Breast Flashcards
Main nerves encountered during axillary dissection?
Long thoracic nerve (serratus anterior), thoracodorsal nerve (latissimus dorsi), intercostal brachial nerve (lateral cutaneous branch of 2nd intercostal nerve, sensation to medial arm/axilla)
Cord-like breast mass: dx/tx?
Mondor’s disease, superficial vein thrombophlebitis, tx w/ NSAIDs - rule out malignancy w/ MMG/US
Tx options for DCIS, margins, lymph nodes, cancer risk
lumpectomy w/ XRT, consider SLNBx in high grade DCIS or w/ large/palpable masses (unable to do SLNBx after most lumpectomies and all mastectomies given disruption of lymphatics) 50% get ipsilateral cancer if not resected, 5% cancer contralateral
Tx options for LCIS, margins, lymph nodes, cancer risk
marker for development of breast ca (not a premalig lesion), ex biopsy or tamoxifen, bilateral mastectomy; more likely to have ductal Ca, 40% get breast ca in either breast
explain the BIRADS classification and recommendation
BIRADS 1 negative - routine screening, 2 benign finding - routine screening, 3 probably benign finding - short term follow up, 4 suspicious abnormality i.e. indeterminate calcification or architecture - CNBx, 5 highly suggestive of Ca - CNBx
Breast cancer screening guidelines
MMG every 2-3 years after age 40, yearly after age 50; high risk screening MMG 10 years before youngest age of first breast ca 1st degree relative
explain levels of axillary lymph nodes
level 1 = lateral to pec minor, 2 = under pec minor 3 = medial to pec minor
What are Rotter’s nodes?
nodes between pec major and pec minor muscles
What is the most important prognostic staging factor in breast ca?
Node status
Explain TNM staging in breast cancer
T1 <2 cm, T2 >2 cm <5 cm, T3 >5 cm, T4 = extension to chest wall, skin edema, ulceration, satellite nodules, inflammatory; N1 = 1-3 axillary/IM nodes, N2 = 4-9 axillary nodes or clinically apparent IM nodes without axillary mets, N3 = 10+ axillary nodes, infraclavicular nodes, or IM nodes in presence of axillary nodes
Ca associations and lifetime risks in BRCA1? BRCA2? hormone receptor status in BRCA1?
BRCA1 - female breast Ca 60%, Ovarian Ca 40%, male breast Ca 1%; BRCA2 = female breast ca 40-55%, ovarian Ca 10%, male breast Ca 10% (100x increase) – BRCA are tumor suppressor genes – BRCA1 breast ca tend to be hormone receptor negative / triple negative
Tx of male breast cancer w/ clinically node negative dz?
Simple mastectomy + SLNBx
Indications for XRT after mastectomy
positive nodes (>4), skin/chest wall involvement, positive margins, large tumor (T3 >5 cm), extracapsular nodal invasion, inflammatory Ca, fixed axillary nodes (N2) or internal mammary nodes (N3)
scaly nipple lesion
Paget’s disease, underlying DCIS/ductal Ca, bx w/ punch/full thickness biopsy, mastectomy+RT or BCT+RT are acceptable, need to include nipple areolar complex – mastectomy often required given extent of underlying cancer
dark purple nodules on arm 10 years after axillary dissection – dx, tx?
Stewart-Treves syndrome -> lymphangiosarcoma from chronic lymphedema; dx via open biopsy, tumor is highly aggressive w/ early mets to lung, tx consists of early wide surgical debridement (may require amputation), survival <2 years
stromal/epithelial frond like pattern breast mass - dx, tx, spread?
Phyllodes tumor, no nodal metastasis -> hematogenous spread, 10% malignant based on mitoses per HPF, WLE w/ 1 cm margins, no ALND
Borders of an axillary lymph node dissection
Axillary vein (superior), serratus anterior (medial), latissimus dorsi (lateral)
hypoplasia of chest wall, amastia, hypoplastic shoulder, no pec muscle
Poland syndrome - men > women, R > L
Gynecomastia: demographics, Ca risk, tx
infancy, puberty, and age >50; not considered risk factor for breast Ca, mammography useful to differentiate from malignancy, can tx w/ tamoxifen (surgery rarely)
Features of pathologic nipple discharge
Serous or bloody, unilateral, uni-duct, spontaneous
Tamoxifen decreases breast cancer risk in high risk patients by ….? What about prophylactic mastectomy
50% risk reduction in subsequent breast Ca (NSABP-P01 trial), 90% risk reduction in prophylactic mastectomy
major side effects of tamoxifen?
increased risk of endometrial adenocarcinoma, increased risk of VTE; cataract formation
Ultrasound features of a benign breast mass?
Homogenous, bilateral edge shadowing, wider than tall
Ultrasound features of a malignant breast mass?
Heterogenous, taller than wide (means the lesion is infiltrative of the natural elements of the breast)
Atypical ductal hyperplasia: risk of breast cancer, management?
5x higher relative risk of breast cancer, similar to DCIS, surgical excision is recommended, margins are not needed, tamoxifen is recommended after excisional biopsy confirms absence of cancer (50% reduction in subsequent cancer); no axillary staging is needed
features of invasive lobular cancers
15% of invasive breast cancers, typically hormone positive, indiscrete on MMG/US, hard to appreciate nodal mets on frozen section
Success rate of SLNBx? Safety of radioactive technetium in pregnancy?
> 95%. false negative rate is around 10%. Radioactive technetium low dose, safe in pregnancy
Summarize main points of NSABP B17
NSABP B17 established that XRT significantly reduces local recurrence when administered after lumpectomy,
Summarize main points of ACOSOG Z0011
ACOSOG Z0011 demonstrated that pt w/ early invasive breast Ca T1/T2 undergoing BCT do not need completion ALND if the SLNBx is positive in <3 nodes
Summarize main points of AMAROS trial
women w/ early breast Ca and no clinically palpable nodes could undergo radiotherapy in place of axillary dissection if LN were determined to be positive
Contraindications to nipple-sparing mastectomy?
Extensive intraductal cancer, associated nipple discharge, Paget disease, cancer within 2 cm of nipple
Pathologic difference between phyllodes and fibroadenoma?
stromal hypercellularity
mammogram showing stellate lesion with transulcent central portion
radial scar (<1 cm) and complex sclerosing lesions (>1 cm) - characteristic central area of fat which differentiates it from carcinomas, need excisional biopsy of entire lesion
Risk factors for breast ca (RR >4, RR 2-4, RR <2)
RR>4 - BRCA2, multiple family members w/ bilateral or premenopausal breast ca, DCIS/LCIS/ADH, RR 2-4 - prior breast ca, rads exposure, 1st deg relative w/ breast ca, age >35 1st birth; RR <2 - early menarche, late menopause, nulliparity, proliferative benign dz, obesity, EtOH use, hormonal replacement therapy
Features of tubular breast carcinoma?
Ductal, 2%, well differentiated, most favorable prognosis
Features of papillary breast carcinoma?
Ductal, <1%, occurs in post menopausal, favorable prognosis (vs micropapillary carcinoma which are aggressive)
Features of medullary breast carcinoma?
Ductal, associated with BRCA1, poorly differentiated w/ aggressive features but generally have favorable prognosis
Features of mucinous breast carcinomas?
Ductal, 5% of invasive breast ca, characterized by mucin component, well differentiated, w/ low rate of mets
Management of early stage triple negative breast cancer?
Lumpectomy/XRT/SLNBx or mastectomy/SLNBx – followed by chemotherapy
Indications for axillary lymph node dissection in breast cancer
clinically node-positive axilla, occult breast cancer presenting as axillary node metastasis, SLN positive patients who fall outside the Z0011 selection criteria (i.e. >2 SLN positive), inflammatory, clinical stage T4, or high-risk T3 breast cancer, sentinel or axillary nodes which remain positive after neoadjuvant chemotherapy, axillary recurrence
Management of inflammatory breast cancer
neoadjuvant chemotherapy followed by either surgery or XRT depending on resectability
route of bone metastasis from breast cancer?
Batson plexus
breast lymphoma: most common type, tx, most common mets
most are B cell (diffuse large B cell), if lesion localized/low grade can consider primary excision, intermediate/high grade need CHOP+radiation, tend to mets to central nervous system
most significant side effect / complication associated with trastuzumab?
herceptin; cardiac toxicity - assoc. w/ cardiac failure manifesting as decreased LVEF, need serial assessment of LVEF
