Breast, Skin & Soft Tissue Flashcards
Breast mass work up - don’t forget to ask
Family history of breast (female & male), ovarian, cervical cancer
Gail model: age, race, hx of breast dz, age of menarche, parity, FMHx, number bx
DONT FORGET to ask about Hx radiation & smoking!!!
Breast BIRADS
BI-RADS 0 - Incomplete → requires more imaging
Includes benign findings on initial screening mammogram that are no longer present
BI-RADS 1 - Negative → routine f/u
BI-RADS 2 - Benign finding → routine f/u
BI-RADS 3 - Probably benign finding (0-2%) → f/u mammogram in 3-6 months
BI-RADS 4 - Suspicious abnormality → Need CNBx
BI-RADS 5 - Highly suggestive of cancer (≥95%) → Need CNBx
DCIS management
BCT with lumpectomy, XRT, 5 years of tamoxifen (AI if post-menopause)
High grade or large tumors (>2.5 cm) → simple mastectomy w SLNBx, no radiation
LCIS management
Excise area of suspicion
Pleomorphic LCIS → Only LCIS that needs negative margins
Recommend Tamoxifen for 5 years vs bilateral prophylactic subcutaneous mastectomy
Who should get neoadjuvant chemotherapy in breast cancer
Any locally advanced tumor (N2/N3, T4, inflammatory) or if tumor is too large for BCT & pt wants BCT
Contraindications for SLNBx in breast CA
Clinically palpable nodes (need ALND which takes levels I & II)
Pregnancy (with blue dye only)
Multicentric disease
Prior axillary surgery
Locally advanced disease or inflammatory (higher false-negative rate following neoadjuvant chemotherapy)
Breast CA patients with positive nodes get adjuvant chemotherapy EXCEPT
+ER & (low risk) postmenopausal→ Aromatase inhibitor only
or low oncotype dx….
Breast CA patients with tumors > 1cm & negative nodes should get adjuvant chemotherapy EXCEPT
+ER
Postmenopausal→ AI only
Premenopausal→ tamoxifen only
Indications for XRT after MASTECTOMY & chemo
≥N2 (advanced nodal disease)
≥T3 (>5 cm) or T4 (inflammatory or Skin/chest wall involvement)
Positive margins of resection
Chemotherapy for breast cancer
TAC (Taxanes (docetaxel & paclitaxel), adriamycin, cyclophosphamide) for 6-12 weeks
Breast cancer in pregnancy - work up, management, what is safe & what is not safe
Mammogram & U/S, NOT MRI; staging w CXR & liver U/S
SAFE IN PREGNANCY
Adriamycin, Cytoxan
Colloid/Tc-99
NOT SAFE IN PREGNANCY
MRI, PET
Radiation
Lymphazurin & methylene blue
Transtuzumab
Tamoxifen/AI
Diagnosis & management of
1. Paget’s
2. Phyllodes
3. Stewart-Treves (lymphangiosarcoma from chronic lymphedema following ALND)
4. Cutaneous angiosarcoma from prior radiation
5. Male breast cancer
Paget’s disease (Patients have DCIS or ductal CA in breast)
Dx: full thickness incisional breast biopsy including the skin (first step)
Tx: need MRM if cancer or multicentric DCIS; otherwise simple mastectomy (including NAC!) with SLNBx if DCIS is present
Phyllodes tumor → The only way to distinguish a fibroadenoma from phyllodes tumor is excision for histologic confirmation
Tx: WLE with negative margins (1 cm); no ALND
Stewart–Treves syndrome (patients present with dark purple nodule or lesion on arm 5–10 years after surgery)
Tx: WLE with 3-6 cm margins
Radiation associated sarcoma or cutaneous angiosarcoma
Tx: Neoadjuvant chemotherapy w taxane & total mastectomy
Male breast cancer tx
Tx: MRM & Tamoxifen, consider neoadjuvant chemotherapy if advanced
SLNBx
- NM injects radiotracer and performs lymphoscintigraphy prior to surgery
- Inject methelyne blue into dermis of lesion & perform massage for 10 minutes
- Perform lymph node dissection
- The hot and blue nodes are identified as SLN, and given a gamma count
–All nodes with gamma counts greater than 10% of the SLN should be removed
–All blue nodes should be removed
–All firm nodes should be removed
MRM procedure
Simple mastectomy
1. Transverse elliptical incision to remove nipple & areola used to exciss breast skin & permit tension free closure
2. Create mastectomy flaps at least 0.5 cm thick
3. Dissect & remove breast with fascia of pectoralis major to borders (sternum medially, slavicle superiorly, LD laterally, rectus sheath inferiorly)
ALND
1. Open clavipectoral fascia
2. Identify axillary vein, thoracodorsal bundle, & long thoracic nerve & preserve
3. Dissect axillary tissue within boundaries of axillary vein superiorly, serratus medially, LD/subscapularis posteriorly, pec major/minor anteriorly
Melanoma stains for what? Who needs staging and with what?
Stains for S-100 & HMB 45
If clinically positive nodes, need CT/PET, brain MRI, LDH
Who needs a SLNBx in melanoma?
SLNB indicated for >1 mm thick, ≤1mm thick w ulcer, or ≥ 1 mitosis per mm2
What margins are needed in Melanoma?
Melanoma in situ or thin lentigo maligna → JUST NEED 0.5 cm MARGINS
≤1.0 mm → 1.0 cm margins
1.1-2.0 mm → 1.0-2.0 cm margins
> 2.0 mm → 2.0 cm margins
Management of positive SLNBx in melanoma
MSLT-2 trial → CLND vs observation w U/S (ie q3 months).
With CLND, there is no difference in melanoma-specific survival, but improved 5-year disease-free survival at the cost of higher likelihood of lymphedema (24% vs 6%)
Adjuvant therapies for melanoma
Nivolumab & Pembrolizumab (PD1 inhibitors) improve recurrence free survival by 10%
Superficial & deep inguinal lymph node dissection
Send Cloquet’s lymph node (bridging node between superficial & deep lymph node basin; if positive, need to do deep inguinal dissection)
SUPERFICIAL
1. Longitudinal incision in femoral triangle, expose femoral vessels, divide & ligate GSV & reflect LNs off femoral vessels. Detach specimen at inguinal ligament & take fatty issue 5 cm above ligament.
2. Detach sarorius proximally, mobilize medially to cover vessels, secure to EO aponeurosis/inguinal ligament
3. Place drain & close
DEEP
1. Second transverse incision above inguinal ligament
2. Detach the inguinal ligament from the
anterior superior iliac spine and reflect medially
3. Dissect the nodal tissue along the external and common femoral vessels and obtura- tor nerve, preserving the nerve, vessels, and ureter.
4. Reconstruct inguinal ligament
5. Place drain, close in layers
Basal cell carcinoma dx & management
MC malignancy in USA
Pearly, rolled borders
Diagnosis/Staging
Pathology → Peripheral palisading of nuclei & stromal retraction
Morpheaform type is most aggressive, has collagenase
Treatment
0.5 cm margins
Regional adenectomy for clinically positive nodes
SCC dx & management; indications for SLNBx if immunosuppressed
0.5-1.0 cm margins
2 cm margins for Marjolin’s ulcers & genitalia
Risk factors that warrant consideration for SNL in immunosuppressed
1. Tumor diameter >2 cm for the trunk and extremities, >1 cm for the face, scalp, hands, and feet
2. Poorly differentiated tumors
3. Presence of angiolymphatic invasion and perineural invasion
4. Tumor depth greater than 6 mm or invasion beyond the subcutaneous fat
Merkel cell cancer diagnosis & staging
Dx with IHC (+NSE, +Cytokeratin, +neurofilament protein)
CK-20, similar to lung small cell cancer (which, unlike MCC, expresses TTF-1)
Most common site of metastasis is LN, skin, lung, CNS, liver
Need whole body PET CT
Merkel cell cancer management
WLE w 2-3 cm margins & SLNBx vs formal LN dissection
If ≥2 cm or +LN, need adjuvant radiation
