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
2
Q
Long thoracic nerve innervates what?
A
Serratus anterior
Injury = winged scapula
3
Q
Perfusion of serratus anterior?
A
Lateral thoracic artery.
4
Q
Latissimus dorsi innervation and perfusion?
A
Thoracodorsal N.
INJURY = weakened adduction, internal rotation at shoulder, extension at shoulder
Thoracodorsal artery.
5
Q
Pec major and pec minor shared innervation from?
A
Medial pectoral N.
6
Q
Lateral pectoral nerve supplies what muscle?
A
Pec MAJOR only.
injury - weakness of flexion of arm at shoulder
7
Q
medial pec N
A
innervates BOTH pec major and minor
injury = weakness of extension, adduction, internal rotation of arm at shoulder
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).
9
Q
What branches supply the breast?
A
Internal thoracic aa, intercostals, thoracoacromial aa, and lateral thoracic aa.
10
Q
Batson’s plexus?
A
Valveless vein plexus between breast and SPINE.
11
Q
Lymphatic drainage from breast?
A
Axillary 97% > internal mammaries 2%
12
Q
Breast ca to supraclavicular nodes? What N.
A
N3 automatically.
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
14
Q
what does BTK say about breast abscess if doesn’t resolve after aspiration?
A
I&D
15
Q
unresolving mastitis - what do you HAVE to rule out
A
inflammatory breast ca (biopsy)
16
Q
how to treat galactocele?
A
aspirate or I&D
17
Q
Rx induced galactorrhea?
A
OCPs, TCAs, phenothiazines, metoclopramide, a-methyl dopa, reserpine
18
Q
dx gynecomastia?
A
2 cm pinch
19
Q
Rx induced gynecomastia?
A
cimetidine, spironolactone, marijuana, idiopathicl
20
Q
Poland’s syndrome?
A
hypoplasia chest wall, amastia, hypoplastic shoulder, no pecs
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
22
Q
mgmt of atypical ductalORlobular hyperplasia?
A
resect without margins; just resect as many calcifications as can
+ endocrine therapy
23
Q
most common cause of bloody nipple discharge?
A
intraductal papilloma
24
Q
mgmt of intraductal papilloma?
A
subareolar resection of involved duct and papilloma (ductogram) after the MRI proves no masses
25
most common cause of breast mass in young women
fibroadenoma
26
gross characteristics of fibroadenoma?
firm, rubbery, well circumscribed, painless, slow growing, mobile (rolls, not fixed).
27
pathology of fibroadenoma?
fibrous tissue compressing epithelial cells WITHOUT STROMAL ELEMENTS
28
mammography of fibroadenoma?
large, coarse calcifications (popcorn) from degeneration
29
mgmt of fibroadenoma?
<40 YO: if mammogram & exam is consistent, get FNA/CORE and observe.
*excise if grows.
>40 YO: excisional bx.
30
giant fibroadenoma
>6 cm (hard to distinguish from phyllodes
31
tubular adenoma variant of fibroadenoma?
BENIGN; variant of pericanalicular fibroadenoma with adenosis-like epithelial proliferation
32
complex fibroadenoma
ca risk... excise.
has elements of sclerosing adenosis, papillary aporcirne hyperplasia, cysts, or epitehlial calcs
33
fibrocystic disease discharge color?
green, yellow, brown.
34
what kind of biopsy for any worrisome discharge?
(worrisome: serous, bloody), gets excisional biopsy.
35
risk of ca from DCIS?
50% ipsilateral, 5% contralateral.
36
DCIS on mammogram?
cluster of calcifications (coarse = fibroadenoma)
37
patterns of DCIS?
solid, cribriform, papillary, comedo.
38
comedo pattern of DCIS?
highest risk; necrotic; must get SIMPLE MASTECTOMY with SNLBx
39
treatment of DCIS?
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)
40
DCIS and her2/neu?
Her2/neu not tested in DCIS. Just ER/PR.
41
risk of ca from LCIS?
40% either breast. 1% per year to either breast.
42
DCIS and LCIS premalignant?
DCIS is; LCIS is not premalignant itself (just marker for higher risk).
43
LCIS mgmt?
nothing vs hormone vs localized excision vs subQ mastectomy
if + ink on tumor for LCIS, just give hormone. no need to re-excise
44
indications for SNLBx in DCIS?
2+cm
HG DCIS
palpable mass
undergoing mastectomy
45
LCIS vs DCIS on histology? Does not have WHAT expressed?
e-cadherin is in DCIS only.
46
excisional bx indication?
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.
47
breast ca rate in US
1 in 8 (12%)
48
breast mass w/u < 40 YO?
US and CNBx.
49
breast mass w/u > 40 YO?
b/l mammograms, US and CXBx.
50
mammogram age cut off seen in BTK?
35 YO
51
breast cyst
if clear, can leave alone; if recur or bloody, need to excise it
52
mammography findings c/f ca?
irregular borders, spiculated, multiple clusters, small/thin/linear, crushed or branching calcifications, ductal asymmetry, distorted architecture.
53
BIRADS?
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
54
breast ca screening guidelines in low risk?
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
55
breast ca screening in high risk?
q1yr @ 10 years younger than age of dx'd family member.
56
nodal levels of breast?
I. lateral/inferior to pec minor muscle
II. beneath pectoralis minor muscle
III. medial to pectoralis minor (extend to thoracic inlet).
57
Rotter's nodes?
between pec major and minor
58
best px factor for breast ca?
nodal involvement. (like lung)
0 nodes: 75% 5 yr
4-10 nodes: 40% 5 yr
59
most common met from breast?
BONE > lung, liver, brain
>0.2mm deposit
very sensitive to radiation
60
biggest breast ca risk factor?
*****BRCA, 2+ primary relative bilateral or premenopausal, DCIS, LCIS, atypical hyperplasia.
61
risk factors for Male breast ca
Estrogen exposure
Significant family hx
BRCA 2>1 10:1
prior chest radiation
androgen insufficiency (testicular atrophy)
obesity
cirrhosis
Klinefelter
62
non-biggest breast ca risk factor?
prior breast ca, radiation, first degree x 1, >35 first birth >>> early menarche, late menopause, nulliparity, proliferative benign disease, obesity, EtOH, hormone replacement therapy.
63
BRCA I ca risks
female ca 65%
ovarian ca 40%****
male 1%
64
BRCA II ca risks
female ca 45%
ovarian 10%
male ca 10%****
65
breast TNM
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
staging off TNM
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
male breast ca treatment?
modified radical mastectomy OR BCT (lump + LN) + XRT
68
types of invasive ductal carcinoma?
medullary: smooth, lymphocytes
tubular: small tubule formations
mucinous: (colloid) abundance of mucin
cirrhotic: worse prognosis
69
mgmt of invasive ductal carcinoma?
modified radical mastectomy OR BCT with XRT
70
invasive lobular carcinoma mammogram difference
no calcifications
often bilateral and multifocal and multicentric
71
signet ring cells of lobular carcinoma?
worst prognosis
72
mgmt of lobular carcinoma?
modified radical mastectomy OR BCT with XRT +/- hormone
73
dx of inflammatory ca
can do full thickness breast biopsy including skin
74
mgmt of inflammatory breast ca?
same as IDC
75
neoadjuvant chemo indications in breast ca?
inflammatory, T3/T4, big tumor, anticipated delays. Like >5cm. Grade 3 (node+)
76
adjuvant radiation indications?
if > 5 cm, if positive margin, if 4+ positive nodes N2+, if skin/chest wall, if fixed nodes or internal mammary nodes
77
adjuvant chemotherapy indications
Oncotype dx
1+cm tumors unless (no nodes and hormone +)
all triple negative or HER2 negative
all positive margins
all node+
all inflammatory
78
simple mastectomy indication?
leaves 1-2% breast tissue, takes out breast, nipple-areolar complex, and necessary skin
79
BCT contraindication
multiCENTRIC (multifocal in same quadrant is ok), prior radiation, diffuse calcifcation (cosmetically bad), very large (cosmetic), early pregnancy (cuz can't radiate)
80
MRM meaning
all breast tissue including nipple/areolar complex
with ALND I and II
81
SLNB indication
1+cm malignant tumor without clinically positive nodes.
82
how to perform SLNB?
lymphazurin blue dye +/- colloid radiotracer (less false negative rates)
use both if hx of reduction
83
hypersensitivity reaction with blue dye?
Type I
84
what if recurrence after BCT/XRT?
salvage MRM
85
chemo in breast?
TAC: taxanes, adriamycin, cyclophosphamide x 6-12 weeks
or olaparib (PARP inhibitor; - form dsDNA breaks) esp in BRCA
86
1+ cm and negative node?
adjuvant unless positive hormone (just hormone therapy)
87
<1 cm and negative
just hormone if indicated
88
tamoxifen ER PR side effects?
blood clot, endometrial ca 0.1%; can decrease osteoporosis/fractures
89
anastrozole side effect
aromatase inhibitor; no T to E; fractures
90
herceptin/trastuzumab side effect
HER2/neu... reversible heart failure
91
Paget's disease presentation
scaly lesion on nipple with concurrent DCIS or ductal ca
92
dx of Paget's
full thickness biopsy including skin = large cells with pale cytoplasm and prominent nucleoli
93
mgmt Paget's disease?
central lumpectomy with SNLB if not multicentric disease
if cancer present, do MRM
94
Phyllodes spread (hem vs lymph)
hematogenous only; no nodal mets
95
malignant potential for Phyllodes? what element increases risk?
10% malignant...
increased risk if mitos > 5 /HPF
96
phyllodes vs fibroadenoma?
very fast growing.... and has SARCOMATOUS/stromal elements ( vimentin and actin) in addition to epithelial
97
mgmt phyllodes
WLE with negative margins (ideally like 1 cm) no ALND
98
Stewart Treves syndrome?
lymphangiosarcoma from chronic (10+ years) lymphedema following ax dissection (purple nodule 5-10 years after surgery)
proliferation of DERMAL VASCULAR ENDOTHELIUM*
99
treatment of stewart treves
mastectomy with excision of overlying skin
100
breast ca in pregnancy
1st and 2nd MRM
late 2nd 3rd: BCT (SNLB with low dose dye) with chemo to bridge to postIdelivery
radiation
101
breast tissue borders?
clavicle and 2nd rib to inframammary fold at 6th rib
sternal border to mid axillary line.
102
floor of breast tissue?
deep pectoral fascia (pec major and serratus anterior mm superiorly; external oblique aponeurosis inferiorly)
103
axillary tail of Spence?
superolateral axillary extension into the apex (costoclavicular ligament) where axillary turns into subclavian v
104
histology of breast
glandular epithelium
fibrous stroma
adipose tissue
105
breast gland
tubuloacinar exocrine epithelial gland
106
when to convert to ALND from SNLB?
2+ SNLB
107
Z0011 trial?
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
Z1071
if clinically positive and under neoadjuvant, can do SNLB and alone; if positive do ALND.
109
3 structures to identify and protect in ALND
thoracodorsal N (lat), axillary V, long thoracic N (serr ant)
110
hx of IDC s/p BCT with XRT now with IDC same breast?
MRM (don’t try to re-SLNB)
111
what age can you start doing mammograms?
30. do not mammo anyone under 30i
112
if CNBx fails to see microcalcifications, what do you do?
SCORE: "straight to excisional bx"
113
men screening if BRCA2 positive?
just earlier prostate screening; nothing with breast.
114
male postop ER+ ca?
tamoxifen (unless VTEs) > anastrozole
115
high oncotype DX score meaning?
candidate for postop chemotherapy (in addition to hormone therapy)
= protein expression in RT-PCR
116
survival and recurrence with BCT vs mastectomy
slightly higher risk recurrence with BCT but same survival
117
smoking effects on TRAM flap for immediate reconstruction?
flap necrosis; decrease risk with delay procedure (ligation epigastric, quit 4 wks before OR)
118
best reconstructive option post mastectomy with least complications (post BCT, I.e.)?
tissue expanders with delayed autologous (lat ie) flap on radiated side OR
DIEP/SIEP (if no abdominal surgery in the past)
119
how long hormone therapy for preventive after ADH dx'd?
5 years
120
dx mammo negative when there's a palpable mass
proceed to US***
121
triple negative mgmt
neoadjuvant chemotherapy for 0.5cm+, mastectomy with SNLB, postop chemo(radiation)
122
margin for IDC?
no ink on tumor
123
Lymphazurin dye = isosulfan rxn
Anaphylaxis type I
124
Methylene blue side effect
Skin necrosis
125
Postop chemotherapy indication
If ERPR+ HER2- send an Oncotype DX and if high, treat.
And triple negative or HER2 cancers
126
Breast implant–associated anaplastic large cell lymphoma (BIA-ALCL)
Rare complication of implant-based reconstruction
Years after implant placement and may be linked to textured implants.
Dx: aspirate/cytology
127
Who gets Oncotype DX?
Her2 negative. People that are questionable.
128
mastalgia tx
vitamins
evening primrose oil, tamoxifen, danazol, bromocriptine
129
best diagnostic test for workup of nipple discharge?
duct excision
130
sclerosing adenosis presentation
microcalcss
131
sclerosing adenosis dx
mammo will be BIRADS 4 so CNBx
132
sclerosing adenosis tx
if no atypia, just observe because not precursor to cancer
133
radial scar presentation
looks like cancerr
134
radial scar other names
sclerosing papillary proliferations
or
benign sclerosing ductal prolferation
135
radial scar dx
mammogram looks like cancer will get a CNBx because at least BIRADS 4
136
radial scar tx
excisional bx as it has small increased risk
137
atpical lobular hyperplasia surveillance
annual breast MRI
138
which is more malignant potential? ALH or ADH?
ALH 8-10 fold increase lifetime
ADH 4-5 fold increase
139
incidence of DCIS and cancer with ADH on excisional bx
10-30% concurrent dx of DCIS
3% concurrent cancer dx
140
LCIS most likely hormone receptor variation?
ERPR+
HER2-
141
syndromes ass'd breast ca
BRCA, Li-Fraumeni p53, Cowden PTEN, Peutz-Jeghers STK11, CDH1
142
specific nodal irradiation (after chemo)?
4+ positive nodes: need supraclavic/infraclavic/axillary nodal radiation
central tumor: internal mammary node radiation
143
NCCN for 70+ YO BCT for T1?
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
best hormone combination for px
ERPR+ > PR+ > ER+ alone
HER2- > HER2+
145
duration of hormone tx
ER or PR: 5 yrs
HER2: 1 yr
146
TRAM flap pedicle
superior epigastric artery
tranverse rectus abdominus myocutaneous flap
147
other abdominal flaps
TRAM, DIEP (deep inf epigastric perforator), SIEA (superficial inferior epigastric artery)
148
non abdominal flaps
GAP (gluteal artery perforator)
TUG or VUG (transverse or vertical upper gracilis)
superior gluteal artery perfroator
lat dorsi myocut flap (thoracodorsal artery)
149
breast implant associated anaplastic large cell lymphoma BIA-ALCL?
rare lymphoma after TEXTURED breast implant
fluid collection around implant... needs ASPIRATION for cytology
150
pseudoangiomatous stromal hyperplasia
benign stromal proliferation with interconnected channels lined with SPINDLE CELLS
can present like RUBBERY MASS like fibroadenoma
can just OBSERVE
151
halsted mastectomy (radical mastectomy)
like MRM but also takes level III ax nodes
152
desmoid pathology on mammogram?
EXCISE. wide local excision
153
ADH risk of ca
25% upstaging
154
CHEK2
serine/threonine kinase for DNA damage repair ...
breast, CRS, bladder ca
155
lymphedema rates after LAD dissection
SLNBx = 3%
ALND = 20-50%
156
mgmt lymphedema
1st phase: decompression (massage, ROM, elevation, compression 30-60 mm Hg wrap)
2nd phase: maintenance
157
types of estrogen suppression
aromatase inhibitors: anastrozole, exemestane
gonadotropin-releasing hormon GRH analog: triptorelin pamoate
LHRH analog: goserelin, leuprolide
permanent ovarian suppression: oophorectomy
SERM: tamoxifen
158
when to do PPX sugery in BRCA?
BSO 35-40YO
no NCCN guideline on breast
159
stage for stage survival M vs F for breast ca
same stage for stage survival
160
radiation MOA
apoptosis (p53)
permanent cell cycle arrest or terminal differentiation
or
inducing MITOTIC arrest in M PHASE
161
XRT on recurrence and survival in IDC
improves both
