Breast

Question 1

Cooper’s ligaments

Answer 1

Extend from deep pec fascia to superficial derm fascia and provide structural support to the breast. Traction on Cooper’s ligaments -> skin dimpling in breast cancer

Question 2

Where do 50% of breast cancers occur?

Answer 2

in the upper outer quadrant

Question 3

How does breast cancer metastasis to the spine occur?

Answer 3

Venous drainage through Batson’s plexus

Question 4

Long thoracic nerve

Answer 4

Innervates serratus anterior. Injury -> winging of scapula

Question 5

Thoracodorsal nerve

Answer 5

Innervates latissimus dorsi. Injury -> cannot push oneself up to sitting position

Question 6

Medial and lateral pectoral nerves

Answer 6

Innervate pec major and minor. Injury -> weakness of pec muscles

Question 7

Intercostobrachial nerve

Answer 7

Crosses axilla transversely to supply inner aspect of arm. Injury -> area of anesthesia on inner arm

Question 8

Mastitis features

Answer 8

Staph or strep usually. Usually during early weeks of breastfeeding. Continue breastfeeding, give dicloxicillin, drain abscess if present

Question 9

Mondor’s disease

Answer 9

Superficial thrombophlebitis of lateral toracic or thoracoepigastric vein -> acute pain in axilla or superior aspect of lateral breast. Tender cord palpated on exam. Dx: US. Tx: salicylates, warm compresses. If no resolution can resect vein.

Question 10

Mammary duct ectasia (plasma cell mastitis)

Answer 10

Inflammation and dilation of mammary ducts. Most commonly occurs in perimenopausal years. Presents with *noncyclical* breast pain with lumps under nipple/areola +/- discharge. Dx: excisional bx to r/o cancer. Tx: excision of affected ducts.

Question 11

Cystosarcoma phyllodes

Answer 11

Variant of fibroadenoma, most are benign. Presents later > 30 yrs old. Distinguishable from fibroadenoma only by biopsy. Tx: small tumors excise with 1 cm margin, large tumors do mastectomy.

Question 12

Intraductal papilloma

Answer 12

Benign local proliferation of ductal epithelial cells. Presents with unilateral bloody discharge. Dx: pathologic eval. Tx: Excision of affected duct.

Question 13

Ductal carcinoma in situ (DCIS) features

Answer 13

Sometimes there is a palpable mass. On mammo, clustered microcalcifications. Increased risk in ipsilateral breast, usu in same quadrant. If small, lumpectomy +/- rads. If large ( > 2 cm), lumpectomy + rads. If diffuse, simple mastectomy.

Question 14

Lobular carcinoma in situ (LCIS) features

Answer 14

Never clinically detectable, usually not seen on mammo and just incidentally found on biopsy. Increased risk in both breasts. Tx: b/l mastectomy only if pt high risk.

Question 15

Infiltrating ductal carcinoma

Answer 15

Most common invasive breast cancer (80%). Mets to axilla, bones, brain, liver, lungs.

Question 16

Infiltrating lobular carcinoma

Answer 16

Second most common invasive breast cancer. 20% have cancer in contralateral breast as well. Lacks microcalcifications and is often multicentric. Mets to axilla, meninges, serosal surfaces.

Question 17

Paget’s disease of the nipple

Answer 17

2% of all invasive breast cancers. Presentation: tender itchy nipple +/- blood discharge +/- subareolar palpable mass. Usu assoc with underlying LCIS or ductal carcinoma.

Question 18

Paget cells

Answer 18

Paget cells are large cells with clear cytoplasm and eccentric, hyperchromic nuclei found throughout the epidermis. Controversy as to their origin.

Question 19

Inflammatory breast carcinoma

Answer 19

2-3% of all invasive breast cancers. Most lethal breast cancer-majority have mets at time of presentation. Presents with “peau d’orange” skin. Tx with chemo followed by surgery and/or rads.

Question 20

Breast cancer in pregnant women

Answer 20

Mammography possible with proper shielding. Radiation tx no advisable so do modified radical mastectomy rather than lumpectomy + ax nod dissection + rads. If LN positive, delay chemo until 2nd trimester.

Question 21

Genetic syndromes assoc with breast cancer

Answer 21

Autosomal dominant: Li-Fraumen (p53), Muir-Torre, BRCA1 and BRCA2, Peutz-Jeghers syndrome (hamartomatous polyps). Autosomal recessive: Ataxia-telangiectasia

Question 22

Radical vs. modified vs. simple mastectomy

Answer 22

Radical = resect all breast tissue, axillary nodes, and pec major/minor muscles. Modified = pec muscles left intact. Simple = resection of breast tissue only

Question 23

Breast cancer staging

Answer 23

Question 24

Tamoxifen

Answer 24

SERM: antagonist in breast, agonist in uterus (inc risk of endometrial cancer) and bone. Used for tx of ER+ breast cancer x 10 years. Also FDA approved for prevention of breast cancer in high risk women.