

1
Q

Estrogen and progesterone effect on breast?

A

E - ductal development (double layer columnar), swells
P - lobular development, maturation of glandular tissue

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2
Q

Long thoracic nerve innervates what?

A

Serratus anterior
Injury = winged scapula

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3
Q

Perfusion of serratus anterior?

A

Lateral thoracic artery.

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4
Q

Latissimus dorsi innervation and perfusion?

A

Thoracodorsal N.
INJURY = weakened adduction, internal rotation at shoulder, extension at shoulder

Thoracodorsal artery.

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5
Q

Pec major and pec minor shared innervation from?

A

Medial pectoral N.

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6
Q

Lateral pectoral nerve supplies what muscle?

A

Pec MAJOR only.

injury - weakness of flexion of arm at shoulder

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7
Q

medial pec N

A

innervates BOTH pec major and minor

injury = weakness of extension, adduction, internal rotation of arm at shoulder

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8
Q

Most commonly injury nerve with modified radical mastectomy or ax LND?

A

Intercostobrachial N. (lateral cutaneous branch of 2nd IC nerve); medial arm and axilla (can transect).

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9
Q

What branches supply the breast?

A

Internal thoracic aa, intercostals, thoracoacromial aa, and lateral thoracic aa.

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10
Q

Batson’s plexus?

A

Valveless vein plexus between breast and SPINE.

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11
Q

Lymphatic drainage from breast?

A

Axillary 97% > internal mammaries 2%

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12
Q

Breast ca to supraclavicular nodes? What N.

A

N3 automatically.

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13
Q

periductal mastitis

A

mammary duct ectasia or plasma cell mastitis

creamy discharge, noncyclical mastodynia, erythema, subaerolar abscess

Bx = dilated ducts, inspissated secretions, periductal inflammation
abx, reassure, continue breastfeeding

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14
Q

what does BTK say about breast abscess if doesn’t resolve after aspiration?

A

I&D

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15
Q

unresolving mastitis - what do you HAVE to rule out

A

inflammatory breast ca (biopsy)

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16
Q

how to treat galactocele?

A

aspirate or I&D

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17
Q

Rx induced galactorrhea?

A

OCPs, TCAs, phenothiazines, metoclopramide, a-methyl dopa, reserpine

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18
Q

dx gynecomastia?

A

2 cm pinch

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19
Q

Rx induced gynecomastia?

A

cimetidine, spironolactone, marijuana, idiopathicl

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20
Q

Poland’s syndrome?

A

hypoplasia chest wall, amastia, hypoplastic shoulder, no pecs

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21
Q

Mondor’s disease?

A

superficial vein thrombophlebitis, cordlike, painful
NSAIDs
mostly superior epigastric vein or lateral thoracic vein

2/2 inflammation not ca

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22
Q

mgmt of atypical ductalORlobular hyperplasia?

A

resect without margins; just resect as many calcifications as can

+ endocrine therapy

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23
Q

most common cause of bloody nipple discharge?

A

intraductal papilloma

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24
Q

mgmt of intraductal papilloma?

A

subareolar resection of involved duct and papilloma (ductogram) after the MRI proves no masses

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25
Q

most common cause of breast mass in young women

A

fibroadenoma

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26
Q

gross characteristics of fibroadenoma?

A

firm, rubbery, well circumscribed, painless, slow growing, mobile (rolls, not fixed).

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27
Q

pathology of fibroadenoma?

A

fibrous tissue compressing epithelial cells WITHOUT STROMAL ELEMENTS

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28
Q

mammography of fibroadenoma?

A

large, coarse calcifications (popcorn) from degeneration

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29
Q

mgmt of fibroadenoma?

A

<40 YO: if mammogram & exam is consistent, get FNA/CORE and observe.
*excise if grows.
>40 YO: excisional bx.

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30
Q

giant fibroadenoma

A

> 6 cm (hard to distinguish from phyllodes

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31
Q

tubular adenoma variant of fibroadenoma?

A

BENIGN; variant of pericanalicular fibroadenoma with adenosis-like epithelial proliferation

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32
Q

complex fibroadenoma

A

ca risk… excise.

has elements of sclerosing adenosis, papillary aporcirne hyperplasia, cysts, or epitehlial calcs

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33
Q

fibrocystic disease discharge color?

A

green, yellow, brown.

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34
Q

what kind of biopsy for any worrisome discharge?

A

(worrisome: serous, bloody), gets excisional biopsy.

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35
Q

risk of ca from DCIS?

A

50% ipsilateral, 5% contralateral.

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36
Q

DCIS on mammogram?

A

cluster of calcifications (coarse = fibroadenoma)

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37
Q

patterns of DCIS?

A

solid, cribriform, papillary, comedo.

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38
Q

comedo pattern of DCIS?

A

highest risk; necrotic; must get SIMPLE MASTECTOMY with SNLBx

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39
Q

treatment of DCIS?

A

lumpectomy 2mm margin
XRT (decreases ipsilateral disease recurrence)
SLNB (if 2+cm HG DCIS, palpable mass, undergoing mastectomy)
+/- hormone tx

simple mastectomy with SNLB if: 2.5+, + margin, comedo, multicentric, recurs (and repeat SLNBx)

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40
Q

DCIS and her2/neu?

A

Her2/neu not tested in DCIS. Just ER/PR.

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41
Q

risk of ca from LCIS?

A

40% either breast. 1% per year to either breast.

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42
Q

DCIS and LCIS premalignant?

A

DCIS is; LCIS is not premalignant itself (just marker for higher risk).

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43
Q

LCIS mgmt?

A

nothing vs hormone vs localized excision vs subQ mastectomy

if + ink on tumor for LCIS, just give hormone. no need to re-excise

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44
Q

indications for SNLBx in DCIS?

A

2+cm
HG DCIS
palpable mass
undergoing mastectomy

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45
Q

LCIS vs DCIS on histology? Does not have WHAT expressed?

A

e-cadherin is in DCIS only.

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46
Q

excisional bx indication?

A

atypical hyperplasia x 2, radial scar with architectural distortion (otherwise can leave alone), CLIS, columnar cell hyperplasia with atypica, papillary lesions, phyllodes tumor, discordant mammogram/core.

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47
Q

breast ca rate in US

A

1 in 8 (12%)

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48
Q

breast mass w/u < 40 YO?

A

US and CNBx.

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49
Q

breast mass w/u > 40 YO?

A

b/l mammograms, US and CXBx.

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50
Q

mammogram age cut off seen in BTK?

A

35 YO

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51
Q

breast cyst

A

if clear, can leave alone; if recur or bloody, need to excise it

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52
Q

mammography findings c/f ca?

A

irregular borders, spiculated, multiple clusters, small/thin/linear, crushed or branching calcifications, ductal asymmetry, distorted architecture.

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53
Q

BIRADS?

A
  1. negative > routine
  2. benign > routine.
  3. probably benign finding (3% risk) > 3-6 mo mammogram repeat
  4. suspicious abnormality (indetermine calcifcations) > core Bx
    (4a: 15%, 4b 35%, 4c 80%)
  5. high suggestive (95%), get core > at least gets excisional (even if benign)
    ZERO. indeterminate > repeat imaging
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54
Q

breast ca screening guidelines in low risk?

A

40-50 q2-3 yrs MAMMOGRAM
q1y @50 YO.

BRCA: 25+ MRI q6 mammogram qo6 (start at 30YO), yearly Ca125/TVUS/pelvic exam after 25

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55
Q

breast ca screening in high risk?

A

q1yr @ 10 years younger than age of dx’d family member.

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56
Q

nodal levels of breast?

A

I. lateral/inferior to pec minor muscle
II. beneath pectoralis minor muscle
III. medial to pectoralis minor (extend to thoracic inlet).

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57
Q

Rotter’s nodes?

A

between pec major and minor

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58
Q

best px factor for breast ca?

A

nodal involvement. (like lung)

0 nodes: 75% 5 yr
4-10 nodes: 40% 5 yr

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59
Q

most common met from breast?

A

BONE > lung, liver, brain
>0.2mm deposit

very sensitive to radiation

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60
Q

biggest breast ca risk factor?

A

*****BRCA, 2+ primary relative bilateral or premenopausal, DCIS, LCIS, atypical hyperplasia.

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61
Q

risk factors for Male breast ca

A

Estrogen exposure
Significant family hx
BRCA 2>1 10:1
prior chest radiation
androgen insufficiency (testicular atrophy)
obesity
cirrhosis
Klinefelter

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62
Q

non-biggest breast ca risk factor?

A

prior breast ca, radiation, first degree x 1, >35 first birth&raquo_space;> early menarche, late menopause, nulliparity, proliferative benign disease, obesity, EtOH, hormone replacement therapy.

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63
Q

BRCA I ca risks

A

female ca 65%
ovarian ca 40%**
male 1%

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64
Q

BRCA II ca risks

A

female ca 45%
ovarian 10%
male ca 10%**

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65
Q

breast TNM

A

T1: 2cm or less
T2: 2-5cm
T3: 5+cm
T4: chest wall, skin edema, ulceration, inflammatory
N1: 1-3 ax nodes or microscopic internal mammary on SNLB
N2: 4-9 ax or clinical internal mammary
N3: 10+ ax or infraclavicular, or internal mammary
M1: mets present

66
Q

staging off TNM

A

I. T1N0
IIA. T0-1N1 or T2N0
IIB. T2N1 or T3N0
IIIA. T0-2N2, T3N1-2
IIIB. T4N0-2
IIIC. 1-4TN3
IV: M1

67
Q

male breast ca treatment?

A

modified radical mastectomy OR BCT (lump + LN) + XRT

68
Q

types of invasive ductal carcinoma?

A

medullary: smooth, lymphocytes
tubular: small tubule formations
mucinous: (colloid) abundance of mucin
cirrhotic: worse prognosis

69
Q

mgmt of invasive ductal carcinoma?

A

modified radical mastectomy OR BCT with XRT

70
Q

invasive lobular carcinoma mammogram difference

A

no calcifications
often bilateral and multifocal and multicentric

71
Q

signet ring cells of lobular carcinoma?

A

worst prognosis

72
Q

mgmt of lobular carcinoma?

A

modified radical mastectomy OR BCT with XRT +/- hormone

73
Q

dx of inflammatory ca

A

can do full thickness breast biopsy including skin

74
Q

mgmt of inflammatory breast ca?

A

same as IDC

75
Q

neoadjuvant chemo indications in breast ca?

A

inflammatory, T3/T4, big tumor, anticipated delays. Like >5cm. Grade 3 (node+)

76
Q

adjuvant radiation indications?

A

if > 5 cm, if positive margin, if 4+ positive nodes N2+, if skin/chest wall, if fixed nodes or internal mammary nodes

77
Q

adjuvant chemotherapy indications

A

Oncotype dx
1+cm tumors unless (no nodes and hormone +)
all triple negative or HER2 negative
all positive margins
all node+
all inflammatory

78
Q

simple mastectomy indication?

A

leaves 1-2% breast tissue, takes out breast, nipple-areolar complex, and necessary skin

79
Q

BCT contraindication

A

multiCENTRIC (multifocal in same quadrant is ok), prior radiation, diffuse calcifcation (cosmetically bad), very large (cosmetic), early pregnancy (cuz can’t radiate)

80
Q

MRM meaning

A

all breast tissue including nipple/areolar complex
with ALND I and II

81
Q

SLNB indication

A

1+cm malignant tumor without clinically positive nodes.

82
Q

how to perform SLNB?

A

lymphazurin blue dye +/- colloid radiotracer (less false negative rates)

use both if hx of reduction

83
Q

hypersensitivity reaction with blue dye?

84
Q

what if recurrence after BCT/XRT?

A

salvage MRM

85
Q

chemo in breast?

A

TAC: taxanes, adriamycin, cyclophosphamide x 6-12 weeks

or olaparib (PARP inhibitor; - form dsDNA breaks) esp in BRCA

86
Q

1+ cm and negative node?

A

adjuvant unless positive hormone (just hormone therapy)

87
Q

<1 cm and negative

A

just hormone if indicated

88
Q

tamoxifen ER PR side effects?

A

blood clot, endometrial ca 0.1%; can decrease osteoporosis/fractures

89
Q

anastrozole side effect

A

aromatase inhibitor; no T to E; fractures

90
Q

herceptin/trastuzumab side effect

A

HER2/neu… reversible heart failure

91
Q

Paget’s disease presentation

A

scaly lesion on nipple with concurrent DCIS or ductal ca

92
Q

dx of Paget’s

A

full thickness biopsy including skin = large cells with pale cytoplasm and prominent nucleoli

93
Q

mgmt Paget’s disease?

A

central lumpectomy with SNLB if not multicentric disease

if cancer present, do MRM

94
Q

Phyllodes spread (hem vs lymph)

A

hematogenous only; no nodal mets

95
Q

malignant potential for Phyllodes? what element increases risk?

A

10% malignant…
increased risk if mitos > 5 /HPF

96
Q

phyllodes vs fibroadenoma?

A

very fast growing…. and has SARCOMATOUS/stromal elements ( vimentin and actin) in addition to epithelial

97
Q

mgmt phyllodes

A

WLE with negative margins (ideally like 1 cm) no ALND

98
Q

Stewart Treves syndrome?

A

lymphangiosarcoma from chronic (10+ years) lymphedema following ax dissection (purple nodule 5-10 years after surgery)

proliferation of DERMAL VASCULAR ENDOTHELIUM*

99
Q

treatment of stewart treves

A

mastectomy with excision of overlying skin

100
Q

breast ca in pregnancy

A

1st and 2nd MRM
late 2nd 3rd: BCT (SNLB with low dose dye) with chemo to bridge to postIdelivery
radiation

101
Q

breast tissue borders?

A

clavicle and 2nd rib to inframammary fold at 6th rib
sternal border to mid axillary line.

102
Q

floor of breast tissue?

A

deep pectoral fascia (pec major and serratus anterior mm superiorly; external oblique aponeurosis inferiorly)

103
Q

axillary tail of Spence?

A

superolateral axillary extension into the apex (costoclavicular ligament) where axillary turns into subclavian v

104
Q

histology of breast

A

glandular epithelium
fibrous stroma
adipose tissue

105
Q

breast gland

A

tubuloacinar exocrine epithelial gland

106
Q

when to convert to ALND from SNLB?

107
Q

Z0011 trial?

A

18F+, early stage T1 or T2, 2 or fewer nodes on SLNB (nonclinical)… 891 patients s/p lumpectomy and positive SLNB with radiation instead of ALND. no difference in mortality or disease free survival

108
Q

Z1071

A

if clinically positive and under neoadjuvant, can do SNLB and alone; if positive do ALND.

109
Q

3 structures to identify and protect in ALND

A

thoracodorsal N (lat), axillary V, long thoracic N (serr ant)

110
Q

hx of IDC s/p BCT with XRT now with IDC same breast?

A

MRM (don’t try to re-SLNB)

111
Q

what age can you start doing mammograms?

A
  1. do not mammo anyone under 30i
112
Q

if CNBx fails to see microcalcifications, what do you do?

A

SCORE: “straight to excisional bx”

113
Q

men screening if BRCA2 positive?

A

just earlier prostate screening; nothing with breast.

114
Q

male postop ER+ ca?

A

tamoxifen (unless VTEs) > anastrozole

115
Q

high oncotype DX score meaning?

A

candidate for postop chemotherapy (in addition to hormone therapy)

= protein expression in RT-PCR

116
Q

survival and recurrence with BCT vs mastectomy

A

slightly higher risk recurrence with BCT but same survival

117
Q

smoking effects on TRAM flap for immediate reconstruction?

A

flap necrosis; decrease risk with delay procedure (ligation epigastric, quit 4 wks before OR)

118
Q

best reconstructive option post mastectomy with least complications (post BCT, I.e.)?

A

tissue expanders with delayed autologous (lat ie) flap on radiated side OR
DIEP/SIEP (if no abdominal surgery in the past)

119
Q

how long hormone therapy for preventive after ADH dx’d?

120
Q

dx mammo negative when there’s a palpable mass

A

proceed to US***

121
Q

triple negative mgmt

A

neoadjuvant chemotherapy for 0.5cm+, mastectomy with SNLB, postop chemo(radiation)

122
Q

margin for IDC?

A

no ink on tumor

123
Q

Lymphazurin dye = isosulfan rxn

A

Anaphylaxis type I

124
Q

Methylene blue side effect

A

Skin necrosis

125
Q

Postop chemotherapy indication

A

If ERPR+ HER2- send an Oncotype DX and if high, treat.
And triple negative or HER2 cancers

126
Q

Breast implant–associated anaplastic large cell lymphoma (BIA-ALCL)

A

Rare complication of implant-based reconstruction
Years after implant placement and may be linked to textured implants.
Dx: aspirate/cytology

127
Q

Who gets Oncotype DX?

A

Her2 negative. People that are questionable.

128
Q

mastalgia tx

A

vitamins
evening primrose oil, tamoxifen, danazol, bromocriptine

129
Q

best diagnostic test for workup of nipple discharge?

A

duct excision

130
Q

sclerosing adenosis presentation

A

microcalcss

131
Q

sclerosing adenosis dx

A

mammo will be BIRADS 4 so CNBx

132
Q

sclerosing adenosis tx

A

if no atypia, just observe because not precursor to cancer

133
Q

radial scar presentation

A

looks like cancerr

134
Q

radial scar other names

A

sclerosing papillary proliferations
or
benign sclerosing ductal prolferation

135
Q

radial scar dx

A

mammogram looks like cancer will get a CNBx because at least BIRADS 4

136
Q

radial scar tx

A

excisional bx as it has small increased risk

137
Q

atpical lobular hyperplasia surveillance

A

annual breast MRI

138
Q

which is more malignant potential? ALH or ADH?

A

ALH 8-10 fold increase lifetime
ADH 4-5 fold increase

139
Q

incidence of DCIS and cancer with ADH on excisional bx

A

10-30% concurrent dx of DCIS
3% concurrent cancer dx

140
Q

LCIS most likely hormone receptor variation?

A

ERPR+
HER2-

141
Q

syndromes ass’d breast ca

A

BRCA, Li-Fraumeni p53, Cowden PTEN, Peutz-Jeghers STK11, CDH1

142
Q

specific nodal irradiation (after chemo)?

A

4+ positive nodes: need supraclavic/infraclavic/axillary nodal radiation

central tumor: internal mammary node radiation

143
Q

NCCN for 70+ YO BCT for T1?

A

can hold radiation if clinically node negative, ER+ (hormone)

it has to be T1!! ER+. ANDDDDDDDD you must take 1 cm margin then (not no ink on tumor)

144
Q

best hormone combination for px

A

ERPR+ > PR+ > ER+ alone

HER2- > HER2+

145
Q

duration of hormone tx

A

ER or PR: 5 yrs
HER2: 1 yr

146
Q

TRAM flap pedicle

A

superior epigastric artery
tranverse rectus abdominus myocutaneous flap

147
Q

other abdominal flaps

A

TRAM, DIEP (deep inf epigastric perforator), SIEA (superficial inferior epigastric artery)

148
Q

non abdominal flaps

A

GAP (gluteal artery perforator)
TUG or VUG (transverse or vertical upper gracilis)
superior gluteal artery perfroator
lat dorsi myocut flap (thoracodorsal artery)

149
Q

breast implant associated anaplastic large cell lymphoma BIA-ALCL?

A

rare lymphoma after TEXTURED breast implant

fluid collection around implant… needs ASPIRATION for cytology

150
Q

pseudoangiomatous stromal hyperplasia

A

benign stromal proliferation with interconnected channels lined with SPINDLE CELLS

can present like RUBBERY MASS like fibroadenoma

can just OBSERVE

151
Q

halsted mastectomy (radical mastectomy)

A

like MRM but also takes level III ax nodes

152
Q

desmoid pathology on mammogram?

A

EXCISE. wide local excision

153
Q

ADH risk of ca

A

25% upstaging

154
Q

CHEK2

A

serine/threonine kinase for DNA damage repair …

breast, CRS, bladder ca

155
Q

lymphedema rates after LAD dissection

A

SLNBx = 3%
ALND = 20-50%

156
Q

mgmt lymphedema

A

1st phase: decompression (massage, ROM, elevation, compression 30-60 mm Hg wrap)
2nd phase: maintenance

157
Q

types of estrogen suppression

A

aromatase inhibitors: anastrozole, exemestane
gonadotropin-releasing hormon GRH analog: triptorelin pamoate
LHRH analog: goserelin, leuprolide
permanent ovarian suppression: oophorectomy
SERM: tamoxifen

158
Q

when to do PPX sugery in BRCA?

A

BSO 35-40YO

no NCCN guideline on breast

159
Q

stage for stage survival M vs F for breast ca

A

same stage for stage survival

160
Q

radiation MOA

A

apoptosis (p53)
permanent cell cycle arrest or terminal differentiation
or
inducing MITOTIC arrest in M PHASE

161
Q

XRT on recurrence and survival in IDC

A

improves both

ABSITE (33 decks)

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