Breast Flashcards
Fibrous bands that provide structural support and insert perpendicularly into the dermis?
suspensory ligaments of Cooper
What are the suspensory ligaments of Cooper?
fibrous bands
provides structural support
Milk-forming glandular unit of the breast?
breast lobule
Retromammary space is a thin layer between pec major and breast tissue, contains what?
lymphatics + small vessels
What m located deep to pec major?
minor
Axillary LN are described as three anatomic levels in relation to pec minor;
Level 1: lateral to the lateral border of pec minor
Level 2: posterior to pec minor
Level 3; medial to pec minor
Lymph nodes found between pec major and pec minor m are called?
Rotter’s nodes (interpectoral group of nodes)
Of lymphatic flow from the breast, 75% is directed into which LN group?
axillary LNs
What nerve courses along medial side of axilla innervating serratus anterior m?
long thoracic n
Division of this nerve leads to winged scapula;
long thoracic nerve–> innervates serratus anterior m
What m does long thoracic nerve innervate?
serratus anterior m
transection leads to winged scapula
Why is the long thoracic nerve preserved during surgery?
innervates serratus anterior m
fixes scapula to chest wall during adduction and extension of arm
transection leads to winged scapula
Thoracodorsal nerve innervates what m?
lattisimus dorsi
Lattisimus dorsi is innervated by what n?
thoracodorsal
Two nerves encountered during an axillary dissection?
long thoracic n
thoracodorsal n
Pec major innervated by what m?
medial pectoral nerve
Medial pectoral nerve innervates what m?
pec major
Mature breast tissue is made of three cell types;
glandular tissue
fibrous stroma/supporting structures
adipose tissue
**adolescents have mostly glandular tissue + fibrous tissue
**post-menopausal women have mostly fat
Function of Cooper’s ligaments?
provide structure and shape to the breast
courses from the skin to underlying deep fascia
What causes skin dimpling we sometimes see with breast Ca?
Cooper’s ligaments are attachments from skin to underlying deep fascia
sometimes Ca infiltrates these ligaments and causes dimpling
Milk-producing parts of the breast?
lobules
In the ductal system why is the basement membrane important?
important boundary between DCIS vs invasive carcinoma
invasive breast cancer penetrates this membrane
Hormone dependent maturation of breasts during puberty is termed?
thelarche
What’s thelarce?
hormone dependent maturation of breast during puberty
**initiated by pituitary gonadotropins releasing estradiol
After birth, principal trigger for lactation?
prolactin
with aid of oxytocin
Median age of menopause?
51
What is menopause?
cessation of menstrual flow for at least 1 year
How does menopause affect breast tissue?
increase fat deposition
decreased connective tissue
disappearance of lobular units
Is breast pain a symptom of breast Ca?
NO
What is fibrocystic disease of the breast?
common during 4-5th decades of life, lasts until menopause
an increased response of breast stroma to circulating hormones
women see breast pain, tenderness, nodules
MOst pts with a simple breast cyst do not require any further evaluation, unless;
it’s a complex cyst with solid intra-cystic components
Cysts commonly seen in pts with fibrocystic disease, however, they’re uncommon in women ages what?
older than 60
younger than 30
Aside from cysts, what do we see histologically in pts with fibrocystic disease of the breast?
see adenosis, sclerosis, apocrine metaplasia, stromal fibrosis, epithelial metaplasia/hyperplasia
In fibrocystic breast disease, histologically we can have typical epithelial hyperplasia and atypical epithelial hyperplasia, what do we worry about?
atypical epithelial hyperplasia (atypical ductal hyperplasia)
is a risk factor for breast Ca development
What is absence of breast tissue called?
amastia
Absence of nipple called?
athelia
Accessory breast tissue called?
polymastia
Accessory nipple called?
supernumerary
Extra nipples are common and occur via what line?
occur along the milk line from axilla to pubis
Accessory breast tissue commonly found where?
axilla
**commonly seen during pregnancy
Gynecomastia?
hypertrophy of breast tissue
Pubertal gynecomastia in boys is common, concerning?
NO
**regresses w/adulthood
When do we perform surgery for pubertal gynecomastia?
if enlargement is unilateral
fails to regress
cosmetically unappealing
Some causes of gynecomastia in men?
drugs; digoxin, thiazides, estrogens, theophylline
hepatic cirrhosis, renal failure, malnutrition
Nipple discharge? Concerning?
nipple discharge in non-lactating women very common
rarely linked to underlying Ca
Galactorrhea?
milky discharge from both breasts
usually due to high prolactin
What nipple discharge is concerning for Ca?
bloody
MCC of spontaneous nipple discharge from a single duct is?
a solitary intraductal papilloma
This is a milk-filled cyst that is round, well-circumscribed and easily movable within the breast;
galactocele
**seen after cessation of lactation or when feeding frequency has decreased
Tx for galactocele?
aspiration of thick milky fluid, sometimes w/brown or dark green tinge
What do we worry about w/paeu d’orange?
edema of the skin breast due to dependent nature of breast and pooling/blockage of lymphatics
lymphatics could be blocked from radiation, mastitis, or inflammatory breast Ca (malignant cells block dermal lymphatics)
What’s Paget’s dx of the breast?
can appear as a dermatitis or eczema on the breast
but there is often an underlying intraductal carcinoma under the nipple
Characteristics of benign breast masses?
usually fibroadenomas + cysts
distinct, well-circumscribed, movable
carcinoma is firm, less circumscribed, moving it causes drag on adjacent tissue
FNA main usefulness is used to distinguish between what and what?
solid vs cystic lesions
If an FNA shows a cystic breast lesions what do you do next?
if cyst is simple on imaging; no further imaging required
if cyst is complex on imaging; carcinoma needs to be ruled out
Method of choice to sample non-palpable image detected breast abnormalities:
core need biopsy
What’s a stereotactic core need biopsy?
pt lies on prone table
breast is compressed
needle takes samples
What % of pts with diagnosis of DCIS from core needle biopsy will have invasive carcinoma at definitive surgery?
10-20%
Primary imaging modality for screening asymptomatic women?
mammography
breast is squeezed between two plexi-glass to reduce thickness thru which radiation tissue must pass
mammography sensitivity is limited by breast density
Why does sensitivity of mammography increase with iage?
younger females have denser breasts
as women age, fatty infiltration ensues, fat doesn’t pick up radiation very well, you get contrast, thus can see smaller lesions
USPSTF recommendation for screening mammography?
recommended for women 50-74 every 2 years
recommended against screening women >75
recommended against screening women 40-49
ACS recommendation for screening mammography?
yearly starting at age 40
continue as long as women is in good health
What does Bi-RADS stand for?
breast imaging reporting and data system
What do we use Bi-RADS for?
used to categorize degree of suspicion of malignancy for a mammographic abnormality
Describe Bi-RADS classification;
0; incomplete; need more imaging
1; negative; annual screening
2; benign; annual screening
3; probably benign 6 month f/u
4; suspicious; bx recommended
5; highly suspicious; >95% malignancy potential
6; known bx proven malignancy
Risk factors for breast cancer development?
age
family hx
hormonal factors
proliferative breast dx
breast/chest wall irradiation at an early age
personal hx of malignancy
lifestyle factors
Most important risk factor for breast Ca development?
age
incidence increases with increasing age (1/8 women will get breast cancer by age 80)
breast cancer rare in pt’s less than 20
Avg. risk of women developing breast cancer in their lifetime?
12.2%
Personal hx of breast cancer in one breast increase what
increases likelihood of a second primary cancer in the contralateral breast
Is LCIS considered breast cancer?
not considered a breast ca
BUT is a marker for increased breast cancer susceptability
Someone has LCIS, and they want something done, what can we do?
close observation (LCIS is not cancer, but is a histological marker for increase breast ca susceptability)
chemoprevention w/tamoxifen/raloxifen
b/l mastectomy
First degree relatives and risk of breast ca?
1st degree relatives; moms, daughters, sisters of pts w/breast cancer have a 2-3 fold increase risk of breast ca
Women with BRC1, BRC2 mutations are at an increased risk of what?
breast + OVARIAN ca
BRC1 is what type of gene?
tumor suppressor gene
with dx susceptability inherited in AD fashion
Which BRC gene associated with increased breast ca risk in males?
BRC2
Women with BRC2 mutation also have a 20-30% increased risk of what type of Ca?
ovarian
Reproductive risk factors for breast cancer?
factors that increase a women’s lifetime estrogen exposure
menarche before 12
first child after 30
nulliparity
menopause after 55
Do HRT increase a woman’s risk of developing breast cancer?
combination estrogen + progesterone for 5 years, increase risk of breast Ca by 20%
What’s the Gail model?
tool used to assess risk of breast ca;
age race age at menarche age at first live birth number of previous breast biopsies number of previous breast biopsies first degree relative w/breast ca presence of proliferative dx w/atypia
Does the Gail model use genetic factors to assess breast ca risk?
NO
Screening recs for a woman with a family hx of breast cancer or ovarian ca syndrome?
monthly self breast exams starting at 18-20
semi-annual CBE starting at 25
annual mammo starting at 25 or 10 years earlier than first diagnosed relative
Drugs currently prescribed to reduce breast cancer risk are?
tamoxifen
raloxifen
How does tamoxifen work?
estrogene antagonist
used in pt’s with ER+ breast cancer
How does raloxifen work?
selective ER modulator
Does prophylactic mastectomy reduce risk of developing breast Ca?
shown to reduce risk of breast ca by 90% in high risk pts
WHat cuases breast cysts to form?
pathogenesis not well understood
arise from destruction and dilation of lobules and terminal ductules
These are epithelial lined cavities containing fluid:
breast cysts
Why do breast cysts vary with menstrual cycles?
they’re influenced by ovarian hormones
most cysts occur in women >35
incidence increases until menopause
then sharp decline
Do breast cysts increase breast cancer risk?
no evidence of increase risk of breast Ca with cyst formation
These are benign solid tumors made of stromal and epithelial elements:
fibroadenomas
What’s a fibroadenoma?
benign solid tumor of breast
made of stromal and epithelial elements
Most common tumor in women younger than 30?
fibroadenoma
2nd most common tumor of breast after carcinoma?
fibroadenoma
What age group do we see fibroadenomas?
women in late teens
early reproductive years
rare in women after 40-45
On clinical exam, these breast masses are firm masses, easily movable, may increase in size of several months,, well encapsulated;
fibroadenomas
Cancer development from fibroadenomas?
exceedingly rare
Breast hamartoma?
indistinguishable from fibroadenoma on exam
a nodule that contains closely packed lobules and prominent extra-lobular ducts
What is lactational mastitis?
bacteria enter breast via nipple into the duct system
caused by s. aureus
sx: fever, leukocytosis, erythema, tenderness
tx; frequent emptying, abx
What’s periductal mastitis or ductal ectasia?
chronic relapsing form of breast infection
seen in women smokers/DM
aerobic/anaerobic flora involved
What are intraductal papillomas?
true polyps of epithelial lined breast ducts
Do intraductal papillomas increase risk of Ca?
NO
What is sclerosing adenosis?
lesions that produce deposition of calcium
can be confused with Ca
has no Ca risk
In pts undergoing bx for microcalcifications; what’s the most frequent diagnosis?
sclerosing adenosis
What’s a radial scar?
group of abnormalities known as complex sclerosing lesions
appear similar to carcinomas on mammo bx they crease spliculated lesions
can even result in skin dimpling
Why do we need to bx radial scars?
need to be excised to rule out underlying carcinoma
assc w/modestly increased risk of breast Ca
This can mimic breast ca by producing a palpable mass on mammo that may contain microcalcifications, usually seen after trauma or surgery or post-radiation;
fat necrosis
Does fat necrosis have any malignant potential?
NO
Histologically how does fat necrosis present?
lipid laden macrophages
scar tissue
chronic inflammatory cells
Risk of isosulfan blue dye?
anaphylactic shock 1%
Risk of methylene blue?
skin necrosis
