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Surgical Recall > Breast > Flashcards

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

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2
Q

What 4 nerves must a surgeon be aware of during an axillary dissection?

A
  1. Long thoracic nerve
  2. Thoracodorsal nerve
  3. Medial pectoral nerve
  4. Lateral pectoral nerve
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3
Q

Where is the long thoracic nerve?

A

Courses along lateral chest wall in midaxillary line on serratus anterior muscle

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4
Q

Which muscles does the long thoracic nerve innervate?

A

Serratus anterior muscle

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5
Q

Where is the thoracodorsal nerve?

A

Courses lateral to the long thoracic nerve on latissimus dorsi muscle

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6
Q

Which muscles does the thoracodorsal nerve innervate?

A

Latissimus dorsi muscle

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7
Q

Where is the medial pectoral nerve?

A

Runs lateral to or through the pectoral minor muscle, laterally to the lateral pectoral nerve

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8
Q

Which muscles does the medial pectoral nerve innervate?

A

Pectoral minor and major muscles

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9
Q

Where is the lateral pectoral nerve?

A

Runs medial to the medial pectoral nerve

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10
Q

Which muscles does the lateral pectoral nerve innervate?

A

Pectoral major muscle

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11
Q

What is the name of the deformity if you cut the long thoracic nerve?

A

Winged scapula

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12
Q

What is the name of the cutaneous nerve that crosses the axilla in a transverse fashion?

A

Intercostobrachial nerve

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13
Q

What is the name of the large vein that marks the upper limit of the axilla?

A

Axillary vein

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14
Q

What is the lymphatic drainage of the breast?

A

Lateral: axillary lymph nodes
Medial: parasternal nodes that run with internal thoracic artery

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15
Q

Where are the level I axillary lymph nodes?

A

Lateral to the pectoral minor muscle

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16
Q

Where are the level II axillary lymph nodes?

A

Deep to the pectoral minor muscle

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17
Q

Where are the level III axillary lymph nodes?

A

Medial to the pectoral minor muscle

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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

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19
Q

What are the suspensory breast ligaments called?

A

Cooper’s ligaments

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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

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21
Q

What is the tail of Spence?

A

Tail of breast tissue that tapers into the axilla

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22
Q

Which hormone is mainly responsible for breast milk production?

A

Prolactin

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23
Q

What is the incidence of breast cancer?

A

12%

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24
Q

What percentage of women with breast cancer have no known risk factor?

A

75%

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25
Q

What percentage of all breast cancers occur in women younger than 30 years?

A

2%

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26
Q

What percentage of all breast cancers occur in women older than 70 years?

A

33%

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27
Q

What are the major breast cancer susceptibility genes?

A

BRCA1 and BRCA2

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28
Q

What option exists to decrease the risk of breast cancer in women with BRCA?

A

Prophylactic bilateral mastectomy

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29
Q

What is the most common motivation for legal cases involving the breast?

A

Failure to diagnose a breast carcinoma

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30
Q

What is the triad of error for misdiagnosed breast cancer?

A
  1. Age
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31
Q

What are the history risk factors for breast cancer?

A 
NAACP:
Nulliparity
Age at menarche ( 55)
Cancer of the breast (in self or family)
Pregnancy with first child (> 30 years)
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32
Q

What are the physical/anatomic risk factors for breast cancer?

A

CHAFED LIPS:
Cancer of the breast, Hyperplasia, Atypical hyperplasia, Female, Elderly, DCIS, LCIS, Inherited genes, Papilloma, Sclerosing adenosis

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33
Q

What is the relative risk for breast cancer with HRT?

A

1-1.5

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34
Q

Is typical fibrocystic disease a risk factor for breast cancer?

A

No

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35
Q

What are the possible symptoms of breast cancer?

A

Asymptomatic, breast mass, pain (most painless), nipple discharge, local edema, nipple retraction, dimple, nipple rash

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36
Q

Why does skin retraction occur in some breast cancers?

A

Tumor involvement of Cooper’s ligaments and subsequent traction on ligaments pull skin inward

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37
Q

What are the signs of breast cancer?

A

Mass (> 1cm), dimple, nipple rash, edema, axillary or supraclavicular nodes

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38
Q

What is the most common site of breast cancer?

A

Approximately 50% develop in the UOQ

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39
Q

What are the different types of invasive breast cancer?

A

Infiltrating ductal carcinoma, medullary carcinoma, infiltrating lobular carcinoma, tubular carcinoma, mucinous carcinoma, inflammatory breast cancer

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40
Q

What is the most common type of breast cancer?

A

Infiltrating ductal carcinoma

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41
Q

What is the differential diagnosis for breast cancer?

A

Fibrocystic disease, fibroadenoma, intraductal papilloma, duct ectasia, fat necrosis, abscess, radial scar, simple cyst

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42
Q

Describe the appearance of the edema of the dermis in inflammatory breast cancer.

A

Peau d’orange

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43
Q

What are the recommendations for breast exams?

A

Self-exam of breasts monthly
20-40 yo: breast exam every 2-3 years
> 40 yo: annual breast exam

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44
Q

What are the recommendations for mammograms?

A

35-40 yo: baseline mammogram
40-50 yo: mammogram every or every other year
> 50 yo: annual mammogram

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45
Q

When is the best time for breast self-exam?

A

1 week after menstrual period

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46
Q

Why is mammography a more useful diagnostic tool in older women than in younger?

A

Breast tissue undergoes fatty replacement with age, making masses more visible.
Young women have more fibrous tissue.

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47
Q

What are the radiographic tests for breast cancer?

A

Mammography, breast U/S, MRI

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48
Q

What is the classic picture of breast cancer on mammogram?

A

Spiculated mass

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49
Q

Which option is best to evaluate a breast mass in a woman younger than 30 years?

A

Breast U/S

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50
Q

What are the methods for obtaining breast tissue for pathologic examination?

A

FNA, core biopsy, mammotome stereotactic biopsy, open biopsy

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51
Q

What are the indications for breast biopsy?

A

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

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52
Q

What is the process for performing a biopsy when a non-palpable mass is seen on mammogram?

A

Stereotactic (mammotome) biopsy or needle localization biopsy

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53
Q

What is needle loc biopsy?

A

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

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54
Q

What is a mammotome biopsy?

A

Mammogram-guided computerized stereotactic core biopsy

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55
Q

What is obtained first, the mammogram or the biopsy?

A

Mammogram is obtained first; otherwise, tissue extraction may alter the mammographic findings

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56
Q

What would be suspicious mammographic findings?

A

Mass, microcalcifications, stellate/spiculated mass

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57
Q

What is a radial scar seen on mammogram?

A

Spiculated mass with central lucency +/- microcalcifications

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58
Q

What tumor is associated with a radial scar?

A

Tubular carcinoma

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59
Q

What is the workup for a breast mass?

A
  1. Clinical breast exam
  2. Mammogram or breast U/S
  3. FNA, core biopsy, or open biopsy
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60
Q

How do you proceed if the mass appears to be a cyst?

A

Aspirate it with a needle

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61
Q

Is the fluid from a breast cyst sent for cytology?

A

Not routinely; bloody fluid should be sent

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62
Q

When do you proceed to open biopsy for a breast cyst?

A
  1. Recurrence of second cyst
  2. Bloody fluid in cyst
  3. Palpable mass after aspiration
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63
Q

What is the preoperative staging workup in a patient with breast cancer?

A 
Bilateral mammogram
CXR: lung mets
LFTs: liver mets
Serum Ca, alkaline phosphatase: bone mets
Other: head CT
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64
Q

What hormone receptors must be checked for in the biopsy specimen?

A

Estrogen and progesterone (guides adjuvant treatment)

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65
Q

What staging system is used for breast cancer?

A

TMN

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66
Q

What is stage I breast cancer?

A

Tumor

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67
Q

What is stage IIA breast cancer?

A

Tumor

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68
Q

What is stage IIB breast cancer?

A

Tumor 2-5 cm with mobile axillary nodes, or

Tumor > 5 cm with no nodes

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69
Q

What is stage IIIA breast cancer?

A

Tumor > 5 cm with mobile axillary nodes, or

Fixed axillary nodes, no mets

70
Q

What is stage IIIB breast cancer?

A 
Peau d'orange skin, or
Chest wall invasion/fixation, or
Inflammatory cancer, or
Breast skin ulceration, or
Breast skin satellite metastases
71
Q

What is stage IIIC breast cancer?

A

Positive supraclavicular, infraclavicular, or internal mammary lymph nodes

72
Q

What is stage IV breast cancer?

A

Distant metastases (including ipsilateral supraclavicular nodes)

73
Q

What are the sites of breast cancer metastases?

A

Lymph nodes, lung/pleura, liver, bones, brain

74
Q

What are the major treatments of breast cancer?

A

Modified radical mastectomy; lumpectomy with radiation and sentinel node dissection

75
Q

What are the indications for radiation therapy after a modified radical mastectomy?

A

Stage IIIA-B, pectoral muscle/fascia invasion, positive internal mammary LN, positive surgical margins, > 3 positive axillary LNs post-menopausal

76
Q

What breast cancers are candidates for lumpectomy and radiation?

A

Stage I and II

77
Q

What approach may allow a patient with stage IIIA cancer to have breast-conserving surgery?

A

Neoadjuvant chemotherapy (provided the preop chemo shrinks the tumor)

78
Q

What is the treatment of inflammatory breast cancer?

A

Chemo first; followed by radiation, mastectomy, or both

79
Q

What is done in a lumpectomy with radiation?

A

Segmental mastectomy, axillary node dissection, and course of radiation therapy after operation (several weeks)

80
Q

What is the major absolute contraindication to lumpectomy and radiation?

A

Pregnancy

81
Q

Other than pregnancy, what are other contraindications to lumpectomy and radiation?

A

Previous radiation to chest, positive margins, collagen vascular disease (e.g. scleroderma), extensive DCIS

82
Q

What is a modified radical mastectomy?

A

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
Q

Where are the drains placed with a modified radical mastectomy?

A
  1. Axilla

2. Chest wall (breast bed)

84
Q

When should the drains be removed after axillary dissection?

A
85
Q

What are the potential complications after a modified radical mastectomy?

A

Ipsilateral arm lymphedema, infection, injury to nerves, skin flap necrosis, hematoma/seroma, phantom breast syndrome

86
Q

During an axillary dissection, should the patient be paralyzed?

A

No, because the nerves are stimulated with resultant muscle contraction to help identify them

87
Q

How can the long thoracic and thoracodorsal nerves be identified during an axillary dissection?

A

Stimulate with forceps, resulting in contraction of anterior serratus or latissimus dorsi

88
Q

What is a sentinel node biopsy?

A

Instead of removing all the axillary lymph nodes, the primary draining node is removed

89
Q

How is the sentinel lymph node found?

A

Inject blue dye and/or technetium-labelled sulfur colloid

90
Q

What follows a positive sentinel node biopsy?

A

Removal of rest of axillary lymph nodes

91
Q

What is now considered the standard of care for lymph node evaluation in women with stage I or IIA breast cancer?

A

Sentinel lymph node dissection

92
Q

What do you do with a mammotome biopsy that returns as “atypical hyperplasia”?

A

Open needle loc biopsy

93
Q

How does tamoxifen work?

A

It binds estrogen receptors

94
Q

What is the treatment for local recurrence in breast after lumpectomy and radiation?

A

Salvage mastectomy

95
Q

Can tamoxifen prevent breast cancer?

A

Yes

96
Q

What are common options for breast reconstruction?

A

TRAM flap, implant, latissimus dorsi flap

97
Q

What is a TRAM flap?

A

Transverse Rectus Abdominis Myocutaneous flap

98
Q

What are the side effects of tamoxifen?

A

Endometrial cancer (2.5 fold), DVT, PE, cataracts, hot flashes, mood swings

99
Q

In high-risk women, is there a way to reduce the risk of developing breast cancer?

A

Yes, tamoxifen

100
Q

What type of chemotherapy is usually used for breast cancer?

A

CMF (Cyclophosphamide, Methotrexate, 5-Fluorouracil), or

CAF (Cyclophosphamide, Adriamycin, 5-Fluorouracil)

101
Q

What is a high-risk tumor in the breast?

A

> 1 cm, lymphatic/vascular invasion, high nuclear grade, high S phase, ER negative, HER-2/neu overexpression

102
Q

What is DCIS?

A

Ductal Carcinoma In Situ

A.K.A. intraductal carcinoma

103
Q

What are the signs and symptoms of DCIS?

A

Usually none

104
Q

What are the mammographic findings of DCIS?

A

Microcalcifications

105
Q

How is the diagnosis of DCIS made?

A

Core or open biopsy

106
Q

What is the most aggressive histologic type of DCIS?

A

Comedo

107
Q

What is the risk of lymph node metastasis with DCIS?

A
108
Q

What is the major risk factor with DCIS?

A

Subsequent development of infiltrating ductal carcinoma in same breast

109
Q

What is the treatment for DCIS tumor

A

Lumpectomy with 1 cm margins +/- XRT

110
Q

What is the treatment for DCIS tumor > 1 cm?

A

Lumpectomy with 1 cm margins and XRT, or

Total mastectomy

111
Q

What is a total mastectomy?

A

Removal of the breast and nipple without removal of the axillary nodes

112
Q

When must a simple mastectomy be performed for DCIS?

A

Diffuse breast involvement; > 1 cm; and contraindication to radiation

113
Q

What is the role of axillary node dissection with DCIS?

A

None

114
Q

What is the role of tamoxifen in DCIS?

A

5 years will lower risk up to 50%

115
Q

What is a memory aid for the breast in which DCIS breast cancer arises?

A

DCIS = Directly in same breast

116
Q

What is LCIS?

A

Lobular Carcinoma In Situ

117
Q

What are the signs and symptoms of LCIS?

A

None

118
Q

What are the mammographic findings for LCIS?

A

None

119
Q

How is the diagnosis of LCIS made?

A

Found incidentally on biopsy

120
Q

What is the major risk with LCIS?

A

Carcinoma of either breast

121
Q

Which breast is most at risk for developing an invasive carcinoma in LCIS?

A

Equal risk

122
Q

What percentage of women with LCIS develop an invasive breast cancer?

A

30% in 20 years

123
Q

What type of invasive breast cancer do patients with LCIS develop?

A

Usually infiltrating ductal carcinoma

124
Q

What medication may lower the risk of developing breast cancer in LCIS?

A

Tamoxifen

125
Q

What is the treatment for LCIS?

A

Close follow-up (or bilateral simple mastectomy in high-risk patients)

126
Q

What is the major difference in the subsequent development of invasive breast cancer with DCIS and LCIS?

A

LCIS cancer develops in either breast

127
Q

How do you remember which breast is at risk for invasive cancers in patients with LCIS?

A

LCIS = Liberally in either breast

128
Q

What is the most common cause of bloody nipple discharge in a young woman?

A

Intraductal papilloma

129
Q

What is the most common breast tumor in patients younger than 30 years?

A

Fibroadenoma

130
Q

What is Paget’s disease of the breast?

A

Scaling rash/dermatitis of the nipple caused by invasion of skin by cells from a ductal carcinoma

131
Q

What is the incidence of breast cancer in men?

A
132
Q

What is the average age of diagnosis of breast cancer in men?

A

65 years

133
Q

What are the risk factors for breast cancer in men?

A

Increased estrogen, radiation, estrogen therapy, Klinefelter’s syndrome, BRCA2

134
Q

Is benign gynecomastia a risk factor for male breast cancer?

A

No

135
Q

What type of breast cancer do men develop?

A

Ductal carcinoma (men do not have lobules)

136
Q

What are the signs and symptoms of breast cancer in men?

A

Breast mass (usually painless), breast skin changes (ulcers, retractions), nipple discharge (usually blood-tinged)

137
Q

What is the most common presentation of breast cancer in men?

A

Painless breast mass

138
Q

How is breast cancer in men diagnosed?

A

Biopsy and mammogram

139
Q

What is the treatment for breast cancer in men?

A
  1. Mastectomy
  2. Sentinel LN dissection of clinically negative axilla
  3. Axillary dissection if clinically positive axillary LN
140
Q

What is the most common cause of green, straw-colored, or brown nipple discharge?

A

Fibrocystic disease

141
Q

What is the most common cause of breast mass after breast trauma?

A

Fat necrosis

142
Q

What is Mondor’s disease?

A

Thrombophlebitis of superficial breast veins

143
Q

What must be ruled out with spontaneous galactorrhea?

A

Prolactinoma

144
Q

What is cystosarcoma phyllodes?

A

Mesenchymal tumor arising from breast lobular tissue.

Most are benign.

145
Q

What is the usual age of the patient with cystosarcoma phyllodes?

A

35-55 years

146
Q

What are the signs and symptoms of cystosarcoma phyllodes?

A

Mobile, smooth breast mass that resembles a fibroadenoma on exam, mammogram and U/S findings

147
Q

How is cystosarcoma phyllodes diagnosed?

A

Core biopsy or excision

148
Q

What is the treatment for cystosarcoma phyllodes?

A

If benign, wide local excision.

If malignant, simple total mastectomy.

149
Q

What is the role of axillary dissection with cystosarcoma phyllodes?

A

Only if clinically palpable axillary nodes

150
Q

Is there a role for chemotherapy with cystosarcoma phyllodes?

A

Consider if large tumor (> 5cm) and stromal overgrowth

151
Q

What is fibroadenoma?

A

Benign tumor of the breast consisting of stromal overgrowth, collagen arranged in swirls

152
Q

What is the clinical presentation of a fibroadenoma?

A

Solid, mobile, well-circumscribed round breast mass, usually

153
Q

How is fibroadenoma diagnosed?

A

Negative FNA, U/S, core biopsy

154
Q

What is the treatment for fibroadenoma?

A

Surgical resection for large or growing lesions.

Small fibroadenomas can be observed.

155
Q

What is fibrocystic disease?

A

Common benign breast condition consisting of fibrous and cystic changes in the breast

156
Q

What are the signs and symptoms of fibrocystic disease?

A

Breast pain or tenderness that varies with the menstrual cycles, cysts, fibrous or nodular fullness

157
Q

How is fibrocystic disease diagnosed?

A

Breast exam, history, FNA

158
Q

What is the treatment for symptomatic fibrocystic disease?

A

NSAIDs, vitamin E, evening primrose oil, stop caffeine

159
Q

What is done if a patient has a breast cyst?

A

Needle drainage:
If bloody or palpable mass after aspiration: open biopsy.
If straw-colored or green: follow closely

160
Q

What is mastitis?

A

Superficial infection of the breast (cellulitis)

161
Q

When does mastitis occur most often?

A

Breast-feeding

162
Q

What bacteria are most commonly the cause of mastitis?

A

Staph aureus

163
Q

How is mastitis treated?

A

Stop breast-feeding and use a breast pump, apply heat, antibiotics

164
Q

Why must a patient with mastitis have close follow-up?

A

To make sure that she does not have inflammatory breast cancer

165
Q

What are the causes of breast abscesses?

A

Mammary ductal ectasia, mastitis

166
Q

What is the most common bacteria in breast abscesses?

A

Nursing: Staph aureus

Non-lactating: mixed

167
Q

What is the treatment of breast abscesses?

A

Antibiotics (dicloxacillin); needle or open drainage with cultures; resection of involved ducts if recurrent; breast pump if feeding

168
Q

What must be ruled out with a breast abscess in a non-lactating woman?

A

Breast cancer

169
Q

What is male gynecomastia?

A

Enlargement of the male breast

170
Q

What are the causes of gynecomastia?

A

Medications, illicit drugs (marijuana), liver failure, increased estrogen, decreased testosterone

171
Q

What is the major differential diagnosis of the older patient with gynecomastia?

A

Male breast cancer

172
Q

What is the treatment for gynecomastia?

A

Stop or change medications; correct underlying cause if hormonal; perform biopsy or subcutaneous mastectomy if refractory to conservative measures and time

Surgical Recall (68 decks)

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