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*OldSurgery > Breast Cancer > Flashcards

Breast Cancer Flashcards

1
Q

3 major structure of the breast

A

skin
sub Q
breast tissue

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2
Q

what is breast tissue made up of?

A

parenchyma and stroma

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3
Q

how many collecting milk duct open to a nipple?

A

5-10

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4
Q

what tissue envelop the breast?

A

fascial tissues

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5
Q

what is an important barrier to prevent invasion of breast cancer into the chest wall

A

pectoral fascia

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6
Q

what is the suspensory system w/ the breast

A

Cooper’s ligaments

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7
Q

where does most of the blood supply for the breast come from?

A

internal mammary (internal thoracic)

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8
Q

what is the lympathic drainage for the breast?

A

97% axillary

3% internal mammary chain

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9
Q

what muscles are found under the breast?

A

Pectoralis major
pectoralis minor
serratus anterior (lateral)
latissimus dorsi (anterior border can be seen)

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10
Q

what nerves innervate the pecs

A

medial and lacteral pectoral nerves (not at risk usually w/ masectomy)

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11
Q

what motor nerves run through the axilla?

A 
lateral thoracic (serratus anterior) 
thoracodorsal (lat dorsi)
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12
Q

what is the sensory cutaneous nerve that runs through the axilla?

A

intercostal-brachial cutaneous nerve

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13
Q

what are the 2 main risk factors for breast cancer?

A

female

advancing age

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14
Q

what reproductive factors are risks for breast cancer development?

A

late age at 1st full term pregnancy (>30)
early menarche (55)
no full term pregnancy, never breast fed

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15
Q

what majority of genetic breast cancer is accounted for by what genes?

A

BRCA1/2 (only 5-10% of breast cancers)

tested by buccal or blood

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16
Q

what model is used to determine risk of breast cancer by combining reproductive factors and family history.

A

Gail model

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17
Q

lifetime risk for someone w/ a BRCA mutations?

A

50-90%

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18
Q

surveillance for BRCA positive patients

A 
exam (2x a year) 
mammo (once a women is 30) 
U/S
MRI q 6 months 
mammo and MRI alternate every 6 months
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19
Q

prevention options for BRCA positive patients

A

bilateral prophylactic mastectomy
BSO
tamoxifen

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20
Q

there is a slightly increased risk of what other cancers with a BRCA mutation?

A

ovarian cancer
pancreatic cancer
melanoma
prostate cancer

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21
Q

why are mammograms controversial in younger women?

A

less effective because tissue in breast is still pretty dense

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22
Q

who are clinical breast exams possibly more effective in?

A

younger patients

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23
Q

when should a women between ages of 50-74 have mammograms?

A

every 2 years (according to task force)

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24
Q

what does a screening mammogram include?

A

CC= cranio-caudal

MLO- mediolateraloblique (chest wall and tail of Spence)

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25
Q

what is in a diagnostic mammography

A

evaluation of physical exam or screening mammo finding

give the tech the authority to get more views

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26
Q

If there is a mass what do you want

A

US and mammogram

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27
Q

what type mammography seems to be more sensitive for dense breasts?

A

digital mammography (now becoming the norm)

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28
Q

what is 3D mammography (doesn’t have clear indications, not covered by insurance)

A

tomosynthesis

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29
Q

on mammorgaphy how do densities show up?

A

white

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30
Q

on mammography how does fat show up?

A

gray

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31
Q

microcalcifications on mamorgraphy are concerning for what?

A

DCIS

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32
Q

what is a BI-RADs ( breast imaging-reporting and data systems) 0

A

needs further eval

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33
Q

what is a BI-RADs 1

A

negative

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34
Q

what is a BI-RADs 5

A

highly suggestive of malignancy

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35
Q

what is a BI-RADs 6

A

known biopsy proven malignancy

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36
Q

is a breast mass w/ a negative mammography the end of the workup?

A

No- send to surgeon for consideration of biopsy

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37
Q

What is the “triad of error” for delayed dx of breast cancer

A

young age (<45)
negative mammogram
self-discovered breast mass

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38
Q

what should you order anytime you are ordering a diagnostic mammograms. good for a specific area you want to investigate

A

US

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39
Q

what is involved in inspection for a clinical breast exam?

A

Upright with arms relaxed, arms raised, pectoralis muscles contracted (hands on hips)
Skin for edema, lesions, retraction, dimpling
Nipple areolar complex for retraction or discharge

40
Q

what is involved in palpation for a clinical breast exam?

A

Upright and supine, examine breasts and LN basins
Have a systematic routine
Use finger pads in small circular motion and palpate at varying depths
Cover the entire breast, from clavicle to beyond inframammary crease, and from sternum through axilla

41
Q

what will a fine needle aspiration give you?

A

nothing about invasion

only a few cells

42
Q

this has become the usual way that malignancy is diagnosed

Often done by radiologists under image guidance

A

core needle biopsy

43
Q

removal of the entire palpable or imaged abnormality

A

excisional biopsy

44
Q

common cause of breast pain, often cyclic

“lump bumpy breasts” can change w/ hormone changes

A

fibrocystic condition

45
Q

fluid filled cyst can become large and painful

A

breast cyst

46
Q

common in young women

Round/oval, solid mass

A

fibroadenoma

47
Q

Tx for fibroadenoma

A

May be observed, excised, or cryoablated

48
Q

subtype of fibroadenoma that needs to be excised w/ clear margins. diagnosable on core biopsy

A

Phyllodes tumor

49
Q

management for breast pain

A

decrease caffeine
vit E
evening primrose oil
(rule out breast pathology first)

50
Q

3 drugs that are avaliable for breast pain, but ADRs limit use

A

danocrine
tamoxifen
bromocriptine

51
Q

breast infections in non-lactating women are usually seen in who?

A

smokers

52
Q

what must you r/o w/ a breast infection?

A

inflammatory breast CA

53
Q

when are breast infections common?

A

during lactation

54
Q

management for breast infection during lactation

A

Management include emptying breast (nurse or pump), antibiotics, and drainage if there is an abscess
It is safe to continue to feed the infant…

55
Q

what are concerning signs on PE?

A

fixed to chest wall or skin
dimpling, nipple retraction or retraction of skin
edema (peau d’organe)

56
Q

how will microcalcifications appear on mammography

A

linear, branching, clustered

concerning for DCIS (but often related to fibrocystic changes)

57
Q

what is a piculated mass concerning for?

A

invasive cancer

58
Q

What are concerning finding son US?

A

irregular, solid mass
taller than wide
shadowing
vascularity

59
Q

what is usually used to get a tissue sample for breast cancer

A

core needle bx

will tell if DCIS or invasive, ductal or lobular, grade, ER/PR and Her2neu status

60
Q

what is a MRI helpful for in diagnosis of breast cancer

A

to evaluate remaining breast tissue, axillary and internal mammary nodes, lungs, bony structures of chest, upper liver
MRI is very sensitive and often leads to “second look” ultrasound to evaluate enhancing lesions seen on MR

61
Q

what is normally the first consultation for a person w/ breast cancer?

A

surgery

62
Q

radiation usually occurs after what?

A

lumpectomy (this radiation is pretty well tolerated)

63
Q

if a patient doesn’t want radiation what should they do

A

be more aggressive in surgical options

64
Q

what does the decision to have chemo depend on?

A

biology of tumor and staging

65
Q

what are the main goals for surgery for breast cancer

A

clear margins

stage tumors

66
Q

when is axillary node dissection done?

A

if more than 2 SLN positive but moving toward less, so now no AND is less than 3 (as long as they get radiation therapy)

67
Q

when is radiation necessary w/ a mastectomy

A

tumor is >5 cm

margins positive or LN positive (>4 LN)

68
Q

do breast conserving therapy and mastectomy have the same survival rate?

A

yes but slightly higher local recurrence rate w/ lumpectomy

69
Q

contradincations to breast conservation therapy

A

tumors in 2 or more separate quadrants of diffuse microcalcifications or inflammatory breast CA
hx or previous radiation to chest/ breast
pregnancy
inability to get clear margins
active autoimmune diseases (especially SLE or scleroderma)

70
Q

reasons for doing a masectomy

A

fear of local recurrence
unable or unwilling to do radiation
“just take it off”

71
Q

how often is radiation treatment

A

5 days / week for 6 weeks

72
Q

side effects of radiation

A

fatigue, skin changes, low risk of cardiac or pulmonary effects

73
Q

– Requires placement of a balloon catheter into the lumpectomy cavity and twice daily radiation for 5 days
Not currently the standard of care

A

mammosite

74
Q

what do most patients do for breast cancer?

A

lumpectomy and SLN biopsy
leaves 2 separate incision (mass and sentinel node)
fairly rapid recovery

75
Q

with nonpalpable tumors how will they be localized?

A

with a wire “needle loc” by radiology

76
Q

is helpful to place the incision and guide tumor resection

A

intraoperative U/S

77
Q

risks of lumpectomy and SLN bx

A

fluid collection (common)
arm numbness (paresthesias on back of upper arm)
arm wekaness
lymphedema

78
Q

what is a TRAM falp?

A

transverse recto abdominal myocutaneous flap
take this muscle and tunnel it under to recreate a breast
this does disrupt the core abdominal muscles

79
Q

what is a DIEP flap?

A

deep inferior epigastric perforators

microvascular anastamosis- needs ICU

80
Q

is all the breast tissue removed w/ a mastecomy

A

no, but some remains on flaps to preserve blood supply of the skin

81
Q

what type chemo is usually done w/ breast cancer

A

adjuvant chemo

after primary tx w/ surgery to reduce risk

82
Q

Treatment given in pre-op setting may shrink the tumor
Provides evidence of whether the chemo will works
May shrink large or fixed tumors to allow clearance of margins and makes BCT more feasible

A

neo-adjuvant therapy

83
Q

what is the usual order of treatment

A

surgery
chemo (if indicated)
radiation
hormonal blockade

84
Q

when is neo-adjuvant chemo always done?

A

inflammatory breast cancer

85
Q

what are hormone blockade drugs?

A

tamoxifen- estrogen receptor blocker

aromatase inhibitors- block production of estrogen

86
Q

who are aromatase inhibitors only used in

A

only for post menopausal women

87
Q

who usually gets chemo?

A

premenopausal and high risk tumors
ER negative
ER, PR, and her2 negative (triple negative) tumors

88
Q

what determines risk of recurrence based on specific genetic information of the tumor specimen

Helpful in women for whom benefit of chemo is unclear (small ER positive tumors with limited LN involvement) will stratify their risk

A

oncotype DX

89
Q

risks from tamoxifen?

A

uterine cancer, blood clots

ADR- hot flashes

90
Q

benefits of tamoxifen

A

increased bone density and lower cholesterol

prevents 1 our of 3 deaths from breast cancer

91
Q

what type cancer does tamoxifen help with?

A

ER positive tumors

92
Q

what other surgery can lower breast cancer risk?

A

ovarian ablation

93
Q

what will often shift shifts pre- and peri-menopausal women into menopause

A

chemo (thought to aid to some of the survival benefit)

94
Q

what are aromatase inhibitors

A

Anastrozole (arimidex), Letrozole (femara), and exemestane (aromasin)

95
Q

what is an antibody to the oncogene (her2-neu)

A

trastuzumab (herceptin)

96
Q

what do you combine trastuzumab with?

A

chemo

97
Q

what are ADRs w/ herceptin?

A

increased risk of heart failure

pts get MUGA scans to monitor

*OldSurgery (22 decks)

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