Chapter 24: Breast Flashcards
Embryology: breast
Formed from the ectoderm milk streak
Hormones that cause..
- Duct development (double layer of columnar cells)
- Lobular development
- Synergizes estrogen and progesterone
- Estrogen: duct development (double layer of columnar cells)
- Progesterone: lobular development
- Prolactin: synergizes estrogen and progesterone
Cyclic change: increases breast swelling, growth of glandular tissue
Estrogen
Cyclic change: increase maturation of glandular tissue; withdrawal causes menses
Progesterone
Cyclic change: cause ovum release
FSH, LH surge
What causes atrophy of breast tissue after menopause?
After menopause, lack of estrogen and progesterone results in atrophy of breast tissue.
Innervates serratus anterior, injury results in winged scapula
Long thoracic nerve
Artery: supplies serratus anterior
Lateral thoracic artery
Innervates latissmus dorsi; injury results in weak arm pull-ups and adduction
Thoracodorsal nerve
Artery: supplies latissimus dorsi
Thoracodorsal artery
Innervates pectoralis major and pectorals minor
Medial pectoral nerve
Nerve: pectorals major only
Lacteral pectoral nerve
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.
Intercostobrachial nerve
Arteries that supply the breast
Internal thoracic artery, intercostal arteries, thoracoacromial artery, and lateral thoracic artery
Valveless vein plexus that allows direct hematogenous metastasis of breast CA to spine
Batson’s plexus
Lymphatic drainage of the breast
- 97% to axillary nodes
- 2% to internal mamillary nodes
- Any quadrant can drain to the internal mammary nodes.
Considered N3 disease
Mets to supraclavicular nodes
Dx: primary axillary adenopathy
1 is lymphoma
Suspensory ligaments of the breast. Divide breast into segments.
Cooper’s ligaments
What does skin dimpling of the breast suggest?
Breast CA involving Cooper’s ligaments dimpling the skin.
What are breast abscesses usually caused by?
MCC?
Usually a/w breast feeding.
MCC: Staph aureus
TX: breast abscess
Percutaneous or incision and drainage; discontinue breastfeeding; breast pump; antibiotics.
MCC infectious mastitis in nonlactating women
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)
What is infectious mastitis usually associated with?
Breastfeeding
Mammary duct ectasia or plasma cell mastitis
Periductal mastitis
S/S: noncyclical mastodynia, erythema, nipple retraction, creamy discharge from nipple; can have sterile or infected subareolar abscess
Periductal mastitis
Risk factors: periductal mastitis
Smoking, nipple piercings
Biopsy: Periductal mastitis
Dilated mammary ducts, inspissated secretions, marked periductal inflammation
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)
Breast cysts filled with milk; occurs with breastfeeding
Tx: ranges from aspiration to incision and drainage.
Galactocele
Can be caused by increased prolactin (pituitary prolactinoma), OCPs, TCAs, phenothiazines, metoclopramide, alpha-methyl dopa, reserpine.
- Is often a/w amenorrhea
Galactorrhea
2-cm pinch of breast tissue.
Tx: will likely regress; may need to resect if cosmetically deforming or causing social problems.
Gynecomastia
What is gynecomastia associated with?
Cimetidine. Spironolactone. Marijuana. Idiopathic in most.
Due to circulating maternal estrogens; will regress.
Neonatal breast enlargement.
MC location of polythelia (accessory breast tissue)
Axilla
MC breast anomaly.
Location?
Accessory nipples
- Found form axilla to groin
What is compromised with breast reduction?
Ability to lactate frequently compromised.
Hypoplasia of chest wall.
Amastia.
Hypoplastic shoulder.
No pectoralis muscle.
Poland’s Syndrome
Pain in breast; rarely represents breast cancer.
Dx: history, breast exam, BL mammogram.
Mastodynia
Tx: Mastodynia
Danazol. OCPs NSAIDs. Evening primrose oil. Bromocriptine. D/C: caffeine, nicotine, methylxanthines.
Pain before menstrual period, most commonly represents acute or subacute.
Cyclic mastodynia.
Continuous pain. MC’ly represents acute or subacute infection; continuous mastodynia is more refractory to treatment than cyclic mastodynia.
Continuous mastodynia.
Superficial vein thrombophlebitis of breast, feels cordlike, can be painful.
Mondor’s disease
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.
Tx: Mondor’s disease
NSAIDs
Dx: breast pain, nipple discharge (usually yellow to brown), lumpy breast tissue that varies with hormonal cycle.
Fibrocystic change.
Types of fibrocystic change.
Papillomatosis. Sclerosing adenosis. Apocrine metaplasia. Duct adenosis. Epithelial hyperplasia. Ductal hyperplasia. Lobular hyperplasia.
What type of fibrocystic disease is associated with risk of CA?
Atypical ductal or lobular hyperplasia.
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).
MCC bloody nipple discharge
Intraductal papilloma
- Usually small, non palpable, close to nipple.
- Not premalignant
Intraductal papilloma
Intraductal papilloma
- Dx?
- Tx?
Dx: contrast ductogram to find papilloma, then needle localization
Tx: Subareolar resection of the involved duct and papilloma.
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
Path: fibroadenoma
prominent fibrous tissue compressing epithelial cells
Mammography: fibroadenoma
Large, coarse calcifications (popcorn lesions) from degeneration.
Criteria for observation of fibroadenoma.
In patients less than 40 years old:
- Mass needs to feel clinically benign (firm, rubbery, rolls, not fixed).
- US or mammogram needs to be consistent with fibroadenoma.
- Need FNA or core needle biopsy to show fibroadenoma.
Tx: enlarging fibroadenoma
Excisional biopsy
Why avoid resection of fibroadenoma in teenagers / younger children?
Resection can affect breast development.
Fibroadenoma: pts > 40
Excisional biopsy to ensure dx
Tx: fibroadenoma
- Pts Observe. No?ex bx.
- Pts > 40: Ex bx to ensure diagnosis
Most nipple discharge is…
Benign
Dx: nipple discharge
History, breast exam, BL mammogram. Try to find the trigger point on exam.
Nipple discharge: green
Tx?
Usually due to fibrocystic disease.
Tx: if cyclical and non spontaneous, reassure pt.
Nipple discharge: bloody
Tx?
MC intraductal papilloma; occasionally ductal CA.
Tx: Need ductogram and excision of that ductal area.
Nipple: serous discharge
Worrisome for cancer. Especially if coming form only 1 duct or spontaneous.
Tx: Excisional biopsy of that ductal area
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.
Discharge:
- Occurs only with pressure, tight garments, exercise, etc.
- Not as worrisome but may still need excisional biopsy (e.g., if bloody)
Nonspontaneous discharge
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).
Malignant cell of the ductal epithelium without invasion of basement membrane
Ductal carcinoma in situ.
DCIS Risk Ca:
Ipsilateral Breast
Contralateral Breast
Ipsilateral breast: 50%
Contralateral breast: 5%
DCIS: premalignant lesion
Yes.
- Usually not palpable and presents as a cluster of calcifications on mammography.
- Can have solid, cribriform, papillary, comedy patterns
DCIS
Most aggressive subtype DCIS
- Necrotic areas
- High risk for multi centricity, micro invasion, recurrence.
Tx?
Comedo pattern DCIS
- Tx: simple mastectomy.
Increased risk of cancer in DCIS?
Comedo type and lesions > 2.5cm
Tx: DICS (not high grade)
Lumpectomy and XRT.
Need 1cm margins.
No ALND or SLNB.
Possibly tamoxifen.
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.
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.
Patient who develop breast CA are more likely to develop a..
Ductal CA (70%)
Possibility of synchronous breast cancer at time of LCIS diagnosis?
5% (most likely ductal CA)
Do you need negative margins for LCIS?
No.
Treatment for LCIS
Nothing. Tamoxifen. BL subcutaneous mastectomy (no ALND).
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.
Country: lowest risk of breast CA worldwide
Japan
United States breast cancer risk
1 in 8 women (12%); 5% in women with no risk factors.
Breast cancer screening decreases mortality by..
25%
Years survival: untreated breast cancer
2-3 years
%: Beast CA with negative mammogram and negative ultrasound
10%
Clinical features of breast CA
Distortion of normal architecture.
Skin / nipple distortion or retraction.
Hard.
Tethered. Indistinct borders.
Symptomatic breast mass work up
Ultrasound & Core needle biopsy. (consider FNA).
- Need mammo in pts
Symptomatic breast mass work up > 40 years old
Need bilateral mammograms.
Ultrasound.
Core needle biopsy.
If core needle biopsy or FNA is indeterminate, non-diagnostic, non-concordant with exam findings / imaging studies..
Will need excisional biopsy.
Clinically indeterminate or suspect solid masses will eventually need..
Excisional biopsy unless CA diagnosis is made prior to that.
Tx: cyst fluid
Bloody: cyst excisional biopsy
Clear/recurs: excisional biopsy.
Complex: excisional biopsy
Test: gives architecture
CNBx
Test: Gives cytology (just the cells)
FNA
Mgmt: malignant breast mass (FNA/CNBx)
Definitive therapy
Mgmt: suspicious breast mass (FNA/CNBx)
Surgical biopsy
Mgmt: atypia breast mass (FNA/CNBx)
Surgical biopsy
Mgmt: non diagnostic breast mass (FNA/CNBx)
Repeated FNA/CNBx or surgical biopsy
Mgmt: benign breast mass (FNA/CNBx)
Possible observation - exam and imaging studies need to concordant with benign disease, otherwise need excisional biopsy.
Sensitivity / specificity: mammography
90%
How does mammography increase with age?
Sensitivity increases with age as the dense parenchymal tissue is replaced with fat.
Size breast mass to be detected by mammography
> 5 mm
Mammography: suggestive of Cancer
Irregular borders. Speculated. Multiple clustered. Small. Thin. Linear. Crushed-like and/or branching calcifications. Ductal asymmetry. Distortion of architecture.
BI-RAD 1.
Negative
Tx: Routine screening
BI-RADs 2
Benign finding
Tx: Routine screening
BI-RADs 3
Probably benign finding
Tx: Routine screening
BI-RADs 4
Suspicious abnormality (eg, indeterminate calcifications or architecture) Tx: definite probability of CA; get CNBx
BI-RADs 5
Highly suggestive of CA (suspicious calcifications or architecture)
Tx: high probability of CA; get CNBx.
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
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.
What allows appropriate staging with SLNBx (mass is still present) and one-step surgery for patients diagnosed with breast cancer?
CNBx without excisional biopsy.
Recommendations: mammogram screening?
Q 2-3 years after age 40, then yearly after 50.
Recommendations: high-risk mammogram screening
10 years before the youngest age of diagnosis of breast CA in first-degree relative.
Why aren’t mammograms generally recommended in patients
Hard to interpret because of dense parenchyma.
How does mammogram radiation dose change in younger patients?
Dose decreases
Node levels:
I?
II?
III?
I: lateral to pectoralis minor muscle
II: beneath pectoralis minor muscle.
III: medial to pectorlis minor muscle
LN: between the pectoralis major and pectoralis minor muscles.
Rotter’s nodes
What nodes do you generally take?
Level I and II. Take level III nodes only if grossly involved.
Most important prognostic staging factor
Nodes
Factors including in prognostic staging
Nodes (most important). Size. Grade. Progesterone / Estrogen receptor status.
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
Most common site for distant metastasis
Bone
Time: Single malignant cell to 1-cm tumor.
Approximately 5-7 years
Location: increased risk of multicentricity
Central and subareolar tumors
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.
Breast CA: moderately increased risk (relative risk 2-4)
- Prior breast cancer
- Radiation exposure
- First degree relative with breast cancer
- Age > 35 first birth
Breast CA: lower increased risk (relative risk
- Early menarche / late menopause
- Nulliparity
- Proliferative benign disease
- Obesity, alcohol, hormone replacement therapy.
BRCA I Cancer Risk
- Female breast CA
- Ovarian CA
- Male breast CA
Lifetime risk..
- Female breast: 60%
- Ovarian: 40%
- Male breast: 1%
BRCA II Cancer Risk
- Female breast CA
- Ovarian CA
- Male breast CA
Lifetime risk..
- Female breast: 60%
- Ovarian: 10%
- Male breast: 10%
Sx Considerations: BRCA families with history of breast cancer
Total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO)
Breast Cancer risk: first degree relative with bilateral, premenopausal breast cancer
50%
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
Why are positive receptors good?
Better response to hormones, chemotherapy, surgery, and better overall prognosis.
Receptor-positive tumors are more common in…
Postmenopausal women
What receptor do you want positive: estrogen or progesterone?
Progesterone receptor-positive tumors have better prognosis than estrogen receptor-positive tumors.
What happens with positive estrogen AND progesterone receptors?
Both positive? Has the best prognosis.
%: Breast cancer negative for both receptors.
10%
-
Male breast cancer
What is male breast cancer associated with?
Steroid use.
Previous XRT.
Family history.
Klinefelter’s syndrome
Tx: male breast cancer
Tx: Modified Radical Mastectomy (MRM)
- 85% of all breast cancer.
Tx?
Ductal CA
Tx: MRM or BCT (breast conserving therapy) with post XRT
Ductal CA: Subtypes
Medullary.
Tubular.
Mucinous.
Scirrhotic.
Ductal CA: smooth borders, increased lymphocytes, bizarre cells, more favorable prognosis.
Medullary ductal CA
Ductal CA: small tubule formations, more favorable prognosis.
Tubular ductal CA
Ductal CA: produces an abdundance of mucin, more favorable prognosis
Mucinous (colloid) ductal CA
Ductal CA: worse prognosis
Schirrhotic