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Fiser's ABSITE Ryan SHORT > Chapter 24 - Breast > Flashcards

Chapter 24 - Breast Flashcards

1
Q

Estrogen leads to what part of breast development?

A

Duct (double layer of columnar cells)

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2
Q

Progesterone leads to what part of breast development?

A

Lobular development

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3
Q

Prolactin has what effect on breast development?

A

Synergizes esterogen and progesterone

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4
Q

Estrogen causes what cyclic change in the breast?

A

Increased breast swelling, growth of glandular tissue

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5
Q

Progesterone causes what cyclic change in the breast?

A

Increased maturation of glandular tissue; withdrawal causes menses

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6
Q

What cyclic change is caused by LH, FHS surge?

A

Causes ovum release

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7
Q

Long thoracic nerve innervates what? Injury results in what?

A

Serratus anterior; winged scapula

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8
Q

Thoracodorsal nerve innervates what? Injury causes what?

A

Latissimus dorsi; weak arm pull-ups and adduction

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9
Q

What artery goes to the serratus anterior?

A

Lateral thoracic artery

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10
Q

What artery goes to latissimus dorsi?

A

Thoracodorsal artery

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11
Q

Medial pectoral nerve innervates what?

A

Pectoralis major and minor

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12
Q

Lateral pectoral nerve innervates what?

A

Pectoralis major only

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13
Q

Intercostobrachial nerve comes from where? Innervates what?

A

From lateral cutaneous branch of the 2nd intercostal nerve; sensation to medial arm and axilla

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14
Q

Branches of what arteries supply the breast?

A

Internal thoracic artery, intercostal arteries, thoracoacromial artery, lateral tthoracic artery

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15
Q

Batson’s plexus allows what to happen in breast cancer?

A

Valveless vein plexus that allows direct hematogenous mets to spine

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16
Q

What does primary axillary adenopathy indicate?

A

1 lymphoma

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17
Q

Positive supraclavicular nodes indicate what stage disease?

A

M1

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18
Q

Most common bacteria in breast abscess?

A

S. aureus, strep; associated with breast feeding

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19
Q

Treatment for abscesses?

A

I&D, d/c breast feeding; ice, heat, pump, antibiotics

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20
Q

Most common bacteria in infectious mastitis?

A

S. aureus; in nonlactating women can be due to chronic inflammatory diseases (actinomyces, TB, syphilis)

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21
Q

Workup for infectious mastitis?

A

Need to rule out necrotic cancer; incisional biopsy including skin

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22
Q

What is periductal mastitis?

A

Mammary duct ectasia or plasma cell mastitis; dilated mammary ducts, inspissated secretions, marked periductal inflammation

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23
Q

Symptoms of periductal mastitis?

A

Noncyclical mastodynia, nipple retraction, creamy discharge from nipple; can have sterile subareolar abscess; pts with difficulty breast feeding

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24
Q

Treatment for periductal mastitis?

A

Reassure if discharge is creamy, non bloody and not associated with nipple retraction; otherwise r/o cancer

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25
Q

What is a galactocele?

A

Breast cysts filled with milk; occurs with breast feeding

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26
Q

Treatment for galactocele?

A

Aspiration to I&D

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27
Q

What is galactorrhea caused by?

A

High prolactin (pituitary prolactinoma), OCPs, TCAs, phenothiazines, metoclopramide, alpha-methyl dopa, reserpine

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28
Q

What is gynecomastia? Caused by?

A

2cm pinch (ouch); cimetidine, spironolactone, marijuana, idiopathic

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29
Q

What is the cause of neonatal breast enlargement?

A

Due to circulating maternal estrogens; will regress

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30
Q

Most common location for accessory breast tissue?

A

Axilla

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31
Q

What is the most common breast abnormality?

A

Accessory nipples

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32
Q

What is Poland’s syndrome?

A

Hypoplasia of chest wall, amastia, hypoplastic shoulder, no pectoralis muscle

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33
Q

Workup for mastodynia?

A

Pain in breast; rarely represents breast CA; H&P and bilateral mammogram

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34
Q

Treatment for mastodynia?

A

Danazol, OCPs, NSAIDs, evening primrose oil, bromocriptine

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35
Q

What is cyclic mastodynia most commonly caused by?

A

Fibrocystic diseased

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36
Q

What is continuous mastodynia caused by?

A

Most commonly acute or subacute infection

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37
Q

What is Mondor’s disease?

A

Superficial vein thrombophlebitis of breast; cordlike, can be painful

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38
Q

What is Mondor’s associated with? Treatment?

A

Trauma and strenuous exercise; NSAIDs

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39
Q

Symptoms of fibrocystic disease?

A

Breast pain, nipple discharge (uncommon, yellow to brown), masses, lumpy breast tissue that varies with hormonal cycle

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40
Q

How can sclerosing adenosis present?

A

Cluster of calcifications on mammogram without mass or pain

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41
Q

How is sclerosing adenosis differentiated from breast CA?

A

By regularity of nuclei and absence of mitoses

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42
Q

Risk factors for benign breast disease?

A

Early menarche, late menopause, small breast size, normal or low body weight, h/o cyclic breast discomfort, irregular menses, h/o spontaneous abortions, postmenopausal status

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43
Q

Most common cause of bloody discharge from nipple?

A

Intraductal papilloma

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44
Q

Malignancy risk with intraductal papilloma?

A

NOT premalignant

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45
Q

Treatment of intraductal papilloma?

A

Resection (subareolar resection curative)

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46
Q

What is the most common breast lesion in adolescents and young women?

A

Fibroadenoma

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47
Q

Characteristics of fibroadenoma?

A

Painless, slow growing, well cicumscribed, firm and rubbery; change size in pregnancy; grows to several cm in size then stop

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48
Q

Pathology of fibroadenoma? Mammography findings?

A

Prominent fibrous tissue compressing epithelial cells; popcorn lesions (large, coarse calcifications)

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49
Q

Work up of nipple discharge?

A

H&P, bilateral mammogram

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50
Q

What is green discharge due to? What is the treatment?

A

Fibrocystic disease; if cyclical and nonspontaneous, reassure patient

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51
Q

What is bloody discharge due to? Treatment?

A

Most commonly intraductal papilloma, occasionally ductal CA; galactogram and excision of that ductal area

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52
Q

What is serous discharge due to? Treatment?

A

Worrisome for cancer; excisional biopsy of that ductal area

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53
Q

What is spontaneous discharge due to? Treatment?

A

Worrisome for cancer no matter what color or consistency; biopsy in area of duct

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54
Q

What is nonspontaneous discharge due to? Treatment

A

Pressure, tight garments, exercise; not as worrisome, however still need biopsy

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55
Q

Characteristics of diffuse papillomatosis? Risk of cancer?

A

Multiple ducts of both breasts, larger when solitary, serous discharge; increased risk of cancer (40%)

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56
Q

Mammogram findings of diffuse papillomatosis?

A

Swiss cheese appearance

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57
Q

Definition of ductal carcinoma in situ?

A

Malignant cells of ductal epithelium without invasion of the basement membrane

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58
Q

% risk of cancer with DCIS?

A

50-60% get cancer if not resected; 5-10% will get cancer in contralateral breast

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59
Q

Mammogram findings with DICS?

A

Usually not palpable; cluster of calcifications on mammography

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60
Q

Margins needed with excision of DCIS?

A

2-3mm

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61
Q

Patterns of DCIS?

A

Solid, cribriform, papillary, comedo

62
Q

What is the most aggressive subtype of DCIS?

A

Comedo pattern; with necrotic areas; high risk fro multicentricity, microinvasion, recurrence

63
Q

What characteristics increase the recurrence risk following excision of DCIS?

A

Comedo type, lesions >2.5cm

64
Q

Treatment for DCIS?

A

Lumpectomy and XRT, ?tamoxifen; simple mastectomy if high grade, if large tumor not amenable to lumpectomy or not able to et good margins; NO ALND

65
Q

Cancer risk with lobular carcinoma in situ?

A

40% get cancer (either breast)

66
Q

Is LCIS premalignant?

A

NO, considered a marker for the development of breast CA; do NOT need negative margins

67
Q

What type of breast CA do patients with LCIS develop?

A

More likely to develop ductal CA (70%)

68
Q

% risk of having synchronous breast CA at the time of diagnosis of LCIS?

A

5%

69
Q

Treatment for LCIS?

A

Nothing, tamoxifen, bilateral subutaneous mastectomy (NO ALND)

70
Q

What country has the lowest rate of breast cancer worldwide?

A

Japan

71
Q

Lifetime risk of breast cancer?

A

1 in 8 women (12%); 4-5% in women with no risk factors

72
Q

What % will screening decrease mortality of breast cancer by?

A

25%

73
Q

Median survival of untreated breast cancer?

A

2-3y

74
Q

Clinical features of breast CA?

A

Distortion of normal breast architecture, skin/nipple distortion or retraction, hard, tethered, indistinct borders

75
Q

Workup for symptomatic breast mass in pt <30y?

A

US: if solid - FNA; excisional biopsy if FNA is nondiagnostic

76
Q

Workup of symptomatic breast mass in patient 30-50y?

A

Bilateral mammograms and FNA; excisional biopsy if FNA nondiagnostic

77
Q

Workup of symptomatic breast mass in pt >50y?

A

Bilateral mammograms and excisional or core needle biopsy

78
Q

Workup for cyst?

A

If fluid bloody: cyst excisional biopsy; clear and recurs, cyst excisional biopsy; complex, cyst excisional biopsy

79
Q

What is the sensitivity/specificity of mammography?

A

90%; sensitivity increases with age as the dense parenchymal tissue is replaced with fat

80
Q

Size of tumor that is able to be detected by mammography?

A

> 5mm

81
Q

General screening guidelines?

A

Mammogram Q2-3y after 40y, yearly after 50y; high risk screening: 10y prior to youngest age of diagnosis of breast CA in 1st degree relative

82
Q

What are the node levels of the breast?

A

I: lateral to pec minor, II: beneath pec minor, III: medial to pec minor; Rotter’s nodes - between the pec major and minor

83
Q

What level node needs to be sampled?

A

Level I

84
Q

What is the most important prognostic factor in breast cancer?

A

Nodal status; also tumor size, grade, progesterone/estrogen receptor status

85
Q

5 year survival is 0 positive nodes?

A

75%

86
Q

% of nonpalpable nodes that are positive at surgery?

A

30%

87
Q

5 year survival if 1-3 nodes are positive?

A

60%

88
Q

5 year survival if 4-10 nodes are positive?

A

40%

89
Q

What is the most common location of distant mets?

A

Bone

90
Q

What characteristics of tumor have increased multicentricity?

A

Central and subareolar tumors

91
Q

T staging for breast cancer?

A

T1: 5cm, T4: skin or chest wall involvement, peau du’orange, inflammatory cancer

92
Q

N staging for breast cancer?

A

N1: ipsilateral axillary nodes, N2: fixed ipsilateral axiallary nodes, N3: ipsilateral internal mammary nodes

93
Q

Factors that will greatly increase breast cancer risk?

A

BRCA gene, >2 primary relatives with bilateral or premenopausal breast CA, DCIS and LCIS, fibrocystic disease with atypical hyperplasia

94
Q

Factors that will moderately increase risk of breast cancer?

A

FH of breast cancer, early menarche, late menopause, nulliparity, radiation, previous breast CA, environmental risk factor (high-fat diet, obesity)

95
Q

How much does a 1st degree relative with bilateral, premenopausal breast cancer increase breast cancer risk?

A

50%

96
Q

Other cancers associated with BRCA I?

A

Ovarian (50%), endometrial CA; consider TAH, bilateral oophrectomies

97
Q

Other cancers associated with BRCA II?

A

Male breast cancer

98
Q

Requisites for prophylactic mastectomy?

A

FH + BRCA gene, LCIS, plus one of the following: anxiety, poor access to follow up exams, difficult lesion to follow, patient preference

99
Q

Receptor positive tumors lead to what prognosis?

A

Better response to hormones, chemo, surgery, and better overall prognosis

100
Q

Which receptor-positive tumors have best prognosis?

A

Progesterone > estrogen; both positive with best prognosis

101
Q

What % of breast cancers are negative for both receptors?

A

10%

102
Q

What type of cancer do males usually have?

A

Ductal

103
Q

Male breast cancer is associated with what?

A

Steroid use, previous XRT, FH, Klinefelter’s syndrome, prolonged hyperestrogenic state

104
Q

Treatment of male breast cancer?

A

Modified radical mastectomy

105
Q

What % of breast CAs are ductal?

A

85%

106
Q

What are the subtypes of ductal CA?

A

Medullary, tubular, mucinous, scirrhotic

107
Q

Characteristics of medullary breast CA?

A

Smooth borders, high lymphocytes, ductal type cancer with bizarre cells; majority E+/P+, more favorable prognosis

108
Q

Characteristics of tubular CA?

A

Small tubule formations, nodes + in 10%, more favorable prognosis

109
Q

Characteristics of mucinous CA?

A

Colloid, produces an abundance of mucin, more favorable prognosis

110
Q

Characteristics of scirrhotic CA?

A

Worse prognosis

111
Q

Treatment for ductal CA?

A

MRM or lumpectomy with ALND (or SNLB); post op XRT

112
Q

What % of breast cancers are lobular?

A

10%

113
Q

Characteristics of lobular CA?

A

Does not form calcifications, infiltrative, inc. bilateral, multifocal and multicentric

114
Q

Lobular cancer with signet ring cells have what prognosis?

A

Worse

115
Q

Treatment for lobular CA?

A

MRM or lumpectomy with ALND (or SLNB); postop XRT

116
Q

Treatment for inflammatory cancer?

A

May need chemo and XRT 1st, then mastectomy

117
Q

Stage of inflammatory cancer?

A

Considered T4

118
Q

Median survival of inflammatory cancer?

A

Very aggressive; 36mo

119
Q

What causes the peau d’orange lymphedema of inflammatory cancer?

A

Dermal lymphatic invasion; erythematous and warm

120
Q

Preoperative studies needed before breast surgery?

A

CXR, bilateral mammorgrams, CBC, LFTs; abdominal CT if LFTs elevated; head CT if headaches; bone scan if bone pain or inc. alk phos

121
Q

Subcutaneous (simple) mastectomy indications?

A

DCIS, LCIS; NOT indicated for breast CA; leaves 1-2% of breast tissue, preserves teh nipple

122
Q

Margins necessary with simple mastectomy?

A

1cm; with SLNB

123
Q

Indications for SLNB?

A

Malignant tumors >1cm; NOT indicated for pts with clincallly positive nodes

124
Q

Complications of lymphazurin blue?

A

Type I hypersensitivity reactions

125
Q

What next if no SLN found during SLND?

A

Formal ALND

126
Q

The sentinal node is found in what % of the time?

A

95%

127
Q

Contraindications to SNLB?

A

Pregnancy, multicenteric disease, neoadjuvant, clinically positive nodes, prior axillary surgery, inflammatory or locally adcanced disease

128
Q

Modified radical mastectomy includes what?

A

All breast tissue including the nipple areolar complex; axillary node dissection (level I)

129
Q

Radical mastectomy includes what?

A

MRM and overlyting skin, pectoralis major and minor, level I, II, III lymph nodes

130
Q

Complications of axillary lymph node dissection?

A

Infection, lymphedema, lymphangiosarcoma, axillary vein thrombosis, lympatic fibrosis, intercostal brachiocutaneous nerve injury

131
Q

Signs of axillary vein thrombosis?

A

Sudden, early, postop swelling

132
Q

Most commonly injured nerve after mastecomy?

A

Intercostal brachiocutaneous nerve; hypersthesia of inner arm and lateral chest wall

133
Q

Radiotherapy dose for breast cancer?

A

5000 rad for lumpectomy and XRT

134
Q

Complications of XRT?

A

Edema, erythema, rib fractures, pneumonitis, ulceration, sarcoma, contralateral breast CA

135
Q

Contraindications of XRT?

A

Scleroderma, previous XRT, SLE, active RA

136
Q

What is the chance of recurrence following lumpectomy with XRT?

A

10%; usually within first 2 years

137
Q

Treatment with local recurrence?

A

Salvage MRM

138
Q

Which patients get chemo?

A

Positive nodes (except postmenopausal women with positive estrogen receptors (tamoxifen), >1cm and negative nodes

139
Q

By what percent does tamoxifen decrease short-term risk of breast cancer by?

A

50-60%

140
Q

What is the risk of blood clots on tamoxifen?

A

1%

141
Q

What is the risk of endometrial cancer in patients that are on tamoxifen?

A

0.1%

142
Q

What are the symptoms of a metastatic flare? What is the treatment?

A

Pain, swelling, erythema in metastatic areas; XRT

143
Q

What is occult breast cancer?

A

Breast-cancer that presents as axillary metastases with unknown primary

144
Q

What percent of occult breast-cancer are found to have breast cancer at mastectomy?

A

70%

145
Q

What are benign conditions that mimic breast cancer?

A

Radial scar, fibromatosis, granular cell tumors, fat necrosis

146
Q

Which malignant tumors have a benign appearance; smooth rounded masses?

A

Mucinous cancer, medullary cancer, cystosarcoma phyllodes

147
Q

How does Paget’s disease present? What is the treatment?

A

Presents with scaly skin lesion on nipple; biopsy shows Paget’s cells. Need modified radical mastectomy if cancer present, otherwise simple mastectomy

148
Q

What percent of cystosarcoma phyllodes are malignant? How is the diagnosis made?

A

10%; based on mitoses per high-power field, resemble giant fibroadenoma, has stromal and epithelial elements

149
Q

What is the treatment for cystosarcoma phyllodes?

A

Wide local excision with negative margins, no ALND

150
Q

What is Stuart-Treves syndrome?

A

Lymphangiosarcoma from chronic lymphedema following axillary dissection, presents with dark purple nodule on the arm 5 to 10 years after surgery

151
Q

What is the prognosis for a mass that presents during pregnancy?

A

Worse prognosis because it tends to present late

152
Q

Treatment for breast cancer that presents during pregnancy?

A

First trimester: MRM; second trimester: MRM; third trimester: MRM or if late can perform lumpectomy with ALND and postpartum XRT; no chemo or radiation while pregnant, no breast-feeding after delivery

Fiser's ABSITE Ryan SHORT (50 decks)

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