Breast Flashcards
1
Q
Forms epithelium of glands and ducts
A
Ectoderm
2
Q
Supporting CT of breast is from
A
mesenchyme
3
Q
Arise from ectoderm on ventral aspect of embryo at
A
4-6 weeks
4
Q
All ridges regress except for a remnant at the
A
fourth ICS thorax
5
Q
Incomplete regression of ridge may lead to
A
polythelia accessory nipple
polymastia accessory mammary gland
6
Q
Anatomic boundaries of breast
A
Superior: second rib
Inferior: sixth to 7th
Medial: sternal border
Lateral: midaxillary line
7
Q
Mastectomy landmarks
A
Superior: clavicle
Inferior: inframammary fold
Medial: sternum
Lateral: lats dorsi
8
Q
Upper outer quadrant of breast extending to axilla forms
A
tail of Spence
9
Q
Forms CT framework of breast by anchoring dermis of skin to superficial fascia of pectoralis major
A
suspensory ligament of Cooper
10
Q
Breast bs
A
Internal thoracic artery
axillary artery
third to fifth intercostals
venous parallels arterial supply
11
Q
Sensory innveration of breast
A
Lateral and anterior cutaneous branches of 2nd to 6th intercostal nerves
12
Q
Innervates latissimus dorsi
Damage causes weak internal rotation and abduction
A
Thoracodorsal nerve
13
Q
Innvervates serratus anterior
Damage causes winged scapula
A
Long thoracic nerve
14
Q
Innervates portions of pecs major
Innervates minor
Damage causes atrophy
A
Medial and lateral anterior thoracic nerves
Medial nerve only
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
16
Q
Level I LN drainage
A
Lateral to pectoralis minor
17
Q
Level II Lymphatic node
A
Deep to pectoralis minor
18
Q
Level III Lymph node
A
Medial to pectoralis minor
19
Q
Superficial areas of breast drain
A
subareolar lymphatic plexus into deep lymphatic plexus
20
Q
Deep tissues drain via
A
axillary lymph
internal thoracic lymph
21
Q
Drainage of breast is primarily
A
axillary node
internal mammary node
22
Q
Group of nodes between pecs major and minor
A
Rotter’s node
23
Q
Removal of all breast tissue
A
Simple mastectomy
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
25
Removal of all breast tissue and pectoralis major and minor with axillary lymph node dissection
Radical mastectomy
26
Acts on ducts in men to destroy ductal epithelium
Androgen
27
Ductal epithelial proliferation
Estrogen from FSH and LH
28
ductal dilation and epithelial differentiation into secretory cell
progesterone
29
80% risk of breast cancer
BRCA1
30
60% risk of breast cancer
BRCA2
31
Breast cancer risk factors
Inc in Ashkenazi jews
Inc risk of male breast cancer with BRCA2
Inc risk of ovarian cancer with BRCA1
32
Inc risk of breast male cancer
BRCA2
33
Inc risk of ovarian cancer with
BRCA1
34
Induce milk production
Prolactin, GH, insulin
35
Associated with hyperestrogenemia
| Stimulates breast tissue
Obesity
| Cirrhosis
36
BRCA1 is located on
```
ch17q
AD
80% breast cancer
40% ovarian
Early disease onset and bilaterality
```
37
BRCA1 mutations necessitate
Bilateral salphingooophorectomy
38
BRCA2 is located on
ch13q involved in DNA repair
Inc risk of breast cancer 60% including males
Inc risk of ovarian cancer 15-25%
39
p53 mutation leads to soft tissue sarcoma, osteosarcoma, breast cancer, brain tumor and leukemia
Li-Fraumeni syndrome
40
PTEN mutation leads to breast
GI
CNS
skin eye thyroid GU bone
Cowden syndrome
41
STK11 mutation
GI
pigmented lesion
Breast
Peutz Jegher
42
DNA repair defect in telangiectasia
cerebellar ataxia
Inc risk of breast cancer
ataxia-telangiectasia
43
```
mismatch repair gene defect resulting in inc risk of colon
endometrial
ovarian
urinary
breast cancer
```
HNPCC
44
Indications for genetic testing for hereditary breast ovarian cancer
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
45
Unilateral, spontaneous, bloody (not serous of green) and clear (rather than milky)
Associated with cancer
46
Mass characterization of malignancy
Fixed
Firm
Nipple retraction and skin change (peau d’ orange)
47
Clinical breast exam is indicated:
Women 20-39 years every 2-3 years
| Women >/= 40 years of age anually
48
Asymptomatic
| Average risk =40
Annual mammography
49
Mammography +
| Palpable lesion
UTZ
50
UTZ: Supple cyst
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
51
Mammography +
| Nonpalpable lesion
Stereotactic biopsy
52
Useful in distinguishing between solid and cystic masses
| Women <35 in whom mammography is more difficult to interpret
Ultrasound
53
Of limited value in <35 bec of increased density of breast tissue
Mammography
54
Views in mammography
craniocaudal
| mediolateral oblique
55
Findings suggestive of malignancy in mammography
solid mass with or without stellate characteristics
asymetric thickening
clustered microcalcification
56
Sensitivity and specificity of mammogram
>90%
57
BIRADS 0
additional evaluation needed
58
BIRADS 1
Negative test
59
BIRADS 2
Benign finding
60
BIRADS 3
Probably benign
| Follow up in 6 months
61
BIRADS 4
Lesions suspicious for cancer
| Biopsy indicated
62
BIRADS 5
Highly suggestive of malignancy
| Biopsy indicated
63
BIRADS 6
Known malignancy
64
Not a replacement for mammography or uts
| Useful as supplemental tool for staging
MRI
65
Screening MRI is recommended
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
Indicated for new diagnoses of breast cancer
| in presence of lobular cancer or dense breast tissue
MRI
67
May be done in the office and yields rapid result
| Cannot differentiate carcinoma in situ from invasive cancer
FNA
68
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
Core biopsy
69
Operative biopsy with or without preoperative needle localization
Indicated for nonpalpable lesions
Needle localization reduces false biopsy result
Excisional biopsy
70
```
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
```
excisional biopsy
71
Clinical breast exam
Every 2-3 years from age 20-39 years
| Annually = 40
72
Mammography
Anually = 40 years
73
20-25% lifetime risk of breast cancer in women exposed to
chest irradiation 10-30 years of age
74
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
Mastodynia
75
Male breast bud due to abnormal hormonal stimulation
Gynecomastia
76
Medications that cause gynecomastia
```
Antipsychotic
Cimetidine
Omeprazole
Spironolactone
Ketoconazole
```
Others:
androgen deficiency, chronic disease (hepatic, renal)
77
33, lactating
diffuse erythematous and tender breast
febrile, tender without mass and leukocytosis
Diff and tx
Puerperal mastitis
Breast abscess
Inflammatory breast cancer
Continue breastfeeding and tx staphylococcus aureus
78
Periductal mastitis and abscesses are found in
young female smokers
| older diabetics with ductal ectasia
79
Lactating women mastitis causative org:
S aureus
80
Nonlactating women causative org:
Polymicrobial, anaerobic flora
81
```
Palpable
Tender
Fluctuang mass
Nipple discharge
Fever
```
Breast abscess
82
Tx of puerperal mastitis
Gram positive cocci: dicloxacillin, cephalosporin
Warm pack, continuation of breast feeding
If abscess is present, consider needle aspiration or incision and drainage
83
Nonpuerperal antibiotics tx
Antibiotics to cover mixed (dicloxacillin and metronidazole)
If abscess is present, needle aspiration or incision and drainage
If recurrent consider subareolar duct excision
84
Consider for women with mastitis or abscess once infection resolved to rule out malig
Mammogram
85
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
Sclerosing adenosis
86
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
Intraductal papilloma
87
Confused with cancer
| Biopsy always warranted
Radial scar of sclerosing adenosis
88
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
Fibroadenoma
89
Fibroadenoma dx
Triple test of clinical exam (rubbery, mobile)
UTZ (lack of cyst cavity)
Biopsy (proliferation of stroma and epithelium)
Confirms diagnosis
90
For small confirmed fibroadenoma, tx
observation
If symptomatic or inc in size resect
91
Benign associated with proliferation of fibrous tissue resulting cyst and nodularity
Due to estrogen stimulation
Most common breast lesion
Fibrocystic disease
| 30-50 yrs
92
Firm mobile asymp but tender
Multiple or bilateral
Size and pain vary with menstrual cycle phase: premenstrual cycle is associated with inc lesion size
Fibrocystic disease
93
Confirms histopath diagnosis of fibrocystic disease
| also drains cyst
FNA
94
Fibocystic change tx
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
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
Phyllodes tumor
Malignant variant: cystosarcoma phyllodes
96
Sclerosing thrombophlebitis of anterior chest wall following radical mastectomy
Cord like mass
Tx: NSAID
Mondor syndrome
97
Hypoplasia or absence of pecs major with lack of breast development and ipsilateral hand development anomaly
Poland syndrome
98
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
Ductal carcinoma in situ
99
Eczematoid lesion of nipple
Associated with underlying DCIS
Always suspect DCIS or IDC
Paget disease of the breast
100
Mammography in DCIS
microcalcification
101
Confirms dx in DCIS
Biopsy
102
Grade of DCIS determined by:
necrosis (comedo)
| nuclear atypia
103
High grade nuclear atypia and necrosis indicate
high grade DCIS
| inc risk of microinvasion and LN metastasis
104
Differentiate Paget from
melanoma
105
Prognostic index helps guide tx with WLE with or without radiation vs simple mastectomy in DCIS
Van Nuys
106
Dec risk of contralateral breast cancer and recurrence
Tamoxifen
107
45, Confirmed LCIS
Post op asks advice on risk of BC and prevention
Counsel?
LCIS associated with inc risk of malignancy in either breast
Tamoxifen dec risk of cancer
Mx: observation, prophylactic mastectomy
108
Indicative of inc risk of ca in ipsilateral breast
DCIS
109
Inc risk of ca in either breast at multiple site
LCIS
110
```
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
LCIS
111
Most common cancer in female
Postmenopausal
1 in every 8-9
Ductal adenocarcinoma
112
Breast ca rf:
```
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
Painless
Firm
Fixed mass
```
Skin retraction
Nipple inversion
Skin changes (peau d orange)
Bleeding
Ulceration
```
Paget of breast
Suspicious axillary nodes
Ductal adenocarcinoma
114
Dx work up of suspicious breast lesion
B mammography
Targeted uts
Biopsy FNA, core or excisional
115
Goal of sx DA
Control of local disease (lumpectomy or mastectomy)
| Evaluation of nodal disease
116
Contraindications to breast conserving surgery
Previous radiation to affected breast
Multicentric disease
Large tumor relative to breast size
High risk of local recurrence
117
Lumpectomy with radiation vs MRM
no difference to overall or disease free survival
118
Nodal disease is evaluated by
sentinel ln biopsy (SLNB)
| axillary lymph node dissection for +SLNBx, known LN + disease from FNA or clinical exam and inflammatory type of disease
119
SLNBx is performed via
preop isosulfan blue or methylene blue
Tc sulfur colloid
80-100% sensitivity
120
Used to decrease rate of local recurrence when used in combination with breast conserving surgery
Radiation
121
Radiation is contraindicated during pregnancy
or
1st and 2nd tri
with prior chest wall radiation
122
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
Chemotherapy
123
Chemotherapy in DCa
Anthracycline (doxorubicin cyclophosphamide, 5-FU-doxorubicin-cyclophosphamide)
Anthracycline with taxane (paclitaxel)
124
Reduces recurrent and mortality of patients with estrogen + tumors
Helps prevent collateral breast cancer and cancer in high risk patients
Hormonal therapy
125
Located on ch17q
Member of epidermal growth factor receptor family
Overexpression assoc with dec disease-free breast cancer survival
HER2/neu
126
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
Tamoxifen
127
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
Anastrozole
128
Contraindications to tamoxifen use
Uterine cancer
Allergy
History of venous thrombosis
129
Response to hormonal therapy
ER+/PR+
ER-/PR+
ER+/PR-
ER-/PR-
130
Monoclonal antibody to HER2 that may be used with HER2/neu + both the adjuvant and metastatic setting
side effect: cardiomyopathy
Trastuzu
131
Trastuzumab SE
cardiomyopathy
132
Inflammatory breast cancer
| Negative node
Stage IIIB
133
Paget disease without mass
Stage 0
134
Cancer >5cm
| Negative node
Stage II
135
Cancer >5cm
| Positive node
Stage III
136
Any size
| Positive ipsilateral supraclavicular lymph node
Stage IIIB
137
Distant metastases
Stage IV
138
Site of breast metastases
bone
lung
brain
139
Lymphangiosarcoma in setting of chronic lymphedema following MRM
Stewart Treves Syndrome
140
```
10% of breast cancer cases
Associated with ill defined fibrotic mass
More likely ER+ PR+
Multicentric, bilateral
Histology: indian filing of tumor cells
```
Lobular carcinoma of breast
141
```
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+
Inflammatory
142
Portends worst prognosis of all types
Inflammatory breast cancer
143
```
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
Male breast cancer
144
diagnosed during pregnancy or within 1 yr of delivery
| Tx during first and second trimester:
Breast cancer in pregnant
MRM
Radiation CI in first and second
Terminate if warrants chemo or radiation at first trimester
145
Breast cancer diagnosed at third trimester tx
lumpectomy with radiation
lumpectomy with axillary node dissection if radiation is deferred
Chemo delayed until delivery
146
Post partum breast ca mx
Breast conservation sx
MRM
lactation supressed
avoid pregnancy for 1 year
147
Difference between MRM and simple mastectomy
Simple mastectomy - removes breast tissue
| MRM - additionally removes pectoralis fascia and axillary lymph node
148
Prophylaxis for BRCA1 +
Bilateral salpingooophorectomy after childbearing
Bilateral risk reducing mastectomy
30% dec breast cancer risk after bilateral oophorectomy
Follow with screening MRI and mammography
149
Mutation in
breast male cancer
Li-Fraumeni
BRCA2
| p53
150
Overexpression of which oncogene is associated with dec disease free survival from breast cancer
HER2/neu
151
Tx options for axillary metastases without known primary
Ipsilateral MRM and chemo
| Axillary lymph node dissection, whole breast radiation therapy, systemic chemotherapy
152
20
Rubbery 1cm mass of left breast
Dx
Fibroadenoma
153
40
Bilateral cyclical painful breast masses
Most likely diagnosis?
Fibrocystic disease
154
35 F
8cm mass
Histology: leaf like appearance
Most likely dx?
Tx?
Phyllodes tumor
Mastectomy because of size
Wide excision with 1cm margin
155
```
39
Family hx of breast cancer
Diagnosed with LCIS of right breast
Options?
What if she was diagnosed with DCIS?
```
LCIS: observation vs bilateral prophylactic mastectomy
DCIS: lumpectomy with radiation or simple mastectomy (and possibly prophylactic contralateral mastectomy)
156
54
Hx of Hodgkin’s lymphoma s/p mantle radiation therapy 1cm breast carcinoma
Mx?
Simple mastectomy
| SLNBx or MRM
157
10 years s/p mastectomy
Stewart Treves syndrome
Tx
Amputation of limb
