Breast Flashcards
1
Q
surgery of the breast
A
- Clinical staging is via physical exam or seen on mammogram/US/MRI
- Pathological staging is a specimen on a microscope
2
Q
surgical anatomy of the breast
A
- Extends from: 2nd to 6th rib and sternal border to mid-axillary line
- Circular except for the extension to the axilla –Tail of Spence
-
Cooper’s ligament
- strands of connective tissue
- holds breast upwards
- “dimpling” occurs when ligaments are compressed by mass
3
Q
nerves of the breast
A
-
Lateral Cutaneous Nerve (T4)
- sensory to breast tissue
-
Long Thoracic Nerve (C5-7)
- supplies Serratus Anterior
- Injury causes winged scapula
- Medial to Thoracodorsal nerve
4
Q
lymphatics of breast
A
- LYMPHATICS OF BREAST – has to do with staging and which surgery we do in a woman – Don’t really need to know the nodes, just the Sentinel lymph node
- 75% of lymph passes through Axillary nodes
- Medial breast drains to Internal Mammary nodes
- Nipple drains to Interpectoral nodes - Rotter Nodes (between Pectoral major muscle and Pectoral minor muscle
- Deep axillary nodes - Grozzman Nodes
- Subarealor nodes -Sappey Nodes
-
First node that drains the breast is the sentinel lymph node – find it surgically via 2 methods: nuclear medicine, and during surgery a blue dye is injected into breast – these 2 methods are 98% accuracy in finding sentinel lymph node
- If the sentinel lymph node has cancer in it, then the pt is automatically stage two and we consider chemo after surgery
5
Q
physiology of breast
A
- Estrogen stimulates development of breast ducts
- Progesterone stimulates breast lobules
- Prolactin stimulates milk production for lactation
- Testosterone in men suppress growth of breast tissue
- We give antiestrogen pill therapy for women who are at high risk or after surgery
6
Q
patient presentation
A
- something or it is found on screening mammogram
- If someone says they feel a lump, that pt needs to be seen within a week
- Nipple inversion is very common, seen in a lot of women
- If you see woman with inverted nipple, document and ask them how long they’ve had it
- If it is a new nipple inversion or retraction, document it – do diagnostic mammogram and send to surgery.
- Sometimes seen in women who have had new drastic weight loss
- Most of the time, a red breast is infection
7
Q
physical exam
A
- Patient should be sitting in chair and have her put hands on hips then hands overhead to inspect.
- Look for –
- Asymmetry
- Skin retraction
- Edema from blocked lymphatic ducts (peau d’orange)
- Nipple inversion (unless it’s normal)
- Erosion
- Palpate for supraclavicular and axillary fossa nodes while sitting
- Supine position palpate centrally out to Tail of Spence
- Lumps in breast are noted by:
- size (in cm)
- shape
- mobility (fixed vs mobile)
- consistency (firm vs rubbery)
- location (hands of clock)
- hard lymph node usually bigger than 2cm and +/- tenderness
- Pain is not a big emergency – as long as she only has breast pain and the imaging is negative, we don’t do much for these women
8
Q
diagnostic testing
A
- Mammogram- most reliable detection of breast cancer before a mass can be palpated
- MRI useful for augmented breasts - NOOOOOO
- MRI is for extremely dense breast tissue but NEVER REPLACES mammogram
- MRI is a vascular study that looks at blood flow – “increased enhancement” usually goes along with a recommendation for a biopsy
- US is go-to for woman less than 30 with a mass because most women less than 30 don’t have breast cancer and we don’t want to expose them to radiation that they don’t need
- Ultrasound to distinguish cystic vs solid mass
9
Q
diagnostics
A
-
Palpable Mass/Lesions – Fine Needle Aspiration (FNA)
- Can be done in office or clinic
-
Nonpalpable Lesions –
- Stereotactic guided CORE biopsy with:
- Mammogram
- X-ray
- You leave a clip in the location that you did the biopsy so that you know where to go back and do surgery
- Stereotactic guided CORE biopsy with:
- Neoadjuvant chemo – doing chemo before the surgery – this is another indication for putting in the clip because the cancer will be obliterated before the surgery and we need to know where to go back in and take out tissue
- Image guided wire localization with excision
- Ultrasound
- Mammogram –
- Most definitive for small nonpalpable lesions
10
Q
lab testing
A
- SERUM ANTIGEN TEST (Tumor Markers)
- CEA
- CA 125
- CA 15-3
- CA 27-29
- HIGH IN 50% OF PATIENTS WITH LOCALIZED BREAST CA
- HIGH IN 65% OF PATIENTS WITH METASTATIC BREAST CA
- We don’t follow these tests because they’re unreliable – only the oncologist will order these
11
Q
indications for surgery
A
- Nontender breast lump that is:
- firm
- hard
- with poorly delineated margins
12
Q
breast cancer
A
- Most common malignancy in women
- Most women diagnosed after age 40 – after they are menopausal
- Women have an 8% chance of getting Breast CA by age 70
- Women 50 or less get genetic testing
13
Q
breast cancer risk factors
A
- Risk increases during childbearing age (25-40)
- Presence of BRCA1 or BRCA2 gene
- Hx of endometrial cancer
- Hx of breast cancer in other breast
- Hx of mother/daughter/sibling with breast cancer
- Oral contraceptives at an early age or before first full-term pregnancy
- Dense breast tissue
- Hormone Replacement Therapy (HRT) in peri and postmenopausal slightly increase risk
- Radiation to breast or chest (Hodgkins lymphoma tx)
- Late menopause after age 55
- First pregnancy after age 35
- Infertility and nulliparity
- Obesity
- 30-60% higher risk than lean weight
- Increase in Estrogen + receptor breast cancer
- Decrease risk before menopause due to:
- Estrogen produced by ovaries
- Increase risk after menopause due to:
- Estrogen produced by fat cells
- Fat tissue has enzyme aromatase that converts androgens (from adrenal gland) to estrogen
- LIVER CIRRHOSIS
- ALCOHOL ABUSE
- 2-5 drinks/day
- 7 drinks/wk for women
- 14 drinks/wk for men
- Breakdown of ETHANOL to acetaldehyde (a toxin/carcinogen)
- Liver not making binding proteins for transport of hormones so estrogen increases
14
Q
breast cancer endocrine receptors
A
-
Estrogen
- 75% of breast cancer grow in response to estrogen
- responds very well to hormone therapy
-
Progesterone
- 65% in response to progesterone
- These cancers responds very well to hormone therapy
-
HER2 = Human epidermal growth factor receptor
- Does not respond to hormone therapy
- Treated with Herceptin
- 3 receptor negative or Triple Negative is
- Neg estrogen, neg progesterone and neg HER2
15
Q
breast cancer genetic markers
A
- 5-10% of breast cancer are inherited mutations
- BRCA1 Mutation
- 55-65% chance of breast CA by age 70
- 39% chance of ovarian CA by age 70
- 8-10% prevalence in Ashkenazi Jews
- 4% prevalence in Hispanics
- 2% prevalence in Caucasians
- Most are Triple Negative
- Risk of pancreatic CA- theres no way to really test for pancreatic CA
- Present with low back pain and jaundice typically
- BRCA2 Mutation
- 45% chance of Breast CA by age 70
- 10-30% chance of Ovarian CA by age 70
- 3% prevalence in African Americans
- 2-3% prevalence in Caucasians
- Most are Estrogen +
- Risk of pancreatic CA
- Other genetic markers are:
- P53
- CHEK 2
- ATM
- PALB2
- Atypia is a risk lesion for breast cancer
- If left untreated, may develop breast cancer
