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Section II General Surgery P203Surgical Recall Sixth > Breast, C56 P399-P418 > Flashcards

Breast, C56 P399-P418 Flashcards

1
Q

ANATOMY OF THE BREAST AND AXILLA
Name the boundaries of the axilla for dissection:
Superior boundary
P399

A

Axillary vein

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2
Q

ANATOMY OF THE BREAST AND AXILLA
Name the boundaries of the axilla for dissection:
Posterior boundary
P399

A

Long thoracic nerve

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3
Q

ANATOMY OF THE BREAST AND AXILLA
Name the boundaries of the axilla for dissection:
Lateral boundary
P399

A

Latissimus dorsi muscle

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4
Q

ANATOMY OF THE BREAST AND AXILLA
Name the boundaries of the axilla for dissection:
Medial boundary
P399

A

Lateral to, deep to, or medial to pectoral
minor muscle, depending on level of
nodes taken

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5
Q 
ANATOMY OF THE BREAST AND AXILLA
What four nerves must the
surgeon be aware of during
an axillary dissection?
P399
A
  1. Long thoracic nerve
  2. Thoracodorsal nerve
  3. Medial pectoral nerve
  4. Lateral pectoral nerve
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6
Q

ANATOMY OF THE BREAST AND AXILLA
Describe the location of these nerves and the muscle each innervates:
Long thoracic nerve
P399

A

Courses along lateral chest wall in
midaxillary line on serratus anterior muscle;
innervates serratus anterior muscle

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7
Q

ANATOMY OF THE BREAST AND AXILLA
Describe the location of these nerves and the muscle each innervates:
Thoracodorsal nerve
P399

A

Courses lateral to long thoracic nerve
on latissimus dorsi muscle; innervates
latissimus dorsi muscle

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8
Q

ANATOMY OF THE BREAST AND AXILLA
Describe the location of these nerves and the muscle each innervates:
Medial pectoral nerve
P399

A

Runs lateral to or through the pectoral
minor muscle, actually lateral to the lateral
pectoral nerve; innervates the pectoral
minor and pectoral major muscles

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9
Q

ANATOMY OF THE BREAST AND AXILLA
Describe the location of these nerves and the muscle each innervates:
Lateral pectoral nerve
P399

A

Runs medial to the medial pectoral
nerve (names describe orientation from
the brachial plexus!); innervates the
pectoral major

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10
Q

ANATOMY OF THE BREAST AND AXILLA
Identify the nerves in the
axilla on the illustration below:
P400 (picture)

A
  1. Thoracodorsal nerve
  2. Long thoracic nerve
  3. Medial pectoral nerve
  4. Lateral pectoral nerve
  5. Axillary vein
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11
Q 
ANATOMY OF THE BREAST AND AXILLA
What is the name of the
deformity if you cut the long
thoracic nerve in this area?
P400
A

“Winged scapula”

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12
Q 
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
A

Intercostobrachial nerve

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13
Q 
ANATOMY OF THE BREAST AND AXILLA
What is the name of the
large vein that marks the
upper limit of the axilla?
P400
A

Axillary vein

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14
Q

ANATOMY OF THE BREAST AND AXILLA
What is the lymphatic
drainage of the breast?
P400

A

Lateral: axillary lymph nodes
Medial: parasternal nodes that run with
internal mammary artery

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15
Q

ANATOMY OF THE BREAST AND AXILLA
What are the levels of axillary
lymph nodes?
P400 (picture)

A

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!)

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16
Q

ANATOMY OF THE BREAST AND AXILLA
What are Rotter’s nodes?
P401

A

Nodes between the pectoralis major and
minor muscles; not usually removed
unless they are enlarged or feel
suspicious intraoperatively

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17
Q

ANATOMY OF THE BREAST AND AXILLA
What are the suspensory
breast ligaments called?
P401

A

Cooper’s ligaments

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18
Q

ANATOMY OF THE BREAST AND AXILLA
What is the mammary “milk
line”?
P401

A

Embryological line from shoulder to
thigh where “supernumerary” breast
areolar and/or nipples can be found

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19
Q

ANATOMY OF THE BREAST AND AXILLA
What is the “tail of Spence”?
P401

A

“Tail” of breast tissue that tapers into the

axilla

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20
Q 
ANATOMY OF THE BREAST AND AXILLA
Which hormone is mainly
responsible for breast milk
production?
P401
A

Prolactin

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21
Q

BREAST CANCER
What is the incidence of
breast cancer?
P401

A

12% lifetime risk

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22
Q 
BREAST CANCER
What percentage of women
with breast cancer have no
known risk factor?
P401
A

75%!

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23
Q 
BREAST CANCER
What percentage of all breast
cancers occur in women
younger than 30 years?
P401
A

≈2%

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24
Q 
BREAST CANCER
What percentage of all
breast cancers occur in
women older than 70 years?
P401
A

33%

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25
Q

BREAST CANCER
What are the major breast
cancer susceptibility genes?
P401

A

BRCA1 and BRCA2 (easily remembered:

BR = BReast and CA = CAncer)

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26
Q 
BREAST CANCER
What option exists to
decrease the risk of breast
cancer in women with BRCA?
P401
A

Prophylactic bilateral mastectomy

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27
Q 
BREAST CANCER
What is the most common
motivation for medicolegal
cases involving the breast?
P401
A

Failure to diagnose a breast carcinoma

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28
Q 
BREAST CANCER
What is the “TRIAD OF
ERROR” for misdiagnosed
breast cancer?
P402
A
  1. Age 75% of cases of
    MISDIAGNOSED breast cancer have
    these three characteristics
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29
Q

BREAST CANCER
What are the history risk
factors for breast cancer?
P402

A

“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)

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30
Q 
BREAST CANCER
What are physical/anatomic
risk factors for breast
cancer?
P402
A 
“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)
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31
Q 
BREAST CANCER
What is the relative risk of
hormone replacement
therapy?
P402
A

1–1.5

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32
Q 
BREAST CANCER
Is “run of the mill”
fibrocystic disease a risk
factor for breast cancer?
P402
A

No

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33
Q

BREAST CANCER
What are the possible
symptoms of breast cancer?
P402

A 
No symptoms
Mass in the breast
Pain (most are painless)
Nipple discharge
Local edema
Nipple retraction
Dimple
Nipple rash
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34
Q

BREAST CANCER
Why does skin retraction
occur?
P403

A

Tumor involvement of Cooper’s ligaments
and subsequent traction on ligaments
pull skin inward

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35
Q

BREAST CANCER
What are the signs of breast
cancer?
P403

A 
Mass (1 cm is usually the smallest lesion
    that can be palpated on examination)
Dimple
Nipple rash
Edema
Axillary/supraclavicular nodes
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36
Q

BREAST CANCER
What is the most common
site of breast cancer?
P403

A

Approximately one half of cancers

develop in the upper outer quadrants

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37
Q

BREAST CANCER
What are the different types
of invasive breast cancer?
P403

A 
Infiltrating ductal carcinoma (≈75%)
Medullary carcinoma (≈15%)
Infiltrating lobular carcinoma (≈5%)
Tubular carcinoma (≈2%)
Mucinous carcinoma (colloid) (≈1%)
Inflammatory breast cancer (≈1%)
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38
Q

BREAST CANCER
What is the most common
type of breast cancer?
P403

A

Infiltrating ductal carcinoma

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39
Q

BREAST CANCER
What is the differential
diagnosis?
P403

A 
Fibrocystic disease of the breast
Fibroadenoma
Intraductal papilloma
Duct ectasia
Fat necrosis
Abscess
Radial scar
Simple cyst
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40
Q 
BREAST CANCER
Describe the appearance of
the edema of the dermis in
inflammatory carcinoma of
the breast.
P403
A

Peau d’orange (orange peel)

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41
Q 
BREAST CANCER
What are the screening
recommendations for breast
cancer:
Breast exam
recommendations?
P403
A 
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
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42
Q 
BREAST CANCER
What are the screening
recommendations for breast
cancer:
Mammograms?
P404
A 
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
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43
Q

BREAST CANCER
When is the best time for
breast self-exams?
P404

A

1 week after menstrual period

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44
Q 
BREAST CANCER
Why is mammography a
more useful diagnostic tool
in older women than in
younger?
P404
A 
Breast tissue undergoes fatty replacement
with age, making masses more visible;
younger women have more fibrous tissue,
which makes mammograms harder to
interpret
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45
Q

BREAST CANCER
What are the radiographic
tests for breast cancer?
P404

A

Mammography and breast ultrasound,

MRI

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46
Q 
BREAST CANCER
What is the classic picture
of breast cancer on
mammogram?
P404 (picture)
A

Spiculated mass

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47
Q 
BREAST CANCER
Which option is best to
evaluate a breast mass in
a woman younger than
30 years?
P404
A

Breast ultrasound

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48
Q 
BREAST CANCER
What are the methods for
obtaining tissue for
pathologic examination?
P404
A 
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)
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49
Q

BREAST CANCER
What are the indications
for biopsy?
P405

A 
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
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50
Q 
BREAST CANCER
What is the process for
performing a biopsy when a
nonpalpable mass is seen on
mammogram?
P405
A

Stereotactic (mammotome) biopsy or

needle localization biopsy

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51
Q

BREAST CANCER
What is a needle loc biopsy (NLB)?
P405

A 
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
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52
Q

BREAST CANCER
What is a mammotome
biopsy?
P405

A

Mammogram-guided computerized

stereotatic core biopsies

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53
Q

BREAST CANCER
What is obtained first, the
mammogram or the biopsy?
P405

A 
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)
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54
Q

BREAST CANCER
What would be suspicious
mammographic findings?
P405

A

Mass, microcalcifications, stellate/

spiculated mass

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55
Q

BREAST CANCER
What is a “radial scar” seen
on mammogram?
P405

A

Spiculated mass with central lucency,

+/– microcalcifications

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56
Q

BREAST CANCER
What tumor is associated
with a radial scar?
P405

A

Tubular carcinoma; thus, biopsy is

indicated

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57
Q

BREAST CANCER
What is the “workup” for a
breast mass?
P405

A
  1. Clinical breast exam
  2. Mammogram or breast ultrasound
  3. Fine needle aspiration, core biopsy, or
    open biopsy
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58
Q

BREAST CANCER
How do you proceed if the
mass appears to be a cyst?
P406

A

Aspirate it with a needle

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59
Q

BREAST CANCER
Is the fluid from a breast
cyst sent for cytology?
P406

A

Not routinely; bloody fluid should be sent

for cytology

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60
Q 
BREAST CANCER
When do you proceed to
open biopsy for a breast
cyst?
P406
A
  1. In the case of a second cyst recurrence
  2. Bloody fluid in the cyst
  3. Palpable mass after aspiration
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61
Q 
BREAST CANCER
What is the preoperative
staging workup in a patient
with breast cancer?
P406
A 
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)
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62
Q 
BREAST CANCER
What hormone receptors
must be checked for in the
biopsy specimen?
P406
A 
Estrogen and progesterone
receptors—this is key for determining
adjuvant treatment; this information
must be obtained on all specimens
(including fine needle aspirates)
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63
Q

BREAST CANCER
What staging system is used
for breast cancer?
P406

A

TMN: Tumor/Metastases/Nodes (AJCC)

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64
Q

BREAST CANCER
Describe the staging (simplified):
Stage I
P406

A

Tumor ≤2 cm in diameter without

metastases, no nodes

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65
Q

BREAST CANCER
Describe the staging (simplified):
Stage IIA
P406

A

Tumor ≤2 cm in diameter with mobile
axillary nodes or
Tumor 2 to 5 cm in diameter, no nodes

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66
Q

BREAST CANCER
Describe the staging (simplified):
Stage IIB
P407

A

Tumor 2 to 5 cm in diameter with mobile
axillary nodes or
Tumor >5 cm with no nodes

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67
Q

BREAST CANCER
Describe the staging (simplified):
Stage IIIA
P407

A

Tumor >5 cm with mobile
axillary nodes or
Any size tumor with fixed axillary nodes,
no metastases

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68
Q

BREAST CANCER
Describe the staging (simplified):
Stage IIIB
P407

A 
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
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69
Q

BREAST CANCER
Describe the staging (simplified):
Stage IIIC
P407

A

Any size tumor, no distant mets
POSITIVE: supraclavicular,
infraclavicular, or internal
mammary lymph nodes

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70
Q

BREAST CANCER
Describe the staging (simplified):
Stage IV
P407

A 
Distant metastases (including ipsilateral
supraclavicular nodes)
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71
Q

BREAST CANCER
What are the sites of
metastases?
P407

A 
Lymph nodes (most common)
Lung/pleura
Liver
Bones
Brain
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72
Q

BREAST CANCER
What are the major
treatments of breast cancer?
P407

A 
Modified radical mastectomy
Lumpectomy and radiation  sentinel
    lymph node dissection
(Both treatments either +/– postop
    chemotherapy/tamoxifen)
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73
Q 
BREAST CANCER
What are the indications for
radiation therapy after a
modified radical mastectomy?
P407
A 
Stage IIIA
Stage IIIB
Pectoral muscle/fascia invasion
Positive internal mammary LN
Positive surgical margins
4 positive axillary LNs postmenopausal
74
Q 
BREAST CANCER
What breast carcinomas are
candidates for lumpectomy
and radiation (breastconserving
therapy)?
P407
A

Stage I and stage II (tumors <5 cm)

75
Q 
BREAST CANCER
What approach may allow a
patient with stage IIIA cancer
to have breast-conserving
surgery?
P408
A

NEOadjuvant chemotherapy—if the

preop chemo shrinks the tumor

76
Q 
BREAST CANCER
What is the treatment of
inflammatory carcinoma of
the breast?
P408
A

Chemotherapy first! Then often
followed by radiation, mastectomy, or
both

77
Q

BREAST CANCER
What is a “lumpectomy and
radiation”?
P408

A

Lumpectomy (segmental mastectomy:
removal of a part of the breast); axillary
node dissection; and a course of radiation
therapy after operation, over a period of
several weeks

78
Q 
BREAST CANCER
What is the major absolute
contraindication to
lumpectomy and radiation?
P408
79
Q 
BREAST CANCER
What are other
contraindications to
lumpectomy and radiation?
P408
A 
Previous radiation to the chest
Positive margins
Collagen vascular disease (e.g.,
    scleroderma)
Extensive DCIS (often seen as diffuse
    microcalcification)
Relative contraindications:
    Lesion that cannot be seen on the
       mammograms (i.e., early
       recurrence will be missed on
       follow-up mammograms)
    Very small breast (no cosmetic
       advantage)
80
Q

BREAST CANCER
What is a modified radical
mastectomy?
P408

A 
Breast, axillary nodes (level II, I), and
nipple–areolar complex are removed
Pectoralis major and minor muscles
are not removed (Auchincloss
modification)
Drains are placed to drain lymph fluid
81
Q

BREAST CANCER
Where are the drains placed
with an MRM?
P408

A
  1. Axilla

2. Chest wall (breast bed)

82
Q

BREAST CANCER
When should the drains be
removed?
P408

A

<30 cc/day drainage

83
Q 
BREAST CANCER
What are the potential
complications after a modified
radical mastectomy?
P409
A

Ipsilateral arm lymphedema, infection,
injury to nerves, skin flap necrosis,
hematoma/seroma, phantom breast
syndrome

84
Q 
BREAST CANCER
During an axillary dissection,
should the patient be
paralyzed?
P409
A

NO, because the nerves (long thoracic/
thoracodorsal) are stimulated with
resultant muscle contraction to help
identify them

85
Q 
BREAST CANCER
How can the long thoracic
and thoracodorsal nerves be
identified during an axillary
dissection?
P409
A

Nerves can be stimulated with a
forceps, which results in contraction of
the latissimus dorsi (thoracodorsal nerve)
or anterior serratus (long thoracic nerve)

86
Q 
BREAST CANCER
When do you remove the
drains after an axillary
dissection?
P409
A

When there is <30 cc of drainage per day,

or on POD #14 (whichever comes first)

87
Q

BREAST CANCER
What is a sentinel node
biopsy?
P409

A

Instead of removing all the axillary
lymph nodes, the primary draining or
“sentinel” lymph node is removed

88
Q

BREAST CANCER
How is the sentinel lymph
node found?
P409

A 
Inject blue dye and/or technetium-labeled
sulfur colloid (best results with both)
89
Q

BREAST CANCER
What follows a positive
sentinel node biopsy?
P409

A

Removal of the rest of the axillary lymph

nodes

90
Q 
BREAST CANCER
What is now considered the
standard of care for lymph
node evaluation in women
with T1 or T2 tumors (stages I
and IIA) and clinically
negative axillary lymph
nodes?
P409
A

Sentinel lymph node dissection

91
Q 
BREAST CANCER
What do you do with a
mammotome biopsy that
returns as “atypical
hyperplasia”?
P409
A

Open needle loc biopsy as many will have

DCIS or invasive cancer

92
Q

BREAST CANCER
How does tamoxifen work?
P409

A

It binds estrogen receptors

93
Q 
BREAST CANCER
What is the treatment for
local recurrence in breast
after lumpectomy and
radiation?
P410
A

“Salvage” mastectomy

94
Q

BREAST CANCER
Can tamoxifen prevent
breast cancer?
P410

A

Yes. In the Breast Cancer Prevention
Trial of 13,000 women at increased risk
of developing breast cancer, tamoxifen
reduced risk by ≈50% across all ages

95
Q

BREAST CANCER
What are common options
for breast reconstruction?
P410

A

TRAM flap, implant, latissimus dorsi flap

96
Q

BREAST CANCER
What is a TRAM flap?
P410 (picture)

A

Transverse Rectus Abdominis

Myocutaneous flap

97
Q

BREAST CANCER
What are side effects of
tamoxifen?
P410

A

Endometrial cancer (2.5X relative
risk), DVT, pulmonary embolus,
cataracts, hot flashes, mood swings

98
Q 
BREAST CANCER
In high-risk women, is there
a way to reduce the risk of
developing breast cancer?
P410
A

Yes, tamoxifen for 5 years will lower the
risk by up to 50%, but, with an increased
risk of endometrial cancer and clots,
it must be an individual patient
determination

99
Q

BREAST CANCER
Give the common adjuvant therapy for the following patients with breast cancer.
(These are rough guidelines; check for current uidelines, as they are always changing.)
(ER estrogen receptor):
Premenopausal, node +,
ER –
P411

A

Chemotherapy

100
Q

BREAST CANCER
Give the common adjuvant therapy for the following patients with breast cancer.
(These are rough guidelines; check for current uidelines, as they are always changing.)
(ER estrogen receptor):
Premenopausal, node +,
ER +
P411

A

Chemotherapy and tamoxifen

101
Q

BREAST CANCER
Give the common adjuvant therapy for the following patients with breast cancer.
(These are rough guidelines; check for current uidelines, as they are always changing.)
(ER estrogen receptor):
Premenopausal, node –,
ER +
P411

102
Q

BREAST CANCER
Give the common adjuvant therapy for the following patients with breast cancer.
(These are rough guidelines; check for current uidelines, as they are always changing.)
(ER estrogen receptor):
Postmenopausal, node +,
ER +
P411

A

Tamoxifen, +/– chemotherapy

103
Q

BREAST CANCER
Give the common adjuvant therapy for the following patients with breast cancer.
(These are rough guidelines; check for current uidelines, as they are always changing.)
(ER estrogen receptor):
Postmenopausal, node +,
ER –
P411

A

Chemotherapy, +/– tamoxifen

104
Q 
BREAST CANCER
What type of chemotherapy
is usually used for breast
cancer?
P411
A

CMF (Cyclophosphamide, Methotrexate,
5-Fluorouracil) or CAF
(Cyclophosphamide, Adriamycin,
5-Fluorouracil)

105
Q 
BREAST CANCER
Chemotherapy for high-risk
tumors with negative lymph
nodes should be considered.
What makes a tumor “HIGH
RISK”?
P411
A 
High risk:
    >1 cm in size
    Lymphatic/vascular invasion
    Nuclear grade (high)
    S phase (high)
    ER negative
    HER-2/neu overexpression
106
Q

DCIS
What does DCIS stand for?
P411

A

Ductal Carcinoma In Situ

107
Q

DCIS
What is DCIS also known as?
P411

A

Intraductal carcinoma

108
Q

DCIS
Describe DCIS.
P411

A

Cancer cells in the duct without invasion
(In situ: Cells do not penetrate the
basement membrane)

109
Q

DCIS
What are the signs/symptoms?
P412

A

Usually none; usually nonpalpable

110
Q

DCIS
What are the mammographic
findings?
P412

A

Microcalcifications

111
Q

DCIS
How is the diagnosis made?
P412

A

Core or open biopsy

112
Q

DCIS
What is the most aggressive
histologic type?
P412

113
Q

DCIS
What is the risk of lymph
node metastasis with DCIS?
P412

A

<2% (usually when microinvasion is

seen)

114
Q

DCIS
What is the major risk with
DCIS?
P412

A

Subsequent development of infiltrating

ductal carcinoma in the same breast

115
Q

DCIS
What is the treatment for DCIS in the following cases:
Tumor <1 cm (low grade)?
P412

A

Remove with 1 cm margins +/– XRT

116
Q

DCIS
What is the treatment for DCIS in the following cases:
Tumor >1 cm?
P412

A

Perform lumpectomy with 1 cm margins
and radiation or total mastectomy (no
axillary dissection)

117
Q

DCIS
What is a total (simple)
mastectomy?
P412

A

Removal of the breast and nipple without
removal of the axillary nodes (always
remove nodes with invasive cancer)

118
Q 
DCIS
When must a simple
mastectomy be performed
for DCIS?
P412
A

Diffuse breast involvement (e.g., diffuse
microcalcifications), >1 cm and
contraindication to radiation

119
Q

DCIS
What is the role of axillary
node dissection with DCIS?
P412

A

No role in true DCIS (i.e., without
microinvasion); some perform a sentinel
lymph node dissection for high-grade
DCIS

120
Q

DCIS
What is adjuvant for DCIS?
P412

A
  1. Tamoxifen

2. Postlumpectomy XRT

121
Q

DCIS
What is the role of
tamoxifen in DCIS?
P412

A

Tamoxifen for 5 years will lower the risk
up to 50%, but with increased risk of
endometrial cancer and clots; it must be
an individual patient determination

122
Q 
DCIS
What is a memory aid for
the breast in which DCIS
breast cancer arises?
P413
A

Cancer arises in the same breast as
DCIS (Think: DCIS = Directly in same
breast)

123
Q

LCIS
What is LCIS?
P413

A

Lobular Carcinoma In Situ (carcinoma
cells in the lobules of the breast without
invasion)

124
Q

LCIS
What are the signs/symptoms?
P413

A

There are none

125
Q

LCIS
What are the mammographic
findings?
P413

A

There are none

126
Q

LCIS
How is the diagnosis made?
P413

A

LCIS is found incidentally on biopsy

127
Q

LCIS
What is the major risk?
P413

A

Carcinoma of either breast

128
Q 
LCIS
Which breast is most at risk
for developing an invasive
carcinoma?
P413
A

Equal risk in both breasts! (Think of
LCIS as a risk marker for future
development of cancer in either breast)

129
Q 
LCIS
What percentage of women
with LCIS develop an
invasive breast carcinoma?
P413
A

≈30% in the 20 years after diagnosis of

LCIS!

130
Q 
LCIS
What type of invasive breast
cancer do patients with LCIS
develop?
P413
A

Most commonly, infiltrating ductal
carcinoma, with equal distribution in
the contralateral and ipsilateral breasts

131
Q 
LCIS
What medication may lower
the risk of developing breast
cancer in LCIS?
P413
A

Tamoxifen for 5 years will lower the risk
up to 50%, but with an increased risk of
endometrial cancer and clots; it must be
an individual patient determination

132
Q

LCIS
What is the treatment of LCIS?
P413

A

Close follow-up (or bilateral simple

mastectomy in high-risk patients)

133
Q 
LCIS
What is the major
difference in the subsequent
development of invasive
breast cancer with DCIS
and LCIS?
P413
A

LCIS cancer develops in either breast;
DCIS cancer develops in the ipsilateral
breast

134
Q 
LCIS
How do you remember
which breast is at risk for
invasive cancers in patients
with LCIS?
P414
A

Think: LCIS = Liberally in either breast

135
Q 
MISCELLANEOUS
What is the most common
cause of bloody nipple
discharge in a young woman?
P414
A

Intraductal papilloma

136
Q 
MISCELLANEOUS
What is the most common
breast tumor in patients
younger than 30 years?
P414
A

Fibroadenoma

137
Q

MISCELLANEOUS
What is Paget’s disease of
the breast?
P414

A

Scaling rash/dermatitis of the nipple
caused by invasion of skin by cells from a
ductal carcinoma

138
Q 
MISCELLANEOUS
What are the common
options for breast
reconstruction after a
mastectomy?
P414
A

Saline implant

TRAM flap

139
Q

MALE BREAST CANCER
What is the incidence of
breast cancer in men?
P414

A

<1% of all breast cancer cases (1/150)

140
Q

MALE BREAST CANCER
What is the average age at
diagnosis?
P414

A

65 years of age

141
Q

MALE BREAST CANCER
What are the risk factors?
P414

A 
Increased estrogen
Radiation
Gynecomastia from increased estrogen
Estrogen therapy
Klinefelter’s syndrome (XXY)
BRCA2 carriers
142
Q 
MALE BREAST CANCER
Is benign gynecomastia a
risk factor for male breast
cancer?
P414
143
Q

MALE BREAST CANCER
What type of breast cancer
do men develop?
P414

A

Nearly 100% of cases are ductal
carcinoma (men do not usually have
breast lobules)

144
Q 
MALE BREAST CANCER
What are the signs/
symptoms of breast cancer
in men?
P415
A 
Breast mass (most are painless), breast
skin changes (ulcers, retraction), and
nipple discharge (usually blood or a
blood-tinged discharge)
145
Q

MALE BREAST CANCER
What is the most common
presentation?
P415

A

Painless breast mass

146
Q

MALE BREAST CANCER
How is breast cancer in men
diagnosed?
P415

A

Biopsy and mammogram

147
Q

MALE BREAST CANCER
What is the treatment?
P415

A
  1. Mastectomy
  2. Sentinel LN dissection of clinically
    negative axilla
  3. Axillary dissection if clinically positive
    axillary LN
148
Q 
BENIGN BREAST DISEASE
What is the most common
cause of green, strawcolored,
or brown nipple
discharge?
P415
A

Fibrocystic disease

149
Q 
BENIGN BREAST DISEASE
What is the most common
cause of breast mass after
breast trauma?
P415
A

Fat necrosis

150
Q

BENIGN BREAST DISEASE
What is Mondor’s disease?
P415

A

Thrombophlebitis of superficial breast veins

151
Q 
BENIGN BREAST DISEASE
What must be ruled out with
spontaneous galactorrhea
( +/-- amenorrhea)?
P415
A

Prolactinoma (check pregnancy test and

prolactin level)

152
Q

CYSTOSARCOMA PHYLLODES
What is it?
P415

A

Mesenchymal tumor arising from breast
lobular tissue; most are benign (Note:
“sarcoma” is a misnomer, as the vast
majority are benign; 1% of breast cancers)

153
Q

CYSTOSARCOMA PHYLLODES
What is the usual age of the
patient with this tumor?
P415

A

35–55 years (usually older than the

patient with fibroadenoma)

154
Q

CYSTOSARCOMA PHYLLODES
What are the signs/
symptoms?
P416

A

Mobile, smooth breast mass that
resembles a fibroadenoma on exam,
mammogram/ultrasound findings

155
Q

CYSTOSARCOMA PHYLLODES
How is it diagnosed?
P416

A

Through core biopsy or excision

156
Q

CYSTOSARCOMA PHYLLODES
What is the treatment?
P416

A

If benign, wide local excision; if

malignant, simple total mastectomy

157
Q 
CYSTOSARCOMA PHYLLODES
What is the role of axillary
dissection with cystosarcoma
phyllodes tumor?
P416
A

Only if clinically palpable axillary nodes,
as the malignant form rarely spreads to
nodes (most common site of metastasis is
the lung)

158
Q 
CYSTOSARCOMA PHYLLODES
Is there a role for
chemotherapy with
cystosarcoma phyllodes?
P416
A

Consider chemotherapy if large tumor

>5 cm and “stromal overgrowth”

159
Q

FIBROADENOMA
What is it?
P416

A

Benign tumor of the breast consisting of
stromal overgrowth, collagen arranged in
“swirls”

160
Q 
FIBROADENOMA
What is the clinical
presentation of a
fibroadenoma?
P416
A

Solid, mobile, well-circumscribed round

breast mass, usually <40 years of age

161
Q

FIBROADENOMA
How is fibroadenoma
diagnosed?
P416

A

Negative needle aspiration looking for

fluid; ultrasound; core biopsy

162
Q

FIBROADENOMA
What is the treatment?
P416

A

Surgical resection for large or growing
lesions; small fibroadenomas can be
observed closely

163
Q

FIBROADENOMA
What is this tumor’s claim
to fame?
P416

A

Most common breast tumor in women

<30 years

164
Q

FIBROCYSTIC DISEASE
What is it?
P416

A

Common benign breast condition
consisting of fibrous (rubbery) and cystic
changes in the breast

165
Q

FIBROCYSTIC DISEASE
What are the signs/symptoms?
P416

A

Breast pain or tenderness that varies with
the menstrual cycle; cysts; and fibrous
(“nodular”) fullness

166
Q

FIBROCYSTIC DISEASE
How is it diagnosed?
P417

A

Through breast exam, history, and aspirated

cysts (usually straw-colored or green fluid)

167
Q 
FIBROCYSTIC DISEASE
What is the treatment for
symptomatic fibrocystic
disease?
P417
A

Stop caffeine
Pain medications (NSAIDs)
Vitamin E, evening primrose oil (danazol
and OCP as last resort)

168
Q

FIBROCYSTIC DISEASE
What is done if the patient
has a breast cyst?
P417

A

Needle drainage: If aspirate is bloody or
a palpable mass remains after aspiration,
an open biopsy is performed
If the aspirate is straw colored or green,
the patient is followed closely; then,
if there is recurrence, a second
aspiration is performed
Re-recurrence usually requires open biopsy

169
Q

MASTITIS
What is it?
P417

A

Superficial infection of the breast (cellulitis)

170
Q

MASTITIS
In what circumstance does it
most often occur?
P417

A

Breast-feeding

171
Q

MASTITIS
What bacteria are most
commonly the cause?
P417

A

Staphylococcus aureus

172
Q

MASTITIS
How is mastitis treated?
P417

A

Stop breast-feeding and use a breast pump

instead; apply heat; administer antibiotics

173
Q

MASTITIS
Why must the patient with
mastitis have close follow-up?
P417

A

To make sure that she does not have

inflammatory breast cancer!

174
Q

BREAST ABSCESS
What are the causes?
P417

A

Mammary ductal ectasia (stenosis of

breast duct) and mastitis

175
Q

BREAST ABSCESS
What is the most common
bacteria?
P417

A

Nursing = Staphylococcus aureus

Nonlactating = mixed infection

176
Q

BREAST ABSCESS
What is the treatment of
breast abscess?
P417

A 
Antibiotics (e.g., dicloxacillin)
Needle or open drainage with cultures
    taken
Resection of involved ducts if recurrent
Breast pump if breast-feeding
177
Q

BREAST ABSCESS
What is lactational mastitis?
P418

A

Infection of the breast during breastfeeding—
most commonly caused by
S. aureus; treat with antibiotics and
follow for abscess formation

178
Q 
BREAST ABSCESS
What must be ruled out
with a breast abscess in a
nonlactating woman?
P418
A

Breast cancer!

179
Q

MALE GYNECOMASTIA
What is it?
P418

A

Enlargement of the male breast

180
Q

MALE GYNECOMASTIA
What are the causes?
P418

A 
Medications
Illicit drugs (marijuana)
Liver failure
Increased estrogen
Decreased testosterone
181
Q

MALE GYNECOMASTIA
What is the major differential
diagnosis in the older patient?
P418

A

Male breast cancer

182
Q

MALE GYNECOMASTIA
What is the treatment?
P418

A

Stop or change medications; correct underlying cause if there is a hormonal imbalance; and perform biopsy or subcutaneous mastectomy (i.e., leave nipple) if refractory to conservative measures and time

Section II General Surgery P203Surgical Recall Sixth (33 decks)

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