Fiser ABSITE Ch. 24 Breast Flashcards
What hormone? duct development (double layer of columnar cells)
Estrogen
What hormone?
lobular development
Progesterone
What hormone?
synergizes estrogen and progesterone
Prolactin
What hormone?
breast swelling, growth of glandular tissue
Estrogen
What hormone?
maturation of glandular tissue; withdrawal causes menses
Progesterone
What hormone?
cause ovum release
FSH, LH surge
innervates serratus anterior; injury results in winged scapula
Long thoracic nerve
innervates latissimus dorsi; injury results in weak arm pullups and adduction
Thoracodorsal nerve
innervates pectoralis major and pectoralis minor
Medial pectoral nerve
innervates pectoralis major only
Lateral 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
List arterial supply to the breast
Branches of internal thoracic artery, intercostal arteries, thoracoacromial artery; and lateral thoracic artery
valveless vein plexus that allows direct hematogeous metastasis of breast CA to spine
Batson’s plexus
Primary axillary adenopathy
1 lymphoma
Supraclavicular pos lymph nodes are considered ? in TMN staging
considered M1 disease
Most common organisms with breast abscess
S. aureus
Dilated mammary ducts, inspissated secretions, marked periductal inflammation; • Symptoms: noncyclical mastodynia, nipple retraction, creamy discharge from nipple; can have sterile subareolar abscess
Periductal mastitis (mammary duct ectasia or plasma cells mastitis)
hypoplasia of chest wall, amastia, hypoplastic shoulder, no pectoralis muscle
Poland’s syndrome
superficial vein thrombophlebitis of breast; feels cord Like, can be painful; • Associated with trauma and strenuous exercise; • Usually occurs in lower outer quadrant; • Tx: NSAIDs
Mondor’s disease
can manifest as a cluster of calcifications on mammogram; with out a mass or pain, can look like breast CA; • Is differentiated from breast CA by regularity of nuclei and absence of mitosis
Sclerosing adenosis
Most common cause of bloody discharge from nipple
Intraductal papilloma
What test can be used to dx Intraductal papilloma?
contrast ductogram
What is the tx for Intraductal papilloma?
resection (subareolar resection usually curative)
Most common breast lesion in adolescents and young women;
Fibroadenoma; 10% multiple; Usually painless, slow growing, well circumscribed, firm, and rubbery
tx of Fibroadenoma >30yr
excisional biopsy to ensure diagnosis
Green nipple discharge indicates?
Fibrocystic disease
Tx: if cyclical and nonspontaneous, reassure patient
Bloody nipple discharge indicates
most commonly intraductal papilloma; occasionally ductal CA; Tx: need galactogram and excision of that ductal area
Serous nipple discharge indicates?
worrisome for cancer, especially if coming from only 1 duct or spontaneous; Tx: excisional biopsy of that ductal area
Tx for Spontaneous nipple discharge
no matter what the color or consistency is worrisome for cancer; • All these patients need some sort of biopsy in the area of the duct causing the discharge
Affects multiple ducts of both breasts
• Are larger than when they occur solitarily
• Usually have serous discharge
• Mammogram shows Swiss cheese appearance
• increased risk of breast CA (40% get breast CA)
DIFFUSE PAPILLOMATOSIS
Malignant cells of the ductal epithelium without invasion of the basement membrane
DCIS; Usually not palpable and presents as a cluster of calcifications on mammography; • Need a 2-3 mm margin with excision
most aggressive subtype of ductal carcinoma in situ; has necrotic areas; • High risk for multicentricity, microinvasion, and recurrence; • Tx: simple mastectomy
Comedo pattern; increased recurrence risk with comedo type and lesions > 2.5 cm
Tx for DUCTAL CARCINOMA IN SITU
lumpectomy and XRT; possibly tamoxifen; • Simple mastectomy if high grade (i.e., comedo type, multicentric, multifocal ), if a large tumor not amenable to lumpectomy, or if not able to get good margins; no ALND
40% get cancer (either breast)
• Considered a marker for the development of breast CA, not premalignant itself
• Has no calcifications; is not palpable
• Primarily found in premenopausal women
• Patients who develop breast CA are more likely to develope ductal CA (70%)
Do not need negative margins
LCIS
Tx for LOBULAR CARCINOMA IN SITU
Tx: nothing, tamoxifen, or bilateral subcutaneous mastectomy (no ALND )
Symptomatic breast mass workup
- ultrasound
- If solid FNA; excisional biopsy if FNA is non diagnostic
- These patients most commonly have fibroadenomas that can be left alone if FNA is diagnostic. However, if the fibroadenoma enlarges, need excisional biopsy
Symptomatic breast mass workup
30-50 years
bilateral mammograms and FNA; excisional biopsy if FNA; nondiagnostic
Symptomatic breast mass workup
>5O years
bilateral mammograms and excisional or core needle biopsy
What is the sensitivity/ specificity of a mammogram? How large does that mass need to be?
90%, 5mm
What is the next step? Suspicious calcifications or architecture on mammography
perform localized stereotactic needle excisional biopsy
What is the next step? Indeterminate calcifications or architecture on mammography
can perform core needle biopsy; if indeterminate, perform localized stereotactic needle excisional biopsy
BI-RADS Classification of Mammographic Abnormalities
category 1
negative, routine screening
BI-RADS Classification of Mammographic Abnormalities
category 2
Benign finding, routine screening
BI-RADS Classification of Mammographic Abnormalities
category 3
Probably benign finding, Short-interval follow- up
BI-RADS Classification of Mammographic Abnormalities
Category 4
Suspicious abnormality; Definite probability of malignancy consider biopsy
BI-RADS Classification of Mammographic Abnormalities
Category 5
Highly suggestive of malignancy; High probability of cancer; appropriate action should be taken.
List Node levels
I - lateral to pectoralis minor muscle
II - beneath pectoralis minor muscle
Ill- medial to pectoralis minor muscle
node between the pectoralis major and pectoralis minor muscles
Rotter’s nodes
most common distant metastasis of breast cancer
Bone
tumors that have increased risk of multicentricity
Central and subareolar tumors
TNM STAGING SYSTEM FOR BREAST CANCER
List the T
Tl : 5 cm
T4: skin or chest wall involvement
TNM STAGING SYSTEM FOR BREAST CANCER
List N
N1: ipsilateral axillary nodes. N2: fixed ipsilateral axillary nodes. N3: ipsilateral internal mammary nodes
TNM STAGING SYSTEM FOR BREAST CANCER
list the stages
I:T1 , NO , IIA: TO-1, N1, or T2, NO, IIB:T2, N1, or T3, NO, IIIA: TO-3, N2, or T3, N1-2 IIIB:Any T4 or N3 tumours IV:M1
Gene mutation associated with ovarian (50%), endometrial CA
BRCA I; Consider TAH and bilateral oophorectomies in BRCA I families
Gene mutation associated with male breast CA
BRCA II
Types of Ductal CA
- Medullary breast CA
- Tubular CA
- Mucinous CA (colloid)
- Scirrhotic CA
Type of ductal Ca smooth borders, increased lymphocytes, ductal type cancer with bizarre cells
• Vast majority are estrogen- and progesterone receptor-positive
• More favorable prognosis
Medullary breast CA
Tx for ductal Ca
MRM or lumpectomy with ALND (or SLNB); postop XRT
10% of all breast CAs
• Does not form calcifications; extensively infiltrative; increased bilateral, multifocal, and multicentric disease
• Signet ring cells confer worse prognosis
• Tx: MRM or lumpectomy with ALND (or SLNB); postop XRT
Lobular cancer
May need chemotherapy and XRT 1st, then mastectomy
• Considered T4 disease
• Very aggressive, median survival of 36 months
• Has dermal lymphatic invasion, which causes peau d’orange lymph edema appearance; erythematous and warm
Inflammatory cancer
What are Contraindications to SLNB?
pregnancy, multicentric disease, neoadjuvant, clinically positive nodes, prior axillary surgery, inflammatory or locally advanced disease
- Removes all breast tissue including the nipple areolar complex
- Includes axillary node dissection ( Ievel I nodes)
Modified radical mastectomy
Includes MRM and overlying skin, pectoralis major and minor muscles, and Ievel l, II, and Ill lymph nodes; • Rarely performed anymore
Radical mastectomy
Complications of mastectomy
infection, flap necrosis, seromas
Complications of axillary lymph node dissection
Infection, lymphedema, lymphangiosarcoma;
Axillary vein thrombosis;
Lymphatic fibrosis;
Intercostal brachiocutaneous nerve
hyperesthesia of inner arm and lateral chest wall; most commonly injured nerve after mastectomy; no significant sequelae
Intercostal brachiocutaneous nerve
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 )
Who gets Chemotherapy?
•Positive nodes - everyone gets chemo except postmenopausal women with
positive estrogen receptors get tamoxifen
•>1 cm and negative nodes - everyone gets chemo except patients with positive estrogen receptors get tamoxifen
•
List 2 main risks of Tamoxifen
1% risk of blood clots; 0.1 % risk of endometrial CA
Malignant tumors with a benign appearance (smooth, rounded masses)
Malignant tumors with a benign appearance (smooth, rounded masses) mucinous CA,
medullary CA,
cystosarcoma phyllodes
Resembles giant fibroadenoma; has stromal and epithelial elements (mesenchymal tissue);
• Can often be large tumors
• Tx: WLE with negative margins; no ALND
Cystosarcoma phyllodes;
• 10% malignant, based on mitoses per high-power field (> 5-10)
Lymphangiosarcoma from chronic lymphedema following axillary dissection (MRM)
• Patients present with dark purple nodule or lesion on arm 5- 10 years after surgery
Stewart-Treves syndrome
DEF: hypoplasia or complete absence of the breast, costal cartilage and rib defects, hypoplasia of the subcutaneous tissues of the chest wall, and brachysyndactyly
Poland’s syndrome
DEF: ovarian agenesis and dysgenesis
Turner’s syndrome
DEF: displacement of the nipples and bilateral renal hypoplasia) may have polymastia as a component
Fleischer’s syndrome
Fibrous bands of connective tissue travel through the breast insert perpendicularly into the dermis, and provide structural support
Cooper’s suspensory ligaments
The breast receives its principal blood supply from?
(a) perforating branches of the internal mammary artery; (b) lateral branches of the posterior intercostal arteries; (c) branches from the axillary artery ( including the highest thoracic, lateral thoracic, and pectoral branches of the thoracoacromial artery)
May provide a route for breast cancer metastases to the vertebrae, skull, pelvic bones, and central nervous system?
Batson’s vertebral venous plexus, which invests the vertebrae and extends from the base of the skull to the sacrum
Resection of the intercostobrachial nerve causes?
Loss of sensation over the medial aspect of the upper arm
Name the Hormone: primary hormonal stimulus for lactogenesis
Prolactin
Name the Hormone: regulate the release of estrogen and progesterone from the ovaries
luteinizing hormone (LH) and follicle-stimulating hormone (FSH)
Name the Hormone: the release of LH and FSH from the basophilic cells of the anterior pituitary is regulated by the secretion of ?
gonadotropin-releasing hormone (GnRH) from the hypothalamus.
Name the hormone: initiates contraction of the myoepithelial cells, which results in compression of alveoli and expulsion of milk into the lactiferous sinuses
Oxytocin
Describe the GAIL model
relative risk model
- age at menarche
- # of biopsies
- Age at 1st live birth
- # of first degree relatives with BC
