Breast Cancer Flashcards by Katherine Daigle

Borders of the Breast:

superior: clavicle
inferior: 6th rib
lateral: lat dorsi
medial: edge of sternum
deep: pec major
superficial: skin

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primary lymphatic drainage of the breast

axillary nodes

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tail of spence:

axillary tail of the breast, laterally across anterior axillary fold

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other lymphatic drainage of the breast:

parasternal nodes

intercostal nodes

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categories of axillary lymph nodes:

Level I: lateral to pec minor
Level II: deep to pec minor
Level III: medial to pec minor

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Nerves to avoid in mastectomy:

thoracodorsal nerve
long thoracic nerve
intercostobrachial nerve

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vessels to avoid in mastectomy:

axillary vein
perforating arteries (branches 2-4 intercostal arteries)

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Staging used for the breast:

Tanner (don’t need to know specifics)

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common sxs prompt women to get breast exams:

pain
rash/redness/overlying skin changes
nipple discharge/changes
swelling
lumps/mass on self-exam

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Types of Mastalgia:

cyclical (majority), non-cyclical, extra-mammary

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etiology of cyclical mastalgia:

effects of hormones: estrogen (ductal); progesterone (stroma); and prolactin (ductal secretion)
-post-menopausal HRT or OCP

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when should mastalgia be worked up:

persistent, unilateral pain/tenderness

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what structure is involved in the p’eau d’orange appearance of breasts?

suspensory ligaments of cooper (connect deep to superficial layers)

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phases of life that gynecomastia is most common:

neonatal
adolescence
senescence
(hormone imbalance)

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etiology of extra-mammary mastalgia:

referred pain:
chest wall pain
para/spinal conditions
trauma
biliary, pleural, cardiac

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etiology of non-cyclical mastalgia:

large breasts
diet lifestyle
HRT
ductal ectasia
mastitis
abscess
hidradenitis suppurativa
prior breast surgery, pregnancy

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suspicious findings on PE:

palpable mass
skin changes
bloody nipple discharge

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first line tx for mastalgia:

physical support (bras, OTC analgesics, compresses, modify OCP/HRT)
adjuncts/alternatives: reduce caffeine intake, evening primrose oil capsules (gamma linoleic acid)

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second line tx for mastalgia:

tamoxifen (lower SE, greater risk of coagulation, cataracts)
danazol (androgenic effects)
SE: hot flashes, vaginal dryness, arthralgia, wt gain, deepening voice

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MCC breast mass in women 4/5th decade life:

fibrocystic disease/changes

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fibrocystic mass description:

firm, mobile, slightly tender mass, less well-defined borders compared to fibroadenoma
fluid filled
round/ovoid
solitary/multiple
(size/tenderness fluctuate with menstrual cycle)

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Dx of simple cysts:

ultrasonography

FNA

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aspirate of simple cysts:

non-bloody, complete cyst collapse

often straw colored/green fluid

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Dx of complex cysts:

ultrasound
FNA (if bloody, sent to cytology)
core needle biopsy
mammography
if recurrence x2--> open biopsy indicated

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fibroadenoma mass description:

typically painless 1-3cm in size well defined, freely mobile, discrete, firm, rounded mass in breast

age of fibrocystic vs fibroadenoma:

Fibrocystic: 4th/5th decade of life Fibroadenoma: young women (teens to 30s)

tx options for fibroadenoma:

excision u/s guided cryoablation vacuum assisted biopsy (outpatient) observation

when is a mammogram indicated?

age >30 and palpable breast mass

risk factors for breast cancer >4.0:

``` female age (65+) BRCA1 or BRCA2 personal hx breast cancer high breast tissue density biopsy confirmed hyperplasia ```

Breast cancer can be broadly categorized based on:

estrogen and progesterone receptivity | HER2 recetpor

tx for hormone receptor positive breast cancer:

selective estrogen receptor modulators (SERMS- tamoxifen; premeno) or aromatase inhibitors (anastrozole; post meno)

triple negative breast cancer

ER neg PR neg HER2 neg (hardest to treat, not responsive to drugs)

most common type of breast cancer:

invasive/infiltrative ductal carcinoma (80%) most are hormone R positive and HER2 negative tx: tamoxifen

multicentricity vs multifocality:

multicentric: separate quadrants of the same breast multifocality: lesions in same quadrant of breast (separated by normal tissue)

two main types of invasive breast cancer:

ductal (MC) | lobular

type of breast cancer that presents as "microcalcifications" on mammogram:

ductal cancer in situ (DCIS)

what is unique about LCIS and DCIS?

they can invade the ipsilateral breast (MC in DCIS)

MC presentation of breast cancer:

single, nontender, immobile mass MC in upper outer quadrant (may present on routine mammogram w/o palpable mass)

Dx of solid mass in postmenopausal woman

cancer until proven otherwise!

Best screening tool for breast cancer:

mammogram (starting at age 45)

benign ultrasound findings:

well-demarcated borders "posterior enlargement" absence of internal echoes (cysts)

suspicious ultrasound findings:

poorly demarcated borders "posterior shadowing" heterogenous internal echoes "taller than wide" orientation

when is MRI preferred for dx:

``` dense breast tissue scars implants h/o breast cancer or contralateral dz women w/ BRCA1/2 mutations ```

standard views for mammograms:

``` medio lateral oblique (MLO) craniocaudal view (CC) ```

definitive dx of breast cancer:

tissue sampling: needle-biopsied (may need u/s or radiological guidance) excisional biopsy (needle vs seed- localized lumpectomy)

Breast cancer staging:

Tumor Nodes Mets: commonly to lymph nodes, lungs, liver, bones, brain

most important factor in prognosis:

axillary lymph node status (estrogen receptor close second)

indications for chemo:

node positive disease | tumors >1cm

neoadjuvant therapy:

preop therapy may make surgery easier/ reduce need for surgery useful in early stage disease and HER positive or triple neg

adjuvant therapy:

post surgery | depends on tumor characteristics

neo/adjuvant therapy:

endocrine, biologic, or cytotoxic medications

main surgery options:

lumpectomy + radiation or mastectomy (same recurrence rates)

simple/total mastectomy:

removes entire breast and pec major fascia | skin or nipple sparing

modified radical (Patey) mastectomy:

simple mastectomy and axillary dissection (levels I-III)

radical (halsted) mastectomy:

removes entire breast, overlying skin, pec major/minor muscles, entire axillary contents

lumpectomy:

(aka wide excision, segmental or partial mastectomy) | excision of malignancy with circumferential margins and microscopically nl tissue

breast reconstruction implant options:

prosthetic implant | or autologous tissue (lat dosri or rectus abdominis)

timing of breast reconstruction:

immediate or delayed | *fun fact: insurance MUST cover

when is a sentinel lymph node biopsy indicated:

early breast cancer | clinical and radiographic node NEGATIVE disease

when is an axillary lymph node dissection indicated:

presence of positive sentinel lymph node | clinically positive axilla

most common complications of breast surgery:

``` bleeding infection seroma deformity (flap necrosis less common) ```

complication of axillary lymph node dissection:

lymphedema | decreased ROM, injury to intercostobrachial nerve