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Surgery > Breast > Flashcards

Breast Flashcards

1
Q

Forms epithelium of glands and ducts

A

Ectoderm

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2
Q

Supporting CT of breast is from

A

mesenchyme

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3
Q

Arise from ectoderm on ventral aspect of embryo at

A

4-6 weeks

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4
Q

All ridges regress except for a remnant at the

A

fourth ICS thorax

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5
Q

Incomplete regression of ridge may lead to

A

polythelia accessory nipple

polymastia accessory mammary gland

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6
Q

Anatomic boundaries of breast

A

Superior: second rib
Inferior: sixth to 7th
Medial: sternal border
Lateral: midaxillary line

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7
Q

Mastectomy landmarks

A

Superior: clavicle
Inferior: inframammary fold
Medial: sternum
Lateral: lats dorsi

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8
Q

Upper outer quadrant of breast extending to axilla forms

A

tail of Spence

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9
Q

Forms CT framework of breast by anchoring dermis of skin to superficial fascia of pectoralis major

A

suspensory ligament of Cooper

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10
Q

Breast bs

A

Internal thoracic artery
axillary artery
third to fifth intercostals
venous parallels arterial supply

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11
Q

Sensory innveration of breast

A

Lateral and anterior cutaneous branches of 2nd to 6th intercostal nerves

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12
Q

Innervates latissimus dorsi

Damage causes weak internal rotation and abduction

A

Thoracodorsal nerve

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13
Q

Innvervates serratus anterior

Damage causes winged scapula

A

Long thoracic nerve

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14
Q

Innervates portions of pecs major

Innervates minor

Damage causes atrophy

A

Medial and lateral anterior thoracic nerves

Medial nerve only

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15
Q

Arises from lateral cutaneous branch of 2nd intercostal nerve

Provides sensation to upper inner aspect of arm and axilla

Damage causes numbness in distribution

A

Intercostobrachial nerve

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16
Q

Level I LN drainage

A

Lateral to pectoralis minor

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17
Q

Level II Lymphatic node

A

Deep to pectoralis minor

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18
Q

Level III Lymph node

A

Medial to pectoralis minor

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19
Q

Superficial areas of breast drain

A

subareolar lymphatic plexus into deep lymphatic plexus

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20
Q

Deep tissues drain via

A

axillary lymph

internal thoracic lymph

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21
Q

Drainage of breast is primarily

A

axillary node

internal mammary node

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22
Q

Group of nodes between pecs major and minor

A

Rotter’s node

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23
Q

Removal of all breast tissue

A

Simple mastectomy

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24
Q

Removal of all breast tissue and pectoralis fascia with axillary lymph node dissection (ie resection of level I and II)

A

Modified Radical Mastectomy

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25
Q

Removal of all breast tissue and pectoralis major and minor with axillary lymph node dissection

A

Radical mastectomy

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26
Q

Acts on ducts in men to destroy ductal epithelium

A

Androgen

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27
Q

Ductal epithelial proliferation

A

Estrogen from FSH and LH

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28
Q

ductal dilation and epithelial differentiation into secretory cell

A

progesterone

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29
Q

80% risk of breast cancer

A

BRCA1

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30
Q

60% risk of breast cancer

A

BRCA2

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31
Q

Breast cancer risk factors

A

Inc in Ashkenazi jews
Inc risk of male breast cancer with BRCA2
Inc risk of ovarian cancer with BRCA1

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32
Q

Inc risk of breast male cancer

A

BRCA2

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33
Q

Inc risk of ovarian cancer with

A

BRCA1

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34
Q

Induce milk production

A

Prolactin, GH, insulin

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35
Q

Associated with hyperestrogenemia

Stimulates breast tissue

A

Obesity

Cirrhosis

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36
Q

BRCA1 is located on

A 
ch17q 
AD
80% breast cancer
40% ovarian 
Early disease onset and bilaterality
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37
Q

BRCA1 mutations necessitate

A

Bilateral salphingooophorectomy

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38
Q

BRCA2 is located on

A

ch13q involved in DNA repair
Inc risk of breast cancer 60% including males
Inc risk of ovarian cancer 15-25%

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39
Q

p53 mutation leads to soft tissue sarcoma, osteosarcoma, breast cancer, brain tumor and leukemia

A

Li-Fraumeni syndrome

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40
Q

PTEN mutation leads to breast
GI
CNS
skin eye thyroid GU bone

A

Cowden syndrome

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41
Q

STK11 mutation
GI
pigmented lesion
Breast

A

Peutz Jegher

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42
Q

DNA repair defect in telangiectasia
cerebellar ataxia
Inc risk of breast cancer

A

ataxia-telangiectasia

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43
Q 
mismatch repair gene defect resulting in inc risk of colon
endometrial 
ovarian
urinary 
breast cancer
A

HNPCC

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44
Q

Indications for genetic testing for hereditary breast ovarian cancer

A

Member of family with BRCA
Personal history of breast cancer
Personal history of ovarian cancer
Dx of breast cancer = 40 years (+/- family hx)
Dx of breast cancer = 50 years or 2 primary breast cancers (bilateral or = 2 ipsilateral or primary tumors) and = 1 first, second, third degree relative with breast cancer = 50 years and or = 1 first second or third degree relative with ovarian cancer
First, second or third degree male relative with breast cancer
Personal history of ovarian cancer
Personal history of male breast cancer especially in setting of >/= 1 of the ff criteria: >/= 1 first, second kr third degree male relative with breast cancer, >/= 1 first, second or third degree female relative with breast or ovarian cancer

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45
Q

Unilateral, spontaneous, bloody (not serous of green) and clear (rather than milky)

A

Associated with cancer

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46
Q

Mass characterization of malignancy

A

Fixed
Firm
Nipple retraction and skin change (peau d’ orange)

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47
Q

Clinical breast exam is indicated:

A

Women 20-39 years every 2-3 years

Women >/= 40 years of age anually

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48
Q

Asymptomatic

Average risk =40

A

Annual mammography

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49
Q

Mammography +

Palpable lesion

A

UTZ

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50
Q

UTZ: Supple cyst

A

Aspiration if resolves, routine follow up
Aspiration no resolution and bloody fluid, decision biopsy -> cancer ->breast conservation or MRM then follow up
benign -> follow up

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51
Q

Mammography +

Nonpalpable lesion

A

Stereotactic biopsy

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52
Q

Useful in distinguishing between solid and cystic masses

Women <35 in whom mammography is more difficult to interpret

A

Ultrasound

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53
Q

Of limited value in <35 bec of increased density of breast tissue

A

Mammography

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54
Q

Views in mammography

A

craniocaudal

mediolateral oblique

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55
Q

Findings suggestive of malignancy in mammography

A

solid mass with or without stellate characteristics
asymetric thickening
clustered microcalcification

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56
Q

Sensitivity and specificity of mammogram

A

> 90%

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57
Q

BIRADS 0

A

additional evaluation needed

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58
Q

BIRADS 1

A

Negative test

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59
Q

BIRADS 2

A

Benign finding

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60
Q

BIRADS 3

A

Probably benign

Follow up in 6 months

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61
Q

BIRADS 4

A

Lesions suspicious for cancer

Biopsy indicated

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62
Q

BIRADS 5

A

Highly suggestive of malignancy

Biopsy indicated

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63
Q

BIRADS 6

A

Known malignancy

64
Q

Not a replacement for mammography or uts

Useful as supplemental tool for staging

A

MRI

65
Q

Screening MRI is recommended

A

for women with known BRCA mutation
those who have not undergone genetic testing but who have first degree relative with known mutation or premenopausal breast cancer
women with >20-25% lifetime risk for breast cancer
women who have history of chest irradiation between 10 and 30 years of age

66
Q

Indicated for new diagnoses of breast cancer

in presence of lobular cancer or dense breast tissue

A

MRI

67
Q

May be done in the office and yields rapid result

Cannot differentiate carcinoma in situ from invasive cancer

A

FNA

68
Q

Indicated for palpable lesion and screening of lesion detected by mammography ultrasound or MRI
Tissue architecture is maintained allowing for determination of invasive versus noninvasive

A

Core biopsy

69
Q

Operative biopsy with or without preoperative needle localization
Indicated for nonpalpable lesions
Needle localization reduces false biopsy result

A

Excisional biopsy

70
Q 
If core biopsy reveals:
lobular carcinoma in situ
radial scar
atypical lobular or ductal hyperplasia
inadequate tissue or results that are discordant with radiologic findings proceed with
A

excisional biopsy

71
Q

Clinical breast exam

A

Every 2-3 years from age 20-39 years

Annually = 40

72
Q

Mammography

A

Anually = 40 years

73
Q

20-25% lifetime risk of breast cancer in women exposed to

A

chest irradiation 10-30 years of age

74
Q

Breast pain that may be benign or pathologic

Cyclic - menstrual, intense before menstruation

Pain at B upper outer quadrant

Tx: Evening primrose oil, supportive bra, NSAID, dec caffeine intake

A

Mastodynia

75
Q

Male breast bud due to abnormal hormonal stimulation

A

Gynecomastia

76
Q

Medications that cause gynecomastia

A 
Antipsychotic
Cimetidine
Omeprazole
Spironolactone
Ketoconazole

Others:
androgen deficiency, chronic disease (hepatic, renal)

77
Q

33, lactating
diffuse erythematous and tender breast
febrile, tender without mass and leukocytosis

Diff and tx

A

Puerperal mastitis
Breast abscess
Inflammatory breast cancer

Continue breastfeeding and tx staphylococcus aureus

78
Q

Periductal mastitis and abscesses are found in

A

young female smokers

older diabetics with ductal ectasia

79
Q

Lactating women mastitis causative org:

A

S aureus

80
Q

Nonlactating women causative org:

A

Polymicrobial, anaerobic flora

81
Q 
Palpable 
Tender
Fluctuang mass
Nipple discharge
Fever
A

Breast abscess

82
Q

Tx of puerperal mastitis

A

Gram positive cocci: dicloxacillin, cephalosporin
Warm pack, continuation of breast feeding
If abscess is present, consider needle aspiration or incision and drainage

83
Q

Nonpuerperal antibiotics tx

A

Antibiotics to cover mixed (dicloxacillin and metronidazole)
If abscess is present, needle aspiration or incision and drainage
If recurrent consider subareolar duct excision

84
Q

Consider for women with mastitis or abscess once infection resolved to rule out malig

A

Mammogram

85
Q

Overgrowth of lobular tissue due to ductal proliferation and stromal fibrosis
Reproductive and menopausal women
Pain and breast mass
Confused with cancer
Not associated with cancer but need excisional biopsy

A

Sclerosing adenosis

86
Q

Bloody discharge from single duct as lesion detected on mammographic screening
Premenopausal women

Work up: ductal lavage, ductography, mammography, epithelial derived polyp

Malignant potential low

Tx: excision

A

Intraductal papilloma

87
Q

Confused with cancer

Biopsy always warranted

A

Radial scar of sclerosing adenosis

88
Q

Benign mass of stromal and glandular element
Most common solid breast lesion in women <30 years
Firm, mobile painful bilateral or multiple

Pain and size may vary with hormonal stimulation

A

Fibroadenoma

89
Q

Fibroadenoma dx

A

Triple test of clinical exam (rubbery, mobile)
UTZ (lack of cyst cavity)
Biopsy (proliferation of stroma and epithelium)

Confirms diagnosis

90
Q

For small confirmed fibroadenoma, tx

A

observation

If symptomatic or inc in size resect

91
Q

Benign associated with proliferation of fibrous tissue resulting cyst and nodularity
Due to estrogen stimulation

Most common breast lesion

A

Fibrocystic disease

30-50 yrs

92
Q

Firm mobile asymp but tender
Multiple or bilateral
Size and pain vary with menstrual cycle phase: premenstrual cycle is associated with inc lesion size

A

Fibrocystic disease

93
Q

Confirms histopath diagnosis of fibrocystic disease

also drains cyst

A

FNA

94
Q

Fibocystic change tx

A

Minimize caffeine to control pain
Take vit E or danazol
Regresses with dec estrogen level

If failure to regress after aspiration, bloody cyst or suspicious for cancer, excise

95
Q

Most common nonepithelial tumor
Large painless mobile rapidly growing histologically leaf like in appearance

Tx: wide local excision with minimum 1 cm margin

If large or recurrent, perform mastectomy
Lymph node not indicated

A

Phyllodes tumor

Malignant variant: cystosarcoma phyllodes

96
Q

Sclerosing thrombophlebitis of anterior chest wall following radical mastectomy
Cord like mass

Tx: NSAID

A

Mondor syndrome

97
Q

Hypoplasia or absence of pecs major with lack of breast development and ipsilateral hand development anomaly

A

Poland syndrome

98
Q

Proliferation of ductal epi
Papillary cribriform or comedo growth pattern
Without invasion of basement membrane

Adenocarcinoma precursor
5 fold inc in ipsilateral breast cancer

Women in 5th to 6th decade

A

Ductal carcinoma in situ

99
Q

Eczematoid lesion of nipple
Associated with underlying DCIS

Always suspect DCIS or IDC

A

Paget disease of the breast

100
Q

Mammography in DCIS

A

microcalcification

101
Q

Confirms dx in DCIS

A

Biopsy

102
Q

Grade of DCIS determined by:

A

necrosis (comedo)

nuclear atypia

103
Q

High grade nuclear atypia and necrosis indicate

A

high grade DCIS

inc risk of microinvasion and LN metastasis

104
Q

Differentiate Paget from

A

melanoma

105
Q

Prognostic index helps guide tx with WLE with or without radiation vs simple mastectomy in DCIS

A

Van Nuys

106
Q

Dec risk of contralateral breast cancer and recurrence

A

Tamoxifen

107
Q

45, Confirmed LCIS
Post op asks advice on risk of BC and prevention

Counsel?

A

LCIS associated with inc risk of malignancy in either breast

Tamoxifen dec risk of cancer

Mx: observation, prophylactic mastectomy

108
Q

Indicative of inc risk of ca in ipsilateral breast

A

DCIS

109
Q

Inc risk of ca in either breast at multiple site

A

LCIS

110
Q 
Proliferation of terminal duct lobule
Not preinvasive to ductal adenocarcinoma
Associated with 30% risk of ductal adenocarcinoma in either breast 
Premenopausal caucasian 
Asymptomatic

Adjacent calcification in mammography

A

LCIS

111
Q

Most common cancer in female

Postmenopausal
1 in every 8-9

A

Ductal adenocarcinoma

112
Q

Breast ca rf:

A 
Advanced age >50
BRCA1/BRCA2
Caucasian race
Delayed menopause or first pregnancy
Early menarche
Family history of breast cancer
Genetic syndrome
History of breast cancer/atypical ductal hyperplasia
113
Q

Painless
Firm
Fixed mass

Skin retraction
Nipple inversion
Skin changes (peau d orange)
Bleeding
Ulceration

Paget of breast

Suspicious axillary nodes

A

Ductal adenocarcinoma

114
Q

Dx work up of suspicious breast lesion

A

B mammography
Targeted uts
Biopsy FNA, core or excisional

115
Q

Goal of sx DA

A

Control of local disease (lumpectomy or mastectomy)

Evaluation of nodal disease

116
Q

Contraindications to breast conserving surgery

A

Previous radiation to affected breast
Multicentric disease
Large tumor relative to breast size
High risk of local recurrence

117
Q

Lumpectomy with radiation vs MRM

A

no difference to overall or disease free survival

118
Q

Nodal disease is evaluated by

A

sentinel ln biopsy (SLNB)

axillary lymph node dissection for +SLNBx, known LN + disease from FNA or clinical exam and inflammatory type of disease

119
Q

SLNBx is performed via

A

preop isosulfan blue or methylene blue
Tc sulfur colloid

80-100% sensitivity

120
Q

Used to decrease rate of local recurrence when used in combination with breast conserving surgery

A

Radiation

121
Q

Radiation is contraindicated during pregnancy

or

A

1st and 2nd tri

with prior chest wall radiation

122
Q

Beneficial to all with high risk of relapse regardless of nodal status

Withheld in patients with tumors <1cm and - lymph nodes

Dec recurrence by 30

A

Chemotherapy

123
Q

Chemotherapy in DCa

A

Anthracycline (doxorubicin cyclophosphamide, 5-FU-doxorubicin-cyclophosphamide)
Anthracycline with taxane (paclitaxel)

124
Q

Reduces recurrent and mortality of patients with estrogen + tumors
Helps prevent collateral breast cancer and cancer in high risk patients

A

Hormonal therapy

125
Q

Located on ch17q
Member of epidermal growth factor receptor family
Overexpression assoc with dec disease-free breast cancer survival

A

HER2/neu

126
Q

Selective estrogen receptor modulator
Standard regimen: 20 mg/d for 5 years
Reduces risk of recurrent and contralateral breast cancer and improves overall disease free survival
Primary prevention of high risk groups (dec up to 50)
Inc risk of endometrial cancer, stroke and thromboembolic event
Benefits include inc bone density and dec low density lipoprotein cholesterol

A

Tamoxifen

127
Q

Aromatase inhibitor used in postmenopausal women in those with contraindication to tamoxifen

Improves disease free survival and risk of contralateral cancer compared to tamoxifen alone

A

Anastrozole

128
Q

Contraindications to tamoxifen use

A

Uterine cancer
Allergy
History of venous thrombosis

129
Q

Response to hormonal therapy

A

ER+/PR+
ER-/PR+
ER+/PR-
ER-/PR-

130
Q

Monoclonal antibody to HER2 that may be used with HER2/neu + both the adjuvant and metastatic setting

side effect: cardiomyopathy

A

Trastuzu

131
Q

Trastuzumab SE

A

cardiomyopathy

132
Q

Inflammatory breast cancer

Negative node

A

Stage IIIB

133
Q

Paget disease without mass

A

Stage 0

134
Q

Cancer >5cm

Negative node

A

Stage II

135
Q

Cancer >5cm

Positive node

A

Stage III

136
Q

Any size

Positive ipsilateral supraclavicular lymph node

A

Stage IIIB

137
Q

Distant metastases

A

Stage IV

138
Q

Site of breast metastases

A

bone
lung
brain

139
Q

Lymphangiosarcoma in setting of chronic lymphedema following MRM

A

Stewart Treves Syndrome

140
Q 
10% of breast cancer cases
Associated with ill defined fibrotic mass
More likely ER+ PR+
Multicentric, bilateral
Histology: indian filing of tumor cells
A

Lobular carcinoma of breast

141
Q 
5% of breast cancer cases
Younger women
Rapid onset breast erythema
Edema, warmth, pain 
Differentiated from mastitis associated with leukocytosis, fever, response to antibiotics

Clinical diagnosis but workup include skin biopsy reveals tumor invasion into lymphatics

Tx: chemo, MRM, radiation, hormonal therapy if ER+

A

Inflammatory

142
Q

Portends worst prognosis of all types

A

Inflammatory breast cancer

143
Q 
Rare
Inc prevalance in men >60
BRCA2 
Family hx of breast cancer
Gynecomastia
Ashkenazi jew
Klinefelter’s syndrome 47 XXY
Radiation

Painless, retroareolar mass with nipple discharge
Mobile, painful and rubbery

Resect MRM, tamoxifen as most are ER +

Metastasis: tamoxifen, orchiectomy

A

Male breast cancer

144
Q

diagnosed during pregnancy or within 1 yr of delivery

Tx during first and second trimester:

A

Breast cancer in pregnant

MRM

Radiation CI in first and second

Terminate if warrants chemo or radiation at first trimester

145
Q

Breast cancer diagnosed at third trimester tx

A

lumpectomy with radiation
lumpectomy with axillary node dissection if radiation is deferred

Chemo delayed until delivery

146
Q

Post partum breast ca mx

A

Breast conservation sx
MRM
lactation supressed
avoid pregnancy for 1 year

147
Q

Difference between MRM and simple mastectomy

A

Simple mastectomy - removes breast tissue

MRM - additionally removes pectoralis fascia and axillary lymph node

148
Q

Prophylaxis for BRCA1 +

A

Bilateral salpingooophorectomy after childbearing
Bilateral risk reducing mastectomy

30% dec breast cancer risk after bilateral oophorectomy

Follow with screening MRI and mammography

149
Q

Mutation in
breast male cancer
Li-Fraumeni

A

BRCA2

p53

150
Q

Overexpression of which oncogene is associated with dec disease free survival from breast cancer

A

HER2/neu

151
Q

Tx options for axillary metastases without known primary

A

Ipsilateral MRM and chemo

Axillary lymph node dissection, whole breast radiation therapy, systemic chemotherapy

152
Q

20
Rubbery 1cm mass of left breast

Dx

A

Fibroadenoma

153
Q

40
Bilateral cyclical painful breast masses

Most likely diagnosis?

A

Fibrocystic disease

154
Q

35 F
8cm mass
Histology: leaf like appearance

Most likely dx?
Tx?

A

Phyllodes tumor
Mastectomy because of size
Wide excision with 1cm margin

155
Q 
39 
Family hx of breast cancer
Diagnosed with LCIS of right breast
Options?
What if she was diagnosed with DCIS?
A

LCIS: observation vs bilateral prophylactic mastectomy
DCIS: lumpectomy with radiation or simple mastectomy (and possibly prophylactic contralateral mastectomy)

156
Q

54
Hx of Hodgkin’s lymphoma s/p mantle radiation therapy 1cm breast carcinoma

Mx?

A

Simple mastectomy

SLNBx or MRM

157
Q

10 years s/p mastectomy
Stewart Treves syndrome

Tx

A

Amputation of limb

Surgery (17 decks)

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