Breast Flashcards
1
Q
What are the 4 boundaries of the axilla for dissection?
A
Superior: axillary vein
Posterior: long thoracic nerve
Lateral: latissimus dorsi
Medial: pectoralis minor
2
Q
What 4 nerves must a surgeon be aware of during an axillary dissection?
A
- Long thoracic nerve
- Thoracodorsal nerve
- Medial pectoral nerve
- Lateral pectoral nerve
3
Q
Where is the long thoracic nerve?
A
Courses along lateral chest wall in midaxillary line on serratus anterior muscle
4
Q
Which muscles does the long thoracic nerve innervate?
A
Serratus anterior muscle
5
Q
Where is the thoracodorsal nerve?
A
Courses lateral to the long thoracic nerve on latissimus dorsi muscle
6
Q
Which muscles does the thoracodorsal nerve innervate?
A
Latissimus dorsi muscle
7
Q
Where is the medial pectoral nerve?
A
Runs lateral to or through the pectoral minor muscle, laterally to the lateral pectoral nerve
8
Q
Which muscles does the medial pectoral nerve innervate?
A
Pectoral minor and major muscles
9
Q
Where is the lateral pectoral nerve?
A
Runs medial to the medial pectoral nerve
10
Q
Which muscles does the lateral pectoral nerve innervate?
A
Pectoral major muscle
11
Q
What is the name of the deformity if you cut the long thoracic nerve?
A
Winged scapula
12
Q
What is the name of the cutaneous nerve that crosses the axilla in a transverse fashion?
A
Intercostobrachial nerve
13
Q
What is the name of the large vein that marks the upper limit of the axilla?
A
Axillary vein
14
Q
What is the lymphatic drainage of the breast?
A
Lateral: axillary lymph nodes
Medial: parasternal nodes that run with internal thoracic artery
15
Q
Where are the level I axillary lymph nodes?
A
Lateral to the pectoral minor muscle
16
Q
Where are the level II axillary lymph nodes?
A
Deep to the pectoral minor muscle
17
Q
Where are the level III axillary lymph nodes?
A
Medial to the pectoral minor muscle
18
Q
What are Rotter’s nodes?
A
Nodes between the pectoral major and minor muscles.
Not usually removed unless they are enlarged or feel suspicious intra-operatively
19
Q
What are the suspensory breast ligaments called?
A
Cooper’s ligaments
20
Q
What is the mammary “milk line”?
A
Embryological line from shoulder to thigh where supernumerary breast areolar and/or nipples can be found
21
Q
What is the tail of Spence?
A
Tail of breast tissue that tapers into the axilla
22
Q
Which hormone is mainly responsible for breast milk production?
A
Prolactin
23
Q
What is the incidence of breast cancer?
A
12%
24
Q
What percentage of women with breast cancer have no known risk factor?
A
75%
25
What percentage of all breast cancers occur in women younger than 30 years?
2%
26
What percentage of all breast cancers occur in women older than 70 years?
33%
27
What are the major breast cancer susceptibility genes?
BRCA1 and BRCA2
28
What option exists to decrease the risk of breast cancer in women with BRCA?
Prophylactic bilateral mastectomy
29
What is the most common motivation for legal cases involving the breast?
Failure to diagnose a breast carcinoma
30
What is the triad of error for misdiagnosed breast cancer?
1. Age < 45
2. Self-diagnosed mass
3. Negative mammogram
31
What are the history risk factors for breast cancer?
```
NAACP:
Nulliparity
Age at menarche (< 13)
Age at menopause (> 55)
Cancer of the breast (in self or family)
Pregnancy with first child (> 30 years)
```
32
What are the physical/anatomic risk factors for breast cancer?
CHAFED LIPS:
Cancer of the breast, Hyperplasia, Atypical hyperplasia, Female, Elderly, DCIS, LCIS, Inherited genes, Papilloma, Sclerosing adenosis
33
What is the relative risk for breast cancer with HRT?
1-1.5
34
Is typical fibrocystic disease a risk factor for breast cancer?
No
35
What are the possible symptoms of breast cancer?
Asymptomatic, breast mass, pain (most painless), nipple discharge, local edema, nipple retraction, dimple, nipple rash
36
Why does skin retraction occur in some breast cancers?
Tumor involvement of Cooper's ligaments and subsequent traction on ligaments pull skin inward
37
What are the signs of breast cancer?
Mass (> 1cm), dimple, nipple rash, edema, axillary or supraclavicular nodes
38
What is the most common site of breast cancer?
Approximately 50% develop in the UOQ
39
What are the different types of invasive breast cancer?
Infiltrating ductal carcinoma, medullary carcinoma, infiltrating lobular carcinoma, tubular carcinoma, mucinous carcinoma, inflammatory breast cancer
40
What is the most common type of breast cancer?
Infiltrating ductal carcinoma
41
What is the differential diagnosis for breast cancer?
Fibrocystic disease, fibroadenoma, intraductal papilloma, duct ectasia, fat necrosis, abscess, radial scar, simple cyst
42
Describe the appearance of the edema of the dermis in inflammatory breast cancer.
Peau d'orange
43
What are the recommendations for breast exams?
Self-exam of breasts monthly
20-40 yo: breast exam every 2-3 years
> 40 yo: annual breast exam
44
What are the recommendations for mammograms?
35-40 yo: baseline mammogram
40-50 yo: mammogram every or every other year
> 50 yo: annual mammogram
45
When is the best time for breast self-exam?
1 week after menstrual period
46
Why is mammography a more useful diagnostic tool in older women than in younger?
Breast tissue undergoes fatty replacement with age, making masses more visible.
Young women have more fibrous tissue.
47
What are the radiographic tests for breast cancer?
Mammography, breast U/S, MRI
48
What is the classic picture of breast cancer on mammogram?
Spiculated mass
49
Which option is best to evaluate a breast mass in a woman younger than 30 years?
Breast U/S
50
What are the methods for obtaining breast tissue for pathologic examination?
FNA, core biopsy, mammotome stereotactic biopsy, open biopsy
51
What are the indications for breast biopsy?
Persistant mass after aspiration, solid mass, blood in cyst aspirate, suspicious lesion by mammography/U/S/MRI, bloody nipple discharge, ulcer or dermatitis of nipple, patient concern
52
What is the process for performing a biopsy when a non-palpable mass is seen on mammogram?
Stereotactic (mammotome) biopsy or needle localization biopsy
53
What is needle loc biopsy?
Needle localization by radiologist, followed by biopsy; removed breast tissue must be checked by mammogram to ensure all of the suspicious lesion has been excised
54
What is a mammotome biopsy?
Mammogram-guided computerized stereotactic core biopsy
55
What is obtained first, the mammogram or the biopsy?
Mammogram is obtained first; otherwise, tissue extraction may alter the mammographic findings
56
What would be suspicious mammographic findings?
Mass, microcalcifications, stellate/spiculated mass
57
What is a radial scar seen on mammogram?
Spiculated mass with central lucency +/- microcalcifications
58
What tumor is associated with a radial scar?
Tubular carcinoma
59
What is the workup for a breast mass?
1. Clinical breast exam
2. Mammogram or breast U/S
3. FNA, core biopsy, or open biopsy
60
How do you proceed if the mass appears to be a cyst?
Aspirate it with a needle
61
Is the fluid from a breast cyst sent for cytology?
Not routinely; bloody fluid should be sent
62
When do you proceed to open biopsy for a breast cyst?
1. Recurrence of second cyst
2. Bloody fluid in cyst
3. Palpable mass after aspiration
63
What is the preoperative staging workup in a patient with breast cancer?
```
Bilateral mammogram
CXR: lung mets
LFTs: liver mets
Serum Ca, alkaline phosphatase: bone mets
Other: head CT
```
64
What hormone receptors must be checked for in the biopsy specimen?
Estrogen and progesterone (guides adjuvant treatment)
65
What staging system is used for breast cancer?
TMN
66
What is stage I breast cancer?
Tumor < 2 cm
67
What is stage IIA breast cancer?
Tumor < 2 cm with mobile axillary nodes, or
| Tumor 2-5 cm with no nodes
68
What is stage IIB breast cancer?
Tumor 2-5 cm with mobile axillary nodes, or
| Tumor > 5 cm with no nodes
69
What is stage IIIA breast cancer?
Tumor > 5 cm with mobile axillary nodes, or
| Fixed axillary nodes, no mets
70
What is stage IIIB breast cancer?
```
Peau d'orange skin, or
Chest wall invasion/fixation, or
Inflammatory cancer, or
Breast skin ulceration, or
Breast skin satellite metastases
```
71
What is stage IIIC breast cancer?
Positive supraclavicular, infraclavicular, or internal mammary lymph nodes
72
What is stage IV breast cancer?
Distant metastases (including ipsilateral supraclavicular nodes)
73
What are the sites of breast cancer metastases?
Lymph nodes, lung/pleura, liver, bones, brain
74
What are the major treatments of breast cancer?
Modified radical mastectomy; lumpectomy with radiation and sentinel node dissection
75
What are the indications for radiation therapy after a modified radical mastectomy?
Stage IIIA-B, pectoral muscle/fascia invasion, positive internal mammary LN, positive surgical margins, > 3 positive axillary LNs post-menopausal
76
What breast cancers are candidates for lumpectomy and radiation?
Stage I and II
77
What approach may allow a patient with stage IIIA cancer to have breast-conserving surgery?
Neoadjuvant chemotherapy (provided the preop chemo shrinks the tumor)
78
What is the treatment of inflammatory breast cancer?
Chemo first; followed by radiation, mastectomy, or both
79
What is done in a lumpectomy with radiation?
Segmental mastectomy, axillary node dissection, and course of radiation therapy after operation (several weeks)
80
What is the major absolute contraindication to lumpectomy and radiation?
Pregnancy
81
Other than pregnancy, what are other contraindications to lumpectomy and radiation?
Previous radiation to chest, positive margins, collagen vascular disease (e.g. scleroderma), extensive DCIS
82
What is a modified radical mastectomy?
Removal of breast, axillary nodes (levels I and II), nipple-areolar complex.
Drains are placed to drain lymph fluid.
Pectoral major and minor muscles are NOT removed.
83
Where are the drains placed with a modified radical mastectomy?
1. Axilla
| 2. Chest wall (breast bed)
84
When should the drains be removed after axillary dissection?
< 30 cc/day drainage or on POD #14 (whichever is first)
85
What are the potential complications after a modified radical mastectomy?
Ipsilateral arm lymphedema, infection, injury to nerves, skin flap necrosis, hematoma/seroma, phantom breast syndrome
86
During an axillary dissection, should the patient be paralyzed?
No, because the nerves are stimulated with resultant muscle contraction to help identify them
87
How can the long thoracic and thoracodorsal nerves be identified during an axillary dissection?
Stimulate with forceps, resulting in contraction of anterior serratus or latissimus dorsi
88
What is a sentinel node biopsy?
Instead of removing all the axillary lymph nodes, the primary draining node is removed
89
How is the sentinel lymph node found?
Inject blue dye and/or technetium-labelled sulfur colloid
90
What follows a positive sentinel node biopsy?
Removal of rest of axillary lymph nodes
91
What is now considered the standard of care for lymph node evaluation in women with stage I or IIA breast cancer?
Sentinel lymph node dissection
92
What do you do with a mammotome biopsy that returns as "atypical hyperplasia"?
Open needle loc biopsy
93
How does tamoxifen work?
It binds estrogen receptors
94
What is the treatment for local recurrence in breast after lumpectomy and radiation?
Salvage mastectomy
95
Can tamoxifen prevent breast cancer?
Yes
96
What are common options for breast reconstruction?
TRAM flap, implant, latissimus dorsi flap
97
What is a TRAM flap?
Transverse Rectus Abdominis Myocutaneous flap
98
What are the side effects of tamoxifen?
Endometrial cancer (2.5 fold), DVT, PE, cataracts, hot flashes, mood swings
99
In high-risk women, is there a way to reduce the risk of developing breast cancer?
Yes, tamoxifen
100
What type of chemotherapy is usually used for breast cancer?
CMF (Cyclophosphamide, Methotrexate, 5-Fluorouracil), or
| CAF (Cyclophosphamide, Adriamycin, 5-Fluorouracil)
101
What is a high-risk tumor in the breast?
> 1 cm, lymphatic/vascular invasion, high nuclear grade, high S phase, ER negative, HER-2/neu overexpression
102
What is DCIS?
Ductal Carcinoma In Situ
| A.K.A. intraductal carcinoma
103
What are the signs and symptoms of DCIS?
Usually none
104
What are the mammographic findings of DCIS?
Microcalcifications
105
How is the diagnosis of DCIS made?
Core or open biopsy
106
What is the most aggressive histologic type of DCIS?
Comedo
107
What is the risk of lymph node metastasis with DCIS?
< 2%
108
What is the major risk factor with DCIS?
Subsequent development of infiltrating ductal carcinoma in same breast
109
What is the treatment for DCIS tumor < 1 cm?
Lumpectomy with 1 cm margins +/- XRT
110
What is the treatment for DCIS tumor > 1 cm?
Lumpectomy with 1 cm margins and XRT, or
| Total mastectomy
111
What is a total mastectomy?
Removal of the breast and nipple without removal of the axillary nodes
112
When must a simple mastectomy be performed for DCIS?
Diffuse breast involvement; > 1 cm; and contraindication to radiation
113
What is the role of axillary node dissection with DCIS?
None
114
What is the role of tamoxifen in DCIS?
5 years will lower risk up to 50%
115
What is a memory aid for the breast in which DCIS breast cancer arises?
DCIS = Directly in same breast
116
What is LCIS?
Lobular Carcinoma In Situ
117
What are the signs and symptoms of LCIS?
None
118
What are the mammographic findings for LCIS?
None
119
How is the diagnosis of LCIS made?
Found incidentally on biopsy
120
What is the major risk with LCIS?
Carcinoma of either breast
121
Which breast is most at risk for developing an invasive carcinoma in LCIS?
Equal risk
122
What percentage of women with LCIS develop an invasive breast cancer?
30% in 20 years
123
What type of invasive breast cancer do patients with LCIS develop?
Usually infiltrating ductal carcinoma
124
What medication may lower the risk of developing breast cancer in LCIS?
Tamoxifen
125
What is the treatment for LCIS?
Close follow-up (or bilateral simple mastectomy in high-risk patients)
126
What is the major difference in the subsequent development of invasive breast cancer with DCIS and LCIS?
LCIS cancer develops in either breast
127
How do you remember which breast is at risk for invasive cancers in patients with LCIS?
LCIS = Liberally in either breast
128
What is the most common cause of bloody nipple discharge in a young woman?
Intraductal papilloma
129
What is the most common breast tumor in patients younger than 30 years?
Fibroadenoma
130
What is Paget's disease of the breast?
Scaling rash/dermatitis of the nipple caused by invasion of skin by cells from a ductal carcinoma
131
What is the incidence of breast cancer in men?
< 1%
132
What is the average age of diagnosis of breast cancer in men?
65 years
133
What are the risk factors for breast cancer in men?
Increased estrogen, radiation, estrogen therapy, Klinefelter's syndrome, BRCA2
134
Is benign gynecomastia a risk factor for male breast cancer?
No
135
What type of breast cancer do men develop?
Ductal carcinoma (men do not have lobules)
136
What are the signs and symptoms of breast cancer in men?
Breast mass (usually painless), breast skin changes (ulcers, retractions), nipple discharge (usually blood-tinged)
137
What is the most common presentation of breast cancer in men?
Painless breast mass
138
How is breast cancer in men diagnosed?
Biopsy and mammogram
139
What is the treatment for breast cancer in men?
1. Mastectomy
2. Sentinel LN dissection of clinically negative axilla
3. Axillary dissection if clinically positive axillary LN
140
What is the most common cause of green, straw-colored, or brown nipple discharge?
Fibrocystic disease
141
What is the most common cause of breast mass after breast trauma?
Fat necrosis
142
What is Mondor's disease?
Thrombophlebitis of superficial breast veins
143
What must be ruled out with spontaneous galactorrhea?
Prolactinoma
144
What is cystosarcoma phyllodes?
Mesenchymal tumor arising from breast lobular tissue.
| Most are benign.
145
What is the usual age of the patient with cystosarcoma phyllodes?
35-55 years
146
What are the signs and symptoms of cystosarcoma phyllodes?
Mobile, smooth breast mass that resembles a fibroadenoma on exam, mammogram and U/S findings
147
How is cystosarcoma phyllodes diagnosed?
Core biopsy or excision
148
What is the treatment for cystosarcoma phyllodes?
If benign, wide local excision.
| If malignant, simple total mastectomy.
149
What is the role of axillary dissection with cystosarcoma phyllodes?
Only if clinically palpable axillary nodes
150
Is there a role for chemotherapy with cystosarcoma phyllodes?
Consider if large tumor (> 5cm) and stromal overgrowth
151
What is fibroadenoma?
Benign tumor of the breast consisting of stromal overgrowth, collagen arranged in swirls
152
What is the clinical presentation of a fibroadenoma?
Solid, mobile, well-circumscribed round breast mass, usually < 40 years
153
How is fibroadenoma diagnosed?
Negative FNA, U/S, core biopsy
154
What is the treatment for fibroadenoma?
Surgical resection for large or growing lesions.
| Small fibroadenomas can be observed.
155
What is fibrocystic disease?
Common benign breast condition consisting of fibrous and cystic changes in the breast
156
What are the signs and symptoms of fibrocystic disease?
Breast pain or tenderness that varies with the menstrual cycles, cysts, fibrous or nodular fullness
157
How is fibrocystic disease diagnosed?
Breast exam, history, FNA
158
What is the treatment for symptomatic fibrocystic disease?
NSAIDs, vitamin E, evening primrose oil, stop caffeine
159
What is done if a patient has a breast cyst?
Needle drainage:
If bloody or palpable mass after aspiration: open biopsy.
If straw-colored or green: follow closely
160
What is mastitis?
Superficial infection of the breast (cellulitis)
161
When does mastitis occur most often?
Breast-feeding
162
What bacteria are most commonly the cause of mastitis?
Staph aureus
163
How is mastitis treated?
Stop breast-feeding and use a breast pump, apply heat, antibiotics
164
Why must a patient with mastitis have close follow-up?
To make sure that she does not have inflammatory breast cancer
165
What are the causes of breast abscesses?
Mammary ductal ectasia, mastitis
166
What is the most common bacteria in breast abscesses?
Nursing: Staph aureus
| Non-lactating: mixed
167
What is the treatment of breast abscesses?
Antibiotics (dicloxacillin); needle or open drainage with cultures; resection of involved ducts if recurrent; breast pump if feeding
168
What must be ruled out with a breast abscess in a non-lactating woman?
Breast cancer
169
What is male gynecomastia?
Enlargement of the male breast
170
What are the causes of gynecomastia?
Medications, illicit drugs (marijuana), liver failure, increased estrogen, decreased testosterone
171
What is the major differential diagnosis of the older patient with gynecomastia?
Male breast cancer
172
What is the treatment for gynecomastia?
Stop or change medications; correct underlying cause if hormonal; perform biopsy or subcutaneous mastectomy if refractory to conservative measures and time
