Chapter 24: Breast Flashcards
1
Q
Embryology: breast
A
Formed from the ectoderm milk streak
2
Q
Hormones that cause..
- Duct development (double layer of columnar cells)
- Lobular development
- Synergizes estrogen and progesterone
A
- Estrogen: duct development (double layer of columnar cells)
- Progesterone: lobular development
- Prolactin: synergizes estrogen and progesterone
3
Q
Cyclic change: increases breast swelling, growth of glandular tissue
A
Estrogen
4
Q
Cyclic change: increase maturation of glandular tissue; withdrawal causes menses
A
Progesterone
5
Q
Cyclic change: cause ovum release
A
FSH, LH surge
6
Q
What causes atrophy of breast tissue after menopause?
A
After menopause, lack of estrogen and progesterone results in atrophy of breast tissue.
7
Q
Innervates serratus anterior, injury results in winged scapula
A
Long thoracic nerve
8
Q
Artery: supplies serratus anterior
A
Lateral thoracic artery
9
Q
Innervates latissmus dorsi; injury results in weak arm pull-ups and adduction
A
Thoracodorsal nerve
10
Q
Artery: supplies latissimus dorsi
A
Thoracodorsal artery
11
Q
Innervates pectoralis major and pectorals minor
A
Medial pectoral nerve
12
Q
Nerve: pectorals major only
A
Lacteral pectoral nerve
13
Q
Lateral cutaneous branch of the 2nd intercostal nerve; provides sensation to medial arm and axilla; encountered just below axillary vein when performing axillary dissection. Can transect without serious consequences.
A
Intercostobrachial nerve
14
Q
Arteries that supply the breast
A
Internal thoracic artery, intercostal arteries, thoracoacromial artery, and lateral thoracic artery
15
Q
Valveless vein plexus that allows direct hematogenous metastasis of breast CA to spine
A
Batson’s plexus
16
Q
Lymphatic drainage of the breast
A
- 97% to axillary nodes
- 2% to internal mamillary nodes
- Any quadrant can drain to the internal mammary nodes.
17
Q
Considered N3 disease
A
Mets to supraclavicular nodes
18
Q
Dx: primary axillary adenopathy
A
1 is lymphoma
19
Q
Suspensory ligaments of the breast. Divide breast into segments.
A
Cooper’s ligaments
20
Q
What does skin dimpling of the breast suggest?
A
Breast CA involving Cooper’s ligaments dimpling the skin.
21
Q
What are breast abscesses usually caused by?
MCC?
A
Usually a/w breast feeding.
MCC: Staph aureus
22
Q
TX: breast abscess
A
Percutaneous or incision and drainage; discontinue breastfeeding; breast pump; antibiotics.
23
Q
MCC infectious mastitis in nonlactating women
A
S. aureus MC in non lactating women can be due to chronic inflammatory diseases (e.g., actinomyces) or autoimmune disease (e.g., SLE) -> may need to r/o necrotic cancer (need incisional biopsy including the skin)
24
Q
What is infectious mastitis usually associated with?
A
Breastfeeding
25
Mammary duct ectasia or plasma cell mastitis
Periductal mastitis
26
S/S: noncyclical mastodynia, erythema, nipple retraction, creamy discharge from nipple; can have sterile or infected subareolar abscess
Periductal mastitis
27
Risk factors: periductal mastitis
Smoking, nipple piercings
28
Biopsy: Periductal mastitis
Dilated mammary ducts, inspissated secretions, marked periductal inflammation
29
Tx: periductal mastitis
If typical creamy discharge is present that is not bloody and not associated with nipple retraction, give antibiotics and reassure; if not or it recurs, need to r/o inflammatory CA (incisional biopsy including the skin)
30
Breast cysts filled with milk; occurs with breastfeeding
| Tx: ranges from aspiration to incision and drainage.
Galactocele
31
Can be caused by increased prolactin (pituitary prolactinoma), OCPs, TCAs, phenothiazines, metoclopramide, alpha-methyl dopa, reserpine.
- Is often a/w amenorrhea
Galactorrhea
32
2-cm pinch of breast tissue.
| Tx: will likely regress; may need to resect if cosmetically deforming or causing social problems.
Gynecomastia
33
What is gynecomastia associated with?
Cimetidine. Spironolactone. Marijuana. Idiopathic in most.
34
Due to circulating maternal estrogens; will regress.
Neonatal breast enlargement.
35
MC location of polythelia (accessory breast tissue)
Axilla
36
MC breast anomaly.
| Location?
Accessory nipples
| - Found form axilla to groin
37
What is compromised with breast reduction?
Ability to lactate frequently compromised.
38
Hypoplasia of chest wall.
Amastia.
Hypoplastic shoulder.
No pectoralis muscle.
Poland's Syndrome
39
Pain in breast; rarely represents breast cancer.
| Dx: history, breast exam, BL mammogram.
Mastodynia
40
Tx: Mastodynia
```
Danazol.
OCPs
NSAIDs.
Evening primrose oil.
Bromocriptine.
D/C: caffeine, nicotine, methylxanthines.
```
41
Pain before menstrual period, most commonly represents acute or subacute.
Cyclic mastodynia.
42
Continuous pain. MC'ly represents acute or subacute infection; continuous mastodynia is more refractory to treatment than cyclic mastodynia.
Continuous mastodynia.
43
Superficial vein thrombophlebitis of breast, feels cordlike, can be painful.
Mondor's disease
44
What is Mondor's disease associated with?
| Def: superficial vein thrombophlebitis of breast
- Associated with trauma and strenuous exercise.
| - Usually occurs in lower outer quadrant.
45
Tx: Mondor's disease
NSAIDs
46
Dx: breast pain, nipple discharge (usually yellow to brown), lumpy breast tissue that varies with hormonal cycle.
Fibrocystic change.
47
Types of fibrocystic change.
Papillomatosis. Sclerosing adenosis. Apocrine metaplasia. Duct adenosis. Epithelial hyperplasia. Ductal hyperplasia. Lobular hyperplasia.
48
What type of fibrocystic disease is associated with risk of CA?
Atypical ductal or lobular hyperplasia.
49
Tx: atypical ductal / lobular hyperplasia subtypes of fibrocystic change?
Resect.
- Do not need to get negative margins with atypical hyperplasia; just remove all suspicious areas (i.e., calcifications that appear on mammogram).
50
MCC bloody nipple discharge
Intraductal papilloma
51
- Usually small, non palpable, close to nipple.
| - Not premalignant
Intraductal papilloma
52
Intraductal papilloma
- Dx?
- Tx?
Dx: contrast ductogram to find papilloma, then needle localization
Tx: Subareolar resection of the involved duct and papilloma.
53
MC breast lesion in adolescents and young women; 10% multiple.
- Usually painless, slow growing, well circumscribed, firm, and rubbery.
- Often grows to several cm in size and then stops.
- Can change in size with menstrual cycle. Can enlarge in pregnancy.
Fibroadenoma
54
Path: fibroadenoma
prominent fibrous tissue compressing epithelial cells
55
Mammography: fibroadenoma
Large, coarse calcifications (popcorn lesions) from degeneration.
56
Criteria for observation of fibroadenoma.
In patients less than 40 years old:
1. Mass needs to feel clinically benign (firm, rubbery, rolls, not fixed).
2. US or mammogram needs to be consistent with fibroadenoma.
3. Need FNA or core needle biopsy to show fibroadenoma.
57
Tx: enlarging fibroadenoma
Excisional biopsy
58
Why avoid resection of fibroadenoma in teenagers / younger children?
Resection can affect breast development.
59
Fibroadenoma: pts > 40
Excisional biopsy to ensure dx
60
Tx: fibroadenoma
- Pts Observe. No?ex bx.
| - Pts > 40: Ex bx to ensure diagnosis
61
Most nipple discharge is...
Benign
62
Dx: nipple discharge
History, breast exam, BL mammogram. Try to find the trigger point on exam.
63
Nipple discharge: green
| Tx?
Usually due to fibrocystic disease.
| Tx: if cyclical and non spontaneous, reassure pt.
64
Nipple discharge: bloody
| Tx?
MC intraductal papilloma; occasionally ductal CA.
| Tx: Need ductogram and excision of that ductal area.
65
Nipple: serous discharge
Worrisome for cancer. Especially if coming form only 1 duct or spontaneous.
Tx: Excisional biopsy of that ductal area
66
Nipple: spontaneous discharge
No matter what the color or consistency is, this is for worrisome for CA -> all these patients need excisional biopsy of duct area causing the discharge.
67
Discharge:
- Occurs only with pressure, tight garments, exercise, etc.
- Not as worrisome but may still need excisional biopsy (e.g., if bloody)
Nonspontaneous discharge
68
Sx: nipple discharge
May have to do a complete subareolar resection if the area above cannot be properly identified (no trigger point or mass felt).
69
Malignant cell of the ductal epithelium without invasion of basement membrane
Ductal carcinoma in situ.
70
DCIS Risk Ca:
Ipsilateral Breast
Contralateral Breast
Ipsilateral breast: 50%
| Contralateral breast: 5%
71
DCIS: premalignant lesion
Yes.
72
- Usually not palpable and presents as a cluster of calcifications on mammography.
- Can have solid, cribriform, papillary, comedy patterns
DCIS
73
Most aggressive subtype DCIS
- Necrotic areas
- High risk for multi centricity, micro invasion, recurrence.
Tx?
Comedo pattern DCIS
| - Tx: simple mastectomy.
74
Increased risk of cancer in DCIS?
Comedo type and lesions > 2.5cm
75
Tx: DICS (not high grade)
Lumpectomy and XRT.
Need 1cm margins.
No ALND or SLNB.
Possibly tamoxifen.
76
Tx: High grade DCIS
Simple mastectomy if high grade (e.g., comedo type, multi centric, multifocal), if a large tumor not amenable to lumpectomy, or if not able to get good margins. No ALND.
77
Considered a marker for the development of breast CA, not premalignant itself.
- 40% get cancer (either breast)
- No calcifications, is not palpable.
- Primarily found in premenopausal women.
Lobular carcionma in situ - LCIS.
78
Patient who develop breast CA are more likely to develop a..
Ductal CA (70%)
79
Possibility of synchronous breast cancer at time of LCIS diagnosis?
5% (most likely ductal CA)
80
Do you need negative margins for LCIS?
No.
81
Treatment for LCIS
Nothing. Tamoxifen. BL subcutaneous mastectomy (no ALND).
82
Indications for Surgical Biopsy after core biopsy
```
Atypical ductal hyperplasia.
Atypical lobular hyperplasia.
Radial scar.
LCIS
Columnar cell hyperplasia with atypia.
Papillary lesion.
Lack of concordance between appearance of mammography lesion and histologic diagnosis.
Nondiagnostic specimen.
```
83
Country: lowest risk of breast CA worldwide
Japan
84
United States breast cancer risk
1 in 8 women (12%); 5% in women with no risk factors.
85
Breast cancer screening decreases mortality by..
25%
86
Years survival: untreated breast cancer
2-3 years
87
%: Beast CA with negative mammogram and negative ultrasound
10%
88
Clinical features of breast CA
Distortion of normal architecture.
Skin / nipple distortion or retraction.
Hard.
Tethered. Indistinct borders.
89
Symptomatic breast mass work up
Ultrasound & Core needle biopsy. (consider FNA).
| - Need mammo in pts
90
Symptomatic breast mass work up > 40 years old
Need bilateral mammograms.
Ultrasound.
Core needle biopsy.
91
If core needle biopsy or FNA is indeterminate, non-diagnostic, non-concordant with exam findings / imaging studies..
Will need excisional biopsy.
92
Clinically indeterminate or suspect solid masses will eventually need..
Excisional biopsy unless CA diagnosis is made prior to that.
93
Tx: cyst fluid
Bloody: cyst excisional biopsy
Clear/recurs: excisional biopsy.
Complex: excisional biopsy
94
Test: gives architecture
CNBx
95
Test: Gives cytology (just the cells)
FNA
96
Mgmt: malignant breast mass (FNA/CNBx)
Definitive therapy
97
Mgmt: suspicious breast mass (FNA/CNBx)
Surgical biopsy
98
Mgmt: atypia breast mass (FNA/CNBx)
Surgical biopsy
99
Mgmt: non diagnostic breast mass (FNA/CNBx)
Repeated FNA/CNBx or surgical biopsy
100
Mgmt: benign breast mass (FNA/CNBx)
Possible observation - exam and imaging studies need to concordant with benign disease, otherwise need excisional biopsy.
101
Sensitivity / specificity: mammography
90%
102
How does mammography increase with age?
Sensitivity increases with age as the dense parenchymal tissue is replaced with fat.
103
Size breast mass to be detected by mammography
> 5 mm
104
Mammography: suggestive of Cancer
Irregular borders. Speculated. Multiple clustered. Small. Thin. Linear. Crushed-like and/or branching calcifications. Ductal asymmetry. Distortion of architecture.
105
BI-RAD 1.
Negative
| Tx: Routine screening
106
BI-RADs 2
Benign finding
| Tx: Routine screening
107
BI-RADs 3
Probably benign finding
| Tx: Routine screening
108
BI-RADs 4
```
Suspicious abnormality (eg, indeterminate calcifications or architecture)
Tx: definite probability of CA; get CNBx
```
109
BI-RADs 5
Highly suggestive of CA (suspicious calcifications or architecture)
Tx: high probability of CA; get CNBx.
110
Tx: BI-RADs 4 lesion CNBx
- Malignancy?
- Non-determinate?
- Benign and concordant with mammogram?
- Malignancy: follow appropriate treatment
- Non-diagnostic, interdeterminate, or benign and non-concordant with mammogram -> need needle localization excisional biopsy
- Benign and concordant with mammogram -> 6 month follow-up
111
Tx: BI-RADs 5 lesion CNBx shows
- Malignancy?
- Any other finding?
- Malignancy: follow appropriate tx
| - Any other finding (non diagnostic, indeterminate, or benign) -> all need needle localization excisional biopsy.
112
What allows appropriate staging with SLNBx (mass is still present) and one-step surgery for patients diagnosed with breast cancer?
CNBx without excisional biopsy.
113
Recommendations: mammogram screening?
Q 2-3 years after age 40, then yearly after 50.
114
Recommendations: high-risk mammogram screening
10 years before the youngest age of diagnosis of breast CA in first-degree relative.
115
Why aren't mammograms generally recommended in patients
Hard to interpret because of dense parenchyma.
116
How does mammogram radiation dose change in younger patients?
Dose decreases
117
Node levels:
I?
II?
III?
I: lateral to pectoralis minor muscle
II: beneath pectoralis minor muscle.
III: medial to pectorlis minor muscle
118
LN: between the pectoralis major and pectoralis minor muscles.
Rotter's nodes
119
What nodes do you generally take?
Level I and II. Take level III nodes only if grossly involved.
120
Most important prognostic staging factor
Nodes
121
Factors including in prognostic staging
Nodes (most important). Size. Grade. Progesterone / Estrogen receptor status.
122
What is survival directly related to in breast cancer?
Number of positive nodes.
- 0: 75% 5-year survival
- 1-3: 60% 5-year survival
- 4-10: 04% 5-year survival
123
Most common site for distant metastasis
Bone
124
Time: Single malignant cell to 1-cm tumor.
Approximately 5-7 years
125
Location: increased risk of multicentricity
Central and subareolar tumors
126
Breast CA: greatly increased risk (relative risk > 4)
- BRCA gene in pt with +fam hx
- > 2 primary relatives with BL or premenopausal breast CA
- DCIS (ipsilateral breast at risk) and LCIS (both breasts have same high risk)
- Fibrocystic disease with atypical hyperplasia.
127
Breast CA: moderately increased risk (relative risk 2-4)
- Prior breast cancer
- Radiation exposure
- First degree relative with breast cancer
- Age > 35 first birth
128
Breast CA: lower increased risk (relative risk
- Early menarche / late menopause
- Nulliparity
- Proliferative benign disease
- Obesity, alcohol, hormone replacement therapy.
129
BRCA I Cancer Risk
- Female breast CA
- Ovarian CA
- Male breast CA
Lifetime risk..
- Female breast: 60%
- Ovarian: 40%
- Male breast: 1%
130
BRCA II Cancer Risk
- Female breast CA
- Ovarian CA
- Male breast CA
Lifetime risk..
- Female breast: 60%
- Ovarian: 10%
- Male breast: 10%
131
Sx Considerations: BRCA families with history of breast cancer
Total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO)
132
Breast Cancer risk: first degree relative with bilateral, premenopausal breast cancer
50%
133
Considerations for prophylactic mastectomy
- Family history + BRCA gene
- LCIS
- Also need one of the following: high patient anxiety, poor patient access for follow-up exams and mammograms, difficult lesion to follow on exam or with mammograms, or patient with preference for mastectomy
134
Why are positive receptors good?
Better response to hormones, chemotherapy, surgery, and better overall prognosis.
135
Receptor-positive tumors are more common in...
Postmenopausal women
136
What receptor do you want positive: estrogen or progesterone?
Progesterone receptor-positive tumors have better prognosis than estrogen receptor-positive tumors.
137
What happens with positive estrogen AND progesterone receptors?
Both positive? Has the best prognosis.
138
%: Breast cancer negative for both receptors.
10%
139
-
Male breast cancer
140
What is male breast cancer associated with?
Steroid use.
Previous XRT.
Family history.
Klinefelter's syndrome
141
Tx: male breast cancer
Tx: Modified Radical Mastectomy (MRM)
142
- 85% of all breast cancer.
| Tx?
Ductal CA
| Tx: MRM or BCT (breast conserving therapy) with post XRT
143
Ductal CA: Subtypes
Medullary.
Tubular.
Mucinous.
Scirrhotic.
144
Ductal CA: smooth borders, increased lymphocytes, bizarre cells, more favorable prognosis.
Medullary ductal CA
145
Ductal CA: small tubule formations, more favorable prognosis.
Tubular ductal CA
146
Ductal CA: produces an abdundance of mucin, more favorable prognosis
Mucinous (colloid) ductal CA
147
Ductal CA: worse prognosis
Schirrhotic
148
- 10% of all breast CA
- Does not form calcifications, extensively infiltrative, increased bilateral, multifocal and multi centric disease.
- signet ring cells confer worse prognosis
Lobular cancer
149
Tx: lobular cancer
MRM or BCT with post op XRT
150
Path: confers worse prognosis in lobular CA
Signet ring cells
151
- Considered T4 disease
- Very aggressive -> median survival of 36 months
- Has dermal lymphatic invasion, which causes peau d'orange lymphedema appearance on breast, erythematous and warm
Inflammatory breast cancer
152
Tx: inflammatory breast CA
Neoadjuvant chemo, then MRM, then adjuvant chemo-XRT (most common method)
153
- Leaves 1%-2% of breast tissue, preserves the nipple
- Not indicated for breast CA treatment
- Used for DCIS and LCIS
Subcutaneous mastectomy
| simple mastectomy
154
- Removes all breast tissue, including the nipple areolar complex
- Includes axillary node dissection (level 1 nodes)
Modified radical mastectomy
155
Surgical options for breast cancer
```
Subcutaneous mastectomy.
Breast-conserving therapy.
Modified radical mastectomy.
SLNB.
ALND.
```
156
Combined with postop XRT; need 1cm margin
Breast-conserving therapy.
157
Absolute contraindications to Breast-Conserving Therapy in invasive CA
- Two or more primary tumors in separate quadrants of the breast.
- Persistant + margins after reasonable surgical attempts
- Pregnancy: BCT with radiation after delivery.
- h/o prior therapeutic radiation to breast region that would result in re-treatment with excessively high radiation dose.
- Diffuse malignant appearing microcalcifications
158
Relative contraindications to breast-conserving therapy in invasive carcinoma
- h/o scleroderma or active SLE
- Large tumor in a small breast that would result in cosmoses unacceptable to pt.
- Very large of pendulous breasts if reproducibility of patient setup and adequate dose homogeneity cannot be ensured.
159
- Indicated only for malignant tumors > 1cm
| - Not indicated in pts with clinically positive nodes (need ALND).
Sentinel lymph node biopsy (SLB)
160
When is accuracy best for sentinel lymph node biopsy?
When primary tumor is present (finds the right lymphatic channels)
161
Dye used for sentinel lymph node biopsy
Lymphazurin blue dye or radio tracer is injected directly into the tumor area.
162
What to do: no radio tracer dye is found during sentinel lymph node biopsy
Do a formal ALND
163
Contraindications: SLNB (sentinel lymph node biopsy)
```
Pregnancy.
Multi centric disease.
Neoadjuvant therapy.
Clinically positive nodes.
Prior axillary surgery.
Inflammatory or locally advanced disease.
```
164
When level nodes do you take for axillary lymph node dissection?
Level 1 and 2 nodes
165
Complications of MRM
Infection.
Flap necrosis.
Seromas.
166
Complications of ALND
- Infection, lymphedema, lymphangiosarcoma.
- Axillary vein thrombosis (sudden early post swelling)
- Lymphatic fibrosis (slow swelling over 18 months)
- Intercostal brachiocutaneous nerve injury
167
ALND: sudden, early, post op swelling
Axillary vein thrombosis
168
ALND: slow swelling over 18 months
Lymphatic fibrosis
169
ALND: hypesthesia of inner arm and lateral chest wall; most commonly injured nerve after mastectomy, no significant sequelae
Intercostal brachiocutaneous nerve injury
170
MC'ly injured nerve after mastectomy
Intercostal brachiocutaneous nerve injury.
171
How long do you leave in drains after ALND?
Drainage
172
Radiation dose of radiotherapy
5,000 rad for BCT and XRT
173
Complications: XRT
Edema. Erythema. Rib fratures. Pneumonitis. Ulceration. Sarcoma. Contralateral breast CA.
174
Contraindications: XRT
Scleroderma (results in severe fibrosis and necrosis). Previous XRT and would exceed recommended dose. SLE (relative). Active rheumatoid arthritis (relative).
175
Indications for XRT after mastectomy.
- > 4 nodes
- Skin or chest wall involvement
- Positive margins
- Tumor > 5 cm (T3)
- Extracapsular nodal invasion.
- Inflammatory CA
- Fixed axillary nodes (N2) or internal mammary nodes (N3)
176
When can you start XRT after BCT?
When you have 1cm negative margins following BCT
177
%: Chance of local recurrence after BCT with XRT
10%
- Usually within 2 years of first operation.
- Need to re-stage with recurrence.
- Need salvage MRM for local recurrence.
178
Chemotherapy regimen
TAC
| taxanes, Adriamycin, cyclophosphamide for 6-12 weeks
179
Who gets chemotherapy with positive nodes?
Everyone EXCEPT postmenopausal women with positive estrogen receptors (they get hormonal therapy only aromatase inhibitor (anastrozole))
180
Tx: postmenopausal, positive nodes, estrogen receptor positive
Hormonal therapy only with aromatase inhibitor (anastrozole)
181
Chemo: > 1cm and negative nodes
Everyone gets chemo except patients with positive estrogen receptors - > they can get hormonal therapy only with tamoxifen if they are premenopausal or aromatase inhibitor (anastrozole) if they are postmenopausal.
182
No chemo.
| Hormonal therapy as above if positive estrogen receptors.
183
Tx after chemo: pts positive for estrogen receptors
Appropriate hormonal therapy
184
Have been shown to decrease recurrence and improve survival
Both chemotherapy and hormonal
185
Taxanes
Docetaxel, paclitaxel
186
- Decreases risk of breast cancer by 50%
| - 1% risk of blood clots; 0.1% risk of endometrial cancer
Tamoxifen
187
What happens to women with breast cancer recurrence?
Almost all women with recurrence die of disease.
188
Increased recurrences and metastases occurs with..
Positive nodes.
Large tumors.
Negative receptors.
Unfavorable subtype.
189
- Pain, swelling, erythema is metastatic areas.
| Tx?
Metastatic flare
- Tx: XRT can help
XRT is good for bone metastasis
190
Breast CA that presents as axillary metastases with unknown primary.
Tx?
Occult breast CA
| - Tx: MRM (70% are found to have breast CA)
191
- Scaly skin lesion on nipple
- Have DCIS or ductal CA in breast
Tx?
Paget's disease
| Tx: need MRM if cancer present; otherwise simple mastectomy (need to include the nipple-areolar complex with Paget's)
192
Bx: Paget's disease
Paget's cells
193
Tx: Paget's disease
Need MRM if cancer present; otherwise simple mastectomy (need to include the nipple-areolar complex with Paget's)
194
- 10% malignant, based on mitoses per high-power field (>5-10)
- No nodal metastases, hematogenous spread if any (rare)
- Resembles giant fibroadenoma; his stromal and epithelial elements (mesencymal tissue)
- Can often be large tumors
Tx?
Cystosarcoma phyllodes
| - Tx: WLE with negative margins; no ALND
195
Tx: Cystosarcoma phyllodes
WLE with negative margins; no ALND
196
- Lymphangiosarcoma from chronic lymphedema following axillary dissection
- Pts present with dark purple nodule or lesion on arm 5-10 years after surgery
Stewart-Treves syndrome
197
- Tends to present late, leading to worse prognosis.
- Mammography and US do not work as well during pregnancy.
- Try to use ultrasound to avoid radiation
Pregnancy with mass
198
Tx: pregnant with mass - cyst
Drain it and send FNA for cytology
199
Tx: pregnant with mass - solid
Perform core needle biopsy or FNA
200
Pregnancy with mass: core needle and FNA equivocal
Need to go to excisional biopsy.
201
If breast CA
- 1st trimester?
- 2nd trimester?
- 3rd trimester?
- 1st: MRM
- 2nd: MRM
- 3rd: MRM or if late can perform lumpectomy with ALND and postpartum XRT
202
Radiation in pregnancy with breast cancer.
No XRT while pregnant, no breastfeeding after delivery.
203
Boundaries of the axilla:
- Superior
- Posterior
- Lateral
- Medial
- Superior: axillary vein
- Posterior: long thoracic nerve
- Lateral: latissimus dorsi
- Medial: lateral to, deep to, or medial to pectoral minor muscle, depending on the level of nodes taken.
204
What four nerves must the surgeon be aware of during an axillary dissection?
1. Long thoracic nerve
2. Thoracodorsal nerve
3. Medial pectoral nerve
4. Lateral pectoral nerve
205
Courses along lateral chest wall in midaxillary line on serratus anterior muscle; innervates serratus anterior muscle
Long thoracic nerve
206
Courses lateral to long thoracic nerve on latissimus doors muscle; innervates latissimus dorsi muscle
Thoracodorsal nerve
207
Runs lateral to or through the pectoral minor muscle, actually lateral to the lateral pectoral nerve, innervates the pectoral minor and pectoral major muscles
Medial pectoral nerve
208
Runs medial to the medial pectoral nerve (names describe orientation from the brachial plexus!); innervates the pectoral major.
Lateral pectoral nerve
209
What is the name of the deformity if you cut the long thoracic nerve in this area?
"Winged scapula"
210
What is the name of the cutaneous nerve that crosses the axillary in a transverse fashion?
Intercostobrachial nerve
211
What is the name of the large vein that marks the upper limit of the axilla?
Axillary vein
212
What is the lymphatic drainage of the breast?
Lateral: axillary lymph nodes
Medial: parasternal nodes that run with internal mammary artery.
213
What are the suspensory breast ligaments called?
Cooper's ligaments
214
What is the mammary "milk line"?
Embryological line from should to thigh where "supernumerary" breast areolar and / or nipple can be found
215
What is the "tail of Spence"?
"Tail" of breast tissue that tapers into the axilla.
216
Which hormone is mainly responsible for breast milk production?
Prolactin
217
What is the incidence of breast cancer?
12% lifetime risk
218
What percentage of women with breast cancer have no known risk factor?
75%
219
What percentage of all breast cancers occur in women younger than 30 years?
~ 2%
220
What percentage of all breast cancers occur in women older than 70 years?
33%
221
What are the major breast cancer suspeptibility genes?
BRCA1/2
222
What option exists to decrease the risk of breast cancer in women with BRCA?
Prophylactic bilateral mastectomy
223
What is the most common motivation for medicolwegal cases involving the breast?
Failure to diagnose a breast carcinoma.
224
What is the train of error for misdiagnosed breast cancer?
1. Age 75% of cases of misdiagnosed breast cancer have these three characteristics.
225
What are the history risk factors for breast cancer?
NAACP
- Nulliparity
- Age at menarche (younger than 13 years)
- Age at menopause (> 55 years)
- Cancer of the breast (in self or family)
- Pregnancy with first child (> 30 yrs)
226
What are physical / anatomic risk factors for breast cancer?
CHAFED LIPS
- Cancer in the breast (3% synchronous contralateral cancer)
- Hyperplasia, Atypical hyperplasia, Female, Elderly, DCIS
- LCIS, Inferited genes, Papilloma, Sclerosing adenosis
227
What is the relative risk of hormone replacement therapy?
1 - 1.5
228
Is "run of the mill" fibrocystic disease a risk factor for breast cancer?
No
229
What are the possible symptoms of breast cancer?
No symptoms. Mass in the breast. Pain (most painless). Nipple discharge. Local edema. Nipple retraction. Dimple. Nipple rash.
230
Why does the skin retraction occur?
Tumor involvement of Cooper's ligaments and subsequent traction on ligaments pull skin inward.
231
What are the signs of breast cancer?
Mass (1 cm is usually the smallest lesion that can be palpated on examination).
Dimple. Nipple rash. Edema. Axillary / supraclavicular nodes.
232
What is the most common site of breast cancer?
Approximately one half of cancers develop in the upper outer quadrants.
233
What are the different types of invasive breast cancer?
```
Infiltrating ductal ca (75%)
Medullary ca (15%)
Infiltrating lobular CA (2%)
Tubular ca (2%)
Mucinous ca (colloid) (1%)
Inflammatory breast ca (1%)
```
234
What is the MC type of breast cancer?
Infiltrating ductal ca
235
What is the differential diagnosis of breast cancer?
Fibrocystic disease of the breast. Fibroadenoma. Intraductal papilloma. Duct ectasia. Fat necrosis. Abscess. Radial scar. Simple cyst.
236
Breast exam recommendations?
Self-exam of breasts monthly.
Ages 20-40 years: breast exam every 2-3 years by a physician.
> 40 years: annual breast exam by physician.
237
When is the best time for breast self-exam?
1 week after menstrual period
238
Why is mammography a more useful diagnostic tool in older women than in younger?
Breast tissue undergoes fatty replacement with age; making masses more visible; younger women have more fibrous tissue, which makes mammograms harder to interpret.
239
What are the radiographic tests for breast cancer?
Mammography and breast ultrasound, MRI
240
What option is best to evaluate a breast mass in a woman younger than 30 years?
Breast ultrasound
241
What are the methods for obtaining tissue for pathologic examination?
FNA, core biopsy (larger needle core sample), mammotome sterotactic biopsy, and open biopsy which can be incisional (cutting a piece of the mass) or excisional (cutting out the entire mass)
242
What are the indications for biopsy of breast mass?
?Persistent mass after aspiration.
solid Mass. Blood in cyst aspirate. Suspicious lesion by mammo/US/MRI. Ulcer or dermatitis of nipple. Patient's concern of persistent breast abnormality.
243
What is the process for performing a biopsy when a non palpable mass is seen on mammo?
Stereotactic (mammotome) biopsy or needle localization therapy
244
What is needle loc biopsy (NLB)?
Needle localization by radiologist, followed by biopsy; removed breast tissue must be checked by mammo to ensure al of the suspicious lesion has been excised.
245
What is a mammotome biopsy?
Mammogram-guided computerized stereotactic core biopsies
246
What is obtained first, the mammogram or the biopsy?
Mammogram is obtained first; otherwise, tissue extraction (core or open) may alter the mammography findings (FNA may be done prior to the mammo because the fine needle will not affect the mammography findings).
247
What would be suspicious mammographic findings?
Mass, microcalcifications, stellate / spiculated mass
248
What is a "radial scar" seen on mammogram?
Spiculated mass with central lucency, +/- microcalcifications
249
What tumor is a/w a radial scar?
Tubular carcinoma, thus, biopsy is indicated.
250
What is the "workup" for a breast mass?
1. Clinical breast exam
2. Mammogram on breast ultrasound.
3. FNA, core biopsy, or open biopsy
251
How do you proceed if the mass appears to be a cyst?
Aspirate it with a needle
252
Is the fluid from a breast cyst sent for cytology?
Not routinely, bloody fluid should be sent for cytology.
253
When do you proceed to open biopsy for a breast cyst?
1. In the case of a second cyst recurrence.
2. Bloody fluid in the cyst.
3. Palpable mass after aspiration.
254
What is the preoperative staging workup in a patient with breast cancer?
1. Bilateral mammo (CA in one breast is a risk for cancer in 2)
2. CXR (lung mets)
3. LFT (liver mets)
4. Serum calcium level, alkaline phosphatase (if these tests indicate bone mets/bone pain, proceed to bone scan)
5. Other: depending s/s
255
What hormone receptors must be checked for in the biopsy specimen?
Estrogen and progesterone receptors
256
What staging system is used for breast cancer?
TMN
257
Stage: tumor
Stage 1
258
Stage: tumor
Stage 2A
259
Stage: Tumor 2-5 cm in diameter with mobile axillary nodes
- or -
Tumor > 5cm with no nodes
Stage 2B
260
Stage: Tumor > 5cm with mobile axillary nodes
- or -
Any size tumor with fixed axillary nodes, no metastases
Stage 3A
261
Stage: Peau d'orange (skin edema) or Chest wall invasion / fixation or Inflammatory cancer or breast skin ulceration or breast skin satellite metastases or any tumor and + ipsilateral internal mammary lymph nodes.
Stage 3B
262
Stage: Any size tumor, no distant mets.
Positive: supraclavicular, infraclavicular, or internal mammary lymph nodes
Stage 3C
263
Stage: distant mets (including ipsilateral supraclavicular nodes)
Stage 4
264
What are the sites of metastases?
Lymph nodes (MC). Lung / pleura. Liver. Bones. Brain.
265
What are the major treatments of breast cancer?
Modified radical mastectomy.
Lumpectomy and radiation + SLND.
(Both: either +/- post op chemo / tamoxifen)
266
What are the indications for radiation therapy after a modified radical mastectomy?
Stage 3A, Stage 3B, Pectoral muscle / fascia invasion.
Positive internal mammary LN.
Positive surgical margins.
> 4 positive axillary LN's postmenopausal.
267
What breast carcinomas are candidates for lumpectomy and radiation (breast-conserving therapy)?
Stage 1 and 2 (tumors
268
What approach may allow a patients with stage 3A cancer to have breast-conserving surgery?
Neoadjuvant chemotherapy - if the prep chemo shrinks the tumor.
269
What is the treatment of inflammatory carcinoma of the breast?
Chemotherapy first! Then often followed by radiation, mastectomy, or both.
270
What is a "lumpectomy and radiation"?
Lumpectomy (segmental mastectomy: removal of a part of the breast); axillary node dissection; and a course of radiation therapy after operation, over a period of several weeks.
271
What is the major absolute contraindication to lumpectomy and radiation?
Pregnancy
272
What is a modified radical mastectomy?
Breast, axillary nodes (level I and 2) and nipple-areolar complex are removed. Pectoralis major and minor muscles are not removed (Auchincloss modification). Drains are placed to drain lymph fluid.
273
Where are the drains placed with an MRM?
1. Axilla
| 2. Chest wall (breast bed)
274
When should the drains be removed s/p MRM?
275
What are the potential complications after a modified radical mastectomy?
Ipsilateral arm lymphedema. Infection. Injury to nerves, skin flap necrosis, hematoma / serum, phantom breast syndrome.
276
During an axillary dissection, should the patient be paralyzed?
No, because the nerves (long thoracic / thoracodorsal) are stimulated with resultant muscle contraction to help identify them.
277
How can the long thoracic and thoracodorsal nerves be identified during an axillary dissection?
Nerves can be stimulated with a forceps, which results in contraction of the latissimus dorsi (thoracodorsal nerve) or anterior serratus (long thoracic nerve)
278
When do you remove the drains after an axillary dissection?
When there is
279
What is a sentinel node biopsy?
Instead of removing all the axillary lymph nodes, the primary draining or "sentinel" lymph node is removed.
280
How is the sentinel lymph node found?
Inject blue dye and/or technetium-labeled sulfur colloid (best results with both)
281
What follows a positive sentinel node biopsy?
Removal of the rest of the axillary lymph nodes
282
What is now considered the standard of care for lymph node evaluation in women with T1 or T2 tumors (stages 1 and 2A) and clinically negative axillary lymph nodes?
Sentinel lymph node dissection
283
What do you do with a mammotome biopsy that returns as "atypical" hyperplasia?
Open needle loc biopsy as many will have DCIS or invasive cancer
284
How does tamoxifen work?
It binds estrogen receptors
285
What is the treatment for local recurrence in breast after lumpectomy and radiation?
"Salvage" mastectomy
286
Can tamoxifen prevent breast cancer?
Yes. In the breast cancer prevention trial of 13,000 women at increased risk, tamoxifen reduces risk by ~ 50% across all ages.
287
What are common options for breast reconstruction?
TRAM flap, implant, latissimus dorsi flap
288
What is a TRAM flap?
Transverse Rectus Abdominis Myocutaneous flap
289
What are the side effects of tamoxifen?
Endometrial cancer (2.5 x relative risk), DVT, PE, cataracts, hot flashes, mood swings
290
In high-risk women, is there a way to reduce the risk of developing breast cancer?
Yes, tamoxifen for 5 yr will lower the risk ~ 5%, but with an increased risk of endometrial cancer and clots, it must be an individual patient determination
291
What type of chemotherapy is usually used for breast cancer?
CMF (cyclophosphamide, methotrexate, 5-fluorouracil) or CAF (cyclophosphamide, adriamycin, 5-fluorouracil)
292
What makes a tumor high risk?
```
> 1 cm in size
Lymphatic / vascular invasion
Nuclear grade (high)
S phase (high)
ER negative
HER-2/neu overexpression
```
293
What is DCIS also known as?
Intraductal carcinoma.
294
Describe DCIS.
Cancer cells in the duct without invasion. (Cells do not penetrate the basement membrane).
295
s/s: DCIS
Usually none; usually nonpalpable
296
DCIS: mammographic findings
Microcalcifications
297
DX: DCIS
Core or open biopsy
298
DCIS: most aggressive subtype
Comedo
299
Risk: lymph node mets DCIS
300
What is the major risk with DCIS?
Subsequent development of infiltrating ductal carcinoma in the same breast
301
Tx: DCIS Tumor
Remove with 1 cm margins +/- XRT
302
Tx: DCIS Tumor > 1cm
Perform lumpectomy with 1 cm margins and radiation or total mastectomy (no axillary dissection)
303
What is a total (simple) mastectomy?
Removal of the breast and nipple without removal of the axillary nodes (always remove nodes with invasive cancer)
304
When must a simple mastectomy be performed for DCIS?
Diffuse breast involvement (e.g., diffuse micro calcifications), > 1cm and contraindication to radiation
305
What is the role of axillary node dissection with DCIS?
No role in true DCIS (i.e., without micro invasion); some perform a sentinel lymph node dissection for high-grade DCIS
306
What is adjuvant for DCIS?
1. Tamoxifen
| 2. Postlumpectomy XRT
307
What is the role of tamoxifen in DCIS?
Tamoxifen for 5 years will lower the risk up to 50%, but with increased risk of endometrial cancer and clots; it must be an individual patient determination.
308
What is a memory aid for the breast in which DCIS breast cancer arises?
Cancer arises in the same breast as DCIS.
309
What is LCIS?
Lobular Carcinoma in Situ (Carcinoma cells in the lobules of the breast without invasion)
310
s/s: LCIS
None
311
Mammographic findings: LCIS
None
312
Dx: LCIS
LCIS is found incidentally on biopsy
313
LCIS: major risk
Carcinoma of either breast
314
Which breast is more at risk for developing an invasive carcinoma?
Equal risk in both breasts! (think of LCIS as a risk marker for future development of cancer in either breast)
315
What percentage of women with LCIS develop an invasive breast carcinoma?
~ 30% in the 20 years after diagnosis of LCIS
316
What type of invasive breast cancer do patients with LCIS develop?
Most commonly, infiltrating ductal carcinoma with equal distribution in the contralateral and ipsilateral breast
317
What medication may lower the risk of developing breast cancer in LCIS?
Tamoxifen for 5 yrs will lower the risk up to 50%, but with an increased risk of endometrial cancer and clots; it must be an individual patient determination.
318
What is the treatment of LCIS?
Close follow-up (or bilateral simple mastectomy in high-risk patients)
319
What is the major difference in the subsequent development of invasive breast cancer with DCIS and LCIS?
LCIS cancer develops in either breast; DCIS cancer develops in the ipsilateral breast.
320
How do you remember which breast is at risk for invasive cancers in patients with LCIS?
LCIS: liberally in either breast
321
MCC bloody nipple discharge in young women
Intraductal papilloma
322
MC breast tumor
Fibroadenoma
323
What is Paget's disease of the breast?
Scaling rash / dermatitis of the nipple caused by invasion of skin by cells from a ductal carcinoma
324
What are the common options for breast reconstruction after a mastectomy?
Saline implant
| TRAM flap
325
What is the incidence of breast cancer in men?
326
What is the average age at diagnosis?
65 years of age
327
What are the risk factors?
Increased estrogen. Radiation. Gynecomastia from increased estrogen. Estrogen therapy. Klinefelter's syndrome (XXY). BRCA2 carriers.
328
Is benign gynecomastia a risk factor for male breast cancer?
No
329
What type of breast cancer do men develop?
Nearly 100% of cases are ductal carcinoma (men do not usually have breast lobules)
330
S/S: Breast cancer in men
Breast mass (most are painless), breast skin changes (ulcers, retraction), and nipple discharge (usually blood or a blood-tinged discharge)
331
MC presentation: breast cancer in main
Painless breast mass
332
Dx: breast cancer in men
Biopsy and mammogram
333
Tx: breast cancer in men
1. Mastectomy
2. Sentinel LN dissection of clinically negative axilla
3. Axillary dissection if clinically positive axillary LN
334
MCC green, straw-colored or brown nipple discharge
Fibrocystic disease
335
MCC breast mass after breast trauma
Fat necrosis
336
Thrombophlebitis of superficial breast veins
Mondor's disease
337
What must be ruled out with spontaneous galactorrhea (+/- amenorrhea)
Prolactinoma (check pregnancy test and prolactin level)
338
Mesenchymal tumor arising from breast lobular tissue; most are benign
Cystosarcoma phyllodes
339
Phyllodes tumor: age
25-55 years (usually older than pt with fibroadenoma)
340
s/s: phyllodes tumor
Mobile, smooth breast mass that resembles a fibroadenoma on exam, mammogram / ultrasound findings
341
Dx: Phyllodes tumor
Core biopsy / excision
342
Tx: Phyllodes tumor
If benign, wide local excision; if malignant, simple total mastectomy.
343
What is the role of axillary dissection with cystosarcoma phyllodes tumor?
Only if clinically palpable axillary nodes, as the malignant form rarely spreads to nodes (MC site of mets is the lung)
344
Is there a role for chemotherapy with cystosarcoma phyllodes?
Consider chemotherapy if large tumor > 5 cm and "stromal overgrowth"
345
Benign tumor of the breast consisting of streams overgrowth, collagen arranged in "swirls"
Fibroadenoma
346
Solid, mobile, well-circumscribed round breast mass, usually
Fibroadenoma
347
Dx: fibroadenoma
Negative needle aspiration looking for fluid; ultrasound, core biopsy
348
Tx: fibroadenoma
Surgical resection for large or growing lesions; small fibroadenomas can be observed closely.
349
MC breast tumor in women
Fibroadenoma
350
Common benign breast condition consisting of fibrous (rubbery) and cystic changes in the breast
Fibrocystic disease
351
S/S Breast pain or tenderness that varies with the menstrual cycle; cysts; and fibrous ("nodular") fullness
Fibrocystic disease
352
Dx: fibrocystic disease
Breast exam, history, and aspirated cysts (usually straw-colored or green fluid)
353
Tx: fibrocystic disease
Stop caffeine.
Pain meds (NSAIDS)
Vitamin E, evening primrose oil (danazol and OCP as last resort)
354
What is done if the patient has a breast cyst?
Aspirate s/t needle drainage:
- Bloody / palpable mass: open bx
- Straw / green color: follow closely, 2nd? needle aspirate
- Re-recurrence usually requires open biopsy
355
Superficial infection of the breast (cellulitis)
Mastitis
356
MCC mastitis
Breast-feeding
357
MCC mastitis - bacteria
S. aureus
358
Tx: mastitis
Stop breast-feeding and use a breast pump instead; apply heat; administer antibiotics
359
Why must the patient with mastitis have close follow-up?
To make sure that she does not have inflammatory breast cancer!
360
Causes of breast abscesses
Mammary ductal ectasia (stenosis of breast duct) and mastitis
361
Breast abscess: MC bacteria
Nursing - S. aureus
| Nonlatating: mixed infection
362
Tx: Breast abscess
Antibiotics (eg, dicloxacillin)
Needle or open drainage with cultures taken.
Resection of involved ducts if recurrent.
Breast pump if breast-feeding.
363
Infection of the breast during breast feeding - most commonly caused by S. aureus; treat with antibiotics and follow for abscess formation
Lactational mastitis
364
What must be ruled out with a breast abscess in a non lactating woman?
Breast cancer
365
Enlargement of the male breast
Male Gynecomastia
366
Causes of male gynecomastia
```
Medications.
Illicit drugs (marijuana)
Liver failure
Increased estrogen
Decreased testosterone
```
367
Major DDX male gynecomastia in the older patient
Male breast cancer
368
Tx: male gynecomastia
Stop or change medications; correct underlying cause if there is a hormonal imbalance; and perform biopsy or subcutaneous mastectomy (i.e., leave nipple) if refractory to conservative measures and time.
