Breast Flashcards
What are the 4 boundaries of the axilla for dissection?
Superior: axillary vein
Posterior: long thoracic nerve
Lateral: latissimus dorsi
Medial: pectoralis minor
What 4 nerves must a surgeon be aware of during an axillary dissection?
- Long thoracic nerve
- Thoracodorsal nerve
- Medial pectoral nerve
- Lateral pectoral nerve
Where is the long thoracic nerve?
Courses along lateral chest wall in midaxillary line on serratus anterior muscle
Which muscles does the long thoracic nerve innervate?
Serratus anterior muscle
Where is the thoracodorsal nerve?
Courses lateral to the long thoracic nerve on latissimus dorsi muscle
Which muscles does the thoracodorsal nerve innervate?
Latissimus dorsi muscle
Where is the medial pectoral nerve?
Runs lateral to or through the pectoral minor muscle, laterally to the lateral pectoral nerve
Which muscles does the medial pectoral nerve innervate?
Pectoral minor and major muscles
Where is the lateral pectoral nerve?
Runs medial to the medial pectoral nerve
Which muscles does the lateral pectoral nerve innervate?
Pectoral major muscle
What is the name of the deformity if you cut the long thoracic nerve?
Winged scapula
What is the name of the cutaneous nerve that crosses the axilla in a transverse fashion?
Intercostobrachial nerve
What is the name of the large vein that marks the upper limit of the axilla?
Axillary vein
What is the lymphatic drainage of the breast?
Lateral: axillary lymph nodes
Medial: parasternal nodes that run with internal thoracic artery
Where are the level I axillary lymph nodes?
Lateral to the pectoral minor muscle
Where are the level II axillary lymph nodes?
Deep to the pectoral minor muscle
Where are the level III axillary lymph nodes?
Medial to the pectoral minor muscle
What are Rotter’s nodes?
Nodes between the pectoral major and minor muscles.
Not usually removed unless they are enlarged or feel suspicious intra-operatively
What are the suspensory breast ligaments called?
Cooper’s ligaments
What is the mammary “milk line”?
Embryological line from shoulder to thigh where supernumerary breast areolar and/or nipples can be found
What is the tail of Spence?
Tail of breast tissue that tapers into the axilla
Which hormone is mainly responsible for breast milk production?
Prolactin
What is the incidence of breast cancer?
12%
What percentage of women with breast cancer have no known risk factor?
75%
What percentage of all breast cancers occur in women younger than 30 years?
2%
What percentage of all breast cancers occur in women older than 70 years?
33%
What are the major breast cancer susceptibility genes?
BRCA1 and BRCA2
What option exists to decrease the risk of breast cancer in women with BRCA?
Prophylactic bilateral mastectomy
What is the most common motivation for legal cases involving the breast?
Failure to diagnose a breast carcinoma
What is the triad of error for misdiagnosed breast cancer?
- Age < 45
- Self-diagnosed mass
- Negative mammogram
What are the history risk factors for breast cancer?
NAACP: Nulliparity Age at menarche (< 13) Age at menopause (> 55) Cancer of the breast (in self or family) Pregnancy with first child (> 30 years)
What are the physical/anatomic risk factors for breast cancer?
CHAFED LIPS:
Cancer of the breast, Hyperplasia, Atypical hyperplasia, Female, Elderly, DCIS, LCIS, Inherited genes, Papilloma, Sclerosing adenosis
What is the relative risk for breast cancer with HRT?
1-1.5
Is typical fibrocystic disease a risk factor for breast cancer?
No
What are the possible symptoms of breast cancer?
Asymptomatic, breast mass, pain (most painless), nipple discharge, local edema, nipple retraction, dimple, nipple rash
Why does skin retraction occur in some breast cancers?
Tumor involvement of Cooper’s ligaments and subsequent traction on ligaments pull skin inward
What are the signs of breast cancer?
Mass (> 1cm), dimple, nipple rash, edema, axillary or supraclavicular nodes
What is the most common site of breast cancer?
Approximately 50% develop in the UOQ
What are the different types of invasive breast cancer?
Infiltrating ductal carcinoma, medullary carcinoma, infiltrating lobular carcinoma, tubular carcinoma, mucinous carcinoma, inflammatory breast cancer
What is the most common type of breast cancer?
Infiltrating ductal carcinoma
What is the differential diagnosis for breast cancer?
Fibrocystic disease, fibroadenoma, intraductal papilloma, duct ectasia, fat necrosis, abscess, radial scar, simple cyst
Describe the appearance of the edema of the dermis in inflammatory breast cancer.
Peau d’orange
What are the recommendations for breast exams?
Self-exam of breasts monthly
20-40 yo: breast exam every 2-3 years
> 40 yo: annual breast exam
What are the recommendations for mammograms?
35-40 yo: baseline mammogram
40-50 yo: mammogram every or every other year
> 50 yo: annual mammogram
When is the best time for breast self-exam?
1 week after menstrual period
Why is mammography a more useful diagnostic tool in older women than in younger?
Breast tissue undergoes fatty replacement with age, making masses more visible.
Young women have more fibrous tissue.
What are the radiographic tests for breast cancer?
Mammography, breast U/S, MRI
What is the classic picture of breast cancer on mammogram?
Spiculated mass
Which option is best to evaluate a breast mass in a woman younger than 30 years?
Breast U/S
What are the methods for obtaining breast tissue for pathologic examination?
FNA, core biopsy, mammotome stereotactic biopsy, open biopsy
What are the indications for breast biopsy?
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
What is the process for performing a biopsy when a non-palpable mass is seen on mammogram?
Stereotactic (mammotome) biopsy or needle localization biopsy
What is needle loc biopsy?
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
What is a mammotome biopsy?
Mammogram-guided computerized stereotactic core biopsy
What is obtained first, the mammogram or the biopsy?
Mammogram is obtained first; otherwise, tissue extraction may alter the mammographic findings
What would be suspicious mammographic findings?
Mass, microcalcifications, stellate/spiculated mass
What is a radial scar seen on mammogram?
Spiculated mass with central lucency +/- microcalcifications
What tumor is associated with a radial scar?
Tubular carcinoma
What is the workup for a breast mass?
- Clinical breast exam
- Mammogram or breast U/S
- FNA, core biopsy, or open biopsy
How do you proceed if the mass appears to be a cyst?
Aspirate it with a needle
Is the fluid from a breast cyst sent for cytology?
Not routinely; bloody fluid should be sent
When do you proceed to open biopsy for a breast cyst?
- Recurrence of second cyst
- Bloody fluid in cyst
- Palpable mass after aspiration
What is the preoperative staging workup in a patient with breast cancer?
Bilateral mammogram CXR: lung mets LFTs: liver mets Serum Ca, alkaline phosphatase: bone mets Other: head CT
What hormone receptors must be checked for in the biopsy specimen?
Estrogen and progesterone (guides adjuvant treatment)
What staging system is used for breast cancer?
TMN
What is stage I breast cancer?
Tumor < 2 cm
What is stage IIA breast cancer?
Tumor < 2 cm with mobile axillary nodes, or
Tumor 2-5 cm with no nodes
What is stage IIB breast cancer?
Tumor 2-5 cm with mobile axillary nodes, or
Tumor > 5 cm with no nodes