Breast, C56 P399-P418 Flashcards
ANATOMY OF THE BREAST AND AXILLA
Name the boundaries of the axilla for dissection:
Superior boundary
P399
Axillary vein
ANATOMY OF THE BREAST AND AXILLA
Name the boundaries of the axilla for dissection:
Posterior boundary
P399
Long thoracic nerve
ANATOMY OF THE BREAST AND AXILLA
Name the boundaries of the axilla for dissection:
Lateral boundary
P399
Latissimus dorsi muscle
ANATOMY OF THE BREAST AND AXILLA
Name the boundaries of the axilla for dissection:
Medial boundary
P399
Lateral to, deep to, or medial to pectoral
minor muscle, depending on level of
nodes taken
ANATOMY OF THE BREAST AND AXILLA What four nerves must the surgeon be aware of during an axillary dissection? P399
- Long thoracic nerve
- Thoracodorsal nerve
- Medial pectoral nerve
- Lateral pectoral nerve
ANATOMY OF THE BREAST AND AXILLA
Describe the location of these nerves and the muscle each innervates:
Long thoracic nerve
P399
Courses along lateral chest wall in
midaxillary line on serratus anterior muscle;
innervates serratus anterior muscle
ANATOMY OF THE BREAST AND AXILLA
Describe the location of these nerves and the muscle each innervates:
Thoracodorsal nerve
P399
Courses lateral to long thoracic nerve
on latissimus dorsi muscle; innervates
latissimus dorsi muscle
ANATOMY OF THE BREAST AND AXILLA
Describe the location of these nerves and the muscle each innervates:
Medial pectoral nerve
P399
Runs lateral to or through the pectoral
minor muscle, actually lateral to the lateral
pectoral nerve; innervates the pectoral
minor and pectoral major muscles
ANATOMY OF THE BREAST AND AXILLA
Describe the location of these nerves and the muscle each innervates:
Lateral pectoral nerve
P399
Runs medial to the medial pectoral
nerve (names describe orientation from
the brachial plexus!); innervates the
pectoral major
ANATOMY OF THE BREAST AND AXILLA
Identify the nerves in the
axilla on the illustration below:
P400 (picture)
- Thoracodorsal nerve
- Long thoracic nerve
- Medial pectoral nerve
- Lateral pectoral nerve
- Axillary vein
ANATOMY OF THE BREAST AND AXILLA What is the name of the deformity if you cut the long thoracic nerve in this area? P400
“Winged scapula”
ANATOMY OF THE BREAST AND AXILLA What is the name of the CUTANEOUS nerve that crosses the axilla in a transverse fashion? (Many surgeons try to preserve this nerve.) P400
Intercostobrachial nerve
ANATOMY OF THE BREAST AND AXILLA What is the name of the large vein that marks the upper limit of the axilla? P400
Axillary vein
ANATOMY OF THE BREAST AND AXILLA
What is the lymphatic
drainage of the breast?
P400
Lateral: axillary lymph nodes
Medial: parasternal nodes that run with
internal mammary artery
ANATOMY OF THE BREAST AND AXILLA
What are the levels of axillary
lymph nodes?
P400 (picture)
Level I (low): lateral to pectoral minor
Level II (middle): deep to pectoral minor
Level III (high): medial to pectoral minor
In breast cancer, a higher level of
involvement has a worse prognosis,
but the level of involvement is less
important than the number of positive
nodes (Think: Levels I, II, and III are
in the same inferior–superior anatomic
order as the Le Fort facial fractures
and the trauma neck zones; I dare you
to forget!)
ANATOMY OF THE BREAST AND AXILLA
What are Rotter’s nodes?
P401
Nodes between the pectoralis major and
minor muscles; not usually removed
unless they are enlarged or feel
suspicious intraoperatively
ANATOMY OF THE BREAST AND AXILLA
What are the suspensory
breast ligaments called?
P401
Cooper’s ligaments
ANATOMY OF THE BREAST AND AXILLA
What is the mammary “milk
line”?
P401
Embryological line from shoulder to
thigh where “supernumerary” breast
areolar and/or nipples can be found
ANATOMY OF THE BREAST AND AXILLA
What is the “tail of Spence”?
P401
“Tail” of breast tissue that tapers into the
axilla
ANATOMY OF THE BREAST AND AXILLA Which hormone is mainly responsible for breast milk production? P401
Prolactin
BREAST CANCER
What is the incidence of
breast cancer?
P401
12% lifetime risk
BREAST CANCER What percentage of women with breast cancer have no known risk factor? P401
75%!
BREAST CANCER What percentage of all breast cancers occur in women younger than 30 years? P401
≈2%
BREAST CANCER What percentage of all breast cancers occur in women older than 70 years? P401
33%
BREAST CANCER
What are the major breast
cancer susceptibility genes?
P401
BRCA1 and BRCA2 (easily remembered:
BR = BReast and CA = CAncer)
BREAST CANCER What option exists to decrease the risk of breast cancer in women with BRCA? P401
Prophylactic bilateral mastectomy
BREAST CANCER What is the most common motivation for medicolegal cases involving the breast? P401
Failure to diagnose a breast carcinoma
BREAST CANCER What is the “TRIAD OF ERROR” for misdiagnosed breast cancer? P402
- Age 75% of cases of
MISDIAGNOSED breast cancer have
these three characteristics
BREAST CANCER
What are the history risk
factors for breast cancer?
P402
“NAACP”:
Nulliparity
Age at menarche (younger than 13 years)
Age at menopause (older than 55 years)
Cancer of the breast (in self or family)
Pregnancy with first child ( >30 years)
BREAST CANCER What are physical/anatomic risk factors for breast cancer? P402
“CHAFED LIPS”: Cancer in the breast (3% synchronous contralateral cancer) Hyperplasia (moderate/florid) (2X risk) Atypical hyperplasia (4X) Female (100X male risk) Elderly DCIS
LCIS Inherited genes (BRCA I and II) Papilloma (1.5X) Sclerosing adenosis (1.5X)
BREAST CANCER What is the relative risk of hormone replacement therapy? P402
1–1.5
BREAST CANCER Is “run of the mill” fibrocystic disease a risk factor for breast cancer? P402
No
BREAST CANCER
What are the possible
symptoms of breast cancer?
P402
No symptoms Mass in the breast Pain (most are painless) Nipple discharge Local edema Nipple retraction Dimple Nipple rash
BREAST CANCER
Why does skin retraction
occur?
P403
Tumor involvement of Cooper’s ligaments
and subsequent traction on ligaments
pull skin inward
BREAST CANCER
What are the signs of breast
cancer?
P403
Mass (1 cm is usually the smallest lesion that can be palpated on examination) Dimple Nipple rash Edema Axillary/supraclavicular nodes
BREAST CANCER
What is the most common
site of breast cancer?
P403
Approximately one half of cancers
develop in the upper outer quadrants
BREAST CANCER
What are the different types
of invasive breast cancer?
P403
Infiltrating ductal carcinoma (≈75%) Medullary carcinoma (≈15%) Infiltrating lobular carcinoma (≈5%) Tubular carcinoma (≈2%) Mucinous carcinoma (colloid) (≈1%) Inflammatory breast cancer (≈1%)
BREAST CANCER
What is the most common
type of breast cancer?
P403
Infiltrating ductal carcinoma
BREAST CANCER
What is the differential
diagnosis?
P403
Fibrocystic disease of the breast Fibroadenoma Intraductal papilloma Duct ectasia Fat necrosis Abscess Radial scar Simple cyst
BREAST CANCER Describe the appearance of the edema of the dermis in inflammatory carcinoma of the breast. P403
Peau d’orange (orange peel)
BREAST CANCER What are the screening recommendations for breast cancer: Breast exam recommendations? P403
Self-exam of breasts monthly Ages 20 to 40 years: breast exam every 2 to 3 years by a physician >40 years: annual breast exam by physician
BREAST CANCER What are the screening recommendations for breast cancer: Mammograms? P404
Recommendations are controversial, but most experts say: Baseline mammogram between 35 and 40 years Mammogram every year or every other year for ages 40 to 50 Mammogram yearly after age 50
BREAST CANCER
When is the best time for
breast self-exams?
P404
1 week after menstrual period
BREAST CANCER Why is mammography a more useful diagnostic tool in older women than in younger? P404
Breast tissue undergoes fatty replacement with age, making masses more visible; younger women have more fibrous tissue, which makes mammograms harder to interpret
BREAST CANCER
What are the radiographic
tests for breast cancer?
P404
Mammography and breast ultrasound,
MRI
BREAST CANCER What is the classic picture of breast cancer on mammogram? P404 (picture)
Spiculated mass
BREAST CANCER Which option is best to evaluate a breast mass in a woman younger than 30 years? P404
Breast ultrasound
BREAST CANCER What are the methods for obtaining tissue for pathologic examination? P404
Fine needle aspiration (FNA), core biopsy (larger needle core sample), mammotome stereotactic biopsy, and open biopsy, which can be incisional (cutting a piece of the mass) or excisional (cutting out the entire mass)
BREAST CANCER
What are the indications
for biopsy?
P405
Persistent mass after aspiration Solid mass Blood in cyst aspirate Suspicious lesion by mammography/ ultrasound/MRI Bloody nipple discharge Ulcer or dermatitis of nipple Patient’s concern of persistent breast abnormality
BREAST CANCER What is the process for performing a biopsy when a nonpalpable mass is seen on mammogram? P405
Stereotactic (mammotome) biopsy or
needle localization biopsy
BREAST CANCER
What is a needle loc biopsy (NLB)?
P405
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
BREAST CANCER
What is a mammotome
biopsy?
P405
Mammogram-guided computerized
stereotatic core biopsies
BREAST CANCER
What is obtained first, the
mammogram or the biopsy?
P405
Mammogram is obtained first; otherwise, tissue extraction (core or open) may alter the mammographic findings (fine needle aspiration may be done prior to the mammogram because the fine needle usually will not affect the mammographic findings)
BREAST CANCER
What would be suspicious
mammographic findings?
P405
Mass, microcalcifications, stellate/
spiculated mass
BREAST CANCER
What is a “radial scar” seen
on mammogram?
P405
Spiculated mass with central lucency,
+/– microcalcifications
BREAST CANCER
What tumor is associated
with a radial scar?
P405
Tubular carcinoma; thus, biopsy is
indicated
BREAST CANCER
What is the “workup” for a
breast mass?
P405
- Clinical breast exam
- Mammogram or breast ultrasound
- Fine needle aspiration, core biopsy, or
open biopsy
BREAST CANCER
How do you proceed if the
mass appears to be a cyst?
P406
Aspirate it with a needle
BREAST CANCER
Is the fluid from a breast
cyst sent for cytology?
P406
Not routinely; bloody fluid should be sent
for cytology
BREAST CANCER When do you proceed to open biopsy for a breast cyst? P406
- In the case of a second cyst recurrence
- Bloody fluid in the cyst
- Palpable mass after aspiration
BREAST CANCER What is the preoperative staging workup in a patient with breast cancer? P406
Bilateral mammogram (cancer in one breast is a risk factor for cancer in the contralateral breast!) CXR (to check for lung metastasis) LFTs (to check for liver metastasis) Serum calcium level, alkaline phosphatase (if these tests indicate bone metastasis/“bone pain,” proceed to bone scan) Other tests, depending on signs/ symptoms (e.g., head CT if patient has focal neurologic deficit, to look for brain metastasis)
BREAST CANCER What hormone receptors must be checked for in the biopsy specimen? P406
Estrogen and progesterone receptors—this is key for determining adjuvant treatment; this information must be obtained on all specimens (including fine needle aspirates)
BREAST CANCER
What staging system is used
for breast cancer?
P406
TMN: Tumor/Metastases/Nodes (AJCC)
BREAST CANCER
Describe the staging (simplified):
Stage I
P406
Tumor ≤2 cm in diameter without
metastases, no nodes
BREAST CANCER
Describe the staging (simplified):
Stage IIA
P406
Tumor ≤2 cm in diameter with mobile
axillary nodes or
Tumor 2 to 5 cm in diameter, no nodes
BREAST CANCER
Describe the staging (simplified):
Stage IIB
P407
Tumor 2 to 5 cm in diameter with mobile
axillary nodes or
Tumor >5 cm with no nodes
BREAST CANCER
Describe the staging (simplified):
Stage IIIA
P407
Tumor >5 cm with mobile
axillary nodes or
Any size tumor with fixed axillary nodes,
no metastases
BREAST CANCER
Describe the staging (simplified):
Stage IIIB
P407
Peau d’orange (skin edema) or Chest wall invasion/fixation or Inflammatory cancer or Breast skin ulceration or Breast skin satellite metastases or Any tumor and + ipsilateral internal mammary lymph nodes
BREAST CANCER
Describe the staging (simplified):
Stage IIIC
P407
Any size tumor, no distant mets
POSITIVE: supraclavicular,
infraclavicular, or internal
mammary lymph nodes
BREAST CANCER
Describe the staging (simplified):
Stage IV
P407
Distant metastases (including ipsilateral supraclavicular nodes)
BREAST CANCER
What are the sites of
metastases?
P407
Lymph nodes (most common) Lung/pleura Liver Bones Brain
BREAST CANCER
What are the major
treatments of breast cancer?
P407
Modified radical mastectomy Lumpectomy and radiation sentinel lymph node dissection (Both treatments either +/– postop chemotherapy/tamoxifen)