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Comprehensive Prep > Chapter 24: Breast > Flashcards

Chapter 24: Breast Flashcards

1
Q

Embryology: breast

A

Formed from the ectoderm milk streak

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2
Q

Hormones that cause.. 1. Duct development (double layer of columnar cells) 2. Lobular development 3. Synergizes estrogen and progesterone

A
  1. Estrogen: duct development (double layer of columnar cells) 2. Progesterone: lobular development 3. Prolactin: synergizes estrogen and progesterone
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3
Q

Cyclic change: increases breast swelling, growth of glandular tissue

A

Estrogen

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4
Q

Cyclic change: increase maturation of glandular tissue; withdrawal causes menses

A

Progesterone

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5
Q

Cyclic change: cause ovum release

A

FSH, LH surge

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6
Q

What causes atrophy of breast tissue after menopause?

A

After menopause, lack of estrogen and progesterone results in atrophy of breast tissue.

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7
Q

Innervates serratus anterior, injury results in winged scapula

A

Long thoracic nerve

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8
Q

Artery: supplies serratus anterior

A

Lateral thoracic artery

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9
Q

Innervates latissmus dorsi; injury results in weak arm pull-ups and adduction

A

Thoracodorsal nerve

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10
Q

Artery: supplies latissimus dorsi

A

Thoracodorsal artery

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11
Q

Innervates pectoralis major and pectorals minor

A

Medial pectoral nerve

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12
Q

Nerve: pectorals major only

A

Lacteral pectoral nerve

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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

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14
Q

Arteries that supply the breast

A

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

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15
Q

Valveless vein plexus that allows direct hematogenous metastasis of breast CA to spine

A

Batson’s plexus

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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.
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17
Q

Considered N3 disease

A

Mets to supraclavicular nodes

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18
Q

Dx: primary axillary adenopathy

A

1 is lymphoma

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19
Q

Suspensory ligaments of the breast. Divide breast into segments.

A

Cooper’s ligaments

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20
Q

What does skin dimpling of the breast suggest?

A

Breast CA involving Cooper’s ligaments dimpling the skin.

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21
Q

What are breast abscesses usually caused by? MCC?

A

Usually a/w breast feeding. MCC: Staph aureus

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22
Q

TX: breast abscess

A

Percutaneous or incision and drainage; discontinue breastfeeding; breast pump; antibiotics.

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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)

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24
Q

What is infectious mastitis usually associated with?

A

Breastfeeding

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25
Q

Mammary duct ectasia or plasma cell mastitis

A

Periductal mastitis

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26
Q

S/S: noncyclical mastodynia, erythema, nipple retraction, creamy discharge from nipple; can have sterile or infected subareolar abscess

A

Periductal mastitis

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27
Q

Risk factors: periductal mastitis

A

Smoking, nipple piercings

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28
Q

Biopsy: Periductal mastitis

A

Dilated mammary ducts, inspissated secretions, marked periductal inflammation

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29
Q

Tx: periductal mastitis

A

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)

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30
Q

Breast cysts filled with milk; occurs with breastfeeding Tx: ranges from aspiration to incision and drainage.

A

Galactocele

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31
Q

Can be caused by increased prolactin (pituitary prolactinoma), OCPs, TCAs, phenothiazines, metoclopramide, alpha-methyl dopa, reserpine. - Is often a/w amenorrhea

A

Galactorrhea

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32
Q

2-cm pinch of breast tissue. Tx: will likely regress; may need to resect if cosmetically deforming or causing social problems.

A

Gynecomastia

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33
Q

What is gynecomastia associated with?

A

Cimetidine. Spironolactone. Marijuana. Idiopathic in most.

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34
Q

Due to circulating maternal estrogens; will regress.

A

Neonatal breast enlargement.

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35
Q

MC location of polythelia (accessory breast tissue)

A

Axilla

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36
Q

MC breast anomaly. Location?

A

Accessory nipples - Found form axilla to groin

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37
Q

What is compromised with breast reduction?

A

Ability to lactate frequently compromised.

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38
Q

Hypoplasia of chest wall. Amastia. Hypoplastic shoulder. No pectoralis muscle.

A

Poland’s Syndrome

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39
Q

Pain in breast; rarely represents breast cancer. Dx: history, breast exam, BL mammogram.

A

Mastodynia

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40
Q

Tx: Mastodynia

A

Danazol. OCPs NSAIDs. Evening primrose oil. Bromocriptine. D/C: caffeine, nicotine, methylxanthines.

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41
Q

Pain before menstrual period, most commonly represents acute or subacute.

A

Cyclic mastodynia.

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42
Q

Continuous pain. MC’ly represents acute or subacute infection; continuous mastodynia is more refractory to treatment than cyclic mastodynia.

A

Continuous mastodynia.

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43
Q

Superficial vein thrombophlebitis of breast, feels cordlike, can be painful.

A

Mondor’s disease

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44
Q

What is Mondor’s disease associated with? Def: superficial vein thrombophlebitis of breast

A
  • Associated with trauma and strenuous exercise. - Usually occurs in lower outer quadrant.
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45
Q

Tx: Mondor’s disease

A

NSAIDs

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46
Q

Dx: breast pain, nipple discharge (usually yellow to brown), lumpy breast tissue that varies with hormonal cycle.

A

Fibrocystic change.

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47
Q

Types of fibrocystic change.

A

Papillomatosis. Sclerosing adenosis. Apocrine metaplasia. Duct adenosis. Epithelial hyperplasia. Ductal hyperplasia. Lobular hyperplasia.

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48
Q

What type of fibrocystic disease is associated with risk of CA?

A

Atypical ductal or lobular hyperplasia.

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49
Q

Tx: atypical ductal / lobular hyperplasia subtypes of fibrocystic change?

A

Resect. - Do not need to get negative margins with atypical hyperplasia; just remove all suspicious areas (i.e., calcifications that appear on mammogram).

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50
Q

MCC bloody nipple discharge

A

Intraductal papilloma

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51
Q
  • Usually small, non palpable, close to nipple. - Not premalignant
A

Intraductal papilloma

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52
Q

Intraductal papilloma - Dx? - Tx?

A

Dx: contrast ductogram to find papilloma, then needle localization Tx: Subareolar resection of the involved duct and papilloma.

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53
Q

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.

A

Fibroadenoma

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54
Q

Path: fibroadenoma

A

prominent fibrous tissue compressing epithelial cells

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55
Q

Mammography: fibroadenoma

A

Large, coarse calcifications (popcorn lesions) from degeneration.

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56
Q

Criteria for observation of fibroadenoma.

A

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.

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57
Q

Tx: enlarging fibroadenoma

A

Excisional biopsy

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58
Q

Why avoid resection of fibroadenoma in teenagers / younger children?

A

Resection can affect breast development.

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59
Q

Fibroadenoma: pts > 40

A

Excisional biopsy to ensure dx

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60
Q

Tx: fibroadenoma

A

Pts < 40 Observe. No ex bx.

Pts > 40: Ex bx to ensure diagnosis

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61
Q

Most nipple discharge is…

A

Benign

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62
Q

Dx: nipple discharge

A

History, breast exam, BL mammogram. Try to find the trigger point on exam.

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63
Q

Nipple discharge: green Tx?

A

Usually due to fibrocystic disease. Tx: if cyclical and non spontaneous, reassure pt.

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64
Q

Nipple discharge: bloody Tx?

A

MC intraductal papilloma; occasionally ductal CA. Tx: Need ductogram and excision of that ductal area.

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65
Q

Nipple: serous discharge

A

Worrisome for cancer. Especially if coming form only 1 duct or spontaneous. Tx: Excisional biopsy of that ductal area

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66
Q

Nipple: spontaneous discharge

A

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.

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67
Q

Discharge: - Occurs only with pressure, tight garments, exercise, etc. - Not as worrisome but may still need excisional biopsy (e.g., if bloody)

A

Nonspontaneous discharge

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68
Q

Sx: nipple discharge

A

May have to do a complete subareolar resection if the area above cannot be properly identified (no trigger point or mass felt).

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69
Q

Malignant cell of the ductal epithelium without invasion of basement membrane

A

Ductal carcinoma in situ.

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70
Q

DCIS Risk Ca: Ipsilateral Breast Contralateral Breast

A

Ipsilateral breast: 50% Contralateral breast: 5%

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71
Q

DCIS: premalignant lesion

A

Yes.

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72
Q

Usually not palpable and presents as a cluster of calcifications on mammography. - Can have solid, cribriform, papillary, comedy patterns

A

DCIS

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73
Q

Most aggressive subtype DCIS - Necrotic areas - High risk for multi centricity, micro invasion, recurrence. Tx?

A

Comedo pattern DCIS - Tx: simple mastectomy.

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74
Q

Increased risk of cancer in DCIS?

A

Comedo type and lesions > 2.5cm

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75
Q

Tx: DICS (not high grade)

A

Lumpectomy and XRT. Need 1cm margins. No ALND or SLNB. Possibly tamoxifen.

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76
Q

Tx: High grade DCIS

A

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.

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77
Q

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.

A

Lobular carcionma in situ - LCIS.

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78
Q

Patient who develop breast CA are more likely to develop a..

A

Ductal CA (70%)

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79
Q

Possibility of synchronous breast cancer at time of LCIS diagnosis?

A

5% (most likely ductal CA)

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80
Q

Do you need negative margins for LCIS?

A

No.

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81
Q

Treatment for LCIS

A

Nothing. Tamoxifen. BL subcutaneous mastectomy (no ALND).

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82
Q

Indications for Surgical Biopsy after core biopsy

A

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.

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83
Q

Country: lowest risk of breast CA worldwide

A

Japan

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84
Q

United States breast cancer risk

A

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

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85
Q

Breast cancer screening decreases mortality by..

A

25%

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86
Q

Years survival: untreated breast cancer

A

2-3 years

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87
Q

%: Beast CA with negative mammogram and negative ultrasound

A

10%

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88
Q

Clinical features of breast CA

A

Distortion of normal architecture. Skin / nipple distortion or retraction. Hard. Tethered. Indistinct borders.

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89
Q

Symptomatic breast mass work up

A

Ultrasound & Core needle biopsy. (consider FNA). - Need mammo in pts

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90
Q

Symptomatic breast mass work up > 40 years old

A

Need bilateral mammograms. Ultrasound. Core needle biopsy.

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91
Q

If core needle biopsy or FNA is indeterminate, non-diagnostic, non-concordant with exam findings / imaging studies..

A

Will need excisional biopsy.

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92
Q

Clinically indeterminate or suspect solid masses will eventually need..

A

Excisional biopsy unless CA diagnosis is made prior to that.

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93
Q

Tx: cyst fluid

A

Bloody: cyst excisional biopsy Clear/recurs: excisional biopsy. Complex: excisional biopsy

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94
Q

Test: gives architecture

A

CNBx

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95
Q

Test: Gives cytology (just the cells)

A

FNA

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96
Q

Mgmt: malignant breast mass (FNA/CNBx)

A

Definitive therapy

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97
Q

Mgmt: suspicious breast mass (FNA/CNBx)

A

Surgical biopsy

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98
Q

Mgmt: atypia breast mass (FNA/CNBx)

A

Surgical biopsy

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99
Q

Mgmt: non diagnostic breast mass (FNA/CNBx)

A

Repeated FNA/CNBx or surgical biopsy

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100
Q

Mgmt: benign breast mass (FNA/CNBx)

A

Possible observation - exam and imaging studies need to concordant with benign disease, otherwise need excisional biopsy.

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101
Q

Sensitivity / specificity: mammography

A

90%

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102
Q

How does mammography increase with age?

A

Sensitivity increases with age as the dense parenchymal tissue is replaced with fat.

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103
Q

Size breast mass to be detected by mammography

A

> 5 mm

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104
Q

Mammography: suggestive of Cancer

A

Irregular borders. Speculated. Multiple clustered. Small. Thin. Linear. Crushed-like and/or branching calcifications. Ductal asymmetry. Distortion of architecture.

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105
Q

BI-RAD 1.

A

Negative Tx: Routine screening

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106
Q

BI-RADs 2

A

Benign finding Tx: Routine screening

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107
Q

BI-RADs 3

A

Probably benign finding Tx: Routine screening

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108
Q

BI-RADs 4

A

Suspicious abnormality (eg, indeterminate calcifications or architecture) Tx: definite probability of CA; get CNBx

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109
Q

BI-RADs 5

A

Highly suggestive of CA (suspicious calcifications or architecture) Tx: high probability of CA; get CNBx.

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110
Q

Tx: BI-RADs 4 lesion CNBx - Malignancy? - Non-determinate? - Benign and concordant with mammogram?

A
  • 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
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111
Q

Tx: BI-RADs 5 lesion CNBx shows - Malignancy? - Any other finding?

A
  • Malignancy: follow appropriate tx - Any other finding (non diagnostic, indeterminate, or benign) -> all need needle localization excisional biopsy.
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112
Q

What allows appropriate staging with SLNBx (mass is still present) and one-step surgery for patients diagnosed with breast cancer?

A

CNBx without excisional biopsy.

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113
Q

Recommendations: mammogram screening?

A

Q 2-3 years after age 40, then yearly after 50.

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114
Q

Recommendations: high-risk mammogram screening

A

10 years before the youngest age of diagnosis of breast CA in first-degree relative.

115
Q

Why aren’t mammograms generally recommended in young patients

A

Hard to interpret because of dense parenchyma.

116
Q

How does mammogram radiation dose change in younger patients?

A

Dose decreases

117
Q

Node levels: I? II? III?

A

I: lateral to pectoralis minor muscle II: beneath pectoralis minor muscle. III: medial to pectorlis minor muscle

118
Q

LN: between the pectoralis major and pectoralis minor muscles.

A

Rotter’s nodes

119
Q

What nodes do you generally take?

A

Level I and II. Take level III nodes only if grossly involved.

120
Q

Most important prognostic staging factor

A

Nodes

121
Q

Factors including in prognostic staging

A

Nodes (most important). Size. Grade. Progesterone / Estrogen receptor status.

122
Q

What is survival directly related to in breast cancer?

A

Number of positive nodes. - 0: 75% 5-year survival - 1-3: 60% 5-year survival - 4-10: 04% 5-year survival

123
Q

Most common site for distant metastasis

A

Bone

124
Q

Time: Single malignant cell to 1-cm tumor.

A

Approximately 5-7 years

125
Q

Location: increased risk of multicentricity

A

Central and subareolar tumors

126
Q

Breast CA: greatly increased risk (relative risk > 4)

A
  • 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
Q

Breast CA: moderately increased risk (relative risk 2-4)

A

Prior breast cancer - Radiation exposure - First degree relative with breast cancer - Age > 35 first birth

128
Q

Breast CA: lower increased risk (relative risk

A
  • Early menarche / late menopause - Nulliparity - Proliferative benign disease - Obesity, alcohol, hormone replacement therapy.
129
Q

BRCA I Cancer Risk - Female breast CA - Ovarian CA - Male breast CA

A

Lifetime risk.. - Female breast: 60% - Ovarian: 40% - Male breast: 1%

130
Q

BRCA II Cancer Risk - Female breast CA - Ovarian CA - Male breast CA

A

Lifetime risk.. - Female breast: 60% - Ovarian: 10% - Male breast: 10%

131
Q

Sx Considerations: BRCA families with history of breast cancer

A

Total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO)

132
Q

Breast Cancer risk: first degree relative with bilateral, premenopausal breast cancer

A

50%

133
Q

Considerations for prophylactic mastectomy

A
  • 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
Q

Why are positive receptors good?

A

Better response to hormones, chemotherapy, surgery, and better overall prognosis.

135
Q

Receptor-positive tumors are more common in…

A

Postmenopausal women

136
Q

What receptor do you want positive: estrogen or progesterone?

A

Progesterone receptor-positive tumors have better prognosis than estrogen receptor-positive tumors.

137
Q

What happens with positive estrogen AND progesterone receptors?

A

Both positive? Has the best prognosis.

138
Q

%: Breast cancer negative for both receptors.

A

10%

139
Q

What is male breast cancer associated with?

A

Steroid use. Previous XRT. Family history. Klinefelter’s syndrome

140
Q

Tx: male breast cancer

A

Tx: Modified Radical Mastectomy (MRM)

141
Q

85% of all breast cancer. Tx?

A

Ductal CA Tx: MRM or BCT (breast conserving therapy) with post XRT

142
Q

Ductal CA: Subtypes

A

Medullary. Tubular. Mucinous. Scirrhotic.

143
Q

Ductal CA: smooth borders, increased lymphocytes, bizarre cells, more favorable prognosis.

A

Medullary ductal CA

144
Q

Ductal CA: small tubule formations, more favorable prognosis.

A

Tubular ductal CA

145
Q

Ductal CA: produces an abdundance of mucin, more favorable prognosis

A

Mucinous (colloid) ductal CA

146
Q

Ductal CA: worse prognosis

A

Schirrhotic

147
Q

10% of all breast CA - Does not form calcifications, extensively infiltrative, increased bilateral, multifocal and multi centric disease. - signet ring cells confer worse prognosis

A

Lobular cancer

148
Q

Tx: lobular cancer

A

MRM or BCT with post op XRT

149
Q

Path: confers worse prognosis in lobular CA

A

Signet ring cells

150
Q

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

A

Inflammatory breast cancer

151
Q

Tx: inflammatory breast CA

A

Neoadjuvant chemo, then MRM, then adjuvant chemo-XRT (most common method)

152
Q

Leaves 1%-2% of breast tissue, preserves the nipple - Not indicated for breast CA treatment - Used for DCIS and LCIS

A

Subcutaneous mastectomy (simple mastectomy)

153
Q

Removes all breast tissue, including the nipple areolar complex - Includes axillary node dissection (level 1 nodes)

A

Modified radical mastectomy

154
Q

Surgical options for breast cancer

A

Subcutaneous mastectomy. Breast-conserving therapy. Modified radical mastectomy. SLNB. ALND.

155
Q

Combined with postop XRT; need 1cm margin

A

Breast-conserving therapy.

156
Q

Absolute contraindications to Breast-Conserving Therapy in invasive CA

A

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

157
Q

Relative contraindications to breast-conserving therapy in invasive carcinoma

A

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.

158
Q

Indicated only for malignant tumors > 1cm - Not indicated in pts with clinically positive nodes (need ALND).

A

Sentinel lymph node biopsy (SLB)

159
Q

When is accuracy best for sentinel lymph node biopsy?

A

When primary tumor is present (finds the right lymphatic channels)

160
Q

Dye used for sentinel lymph node biopsy

A

Lymphazurin blue dye or radio tracer is injected directly into the tumor area.

161
Q

What to do: no radio tracer dye is found during sentinel lymph node biopsy

A

Do a formal ALND

162
Q

Contraindications: SLNB (sentinel lymph node biopsy)

A

Pregnancy. Multi centric disease. Neoadjuvant therapy. Clinically positive nodes. Prior axillary surgery. Inflammatory or locally advanced disease.

163
Q

When level nodes do you take for axillary lymph node dissection?

A

Level 1 and 2 nodes

164
Q

Complications of MRM

A

Infection. Flap necrosis. Seromas.

165
Q

Complications of ALND

A
  • Infection, lymphedema, lymphangiosarcoma. - Axillary vein thrombosis (sudden early post swelling) - Lymphatic fibrosis (slow swelling over 18 months) - Intercostal brachiocutaneous nerve injury
166
Q

ALND: sudden, early, post op swelling

A

Axillary vein thrombosis

167
Q

ALND: slow swelling over 18 months

A

Lymphatic fibrosis

168
Q

ALND: hypesthesia of inner arm and lateral chest wall; most commonly injured nerve after mastectomy, no significant sequelae

A

Intercostal brachiocutaneous nerve injury

169
Q

MC’ly injured nerve after mastectomy

A

Intercostal brachiocutaneous nerve injury.

170
Q

How long do you leave in drains after ALND?

A

Drainage

171
Q

Radiation dose of radiotherapy

A

5,000 rad for BCT and XRT

172
Q

Complications: XRT

A

Edema. Erythema. Rib fratures. Pneumonitis. Ulceration. Sarcoma. Contralateral breast CA.

173
Q

Contraindications: XRT

A

Scleroderma (results in severe fibrosis and necrosis). Previous XRT and would exceed recommended dose. SLE (relative). Active rheumatoid arthritis (relative).

174
Q

Indications for XRT after mastectomy.

A

> 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)

175
Q

When can you start XRT after BCT?

A

When you have negative margins following BCT

176
Q

%: Chance of local recurrence after BCT with XRT

A

10% - Usually within 2 years of first operation. - Need to re-stage with recurrence. - Need salvage MRM for local recurrence.

177
Q

Chemotherapy regimen

A

TAC (taxanes, Adriamycin, cyclophosphamide for 6-12 weeks)

178
Q

Who gets chemotherapy with positive nodes?

A

Everyone EXCEPT postmenopausal women with positive estrogen receptors (they get hormonal therapy only aromatase inhibitor (anastrozole))

179
Q

Tx: postmenopausal, positive nodes, estrogen receptor positive

A

Hormonal therapy only with aromatase inhibitor (anastrozole)

180
Q

Chemo: > 1cm and negative nodes

A

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.

181
Q

Tx after chemo: pts positive for estrogen receptors

A

Appropriate hormonal therapy

182
Q

Have been shown to decrease recurrence and improve survival

A

Both chemotherapy and hormonal

183
Q

Taxanes

A

Docetaxel, paclitaxel

184
Q

Decreases risk of breast cancer by 50% - 1% risk of blood clots; 0.1% risk of endometrial cancer

A

Tamoxifen

185
Q

What happens to women with breast cancer recurrence?

A

Almost all women with recurrence die of disease.

186
Q

Increased recurrences and metastases occurs with..

A

Positive nodes. Large tumors. Negative receptors. Unfavorable subtype.

187
Q

Pain, swelling, erythema is metastatic areas. Tx?

A

Metastatic flare - Tx: XRT can help XRT is good for bone metastasis

188
Q

Breast CA that presents as axillary metastases with unknown primary. Tx?

A

Occult breast CA - Tx: MRM (70% are found to have breast CA)

189
Q

Scaly skin lesion on nipple - Have DCIS or ductal CA in breast Tx?

A

Paget’s disease Tx: need MRM if cancer present; otherwise simple mastectomy (need to include the nipple-areolar complex with Paget’s)

190
Q

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?

A

Cystosarcoma phyllodes - Tx: WLE with negative margins; no ALND

191
Q

Tx: Cystosarcoma phyllodes

A

WLE with negative margins; no ALND

192
Q

Lymphangiosarcoma from chronic lymphedema following axillary dissection - Pts present with dark purple nodule or lesion on arm 5-10 years after surgery

A

Stewart-Treves syndrome

193
Q

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

A

Pregnancy with mass

194
Q

If breast CA - 1st trimester? - 2nd trimester? - 3rd trimester?

A
  • 1st: MRM - 2nd: MRM - 3rd: MRM or if late can perform lumpectomy with ALND and postpartum XRT
195
Q

Radiation in pregnancy with breast cancer.

A

No XRT while pregnant, no breastfeeding after delivery.

196
Q

Boundaries of the axilla: - Superior - Posterior - Lateral - Medial

A

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.

197
Q

Courses along lateral chest wall in midaxillary line on serratus anterior muscle; innervates serratus anterior muscle

A

Long thoracic nerve

198
Q

Courses lateral to long thoracic nerve on latissimus doors muscle; innervates latissimus dorsi muscle

A

Thoracodorsal nerve

199
Q

Runs lateral to or through the pectoral minor muscle, actually lateral to the lateral pectoral nerve, innervates the pectoral minor and pectoral major muscles

A

Medial pectoral nerve

200
Q

Runs medial to the medial pectoral nerve (names describe orientation from the brachial plexus!); innervates the pectoral major.

A

Lateral pectoral nerve

201
Q

What is the name of the cutaneous nerve that crosses the axillary in a transverse fashion?

A

Intercostobrachial nerve

202
Q

What is the lymphatic drainage of the breast?

A

Lateral: axillary lymph nodes Medial: parasternal nodes that run with internal mammary artery.

203
Q

What is the mammary “milk line”?

A

Embryological line from should to thigh where “supernumerary” breast areolar and / or nipple can be found

204
Q

What is the “tail of Spence”?

A

“Tail” of breast tissue that tapers into the axilla.

205
Q

What percentage of women with breast cancer have no known risk factor?

A

75%

206
Q

What percentage of all breast cancers occur in women younger than 30 years?

A

~ 2%

207
Q

What percentage of all breast cancers occur in women older than 70 years?

A

33%

208
Q

What are the history risk factors for breast cancer?

A

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)

209
Q

What are physical / anatomic risk factors for breast cancer?

A

CHAFED LIPS - Cancer in the breast (3% synchronous contralateral cancer) - Hyperplasia, Atypical hyperplasia, Female, Elderly, DCIS - LCIS, Inferited genes, Papilloma, Sclerosing adenosis

210
Q

What is the relative risk of hormone replacement therapy?

A

1 - 1.5

211
Q

Is “run of the mill” fibrocystic disease a risk factor for breast cancer?

A

No

212
Q

What are the possible symptoms of breast cancer?

A

No symptoms. Mass in the breast. Pain (most painless). Nipple discharge. Local edema. Nipple retraction. Dimple. Nipple rash.

213
Q

What is the most common site of breast cancer?

A

Approximately one half of cancers develop in the upper outer quadrants.

214
Q

What are the different types of invasive breast cancer?

A

Infiltrating ductal ca (75%) Medullary ca (15%) Infiltrating lobular CA (2%) Tubular ca (2%) Mucinous ca (colloid) (1%) Inflammatory breast ca (1%)

215
Q

What is the MC type of breast cancer?

A

Infiltrating ductal ca

216
Q

Breast exam recommendations?

A

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.

217
Q

When is the best time for breast self-exam?

A

1 week after menstrual period

218
Q

What option is best to evaluate a breast mass in a woman younger than 30 years?

A

Breast ultrasound

219
Q

What are the indications for biopsy of breast mass?

A

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.

220
Q

What is the process for performing a biopsy when a non palpable mass is seen on mammo?

A

Stereotactic (mammotome) biopsy or needle localization therapy

221
Q

What is obtained first, the mammogram or the biopsy?

A

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).

222
Q

What would be suspicious mammographic findings?

A

Mass, microcalcifications, stellate / spiculated mass

223
Q

What is a “radial scar” seen on mammogram?

A

Spiculated mass with central lucency, +/- microcalcifications

224
Q

What tumor is a/w a radial scar?

A

Tubular carcinoma, thus, biopsy is indicated.

225
Q

What is the “workup” for a breast mass?

A
  1. Clinical breast exam 2. Mammogram on breast ultrasound. 3. FNA, core biopsy, or open biopsy
226
Q

Is the fluid from a breast cyst sent for cytology?

A

Not routinely, bloody fluid should be sent for cytology.

227
Q

When do you proceed to open biopsy for a breast cyst?

A
  1. In the case of a second cyst recurrence. 2. Bloody fluid in the cyst. 3. Palpable mass after aspiration.
228
Q

What is the preoperative staging workup in a patient with breast cancer?

A
  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
229
Q

What are the sites of metastases?

A

Lymph nodes (MC). Lung / pleura. Liver. Bones. Brain.

230
Q

What are the major treatments of breast cancer?

A

Modified radical mastectomy. Lumpectomy and radiation + SLND. (Both: either +/- post op chemo / tamoxifen)

231
Q

What are the indications for radiation therapy after a modified radical mastectomy?

A

Stage 3A, Stage 3B, Pectoral muscle / fascia invasion. Positive internal mammary LN. Positive surgical margins. > 4 positive axillary LN’s postmenopausal.

232
Q

What breast carcinomas are candidates for lumpectomy and radiation (breast-conserving therapy)?

A

Stage 1 and 2

233
Q

What approach may allow a patients with stage 3A cancer to have breast-conserving surgery?

A

Neoadjuvant chemotherapy - if the preo chemo shrinks the tumor.

234
Q

What is the treatment of inflammatory carcinoma of the breast?

A

Chemotherapy first! Then often followed by radiation, mastectomy, or both.

235
Q

What is the major absolute contraindication to lumpectomy and radiation?

A

Pregnancy

236
Q

What is a modified radical mastectomy?

A

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.

237
Q

What are the potential complications after a modified radical mastectomy?

A

Ipsilateral arm lymphedema. Infection. Injury to nerves, skin flap necrosis, hematoma / serum, phantom breast syndrome.

238
Q

During an axillary dissection, should the patient be paralyzed?

A

No, because the nerves (long thoracic / thoracodorsal) are stimulated with resultant muscle contraction to help identify them.

239
Q

How can the long thoracic and thoracodorsal nerves be identified during an axillary dissection?

A

Nerves can be stimulated with a forceps, which results in contraction of the latissimus dorsi (thoracodorsal nerve) or anterior serratus (long thoracic nerve)

240
Q

How is the sentinel lymph node found?

A

Inject blue dye and/or technetium-labeled sulfur colloid (best results with both)

241
Q

What follows a positive sentinel node biopsy?

A

Removal of the rest of the axillary lymph nodes

242
Q

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?

A

Sentinel lymph node dissection

243
Q

What do you do with a mammotome biopsy that returns as “atypical” hyperplasia?

A

Open needle loc biopsy as many will have DCIS or invasive cancer

244
Q

What is the treatment for local recurrence in breast after lumpectomy and radiation?

A

“Salvage” mastectomy

245
Q

Can tamoxifen prevent breast cancer?

A

Yes. In the breast cancer prevention trial of 13,000 women at increased risk, tamoxifen reduces risk by ~ 50% across all ages.

246
Q

What are common options for breast reconstruction?

A

TRAM flap, implant, latissimus dorsi flap

247
Q

What is a TRAM flap?

A

Transverse Rectus Abdominis Myocutaneous flap

248
Q

What are the side effects of tamoxifen?

A

Endometrial cancer (2.5 x relative risk), DVT, PE, cataracts, hot flashes, mood swings

249
Q

In high-risk women, is there a way to reduce the risk of developing breast cancer?

A

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

250
Q

What type of chemotherapy is usually used for breast cancer?

A

CMF (cyclophosphamide, methotrexate, 5-fluorouracil) or CAF (cyclophosphamide, adriamycin, 5-fluorouracil)

251
Q

What makes a tumor high risk?

A

> 1 cm in size Lymphatic / vascular invasion Nuclear grade (high) S phase (high) ER negative HER-2/neu overexpression

252
Q

Describe DCIS.

A

Cancer cells in the duct without invasion. (Cells do not penetrate the basement membrane).

253
Q

s/s: DCIS

A

Usually none; usually nonpalpable

254
Q

DCIS: mammographic findings

A

Microcalcifications

255
Q

DCIS: most aggressive subtype

A

Comedo

256
Q

What is the major risk with DCIS?

A

Subsequent development of infiltrating ductal carcinoma in the same breast

257
Q

Tx: DCIS Tumor

A

Remove with (-) margins +/- XRT

258
Q

Tx: DCIS Tumor > 1cm

A

Perform lumpectomy with (-) margins and radiation or total mastectomy (no axillary dissection)

259
Q

What is a total (simple) mastectomy?

A

Removal of the breast and nipple without removal of the axillary nodes (always remove nodes with invasive cancer)

260
Q

When must a simple mastectomy be performed for DCIS?

A

Diffuse breast involvement (e.g., diffuse micro calcifications), > 1cm and contraindication to radiation

261
Q

What is the role of axillary node dissection with DCIS?

A

No role in true DCIS (i.e., without micro invasion); some perform a sentinel lymph node dissection for high-grade DCIS

262
Q

What is adjuvant for DCIS?

A
  1. Tamoxifen 2. Postlumpectomy XRT
263
Q

What is the role of tamoxifen in DCIS?

A

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.

264
Q

Mammographic findings: LCIS

A

None

265
Q

Dx: LCIS

A

LCIS is found incidentally on biopsy

266
Q

What percentage of women with LCIS develop an invasive breast carcinoma?

A

~ 30% in the 20 years after diagnosis of LCIS

267
Q

What medication may lower the risk of developing breast cancer in LCIS?

A

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.

268
Q

What is Paget’s disease of the breast?

A

Scaling rash / dermatitis of the nipple caused by invasion of skin by cells from a ductal carcinoma

269
Q

What are the risk factors of male breast cancer?

A

Increased estrogen. Radiation. Gynecomastia from increased estrogen. Estrogen therapy. Klinefelter’s syndrome (XXY). BRCA2 carriers.

270
Q

Is benign gynecomastia a risk factor for male breast cancer?

A

No

271
Q

What type of breast cancer do men develop?

A

Nearly 100% of cases are ductal carcinoma (men do not usually have breast lobules)

272
Q

S/S: Breast cancer in men

A

Breast mass (most are painless), breast skin changes (ulcers, retraction), and nipple discharge (usually blood or a blood-tinged discharge)

273
Q

MCC green, straw-colored or brown nipple discharge

A

Fibrocystic disease

274
Q

Mesenchymal tumor arising from breast lobular tissue; most are benign

A

Cystosarcoma phyllodes

275
Q

Phyllodes tumor: age

A

25-55 years (usually older than pt with fibroadenoma)

276
Q

s/s: phyllodes tumor

A

Mobile, smooth breast mass that resembles a fibroadenoma on exam, mammogram / ultrasound findings

277
Q

Tx: Phyllodes tumor

A

If benign, wide local excision; if malignant, simple total mastectomy.

278
Q

What is the role of axillary dissection with cystosarcoma phyllodes tumor?

A

Only if clinically palpable axillary nodes, as the malignant form rarely spreads to nodes (MC site of mets is the lung)

279
Q

Is there a role for chemotherapy with cystosarcoma phyllodes?

A

Consider chemotherapy if large tumor > 5 cm and “stromal overgrowth”

280
Q

Benign tumor of the breast consisting of streams overgrowth, collagen arranged in “swirls”

A

Fibroadenoma

281
Q

S/S Breast pain or tenderness that varies with the menstrual cycle; cysts; and fibrous (“nodular”) fullness

A

Fibrocystic disease

282
Q

Tx: fibrocystic disease

A

Stop caffeine. Pain meds (NSAIDS) Vitamin E, evening primrose oil (danazol and OCP as last resort)

283
Q

What is done if the patient has a breast cyst?

A

Aspirate s/t needle drainage: - Bloody / palpable mass: open bx - Straw / green color: follow closely, 2nd? needle aspirate - Re-recurrence usually requires open biopsy

Comprehensive Prep (45 decks)

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