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Breast - Non Cosmetic MJS > Breast - Non Cosmetic > Flashcards

Breast - Non Cosmetic Flashcards

1
Q

Lifetime risk of breast CA

A

12%

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2
Q

Difference between multifocal DCIS and multicentric DCIS

A

Multifocal DCIS present in more than 2 areas within SAME quadrant
Multicentric DCIS present in discontinuous foci involving more than one breast quadrant

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3
Q

Median age of diagnosis of breast cancer

A

62

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4
Q

Risk Factors for Breast CA

A

Age at Menarche: reduction of risk of 5-10% for each year delay in age at menarche
Gene mutations: BRCA, p53, PTEN, cdh1 …
Parity: Each birth reduces the relative risk of breast cancer by 7%
Age at First Full-Term Pregnancy: Increased risk with first full term pregnancy > 35, difficult to quantify
Breastfeeding: Relative risk of breast cancer decreased by 4.3% for every 12 months of breastfeeding
Age at Menopause: For each year delay in age of menopause, the risk for breast cancer increases by 3%
Exogenous Hormones: Use increases the risk by 2.3% for each year of use. This effect disappears 5 years after discontinuing, regardless of duration of use.
Obesity: 1.25 to 2-fold excess risk among postmenopausal obese women
Alcohol: Increased relative risk of 32% for 4-6 drinks/week
Physical Activity: Risk reductions of 10-50%
Ionizing Radiation: Depends on age at exposure. The elevated risk persists.
Mammographic Density: Women with dense breast tissue have a 2 to 6-fold increased risk

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5
Q

If left untouchced what % of DCIS will progress to Cancer

A

30%

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6
Q

Candidates for breast conserving therapy in DCIS

A
  1. Unicentric (Localized) Disease
  2. Tumor to breast esize ratio allows for acceptable cosmetic results
  3. Possible to attain margins greater or equal to 2mm.
  4. No evidence of diffuse microcalcification or multicentric disease
  5. No contraindication to radiation therapy
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7
Q

Patient on Tamoxifen for ER+ tumor following their oncoplastic reduction. What side effects do you council them on.

A

vasomotor symptoms, DVT/PE, stroke, cataract formation, benign ovarian cysts, risk for endometrial cancer increased 2-7x

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8
Q

Name the hereditary breast cancers secondary to genetic mutations

A

BRCA1, BRCA2, p53 (Li Fraumeni Syndrome), PTEN (Cowdens Disease), STK11 (Peutz-Jeghers), Lynch Syndrome

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9
Q

BRCA1 mutation lifetime risk of breast CA?

BRCA2 mutation lifetime risk of breast CA?

A 
BRCA1= 55%-65%
BRCA2= 45%-55%
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10
Q

What is the most suspicious mammographic findings for malignancy

A
  1. spiculated massess with associated architectural distortional
  2. clustered microcalcifications in a linear or branching array
  3. microcalcifications associated with a mass.
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11
Q

In which patients is ultrasound a better test than mammography for diagnosing breast cancer

A

young females with dense breasts

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12
Q

Molecular subtypes of breast CA

A

Luminal A- ER+, PR+, HER2-, Ki67 low
Luminal B- ER+, PR+ HER2+ (or HER2- with Ki67 high)
Basal Like - ER-, PR-, HER2-
HER2 enriched - ER-, PR-, HER2+

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13
Q

Define locally advanced breast cancer

A

Generally = Stage III

  1. Any tumour greater than 5cm (T4)
  2. Any size tumour with multiple nodes involved (N2 or greater or greater than 4-9 nodes.)
  3. Inflammatory Breast cancer
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14
Q

Inflammatory breast cancer is denoted within AJCC staging system at what T class

A

T4d = an aggressive form of locally advanced breast cancer

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15
Q

characteristic pathologic finding making diagnosis of inflammatory breast cancer

A

dermal lymphatic invasion by carcinoma on skin punch biopsy

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16
Q

Can you do immediate breast reconstruction in inflammatory breast cancer

A

no. Immidiate reconstruction is contraindicated in the setting of inflammatory breast cancer. breast recon should be delayed as nearly all patients will require chest wall and regional nodal radiation, to include axillary , periclavicular and IM nodes.

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17
Q

List conventional indications for nipple sparing mastectomy

A
  1. women with early stage tumors located more than 2 cm from the nipple with a clinically negative axilla
  2. very large or ptotic breasts are relative contraindications
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18
Q

What is the relative risk reduction for breast CA with a prophylactic mastectomy in high risk patients

A

90-95%

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19
Q

Studies have shown that X % of patients with early stage clinically node negative breast cancer will have a positive sentinel node

A

24%

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20
Q

ALND consists of removal of what

A

Level 1 and Level 2 axillary nodal tissue. Level 3 removal increases risk of lymphedema substantially so is only removed when clinically positive.

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21
Q

Describe the concept of delayed-immidiate breast recosntruction

A

In cases where the need for PMRT is unknown the patient undergoes skin sparing mastectimy with insertion of a saline filled tissue expander. This serves as a scaffold to preserve the 3D contour of the breast skin envelope. Following pathologic evaluation, if the patient needs PMRT, the expander is deflated to allow radiation therapy, followed by delayed recon, usually autologous. If no PMRT required, they are serially expanded and then can undergo autologous or alloplastic reconstruction

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22
Q

Results of the ATAC trial

A

trial assessing the efficacy and side effect profiles of anastrazole and tamoxifen in post menopausal women. For postmenopausal patients with early stage cancer anastrazole had higher disease free survival and longer time to recurrence . The incidence of edometrial cancer, VTE and vaginal symptoms was also decreased with anastrazole. As a result of the ATAC trial, anastrazole is now the preferred hormone therapy over tamoxifen for postmenopausal patients with receptor positive breast cancer

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23
Q

How long should you hold Tamoxifen before performing a DIEP

A

2 weeks. It increases the risk of VTE

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24
Q

Describe the Huger Zones

A

The 3 vascular zones of the abdominal wall.
Zone 1=costal margins, lateral edge of recutus down to pubis. Supplied by the superior and inferior epigastric system.
Zone 2= Anything inferior to line between iliac crests. SCIA, DCIA and External Puodendal arteries.
Zone 3=Lateral to rectus above the line between iliac crests. Intercostal, subcostal and lumbar

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25
Q

Describe blood supply to umbilicus (4)

A
  1. Subdermal Plexus
  2. DIEA
  3. Ligamentum Teres Hepatis
  4. Medial Umbilical Ligament
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26
Q

Define Supercharge and Turbocharge

A

A “supercharged” flap receives vascular augmentation from an unrelated source vessel (arrow).

A “turbocharged” flap obtains enhanced vascularity from a source already present within the flap territory, either directly or by means of an interposed vein graft.

27
Q

Pedicle length of DIEA/V

A

11.8cm

28
Q

You use ICG to assess flap perfusion intraop. How long does it take for image to come up after ICG injfection

A

around 15s

29
Q

DIEA comes off of what source artery
IMA comes off what source artery
SIEA comes off what source artery

A

DIEA external iliac artery just proximal to the inguinal ligament.
DSEA, continuation of IMA which is off subcalvian artery
SIEA comes of the Common Femoral Artery 2-3cm below the inguinal ligament

30
Q

What % of patients dont have SIEA?

A

35% which is why the anatomy is unreliable

31
Q

Pedicle length and diamter of DIEA

A

16cm length, 3.5mm diameter

32
Q

SIEV diameter and location

A

4mm. Its not accompanied by an artery. Usually 7cm from midline. Its medial and superficial to SIEA.

33
Q

What is the sensory innervation to the abdominal skin in a DIEP flap

A

lateral and anterior cutaneous branches of the intercostal nerves.

34
Q

You want to neurotize your DIEP flap. How do you do it.

A

recipient nerve used for breast flap neurotization can be the lateral cutaneous branch of the fourth
intercostal nerve, (which frequently is injured during
mastectomy and lies in a separate microsurgical field,
thereby increasing the flap inset complexity) or anterior
cutaneous branch of the third intercostal nerve. Use nerve conduit or direct neurorraphy of this recipient to your donor nerve.
The donor nerve is a cutaneous nerve that is identified with the most inferior lateral perforator vessels. The nerve is then dissected for neurotization and divided at the level of the fascia where it is a pure sensory nerve. This also allows for the preservation of the motor branches that are important for rectus muscle motor function while providing sensory neural input to a major portion of the flap.

35
Q

Pfanenstiel incision- contraindication for what flap

A

SIEA. Not DIEP

36
Q

Location of SIEA relative to SIEV

A

SIEV 5-7cm from midline. SIEA 2 cm lateral and deep to scarpas.

37
Q

Secondary pedicle options for perfusion of zone II in DIEP flap

A
  1. DCIA
  2. SCIA
  3. SIEA
  4. LAP
38
Q

If all goes well, when do you plan volume and symmetry adjustments, nipple reconstruction and scar revision post DIEP breast reconstruction

A

6 months-12 months

39
Q

Superior Gluteal Artery length and diameter

A

5-10cm length, 2-3mm diameter

40
Q

The Inferior gluteal artery is accompanied by which Structures?

A

Sciatic Nerve, internal pudendal artery and vein and poster femoral cutaneous nerve

41
Q

SGAP and IGAP Flaps can be harvested as sensate flaps based on what

A

Superior middle and inferior cluneal nerves

42
Q

length and Diamter of Thoracodorsal Artery

A

The average
length of the thoracodorsal artery is 8.4cm (range, 5.9–
14cm), and the diameter of the vessel at its origin is 3mm
(range, 2–5mm)

43
Q

Why is it important to localize the arcuate line in DIEP flap breast reconstruction

A

its where the inferior epigastric vessels perforate the rectus abdominis.

44
Q

Name complications of TUG flap harvest for breast reconstruction.

A
  1. numbness of the medial thigh
  2. potential for chronic lymphedema of the lower leg
  3. contour deformities of the medial
    thigh
  4. widening of the medial thigh scar need to be considered.
45
Q

What is the first structure you are going to see when harvesting your TUG flap anterior to posterior

A

Saphenous Vein. Preserve it to make sure you preserve the lymphatics.

46
Q

You are raising a TUG flap for breast reconstruction. Describe your landmarks

A

Draw a line form ischium to medial femoral condyle. This is the axis of gracilis. You can also palpate for the adductor longus. Gracilis is 2 finger bredths posterior to it.

47
Q

Describe how you find the pedicle in TUG flap elevation.

A

Dissection is carried anterior to posterior. It starts over adductor longus fascia and proceeds posteriorly. After you pass the saphenous vein and reach the medial edge of adductor longus, incise the fascia and but a self retaining retractor between the adductor longus and gracilis. The pedicle will be found under the adductor longus entering the gracilis.

48
Q

Why is it important to try to preserve the greater saphenous nerve in raising a TUG flap

A

The lymphatics underneath it, if disrupted can lead to lower extremity lymphedema.

49
Q

What is Mondors Disease and how do you treat it?

A

Superficial thrombophlebitis of the anterolateral thoracoabdominal wall.
Self-limiting
Treatment: Heat, anti-inflammatory medications and supportive bra

50
Q

Patient is candidate for oncoplastic reconstruction. She asks what the chances of positive margins are post tumour excision

A

Up to 36% of simple excisions fail to achieve adequate margins in a single operation, leading to re-excision,worsening cosmesis, and conversions to mastectomy

51
Q

Benefits of oncoplastic reconstruction over mastectomy

A
  1. feeling of wholness,
  2. preservation of breast sensation
  3. limited morbidity from device based or autologous reconstruction.
52
Q

You plan on doing an oncoplastic reconstruction of a breast following a 2 cm inferior pole tumor removal. You plan a circumvertical approach. Patient wants liposuction. Can you do it?

A

Not recommended for fear of seeding cancer cells.

53
Q

Difference between MSK and MD Anderson Delayed Immediate Breast Reconstruction protocols

A

If there is a need for PMRT, MD anderson, deflates expander, radiates it and then rapidly inflates 2 weeks post radiation, then exchanges to implant. MSK, rapidly inflates during chemotherapy, exchanges to implant 4 weeks post, then radiates implant.

54
Q

Describe the ideal breast conserving therapy patient that would be a great candidate for oncoplastic techniques

A

The ideal patient is one where the
tumor can be excised within the expected breast
reduction specimen, in medium to large or ptotic
breasts where sufficient breast parenchyma remains
following resection to reshape the mound.

55
Q

Locoregional recurrence rate for 1. lumpectomy 2. oncoplstic breast conserving surgery 3. mastectomy

A

20-40%, 8-10%, 3-5%

56
Q

Patient has large pendulous breasts and you explain that its safer to to free nipple grafts than to pedicle the NAC> what do you council them on

A

Flatter NAC that lacks sensation and the ability to breast feed.

57
Q

What is the circumference of a 4.5cm diameter NAC?

A

The circumference of a 5-cm-diameter areola is
16 cm, and the circumference of a 4.5-cm-diameter
areola is 14 cm (the original Wise pattern).

58
Q

What percentage of woman undergoing BBR will be able to breastfeed?

A

60-70%

59
Q

An augment alone will elevate NAC by how much

A

1-2cm

60
Q

Disadvantages of periareolar mastopexy incision

A

only mind cephalic movement of NAC. Flat boxey NAC, widened periareolar scars.

61
Q

Reduction in visualization with mammography post augmentation (submuscular vs subglandular)

A

Eklund Displacement views are needed.

Subglandular reduces visualization by 36-44% and Submuscular reduces visualization by 15-25%)

62
Q

ideal NAC diameter in males. Ideal SNN in males

A

2.8cm diameter and 20cm SNN

63
Q

What is supernumary breast associated with

A

Renal problems.

Breast - Non Cosmetic MJS (1 decks)

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