breast questions Flashcards by Glo Sa

Levels of axillary LN

1- lateral to pec minor
2 - underneath pec minor
3 - medial to pec minor

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Important nerves

1 - long thoracic - 
2 - Intercostal brachial nerve **** MC 
3 - Thoracodorsal nerve 
4 - medial pectoral nerve -  
5 - lateral pectoral nerve

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Intercostal brachial nerve

provides sensation to medial arm

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Thoracodorsal nerve

lattisimus dorsi - weak arm adduction

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medial pectoral nerve

pec major and minor (MM, cap M)

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lateral pectoral nerve

pec minor only

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Blood supply

Intermal mammary
 
Intercostal  
Thoracoacromial  
Lateral thoracic artery

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BiRADs

1 - normal — routine screening 
2 - benign — same as above 
3 - decrease interval to 6 months to repeat imaging 
4 - bx and further tissue analysis 
5 - same as above 
6 - confirmed diagnosis 
0 - not enough info

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Nipple discharge

3 % later diagnosis with cancer if < 40 year old
> 60, 33% Cancer risk
— bloody, spontaneous discharge, persistent after a week, unilateral
— mammography, ductal fluid cytology, duct excision to look at underlying pathology

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MC cause of bloody discharge

Intraductal papilloma

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If cyst on US

Bloody or recurrent, send for cytology

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Phyllodes tumor

Malignant potential, wide local excision with 1 cm margin. If > 5 mitosis per hpf, higher risk, rarely goes to node. So may not need LN excision

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Radial scar

Sclerosis proliferations - mammography appearance can show calcifications, only small increased risk of cancer, need to bx to rule out

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MC organism in abscess

Gram + staph

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Hereditary disorder increase risk

BRACA 1/2- 10-20 fold, 30-60% chance of having this by age 60 
Le freumani - p53 
Cowden syndrome -p10 
Putzjieger-stk11 
Chd1 - gastric cancer

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Gail model

Women risk of developing breast cancer within 5 year and life time 
age  
Age at menarche  
Time of first child born  
Family hx of breast cancer  
Number fo breast bx  
Number of bx showing atypical hyperplasia  
Race and ethnicity

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DCIS tx

Lumpectomy with radiation and hormonal therapy if hormone receptor +, tamoxifen for 5 years; if post menopause aromatase inhibitors

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Mastectomy

Multi quadrant disease, large lesion, contraindication to pst op radiation need sentinel LN bx, to 25% may show invasive pathology

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Margins for DCIS

1-2 mm margin spreads along the basement membrane can be contiguous

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Invasive ductal margins

Only need negative ink

Canceling for post radiation

Radiation in breast conservation - decreased risk of recurrence by 50%, but no difference than mastectomy in overall survival
Mastectomy

Overall survival is the same, there is increased risk of recurrence in breast conservation, adding radiation decreases risk by 50%

LCIS

Not a premalignant lesion, but it increases risk of cancer in both breast, need excisions bx

Tx LCIS

Wire localized excision to rule out
+ margin: surgically complete, don’t need negative margins
— risk of developing ductal cancer half percent risk increased per year, but could consider hormonal therapy

Invasive cancer - staging

T0 
T1: 0-2 cm 
T2: 2-5 
T3: >5 
T4 Invasion of wall- pec major is not considered chest wall

N1:1-3
N2: 4-9
N3: 10 or supra or infraclavicular staging

M1: distal mets

Staging

Stage 1: T1N0M0: - small tumor and no nodes Stage 2: T3N0, T2N1 - Larger tumor or minor nodal involvement Stage 3a- T4N0, T3N2 - local invasion or more modes Stage 3b- T3N2 Stage 3c - clavicular nodes, any T but N3 disease Stage 4: distal mets

Treatment 1-2 stage

Surgery and adjuvant chemo and rads- breast conservation therapy, whole breast radiation survival equivalent of mastectomy Contradiction: radiation after, if no candidates pregnant multi centric disease, + pathologic margins after re-excisions, previous radiation or active connective tissue or greater than 5 cm

Locally advanced operatively tumor, surgery first or neoadjuvant for downstaging

3b/3c

Locally advance inoperative,y neadjuvant first and surgery if they respond

Primary chemo

Surgical axillary staging

Invasive tumor, need SLN bx .

z11 trial

Comparing patients with small tumors and small amount axillary disease to wether they need axillary dissection or radiation can treat axilla adequate. Patients > 18 age, < 5 cm (T2 or less), < 3 + LN (N1) breast conservation therapy w/ whole breast radiation. RTC. 1 group: if + SLN, got axillary dissection (morbid procedure) 2 group: whole breast radiation which treats the axilla — no difference in local recurrence, overall survival 6.3 years

axillary dissection

clinically + nodes confirmed by FNA or core needle bx, - level 1-2 for breast cancer . Or SLN that were not identified

Chemo

> 1 cm , + node, tripple neg nodes (ER,PR,HER2) — TAC (taximes, peripheral neuropathy), adreomycin (doxorubicin ,cardiomyopathy cyclophosphamide, hemorrhagic cystitis give MESNA)

Neoadjuvant for

Locally advanced, N2/N3, too large relative to rest of breast

Radiotherapy

Whole breast decreased local recurrence and survival , give after chemo. If LN>4, infraclavicular, supraclavicular radaiotn to inter

85-90 yo cancer breast

If > 70 , negative margins after lumpectomy ER+TN1, may not need radiation and just hormonal therapy

Radiation after mastectomy

If + axillary LN, tumors > 5cm ,+ margins

All positives

5 years of tamoxifen

HER 2

Transtuzumab for HER 2 for 1 year

Inflammatory breast cancer r

Rapid diffuse involvement of entire breast, skin changes from lymphatic invasion T4, at least stage 3 b

Pagets disease

Scaling and ulceration of nipple, concerning for malignancy. HER2+, HR -,

Breast cancer in pregnancy

1st- modified radical mastectomy because can’t undergo radiation 2nd - can do breast conservation, SLN and modified isotope dosing , chemo can be given, after delivery will undergo radiation

Dominant breast mass next

Bilateral mammography and Us depending on age

MC site mets

Lung, brain, bone, liver

.1mm lesion of isolated cell deposits

Not considered mets

BRACA 1/2

Breast and ovarian , high in 1 40%,

Tamoxifen risks

Thromboembolism, uterine Cancer

Tender palpable cord

Superficial thrombophlebitis - given NSAIDs, mammography and all the other screening.

Stuart treves syndrome

Lesion many years after axillary dissection - lyphangiosarcoma