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Surgery > breast > Flashcards

breast Flashcards

1
Q

fibroadenoma

A

-MC benign in young females < 30
-<5cm usually
-50s-60s- giant fibroadenoma
-mobile, round, rubbery, firm (cyst is non-firm), non-tender
-can be multiple and bilateral
-does NOT change with period

-DX
-to DX- core biopsy (with needle) via US!!!!
-US to r/o or in cyst
-phyllodes tumor would be bigger
-dense tissue -> acoustic shadowing
-hypoechoic -> not fluid
-FNA

-TX
-excision depends on if pt is symptomatic
-potential excision is usually >3cm or pt preference

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2
Q

metastasis

A

-vertebral veins drain into the batson plexus -> this plexus has no valves
-lymphatics and veins drain breasts
-can go up and down with breathing - from brain to sacrum
-bone pain?
-pain over spine?
-changes in vision?
-seizures? -> brain tumor

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3
Q

ductal carcinoma in situ (DCIS)

A

-MC non invasive breast cancer- 80%
-non palpable
-begins in milk ducts and invades surrounding tissue
-not invasive yet
-asymptomatic

-dx-
-detected via screening - microcalcifications
-biopsy

-tx- excision
-Usually hormone receptor positive and HER 2 negative

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4
Q

invasive ductal and lobular carcinoma

A

-INVASIVE DUCTAL CARCINOMA (IDC)
-80%- MC
-Usually hormone receptor positive and HER 2 negative
-nests and cords of tumors cells assoc with gland formation

-INVASIVE LOBULAR CARCINOMA (ILC)
-5-10%
-older women- postmenopausal!
-diffuse
-bilateral
-at dx usually large
-usually incidental finding
-Almost always estrogen and progesterone receptor positive -> good for medication therapy

-S&S
-breast/axillary lump
-asymmetry
-swelling
-abnormal nipple discharge
-nipple retraction
-skin changes- dimpling
-mastalgia

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5
Q

anatomy of breast

A

-superior-clavicle
-inferior- rectus sheath
-medial-sternum
-lateral- lat dorsi
-beware of serratus anterior nerve -> long thoracic

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6
Q

breast dimpling

A

-shortening of suspensory ligaments
-cancer
-inflammation
-fat fibrosis 2ndary to trauma
-has it always been there?

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7
Q

fat necrosis

A

-caused by acute inflammatory response due to trauma (including surgery)
-asymptomatic usually -> can have lump, fluid discharge, skin dimpling, pain, nipple inversion
-can progress to chronic fibrotic change -> solid irregular lump
-due to calcified irregular, speculated mass -> must biopsy to r/o cancer
-tx- self limiting

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8
Q

lymphatics

A

-axillary nodes in tail of spence
-subclavicular
-mediastinal nodes
-areolar nodes

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9
Q

mastitis/breast abscess

A

-commonly occurs during breast feeding
-if you see in pt without lactation -> think inflammatory breast carcinoma (can have it secondary to trauma with hematoma)
-pain, swelling, induration, redness
-smoking- damage to subareolar duct walls -> bacteria
-bleeding/discharge
-staph aureus MC

-tx-
-antibiotics
-US needle aspiration
-or operative (I&D) -> can cause fistula
-IF NOT GETTING BETTER R/O CANCER

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10
Q

zuska’s disease (periductal mastitis)

A

-periductal mastitis
-abscess within the duct
-discharge
-reoccurring
-behind the
-risk factor: smoking
-antibiotics
-resection
-terminal ducts also removed depending on pt

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11
Q

hidradenitis suppurativa

A

-no cure
-accessory gland of Montgomery involved here
-clindamycin
-biologics
-surgical approach - unroofing areas where there are tracts -> grafting
-obesity associated -> wt loss

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12
Q

mondor’s disease

A

-veins - lateral thoracic, thoracoepigastric, superficial epigastric vein
-thrombophlebitis
-pain over vein, redness, dimpling
-cord like on palpation
-arm elevation creates a groove in the breast
-anti-inflammatory meds
-warm compress
-resolves 4-5 weeks
-can be refractory to therapy -> segment of involved vein is to be surgically removed

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13
Q

cystosarcoma phyllodes

A

-30-40s (but can happen in any age)
-huge, rapid growth
-dont invade tissue locally
-normal architecture
-can undergo malignant transformation (1/3)
-MUST resect!
-core needle bx needed!! -> bc inflammation and necrosis present
-FNA is inaccurate
-10% chance of reoccurrence

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14
Q

mammary dysplasia/fibrocystic disease/cystic mastitis

A

-MC benign in child bearing age women
-mastodynia- PAIN in breast tissue
-clear nipple discharge
-dx 3-5 days after period -> lumpiness from period will go down
-fluctuation dependent on period
-lumpy breast, multiple
-50% of females, very common

-DX-
-US to eval
-green/dark brown fluid when aspirated (FNA)

-TX-
-if mass is still there or bloody after aspiration -> biopsy

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15
Q

intraductal papilloma

A

-MCC of bloody nipple discharge
-clear or bloody discharge
-40-50yo
-not always assoc with cancer (50% of time)
-mammogram to exclude cancer
-dense breast -> MRI
-galactogram/ductogram- dye -> view lesions/deformity
-17-20% are cancerous
-biopsy to r/o ductal carcinoma (not from his slides)

-tx-
-depends on how big it is and how many are present, pts risk factors -> more likely cancer -> remove

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16
Q

lobular carcinoma in situ (LCIS)

A

-lesions of secretory lobules
-contained within basement membrane
-more risk for invasive breast cancer
-bilateral mirror image

-asymptomatic - incidental finding during bx

-tx- low grade- monitor
-less likely to have nodal metastasis then DCIS
-bilateral prophylactic mastectomy in BRCA pts

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17
Q

noninvasive in situ carcinoma

A

-80% ductal
-10% lobular

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18
Q

risk factors for breast cancer

A

-Advancing age and female sex are the most common risk factors.
-BRCA 1 and 2, account for about 10% of breast cancers.
-History of DCIS.
-High BMI.
-First birth at age > 30 years or nulliparity.
-Early menarche (before age 13).
-Family history of breast or ovarian cancer.
-Late menopause
-Postmenopausal hormone therapy use (white women, normal BMI, dense breasts).
-Prior Chest wall radiation
-longer exposure to estrogen -> more risk

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19
Q

classification breast cancer

A

-by region/origination -> lobular or ductal
-hormonal receptivity and human epidermal growth factor receptor 2 (HER-2) expression

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20
Q

hormone receptivity

A

-Refers to the presence or absence of estrogen and progesterone receptor expression in the malignancy.
-Hormone receptor positive breast cancer, especially when non-metastatic, is amenable to hormone-blocking therapy -> tamoxifen
-HER-2 positive malignancies are generally responsive to HER-2 directed monoclonal antibodies.
-Hormone receptor positive (er/pr), HER-2 negative is the most common expression status of breast cancer.

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21
Q

triple negative breast cancer

A

-low levels of estrogen and progesterone receptor, and HER2 neg
-12% of women with breast cancer
-more common in non-Hispanic black women
-any age
-dx at earlier ages than other subtypes
-More likely to be dx at later stage (stage III or IV).
-Tend to be higher grade and more aggressive than hormone receptor positive HER-2 negative disease

-tx- chemo before surgery
-radiation

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22
Q

different types of breast cancer

A

-ductal carcinoma in situ (DCIS)- heterogenous category of noninvasive noninfiltrating malignancies that are localized inside mammary ducts
-sometimes invasive ductal carcinoma (IDC) will have mammographic or histologic evidence of DCIS
-DCIS -> further classified depending on morphology, location, cytological characteristics

-DCIS and LCIS are usually hormone receptor positive and HER2 neg
-IDC is MC type
-70% of women with IDC will be hormone receptor positive and HER2 neg

-Medullary breast cancer

-Inflammatory breast cancer

-Mammary Paget disease is an adenocarcinoma affecting the nipple and areola -> dry and flakey

-Tubular, papillary, and mucinous breast cancers

-Phylloides tumors are less common cancers

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23
Q

medullary breast cancer

A

-more common in younger women who carry a BRCA 1 mutation!
-rare
-aggressive
-usually triple neg- hormone and HER2 -> but better prognosis bc less likely to metastasize to axilla!!!
-chemo and surgery

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24
Q

clinical assessment and differentials

A

-Palpable breast mass is evident in about 30%
-Visible signs include:
-Dimpling (peau d’orange)
-Erythema
-Edema
-Blistering
-Excoriations
-Sanguineous nipple discharge
-Nipple retraction.
-**Skin changes such as peau d’orange and blistering are strongly associated with inflammatory breast CA

-Remember to rule out malignancy in pts being treated for mastitis or a breast abscess that is not improving clinically!!!!! -> could also be fungal or not staph aureus

25
Q

DDx of breast mass

A

-Benign conditions such as:
-Fibroadenoma
-Breast cyst
-Intraductal papilloma
-Fibrocystic changes

-**Once a mass has been palpated, the next steps are to refer the patient for a diagnostic mammogram and ultrasound

26
Q

diagnosing cancer- when to get MRI

A

-Initial Imaging:
-Mammography
-Ultrasound

-MRI:
-Dense breasts
-Hx of breast CA
-Evaluation of contralateral disease- lobular (bilateral)
-High cancer risk
-Surgical planning
-Identifying skin changes skin involvement
-breast implants

27
Q

findings in invasive breast cancer

A

-Irregularly shaped mass
-Spiculation
-Pleomorphic microcalcifications
-Anatomical distortion around it
-Axillary lymphadenopathy
-Posterior acoustic shadowing - from dense tissue

-Breast Imaging and Reporting Data System (BI-RADS)- staging

28
Q

BI-RADS classification

A

4- core biopsy, aspiration

-standard- mammo every two years at age 40 and continue until age 74

29
Q

confirmation of breast cancer

A

-Confirmation by tissue biopsy:
-Percutaneous US guided core needle biopsy, excisional biopsy
-Stereotactic biopsy
-MRI-guided biopsy

-**Preferred method for most is US guided large-bore core needle biopsy with or without a vacuum-assisted device.

30
Q

tissue biopsy results

A

-Contain information about:
-Tumor grade, based on cell differentiation
-Low-grade tumors (grade 1) are well differentiated
-High-grade (grade 4) tumors are undifferentiated
-Immunohistology, based on hormone receptivity and HER-2 expression.

-Oncotype DX Breast Recurrence Score tell you if you need neoadjuvant chemotherapy and risk of recurrence in patients with early stage breast cancer -> 25-100

31
Q

more testing after dx of breast cancer

A

-Increased risk in Cowden syndrome and Li-Fraumeni syndrome.
-Patients with a family history of:
-Cancer of the breast
-Ovary
-Pancreas
-Prostate
-Colon
-Thyroid,
-Endometrium

-Should undergo more extensive genetic testing!
-send to geneticist

32
Q

cowden syndrome

A
33
Q

tumor staging- who gets BRCA testing

A

-Breast cancer is staged using the TNM (tumor, nodes, metastasis) classification system
-Most women with a biopsy-proven malignancy should undergo genetic testing for BRCA 1 and 2 mutations:

-breast malignancy dx at age 50 or younger
-bilateral breast malignancy
-personal or family hx of breast of ovarian cancer
-multiple breast malignancies in pt family
-male breast cancer in family
-ashkenazi jewish heritage

34
Q

treatment decision

A

-Tx of breast cancer, including surgery, depends on the size of the lesion, hormone receptivity and histologic markers (differentiated/undifferentiated), presence or absence of metastatic or contralateral disease, patient age, and patient preference

35
Q

surgical options for breast cancer

A

-Lumpectomy
-Mastectomy, and bilateral mastectomy
-Breast-conserving surgery (lumpectomy) *preferred intervention for most pts with unilateral disease, but many patients still opt for mastectomy
-many do mastectomy with immediate reconstruction (flap surgery)
-lumpectomy requires radiation of breast and axillary nodes after
-Sentinel lymph node biopsy preferred over wide lymph node dissection if no evidence of axillary lymph node involvement
-preserve skin and nipple

-With lymph node involvement, expert consensus remains mixed as to whether axillary node dissection has clinical benefit.
-antibiotics, drains, foley, doppler signals for good perfusion
-get attending IMMEDIATELY if there is a problem

36
Q

chemotherapy

A

-Hormone reception status.
-HER-2 status.
-Presence or absence of metastatic disease.
-Oncotype DX recurrence score.
-Locally advanced disease and triple negative breast cancer usually are treated with presurgical neoadjuvant chemotherapy

-doxorubicin
-cyclophosphamide
-paclitaxel

37
Q

chemo meds complications

A

-Doxorubicin:
-Nausea, vomiting
-Diarrhea, and fatigue
-Discoloration of their nails
-Reddish discoloration of urine, tears, and sweat
-alopecia
-HEART failure!
-do echo prior to starting

-Cyclophosphamide:
-Neutropenia
-Alopecia
-Nausea and vomiting
-hemorrhagic cystitis!!
-kidney toxicity

-Paclitaxel:
-Neutropenia,
-Alopecia
-Arthralgias
-Myalgias
-Peripheral neuropathy!!
-Mucositis
-CNS toxicity
-decrease bone marrow

38
Q

adjunctive chemo

A

-Aromatase inhibitors and selective estrogen receptor modulators (SERMs): nonmetastatic estrogen and progesterone receptor positive breast cancer

-HER-2 positive breast cancer can be responsive to HER-2 blockers such as pertuzumab and trastuzumab

-Neoadjuvant and adjuvant anthracycline-based chemotherapy (doxo, pac, cyclo), in addition to HER-2 blocking monoclonal antibodies, has shown clinical superiority.

39
Q

HER2 blockers

A

-pertuzumab

-trastuzumab:
-monitor ejection fraction before and after tx
-Primary resistance in >30% of pts, and secondary resistance occurs in >70% of pts

40
Q

selective estrogen receptor modulators (SERMS)

A

-SERMs are used in PREMENOPAUSAL pts
-hormone receptor + breast cancer use a SERM for 5 years -> then an aromatase inhibitor for 5 years
-causes premature menopause

-high risk pts (< 35 yo with positive nodes, high-grade, or large tumors) with hormone receptor + and HER-2 neg may benefit from using:
-aromatase inhibitor- exemestane, anastrozole
AND
-chemical ovarian suppression with a gonadotropic releasing hormone agonist (leuprolide/lupron or goserelin) OR
-oophorectomy OR
-ovarian radiation

-Tamoxifen is the MC used SERM!

41
Q

tamoxifen

A

-SERM
-Tamoxifen associated with endometrial hyperplasia and carcinoma
-Any new abnormal uterine bleeding must be reported to gynecologist
-bone pain
-hypercalcemia
-Avoid co prescribing paroxetine, fluoxetine, bupropion, and duloxetine, because these medications are strong inhibitors of CYP2D6 and may lower tamoxifen’s effectiveness
-Escitalopram, citalopram, sertraline, and desvenlafaxine are moderate inhibitors of CYP2D6.
-Venlafaxine seems to have a negligible effect on CYP2D6

42
Q

aromatase inhibitors

A

-Use in natural and surgically induced menopause
-work in periphery in fat

-Postmenopausal:
-Age 60 years or older
-Oophorectomy
-Under age 60 years with amenorrhea for at least 12 months without any exogenous medications that could alter ovarian function
-< 60 years and taking a SERM, but has serum estradiol (low) and/or FSH (high) that are consistent with menopause

-Experience accelerated bone loss, so monitor bone density.
-Consider bisphosphonates in postmenopausal women with hormone receptor positive breast cancer to help prevent further bone loss from aromatase inhibitor therapy.
-Can cause significant joint pain -> NSAIDs and acetaminophen.
-Some relief from physical therapy, acupuncture, exercise, and other complementary therapies

43
Q

triple negative subtype tx

A

-combination of doxorubicin, cyclophosphamide, and paclitaxel

44
Q

radiation therapy

A

-Either before or more commonly after surgery.
-Whole-breast and targeted nodal radiation -> “gold standard”.
-Typically receive radiation therapy 5x/week for 4 - 7 weeks.
-A “boost” of lower radiation may be considered in women at high risk of recurrence.
-Accelerated partial breast irradiation may be considered in women > 50 years who are node-negative, hormone receptor positive, and BRCA-negative.
-Women who undergo breast-conserving surgery receive postsurgical radiation of the breast and axilla (bc nodes are here and can have undetected spread there)
-Women with positive lymph nodes and tumors > 5 cm, radiation may be used on the axilla (axillary), supraclavicular areas (subclavicular), and sternum (substernal)

45
Q

radiation precautions

A

-Avoid use of deodorants, antiperspirants, and underwire bras.
-Topical creams, lotions, and ointments.
-Thicker applications could affect the radiation dose received.
-Heavily perfumed lotions and creams on the breast,
-Use only specific topical products (such as aloe vera and hydrocortisone)

46
Q

ADRs radiation

A

-Fatigue.
-Pain
-bone marrow suppression
-Breast discoloration.
-Women with large breasts are also at risk of developing a candida dermatitis under the breast.

47
Q

USPSTF recommendations (didnt talk ab it)

A

-US Preventive Services Taskforce (USPSTF) recommends screening mammography in women ages 50 to 74 years.
-Women ages 40 to 49 years should have a screening regimen based on the best-available evidence, including the patient’s risk factors, through shared decision-making.
-Annual mammography is not recommended for average-risk women in any age group, and the benefit of screening in women over age 75 years has not been established.
-The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of adjunctive screening for breast cancer using breast ultrasonography, magnetic resonance imaging, DBT, or other methods in women identified to have dense breasts on an otherwise negative screening mammogram (Dense Breasts).

48
Q

ACOG (didnt talk ab it)

A

American College of Obstetricians and Gynecologists (ACOG) advocates for individualized shared decision-making about screening with each patient, taking into consideration the patient’s risk factors and values

49
Q

breast self exam and clinical breast exam

A

-Monthly breast self-examinations are NOT explicitly recommended by any professional organization.
-Clinical breast examination recommendations vary by professional organization:
-ACOG and the National Comprehensive Cancer Network recommend clinical breast examinations every 1 to 3 years.
-American Cancer Society and the USPSTF do not recommend clinical breast examinations

50
Q

deep inferior epigastric perforator (DIEP)

A

-breast reconstruction
-corrective DIEP flap
-muscle transplant
-anastomose deep inferior epigastric perforator

-you can also do transversus rectus abdominus myocutaneous (TRAM) flap

51
Q

TRAM candidates

A

-Are not a candidate for implant reconstruction.
-Have had failed reconstruction using a breast implant.
-Have had radiation administered to your chest wall.
-Have sufficient tissues in your lower abdomen to create one or both breasts.
-Have never had surgery on your abdomen.
-Prefer to reconstruct one or both breasts using your own tissue

-NOT GOOD CANDIDATES:
-Are obese.
-Cannot tolerate prolonged general anesthesia.
-Do not want a lower abdominal scar.
-Have an overly large abdominal pannus (hanging flap of tissue).
-Have diabetes mellitus.
-Have had abdominal surgery (e.g. an abdominoplasty).
-Lack sufficient lower abdominal tissue to create acceptable breast volume.
-Smoke (or quit smoking only recently).

52
Q

other breast reconstruction options

A

-Deep inferior epigastric perforator(DIEP)flap: Uses tissue from the lower abdomen.
-Latissimus dorsi flap: Uses tissue from the upper back.
-Superficial inferior epigastric artery (SIEA) flap: Uses tissue from the lower abdomen.
-Superior or inferior gluteal artery perforator (SGAP/IGAP) flap: Uses tissue from the buttocks.
-Transverse upper gracilis (TUG) flap: Uses tissue from the inner thigh and underlying gracilis muscle

53
Q

vioptix

A

-transcutaneous oxygen level monitoring
-target is what the O2 was at in the surgical room
-notify attending immediately if it waivers
->70% O2
-give aspirin bc of the anastomosis

54
Q

breast cysts

A

-fluid filled
-lobules become distended due to blockage
-perimenopausal
-smooth, soft, can be painful

-dx- US- def dx
-mammo - halo shape

-tx-
-aspiration if persisting, symptomatic, unknown dx
-if there is blood or lump does not disapear after aspiration -> RO cancer

55
Q

mammary duct ectasia

A

-dilation and shortening of lactiferous ducts
-perimenopausal
-green/yellow nipple discharge
-palpable mass
-nipple retraction
-seen on mammo
-bx- multiple plasma cells

-tx- no tx unless you cant r/o cancer
-is nipple discharge is severe -> duct excision
-atkins microdochectomy

56
Q

paget’s disease of nipple

A

-adenocarcinoma!
-rough, scaling, ulcerating, eczematous change to nipple
-underlying neoplasm 85% of the time
-itching, red
-flaking, thick skin
-painful, sensitive
-flattened nipple
-yellow or bloody discharge
-does NOT spare the nipple (eczema does- only areola)

-dx-
-bx
-US, mammo, MRI

-tx- surgery

57
Q

inflammatory breast cancer

A

-rare but aggressive- worser prognosis
-swelling
-red
-warm
-SKIN changes- dimple, thickened, blistering
-pain

-dx-
-US, Mammo
-!!!!skin biopsy NOT breast biopsy -> dermal lymphatic invasion by tumor cells is hallmark

-Tx-
-chemo before surgery
-radiation after
-targeted therapy if possible

58
Q

when do we get MRI

A

-dense breast
-breast implants
-involvement of skin

Surgery (21 decks)

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