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
2
Q
ANATOMY OF THE BREAST AND AXILLA
Name the boundaries of the axilla for dissection:
Posterior boundary
P399
A
Long thoracic nerve
3
Q
ANATOMY OF THE BREAST AND AXILLA
Name the boundaries of the axilla for dissection:
Lateral boundary
P399
A
Latissimus dorsi muscle
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
5
Q
ANATOMY OF THE BREAST AND AXILLA What four nerves must the surgeon be aware of during an axillary dissection? P399
A
- Long thoracic nerve
- Thoracodorsal nerve
- Medial pectoral nerve
- Lateral pectoral nerve
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
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
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
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
10
Q
ANATOMY OF THE BREAST AND AXILLA
Identify the nerves in the
axilla on the illustration below:
P400 (picture)
A
- Thoracodorsal nerve
- Long thoracic nerve
- Medial pectoral nerve
- Lateral pectoral nerve
- Axillary vein
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”
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
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
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
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!)
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
17
Q
ANATOMY OF THE BREAST AND AXILLA
What are the suspensory
breast ligaments called?
P401
A
Cooper’s ligaments
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
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
20
Q
ANATOMY OF THE BREAST AND AXILLA Which hormone is mainly responsible for breast milk production? P401
A
Prolactin
21
Q
BREAST CANCER
What is the incidence of
breast cancer?
P401
A
12% lifetime risk
22
Q
BREAST CANCER What percentage of women with breast cancer have no known risk factor? P401
A
75%!
23
Q
BREAST CANCER What percentage of all breast cancers occur in women younger than 30 years? P401
A
≈2%
24
Q
BREAST CANCER What percentage of all breast cancers occur in women older than 70 years? P401
A
33%
25
BREAST CANCER
What are the major breast
cancer susceptibility genes?
P401
BRCA1 and BRCA2 (easily remembered:
| BR = BReast and CA = CAncer)
26
```
BREAST CANCER
What option exists to
decrease the risk of breast
cancer in women with BRCA?
P401
```
Prophylactic bilateral mastectomy
27
```
BREAST CANCER
What is the most common
motivation for medicolegal
cases involving the breast?
P401
```
Failure to diagnose a breast carcinoma
28
```
BREAST CANCER
What is the “TRIAD OF
ERROR” for misdiagnosed
breast cancer?
P402
```
1. Age 75% of cases of
MISDIAGNOSED breast cancer have
these three characteristics
29
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)
30
```
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)
31
```
BREAST CANCER
What is the relative risk of
hormone replacement
therapy?
P402
```
1–1.5
32
```
BREAST CANCER
Is “run of the mill”
fibrocystic disease a risk
factor for breast cancer?
P402
```
No
33
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
```
34
BREAST CANCER
Why does skin retraction
occur?
P403
Tumor involvement of Cooper’s ligaments
and subsequent traction on ligaments
pull skin inward
35
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
```
36
BREAST CANCER
What is the most common
site of breast cancer?
P403
Approximately one half of cancers
| develop in the upper outer quadrants
37
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%)
```
38
BREAST CANCER
What is the most common
type of breast cancer?
P403
Infiltrating ductal carcinoma
39
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
```
40
```
BREAST CANCER
Describe the appearance of
the edema of the dermis in
inflammatory carcinoma of
the breast.
P403
```
Peau d’orange (orange peel)
41
```
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
```
42
```
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
```
43
BREAST CANCER
When is the best time for
breast self-exams?
P404
1 week after menstrual period
44
```
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
```
45
BREAST CANCER
What are the radiographic
tests for breast cancer?
P404
Mammography and breast ultrasound,
| MRI
46
```
BREAST CANCER
What is the classic picture
of breast cancer on
mammogram?
P404 (picture)
```
Spiculated mass
47
```
BREAST CANCER
Which option is best to
evaluate a breast mass in
a woman younger than
30 years?
P404
```
Breast ultrasound
48
```
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)
```
49
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
```
50
```
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
51
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
```
52
BREAST CANCER
What is a mammotome
biopsy?
P405
Mammogram-guided computerized
| stereotatic core biopsies
53
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)
```
54
BREAST CANCER
What would be suspicious
mammographic findings?
P405
Mass, microcalcifications, stellate/
| spiculated mass
55
BREAST CANCER
What is a “radial scar” seen
on mammogram?
P405
Spiculated mass with central lucency,
| +/– microcalcifications
56
BREAST CANCER
What tumor is associated
with a radial scar?
P405
Tubular carcinoma; thus, biopsy is
| indicated
57
BREAST CANCER
What is the “workup” for a
breast mass?
P405
1. Clinical breast exam
2. Mammogram or breast ultrasound
3. Fine needle aspiration, core biopsy, or
open biopsy
58
BREAST CANCER
How do you proceed if the
mass appears to be a cyst?
P406
Aspirate it with a needle
59
BREAST CANCER
Is the fluid from a breast
cyst sent for cytology?
P406
Not routinely; bloody fluid should be sent
| for cytology
60
```
BREAST CANCER
When do you proceed to
open biopsy for a breast
cyst?
P406
```
1. In the case of a second cyst recurrence
2. Bloody fluid in the cyst
3. Palpable mass after aspiration
61
```
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)
```
62
```
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)
```
63
BREAST CANCER
What staging system is used
for breast cancer?
P406
TMN: Tumor/Metastases/Nodes (AJCC)
64
BREAST CANCER
Describe the staging (simplified):
Stage I
P406
Tumor ≤2 cm in diameter without
| metastases, no nodes
65
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
66
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
67
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
68
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
```
69
BREAST CANCER
Describe the staging (simplified):
Stage IIIC
P407
Any size tumor, no distant mets
POSITIVE: supraclavicular,
infraclavicular, or internal
mammary lymph nodes
70
BREAST CANCER
Describe the staging (simplified):
Stage IV
P407
```
Distant metastases (including ipsilateral
supraclavicular nodes)
```
71
BREAST CANCER
What are the sites of
metastases?
P407
```
Lymph nodes (most common)
Lung/pleura
Liver
Bones
Brain
```
72
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)
```
73
```
BREAST CANCER
What are the indications for
radiation therapy after a
modified radical mastectomy?
P407
```
```
Stage IIIA
Stage IIIB
Pectoral muscle/fascia invasion
Positive internal mammary LN
Positive surgical margins
4 positive axillary LNs postmenopausal
```
74
```
BREAST CANCER
What breast carcinomas are
candidates for lumpectomy
and radiation (breastconserving
therapy)?
P407
```
Stage I and stage II (tumors <5 cm)
75
```
BREAST CANCER
What approach may allow a
patient with stage IIIA cancer
to have breast-conserving
surgery?
P408
```
NEOadjuvant chemotherapy—if the
| preop chemo shrinks the tumor
76
```
BREAST CANCER
What is the treatment of
inflammatory carcinoma of
the breast?
P408
```
Chemotherapy first! Then often
followed by radiation, mastectomy, or
both
77
BREAST CANCER
What is a “lumpectomy and
radiation”?
P408
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
```
BREAST CANCER
What is the major absolute
contraindication to
lumpectomy and radiation?
P408
```
Pregnancy
79
```
BREAST CANCER
What are other
contraindications to
lumpectomy and radiation?
P408
```
```
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
BREAST CANCER
What is a modified radical
mastectomy?
P408
```
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
BREAST CANCER
Where are the drains placed
with an MRM?
P408
1. Axilla
| 2. Chest wall (breast bed)
82
BREAST CANCER
When should the drains be
removed?
P408
<30 cc/day drainage
83
```
BREAST CANCER
What are the potential
complications after a modified
radical mastectomy?
P409
```
Ipsilateral arm lymphedema, infection,
injury to nerves, skin flap necrosis,
hematoma/seroma, phantom breast
syndrome
84
```
BREAST CANCER
During an axillary dissection,
should the patient be
paralyzed?
P409
```
NO, because the nerves (long thoracic/
thoracodorsal) are stimulated with
resultant muscle contraction to help
identify them
85
```
BREAST CANCER
How can the long thoracic
and thoracodorsal nerves be
identified during an axillary
dissection?
P409
```
Nerves can be stimulated with a
forceps, which results in contraction of
the latissimus dorsi (thoracodorsal nerve)
or anterior serratus (long thoracic nerve)
86
```
BREAST CANCER
When do you remove the
drains after an axillary
dissection?
P409
```
When there is <30 cc of drainage per day,
| or on POD #14 (whichever comes first)
87
BREAST CANCER
What is a sentinel node
biopsy?
P409
Instead of removing all the axillary
lymph nodes, the primary draining or
“sentinel” lymph node is removed
88
BREAST CANCER
How is the sentinel lymph
node found?
P409
```
Inject blue dye and/or technetium-labeled
sulfur colloid (best results with both)
```
89
BREAST CANCER
What follows a positive
sentinel node biopsy?
P409
Removal of the rest of the axillary lymph
| nodes
90
```
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
```
Sentinel lymph node dissection
91
```
BREAST CANCER
What do you do with a
mammotome biopsy that
returns as “atypical
hyperplasia”?
P409
```
Open needle loc biopsy as many will have
| DCIS or invasive cancer
92
BREAST CANCER
How does tamoxifen work?
P409
It binds estrogen receptors
93
```
BREAST CANCER
What is the treatment for
local recurrence in breast
after lumpectomy and
radiation?
P410
```
“Salvage” mastectomy
94
BREAST CANCER
Can tamoxifen prevent
breast cancer?
P410
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
BREAST CANCER
What are common options
for breast reconstruction?
P410
TRAM flap, implant, latissimus dorsi flap
96
BREAST CANCER
What is a TRAM flap?
P410 (picture)
Transverse Rectus Abdominis
| Myocutaneous flap
97
BREAST CANCER
What are side effects of
tamoxifen?
P410
Endometrial cancer (2.5X relative
risk), DVT, pulmonary embolus,
cataracts, hot flashes, mood swings
98
```
BREAST CANCER
In high-risk women, is there
a way to reduce the risk of
developing breast cancer?
P410
```
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
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
Chemotherapy
100
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
Chemotherapy and tamoxifen
101
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
Tamoxifen
102
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
Tamoxifen, +/-- chemotherapy
103
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
Chemotherapy, +/-- tamoxifen
104
```
BREAST CANCER
What type of chemotherapy
is usually used for breast
cancer?
P411
```
CMF (Cyclophosphamide, Methotrexate,
5-Fluorouracil) or CAF
(Cyclophosphamide, Adriamycin,
5-Fluorouracil)
105
```
BREAST CANCER
Chemotherapy for high-risk
tumors with negative lymph
nodes should be considered.
What makes a tumor “HIGH
RISK”?
P411
```
```
High risk:
>1 cm in size
Lymphatic/vascular invasion
Nuclear grade (high)
S phase (high)
ER negative
HER-2/neu overexpression
```
106
DCIS
What does DCIS stand for?
P411
Ductal Carcinoma In Situ
107
DCIS
What is DCIS also known as?
P411
Intraductal carcinoma
108
DCIS
Describe DCIS.
P411
Cancer cells in the duct without invasion
(In situ: Cells do not penetrate the
basement membrane)
109
DCIS
What are the signs/symptoms?
P412
Usually none; usually nonpalpable
110
DCIS
What are the mammographic
findings?
P412
Microcalcifications
111
DCIS
How is the diagnosis made?
P412
Core or open biopsy
112
DCIS
What is the most aggressive
histologic type?
P412
Comedo
113
DCIS
What is the risk of lymph
node metastasis with DCIS?
P412
<2% (usually when microinvasion is
| seen)
114
DCIS
What is the major risk with
DCIS?
P412
Subsequent development of infiltrating
| ductal carcinoma in the same breast
115
DCIS
What is the treatment for DCIS in the following cases:
Tumor <1 cm (low grade)?
P412
Remove with 1 cm margins +/-- XRT
116
DCIS
What is the treatment for DCIS in the following cases:
Tumor >1 cm?
P412
Perform lumpectomy with 1 cm margins
and radiation or total mastectomy (no
axillary dissection)
117
DCIS
What is a total (simple)
mastectomy?
P412
Removal of the breast and nipple without
removal of the axillary nodes (always
remove nodes with invasive cancer)
118
```
DCIS
When must a simple
mastectomy be performed
for DCIS?
P412
```
Diffuse breast involvement (e.g., diffuse
microcalcifications), >1 cm and
contraindication to radiation
119
DCIS
What is the role of axillary
node dissection with DCIS?
P412
No role in true DCIS (i.e., without
microinvasion); some perform a sentinel
lymph node dissection for high-grade
DCIS
120
DCIS
What is adjuvant for DCIS?
P412
1. Tamoxifen
| 2. Postlumpectomy XRT
121
DCIS
What is the role of
tamoxifen in DCIS?
P412
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
```
DCIS
What is a memory aid for
the breast in which DCIS
breast cancer arises?
P413
```
Cancer arises in the same breast as
DCIS (Think: DCIS = Directly in same
breast)
123
LCIS
What is LCIS?
P413
Lobular Carcinoma In Situ (carcinoma
cells in the lobules of the breast without
invasion)
124
LCIS
What are the signs/symptoms?
P413
There are none
125
LCIS
What are the mammographic
findings?
P413
There are none
126
LCIS
How is the diagnosis made?
P413
LCIS is found incidentally on biopsy
127
LCIS
What is the major risk?
P413
Carcinoma of either breast
128
```
LCIS
Which breast is most at risk
for developing an invasive
carcinoma?
P413
```
Equal risk in both breasts! (Think of
LCIS as a risk marker for future
development of cancer in either breast)
129
```
LCIS
What percentage of women
with LCIS develop an
invasive breast carcinoma?
P413
```
≈30% in the 20 years after diagnosis of
| LCIS!
130
```
LCIS
What type of invasive breast
cancer do patients with LCIS
develop?
P413
```
Most commonly, infiltrating ductal
carcinoma, with equal distribution in
the contralateral and ipsilateral breasts
131
```
LCIS
What medication may lower
the risk of developing breast
cancer in LCIS?
P413
```
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
LCIS
What is the treatment of LCIS?
P413
Close follow-up (or bilateral simple
| mastectomy in high-risk patients)
133
```
LCIS
What is the major
difference in the subsequent
development of invasive
breast cancer with DCIS
and LCIS?
P413
```
LCIS cancer develops in either breast;
DCIS cancer develops in the ipsilateral
breast
134
```
LCIS
How do you remember
which breast is at risk for
invasive cancers in patients
with LCIS?
P414
```
Think: LCIS = Liberally in either breast
135
```
MISCELLANEOUS
What is the most common
cause of bloody nipple
discharge in a young woman?
P414
```
Intraductal papilloma
136
```
MISCELLANEOUS
What is the most common
breast tumor in patients
younger than 30 years?
P414
```
Fibroadenoma
137
MISCELLANEOUS
What is Paget’s disease of
the breast?
P414
Scaling rash/dermatitis of the nipple
caused by invasion of skin by cells from a
ductal carcinoma
138
```
MISCELLANEOUS
What are the common
options for breast
reconstruction after a
mastectomy?
P414
```
Saline implant
| TRAM flap
139
MALE BREAST CANCER
What is the incidence of
breast cancer in men?
P414
<1% of all breast cancer cases (1/150)
140
MALE BREAST CANCER
What is the average age at
diagnosis?
P414
65 years of age
141
MALE BREAST CANCER
What are the risk factors?
P414
```
Increased estrogen
Radiation
Gynecomastia from increased estrogen
Estrogen therapy
Klinefelter’s syndrome (XXY)
BRCA2 carriers
```
142
```
MALE BREAST CANCER
Is benign gynecomastia a
risk factor for male breast
cancer?
P414
```
No
143
MALE BREAST CANCER
What type of breast cancer
do men develop?
P414
Nearly 100% of cases are ductal
carcinoma (men do not usually have
breast lobules)
144
```
MALE BREAST CANCER
What are the signs/
symptoms of breast cancer
in men?
P415
```
```
Breast mass (most are painless), breast
skin changes (ulcers, retraction), and
nipple discharge (usually blood or a
blood-tinged discharge)
```
145
MALE BREAST CANCER
What is the most common
presentation?
P415
Painless breast mass
146
MALE BREAST CANCER
How is breast cancer in men
diagnosed?
P415
Biopsy and mammogram
147
MALE BREAST CANCER
What is the treatment?
P415
1. Mastectomy
2. Sentinel LN dissection of clinically
negative axilla
3. Axillary dissection if clinically positive
axillary LN
148
```
BENIGN BREAST DISEASE
What is the most common
cause of green, strawcolored,
or brown nipple
discharge?
P415
```
Fibrocystic disease
149
```
BENIGN BREAST DISEASE
What is the most common
cause of breast mass after
breast trauma?
P415
```
Fat necrosis
150
BENIGN BREAST DISEASE
What is Mondor’s disease?
P415
Thrombophlebitis of superficial breast veins
151
```
BENIGN BREAST DISEASE
What must be ruled out with
spontaneous galactorrhea
( +/-- amenorrhea)?
P415
```
Prolactinoma (check pregnancy test and
| prolactin level)
152
CYSTOSARCOMA PHYLLODES
What is it?
P415
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
CYSTOSARCOMA PHYLLODES
What is the usual age of the
patient with this tumor?
P415
35–55 years (usually older than the
| patient with fibroadenoma)
154
CYSTOSARCOMA PHYLLODES
What are the signs/
symptoms?
P416
Mobile, smooth breast mass that
resembles a fibroadenoma on exam,
mammogram/ultrasound findings
155
CYSTOSARCOMA PHYLLODES
How is it diagnosed?
P416
Through core biopsy or excision
156
CYSTOSARCOMA PHYLLODES
What is the treatment?
P416
If benign, wide local excision; if
| malignant, simple total mastectomy
157
```
CYSTOSARCOMA PHYLLODES
What is the role of axillary
dissection with cystosarcoma
phyllodes tumor?
P416
```
Only if clinically palpable axillary nodes,
as the malignant form rarely spreads to
nodes (most common site of metastasis is
the lung)
158
```
CYSTOSARCOMA PHYLLODES
Is there a role for
chemotherapy with
cystosarcoma phyllodes?
P416
```
Consider chemotherapy if large tumor
| >5 cm and “stromal overgrowth”
159
FIBROADENOMA
What is it?
P416
Benign tumor of the breast consisting of
stromal overgrowth, collagen arranged in
“swirls”
160
```
FIBROADENOMA
What is the clinical
presentation of a
fibroadenoma?
P416
```
Solid, mobile, well-circumscribed round
| breast mass, usually <40 years of age
161
FIBROADENOMA
How is fibroadenoma
diagnosed?
P416
Negative needle aspiration looking for
| fluid; ultrasound; core biopsy
162
FIBROADENOMA
What is the treatment?
P416
Surgical resection for large or growing
lesions; small fibroadenomas can be
observed closely
163
FIBROADENOMA
What is this tumor’s claim
to fame?
P416
Most common breast tumor in women
| <30 years
164
FIBROCYSTIC DISEASE
What is it?
P416
Common benign breast condition
consisting of fibrous (rubbery) and cystic
changes in the breast
165
FIBROCYSTIC DISEASE
What are the signs/symptoms?
P416
Breast pain or tenderness that varies with
the menstrual cycle; cysts; and fibrous
(“nodular”) fullness
166
FIBROCYSTIC DISEASE
How is it diagnosed?
P417
Through breast exam, history, and aspirated
| cysts (usually straw-colored or green fluid)
167
```
FIBROCYSTIC DISEASE
What is the treatment for
symptomatic fibrocystic
disease?
P417
```
Stop caffeine
Pain medications (NSAIDs)
Vitamin E, evening primrose oil (danazol
and OCP as last resort)
168
FIBROCYSTIC DISEASE
What is done if the patient
has a breast cyst?
P417
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
MASTITIS
What is it?
P417
Superficial infection of the breast (cellulitis)
170
MASTITIS
In what circumstance does it
most often occur?
P417
Breast-feeding
171
MASTITIS
What bacteria are most
commonly the cause?
P417
Staphylococcus aureus
172
MASTITIS
How is mastitis treated?
P417
Stop breast-feeding and use a breast pump
| instead; apply heat; administer antibiotics
173
MASTITIS
Why must the patient with
mastitis have close follow-up?
P417
To make sure that she does not have
| inflammatory breast cancer!
174
BREAST ABSCESS
What are the causes?
P417
Mammary ductal ectasia (stenosis of
| breast duct) and mastitis
175
BREAST ABSCESS
What is the most common
bacteria?
P417
Nursing = Staphylococcus aureus
| Nonlactating = mixed infection
176
BREAST ABSCESS
What is the treatment of
breast abscess?
P417
```
Antibiotics (e.g., dicloxacillin)
Needle or open drainage with cultures
taken
Resection of involved ducts if recurrent
Breast pump if breast-feeding
```
177
BREAST ABSCESS
What is lactational mastitis?
P418
Infection of the breast during breastfeeding—
most commonly caused by
S. aureus; treat with antibiotics and
follow for abscess formation
178
```
BREAST ABSCESS
What must be ruled out
with a breast abscess in a
nonlactating woman?
P418
```
Breast cancer!
179
MALE GYNECOMASTIA
What is it?
P418
Enlargement of the male breast
180
MALE GYNECOMASTIA
What are the causes?
P418
```
Medications
Illicit drugs (marijuana)
Liver failure
Increased estrogen
Decreased testosterone
```
181
MALE GYNECOMASTIA
What is the major differential
diagnosis in the older patient?
P418
Male breast cancer
182
MALE GYNECOMASTIA
What is the treatment?
P418
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
