Breast Flashcards
sensation to medial arm
intercostobrachial n. (off 2nd intercostal n), can be sacrificed
innervation to serratus anterior; injury called?
long thoracic n.
winged scapula
innervation to latissimus dorsi and injury?
thoracodorsal n.
weak arm adduction/pull ups
innervation to pec major/pec minor
medial pectoral n to both
lateral pectoral n to pec minor only
Batson’s plexus
Clinical significance
valveless vertebral veins
allows direct mets to spine from breast
Poland syndrome
amastia, hypoplastic shoulder, no pectoralis
Mastodynia and tx?
Breast pain
Rx with danazol, OCP, evening primrose oil, tamoxifen (first line)
Vitamin E not useful
Mondor’s disease and tx
thrombophlebitis of superficial vein of breast
Cord like mass laterally
Rx: NSAIDs
T1
T2
T3
T4
T1<2cm
T2 2-5 cm
T3 >5 cm
T4 skin or chest wall involvement
N1
N2
N3
positive ax nodes
matted or fixed nodes
internal mammary nodes
Stage I
Stage II
Stage III
Stage IV
T1
up to T2N1 or T3N0
T4 or N2
Mets (include supraclavicular nodes, unlike lung cancer)
Breast met MC sites
bone
lung
brain
Her2Neu
marker for breast CA
implies worse prognosis
Herceptin now available for rx
Worse prognosis markers
Erb B 2
p53
cathepsin
How long does it take approximately for tumor to grow to 1 cm?
approximately 5 years
Tamoxifen risks
Increase endometrial cancer
DVT
increased risk of atypical hyperplasia
raises risk x4
best prognosis of ER/PR
ER+PR+ > ER-PR+ > ER+PR- > ER-PR-
Tx of DCIS
Precursor for invasive carcinoma
Lumpectomy + radiation
Mastectomy for high grade/large tumor/poor margins
Tx of LCIS
30-40% develop invasive carcinoma (either breast) Tx options: -nothing -tamoxifen -b/l mastectomy
Comedo breast cancer tx
Mastectomy
Poor prognosis
Paget’s disease of the breast
Eczematous lesions on nipple, there is underlying DCIS or ductal CA
Cystosarcoma phyllodes (phyllodes tumor) and tx?
10% malignant
Rare nodal mets
HEMATOGENOUS spread (not lymphatic) because it’s a SARCOMA
Tx: WLE, no ALND
BRCA risk of cancer
85% have CA by age 70
BRCA1 ovarian CA (50%)
BRCA2 male breast CA
Indications for radiation after mastectomy
> 4 nodes
Skin or chest wall involvement
+margins
Stewart Treves syndrome (cutaneous angiosarcoma)
Lymphangiosarcoma in lymphedematous limb, presents with purplish mass on arm ~10 yrs s/p MRM
Bloody nipple discharge
intraductal papilloma no risk of CA #1 cause of bloody nipple discharge, 1/2 are serous though
BRCA 1
Chromosome 17 Risk of colon ca Earlier age of onset 60% risk of breast cancer 40% risk of ovarian cancer
BRCA 2
Chromosome 13
Male breast cancer
Older age onset >50 yo
Risk of bladder/pancreatic cancer
Who should get screening breast MRI?
Patients with lifetime risk exceeding 20-25%
- strong family hx
- prior tx of Hodgkin disease with mantle radiation
- BRCA mutation
Pleomorphic LCIS tx
different from classic LCIS
more similar to DCIS and invasive lobular carcinoma
excisional biopsy should be performed of the lesions with wire localization
Proper test for suspected Paget’s disease?
Full thickness nipple biopsy to confirm Paget’s first - then proceed with partial or total mastectomy once confirmed
85-92% of women with Paget’s have breast cancer
Which lesions are associated with increased breast cancer risk?
- atypical ductal hyperplasia
- sclerosing adenosis
- fat necrosis
- complex sclerosing lesion
- radial scars
Atypical ductal hyperplasia - 4 fold increased risk of developing breast cancer
Granulomatous mastitis sx and tx
idiopathic inflammatory condition
often presents with abscesses and fistulas
tx: core biopsy, observation and course of steroids, surgical excision for steroid refractory patients
First line treatment for gynecomastia
Anti-estrogen treatments - tamoxifen
Surgery for those who do not respond to medical treatment - liposuction or removal of glandular breast tissue through periareolar incision
Hormone replacement therapy affect on breast cancer risk
OCP use slightly increases risk of breast cancer - 10 years after cessation of birth control pills, the risk returns to baseline
Combination hormone therapy increases risk of breast cancer and CV disease in post-menopausal women
Periareolar mammary duct fistula
Chronically discharging nipple lesion, tracks to a major subareolar milk duct
Recurring abscesses will drain along the tract, forming a chronic fistula
Tx: excision of entire fistula tract - can be closed primarily if there is no acute infection
Risk of lymphedema with SLNB vs ax dissection
7% risk in SLNB 6 months after surgery
20% risk in ax dissection
Tumor emboli in the dermal lymphatic channels
Pathognomonic histologic finding of inflammatory breast cancer
Tx of inflammatory breast cancer
Neoadjuvant chemo
MRM
Post-op radiation
Tx of locally advanced non-inflammatory breast cancer
Neoadjuvant chemo
Can attempt BCT
Post-op radiation
Pregnancy associated breast cancer treatment
Surgery is 1st line treatment - can be performed safely at any trimester (mastectomy or BCT)
SLNB is ok during pregnancy - radioisotope stays trapped at injection site until decay occurs, half life is 6 hours
Chemotherapy can be given after the 1st trimester adjuvant or neoadjuvant
Tamoxifen should be delayed until after delivery
Subareolar breast abscess treatment
US to differentiate between mastitis and breast abscess
MRSA coverage with abx tx - continued until complete clinical resolution
US guided aspiration of abscess for simple abscess
Surgical I/D for multiloculated or recurrent abscess
Fibroadenoma histologic elements
Stromal and epithelial tissue
Similar histologically to phyllodes tumor
Phyllodes tumors dx and tx
Benign vs malignant differentiation - molecular analysis
Hematogenous spread - SLNB not indicated
1 cm margin for malignant phyllodes tumor - can pursue BCT
50% local recurrence rate
Which BIRADs classifications require biopsy?
4 and 5
If BIRADS5 biopsy is benign - discordant results and should proceed with surgical excisional biopsy to confirm
BIRADS4 lesions is benign on biopsy - ok to observe
BIRADS classifications
0 - inconclusive 1 - negative 2- benign 3 - probably benign 4 - suspicious 5 - highly suggestive of malignancy 6 - biopsy proven malignancy
