Fiser Chapter 24 BREAST Flashcards
Breast develops from what
Ectoderm milk streak
Estrogen, progesterone, and prolactin in breast development
Estrogen -> duct development (double layer of columnar cells)
Progesterone -> lobular development
Prolactin -> synergizes estrogen and progesterone
Cyclic hormone changes in breast
Estrogen -> increases breast swelling and growth of glandular tissue
Progesterone -> increases maturation of glandular tissue, withdrawal causes menses
FSH, LH surge -> ovum release
After menopause, lack of estrogen and progesterone results in atrophy of breast tissue
Long thoracic nerve
Serratus anterior; injury causes winged scapula
Blood and nerve supply to serratus anterior
Long thoracic nerve
Lateral thoracic artery
Thoracodorsal nerve
Latissimus dorsi; injury causes weak arm pull-ups and adduction
Blood and nerve supply to latissimus dorsi
Thoracodorsal nerve
Thoracodorsal artery
Pectoralis muscle nerves
Pectoralis major: medial pectoral nerve, lateral pectoral nerve
Pectoralis minor: medial pectoral nerve
Intercostobrachial nerve
Lateral cutaneous branch of 2nd intercostal nerve
Provides sensation to medial arm and axilla; encountered just below axillary vein when performing ax dissection; can transect without serious consequences
Breast blood supply
Branches of internal thoracic artery, intercostal arteries, thoracoacromial artery, and lateral thoracic artery
Batson’s plexus
Valveless vein plexus that allows direct hematogenous metastasis of breast CA to spine
Breast lymphatic drainage
97% to axillary nodes
2% to internal mammary nodes (any quadrant can drain to internal mammary nodes)
Primary axillary adenopathy
1 is lymphoma
Breast cancer with positive supraclavicular nodes
N3 disease
Cooper’s ligaments
Suspensory ligaments; divide breast into segments
Breast CA involving these strands can dimple the skin
Breast abscess most common bacteria
Staph aureus; strep
Usually associated with breastfeeding
Breast abscess tx
Perc or I&D; discontinue breast feeding; breast pump, antibiotics
Infectious mastitis most common bacteria
S aureus most common in nonlactating women, can be due to chronic inflammatory diseases (actinomyces) or autimmune disease (SLE) -> may need to r/o necrotic cancer (need incision biopsy including skin)
Most commonly associated with breastfeeding though
Smoker with nipple piercing, presents with noncyclical mastodynia, erythema, nipple retraction, creamy discharge from nipple. On biopsy has dilated mammary ducts, inspissated secretions, marked periductal inflammation
Periductal mastitis: mammary duct ectasisa or plasma cell mastitis
-can have sterile or infected subareolar abscess
- Tx: ABX and reassurance, if typical creamy discharge is present that is not bloody and not associated with nipple retraction
- If bloody or nipple retraction or recurs, INCISIONAL BIOPSY WITH SKIN to r/o inflammatory breast CA
Lactating woman with breast cyst filled with milk
Glactocele
Tx: Aspiration or I&D
Causes of galactorrhea
- Increased prolactin (pituitary prolactinoma)
- OCPs
- TCAs
- Phenothiazines
- Metoclopramide
- Alpha-methyl dopa
- Reserpine
-Often associated with amenorrhea
Gynecomastia causes
- Cimetidine
- Spironolactone
- Marijuana
- Most are idiopathic
- 2-cm pinch
- Tx: will likely regress; may need to resect if cosmetically deforming or causing social problems
Neonatal breast enlargement due to what
Circulating maternal estrogens; will regress
Accessory breast tissue (most common in axilla)
Polythelia
Most common breast anomaly
Accessory nipples (can be found from axilla to groin)
Side effect of breast reduction
Compromised lactation
Hypoplasia of chest wall, amastia, hypoplastic shoulder, no pectoralis muscle
Poland’s syndrome
Mastodynia workup, tx
Cyclic mastodynia: pain before menstrual period, most commonly from fibrocystic disease
Continuous mastodynia: most commonly represents acute or subacute infection; continuous mastodynia is more refractory to treatment than cyclic mastodynia
Dx: H&P, bilateral mammogram
Tx: danazol, OCPs, NSAIDs, evening primrose oild, bromocriptine, stop caffeine/nicotine/methylxanthines
Superficial vein thrombophlebitis of breast; feels cordlike; can be painful
Mondor’s disease
- Associated with trauma and strenuous exercise
- Usually in lower outer quadrant
Tx: NSAIDs
Breast pain, nipple discharge (yellow-to-brown), lumpy breast tissue, varies with hormonal cycle; dx and cancer risk?
Fibrocystic disease (many types- papillomatosis, sclerosing adenosis, apocrine metaplasia, duct adenosis, epithelial hyperplasia, ductal hyperplasia, lobular hyperplasia)
- Only cancer risk is in ATYPICAL DUCTAL OR LOBULAR HYPERPLASIA. Resect these lesions
- Do NOT need negative margins with atypical hyperplasia, just remove all suspicious areas (ie calcifications) that appear on mammogram
Most common cause of bloody nipple discharge; dx; cancer risk?
Intraductal papilloma: usually small, nonpalpable, close to nipple
NOT premalignant
-Contrast ductogram to find papilloma then needle localization; tx subareolar resection of involved duct and papilloma
Most common breast lesion in adolescents and young women
Fibroadenoma
Young woman with painless, slow growing, well circumscribed, firm, rubbery lesion, changes in size with menstrual cycle
Fibroadenoma: 10% are multiple
Biopsy: fibrous tissue compressing epithelial cells
Mammo: can have large, course calcifications (popcorn lesions) on mammography from degeneration
<40yo: as long as clinically benign (firm, rubbery, rolls, mobile), US or mammo consistent with fibroadenoma, and RNA or core needle biopsy shows fibroadenoma, CAN OBSERVE; otherwise excisional biopsy (also excise if growing). Avoid resection in teens and children as can affect breast development
> 40yo: excisional biopsy to ensure diagnosis
Nipple discharge
- Get H&P, bilateral mammo
- Usually benign
- Try to find trigger point of mass on exam, if cannot find then may need COMPLETE subareolar resection
Green nipple discharge
Fibrocystic disease: if cyclical and nonspontaneous, reassure patient.
Bloody nipple discharge
Most commonly intraductal papilloma, but occasionally ductal CA: need ductogram and EXCISION of that ductal area
Serous nipple discharge
Worrisome for cancer, especially if coming from only 1 duct or spontaneous: EXCISIONAL biopsy of that ductal area
Spontaneous nipple discharge
No matter what color or consistency, is worrisome for CA: EXCISIONAL biopsy of duct area causing the discharge
Nonspontaneous nipple discharge (only with pressure, tight garments, exercise, etc)
Not as worrisome but may still need excisional biopsy (eg if bloody)
Cluster of calcifications on mammography, pathology shows malignant cells of ductal epithelium without invasion of BM
DCIS:
- Premalignant: 50% get cancer of same breast if not resected; 5% get cancer of other breast
- Can have solid, cribriform, papillary, and comedo patterns.
- COMEDO MOST AGGRESSIVE SUBTYPE: necrotic areas, high risk for multicentricity, microinvasion, recurrence. Tx: Simple mastectomy
- Also higher recurrence if > 2.5 cm
DCIS treatment
Lumpectomy and XRT. Need 1 cm margins (?).
Simple mastectomy if high grade (eg comedo type, multicentric, multifocal), if large tumor not amenable to lumpectomy, or not able to get good margins; then maybe SLNB
NO ALND OR SLNB
Possibly tamoxifen
LCIS
Marker for development of breast ca (not premalignant itself): 40% get cancer (either breast, more likely ductal cancer); 5% risk of having synchronous breast CA at time of diagnosis
- Primarily found in premenopausal women
- NO calcifications, not palpable, usually incidental finding, multifocal disease common
- Tx: nothing, tamoxifen, or bilateral subcutaneous mastectomy (no ALND); do NOT need negative margins
Indications for surgical biopsy after core biopsy
- Atypical ductal hyperplasia
- Atypical lobular hyperplasia
- Radial scar
- LCIS
- Columnar cell hyperplasia with atypia
- Papillary lesions
- Lack of concordance between appearance of mammographic lesion and histologic diagnosis
- Nondiagnostic specimen (including absence of calcifications on specimen radiograph when biopsy performed for calcifications)
Breast cancer epidemiology
- Less in poor areas
- Japan lowest rate
- 1 in 8 women (12%) in US; 5% in women with no risk factors
- Screening decreases mortality by 25%
- Untreated: median survival 2-3 years
- 10% of breast CAs have negative mammogram and US
Clinical features of breast CA
- Distortion of normal architecture
- Skin/nipple distortion or retraction
- Hard, tethered, indistinct borders
Symptomatic breast mass workup
<40yo: US and core needle bx (consider FNA), mammogram if exam or US indeterminate or suspicious for CA otherwise avoid radiation
> 40yo: bilateral mammograms, US, core needle biopsy
- If CNBx or FNA indeterminate, non-diagnostic, or non-concordant with exam findings/imaging -> EXCISIONAL BIOPSY
- Cyst fluid: if bloody or complex, need excisional biopsy; if clear and recurs, need excisional biopsy
Difference between CNBx and FNA
CNBx gives architecture
FNA gives cytology (just the cells)
Mammography sensitivity, specificity, cancer features
90% sensitivity and specificity (sensitivity increases with age as dense parenchymal tissue replaced with fat)
Mass must be at least 5 mm to be detected
Cancer features: irregular borders; speculated; multiple clustered, small, thin, linear, crushed-like and/or branching calcifications; ductal asymmetry, distortion of architecture
BI-RADS classification of mammographic abnormalities
- Negative -> routine screening
- Benign finding -> routine screening
- Probably benign finding -> short interval follow-up
- Suspicious abnormality (eg indeterminate calcifications or architecture) -> Definite probability of CA; get CNBx
- Highly suggestive of CA (suspicious calcifications or architecture) -> High probability of CA; get CNBx
CNBx shows non-diagnostic, indeterminate, or benign but non-cordinant with mammogram -> next step?
Needle localization excisional biopsy
Benign and concordant with BI-RADS 4 mammo, then 6 month follow-up
What’s the point of CNBx in BI-RADS 4 and 5?
Allows appropriate staging with SLNBx (mass still present) and one-step surgery (avoids 2 surgeries) for patients diagnosed with breast Ca
Breast cancer screening
40yo: mammogram every 2-3 years
50yo: mammogram yearly
High-risk: mammogram 10 years before the youngest age of diagnosis of breast CA in first-degree relative
Node levels
I: lateral to pec minor
II: beneath pec minor
III: medial to pec minor
Rotter’s nodes: between pec major and pec minor
ALND: take level I and II (and III only if grossly involved)
Most important prognostic staging factor in breast cancer?
Nodes: survival is directly related to the number of positive nodes
0: 75% 5-year survival
1-3: 60% 5-year survival
4-10: 40% 5-year survival
Other: size, grade, hormone receptor status
Central and subareolar tumors have increase risk of multicentricity
Takes about 5-7 years to go from single malignant cell to 1 cm tumor
Most common site for distant metastasis in breast disease
Bone
Other: lung, liver, brain
Breast cancer T staging
T1: up to 2 cm
T2: 2-5 cm in greatest dimension
T3: > 5 cm
T4: any size, but direct extension to chest wall (not including pec muscle), skin edema, ulceration, satellite skin nodules, or inflammatory carcinoma = stage IIIB
Breast cancer N staging
N0: none
N1: 1-3 axillary nodes or path positive IM nodes
N2: 4-9 axillary nodes or clinically apparent IM nodes
N3: 10 or more axillary nodes, or in infraclavicular nodes, or in axillary and IM nodes, or supraclavicular nodes
Breast cancer M staging
M1 distant metastasis = Stage IV
Who has greatly increased breast cancer risk (relative risk >4)?
- BRCA gene in patient with family history of breast cancer
- At least 2 primary relatives with bilateral or premenopausal breast cancer
- DCIS (ipsilateral breast at risk) or LCIS (both breasts have same high risk)
- Fibrocystic disease with ATYPICAL HYPERPLASIA
Who has moderately increased breast cancer risk (relative risk 2-4)?
- Prior breast cancer
- Radiation exposure
- First-degree relative with breast cancer
- Age > 35 first birth
Who has lower increased breast cancer risk (relative risk <2)?
- Early menarche
- Late menopausea
- Nulliparity
- Proliferative benign disease
- Obesity
- Alcohol use
- Hormone replacement therapy
BRCA I and II (+ family history of breast cancer) and lifetime cancer risk
BRCA I: breast (60%), ovarian ca (40%), and male (1%)
BRCA II: breast (60%), male breast ca (10%), and ovarian (10%)
-Higher breast ca risk if first degree relative with bilateral premenopausal breast cancer
BRCA families with history of breast cancer, what is treatment?
- Consider total abdominal hysterectomy and bilateral salpingooophorectomy
- Consider prophylactic mastectomy
Who should consider prophylactic mastectomy?
- Family history + BRCA
- LCIS
- But also need one of: high anxiety, poor access for follow-up and mammos, difficult lesion to follow on exam or with mammos, or patient preference for mastectomy
Breast cancer receptors
- Positive receptos have better response to hormones, chemotherapy, surgery, and better overall prognosis; receptor-positive tumors are more common in Postmenopausal women
- PR positive tumors have better prognosis than ER positive tumors
- Tumors that are both PR and ER positive have the best prognosis
- 10% of all breast ca is negative for both receptors
Male breast cancer: what type is it? prognosis? associations? treatment?
-Usually ductal
<1% of all breast cancers
- Poorer prognosis d/t late presentation
- Increased pectoral muscle involvement
- Associated with steroid use, previous XRT, family history, Klinefelter’s syndrome
Tx: MRM
What percentage of breast cancer is ductal versus lobular?
85% ductal, 10% lobular
Ductal breast cancer subtypes
- Medullary
- Tubular
- Mucinous
- Scirrhotic
What kind of breast cancer has smooth borders, increased lymphocytes, bizarre cells
-Medullary (ductal cancer)
What kind of breast cancer has small tubule formations?
-Tubular (ductal)
What kind of breast cancer produces an abundance of mucin?
-Mucinous/colloid (ductal)
What kind of breast cancer has a bad prognosis?
Scirrhotic (ductal)
Breast cancer tx
MRM or BCT with postop XRT
What kind of breast cancer does not form calcifications?
Lobular breast cancer: no calcs, extensively infiltrative, more often bilateral, multifocal and multicentric
-Signet ring cells confer worse prognosis
What kind of breast cancer has dermal lymphatic invasion?
Inflammatory breast cancer: considered T4 disease, very aggressive (median survival 36 months)
-Peau d’orange lymphedema appearance on breast; erythematous and warm
Tx of inflammatory breast cancer
Neoadjuvant chemo, then MRM, then adjuvant chemo-XRT (most common method)
Surgical options for breast cancer
- Subcutaneous mastectomy (simple mastectomy): leaves 1-2% of breast tissue, preserves nipple; ONLY FOR DCIS AND LCIS (not breast cancer)
- Breast-conserving therapy = lumpectomy, quadrectomy, etc. plus ALND or SLNB; combined with postop XRT; need 1 cm margin (?)
- Modified radical mastectomy: removes all breast tissue including nipple areolar complex; includes ALND (level I nodes)
Contraindications to BCT in invasive carcinoma
ABSOLUTE:
- two or more primary tumors in separate quadrants
- positive margins after reasonable surgical attempts
- pregnancy (no XRT; but may be ok if in 3rd trimester and can do XRT postpartum)
- History of prior breast XRT that would result in retreatment to an excessively high radiation dose
- Diffuse malignant-appearing calcifications
RELATIVE:
- History of scleroderma or active SLE
- Large tumor in small breast that would have cosmetic result unacceptable to patient
- Very large or pendulous breasts if reproducibility of patient setup and adequate dose homogeneity cannot be ensured
Advantages of SLN over ALND
- Fewer complications
- Usually find 1-3 nodes; 95% of the time, the sentinel node is found
SLNB indications
- Only for malignant tumors > 1cm
- Accuracy best when primary tumor is present (finds right lymphatic channels)
- Well suited for small tumors with low risk of axillary metastases
SLNB contraindications
- Clinically positive nodes -> ALND
- If no radiotracer or dye is found during SLNB -> ALND
- Multicentric disease, neoadjuvent therapy, prior axillary surgery, inflammatory or locally advanced disease, pregnancy
SLNB procedure
Lymphazurin blue dye or radiotracer is injected directly into tumor area
-Lumphazurin blue dye has had Type I Hypersensitivity reactions reported
ALND procedure (what nodes are taken?)
Level I and II nodes
Complications of MRM
Infection
Flap necrosis
Seromas
Complications of ALND
- Infection
- Lymphedema
- Lymphangiosarcoma
- Axillary vein thrombosis
- Lymphatic fibrosis
- Intercostal brachiocutaneous nerve injury
Sudden, early, postop swelling after ALND
Axillary vein thrombosis
Slow swelling over 18 months after ALND
Lymphatic fibrosis
Hyperesthesia of inner arm and lateral chest wall after ALND
Intercostal brachiocutaneous nerve injury: most commonly injured nerve after mastectomy; no significant sequelae
Breast cancer XRT
-5,000 rad for BCT and XRT
Complications of XRT
- Edema
- Erythema
- Rib fractures
- Pneumonitis
- Ulceration
- Sarcoma
- Contralateral breast cancer
Contraindications to breast cancer XRT
- Scleroderma, SLE, active rheumatoid arthritis
- Previous XRT and would exceed recommended dose
Indications for XRT after mastectomy
> 4 nodes
Skin or chest wall involvement
Inflammatory cancer
Positive margins
Tumor > 5 cm (T3)
Fixed axillary nodes (N2) or internal mammary nodes (N3)
Extracapsular nodal invasion (?)
BCT with XRT methods
Need negative margins (1 cm) following BCT before starting XRT
10% chance of local recurrence, usually within 2 years of 1st operation, need to re-stage with recurrence
Need salvage MRM with local recurrence
Breast cancer recurrence (in same site) after BCT, what is treatment?
Salvage MRM (must also re-stage)
Breast cancer chemotherapy indications
-Positive nodes (unless postmenopausal with positive nodes -> then anastrozole)
> 1 cm tumor (unless positive estrogen receptors -> tamoxifen or anastrozole)
After chemo, patients positive for ER should receive appropriate hormonal therapy
Chemotherapy used for breast cancer
TAC for 6-12 weeks
- Taxanes (docetaxel, paclitaxel)
- Adriamycin
- Cyclophosphamide
Tamoxifen effect on recurrence; side effects
Decreases by 50%
Side effects:
- blood clots (1%)
- endometrial cancer (0.1%)
Who has increased recurrences and metastases?
- Positive nodes
- Large tumors
- Negative receptors
- Unfavorable subtype
Woman with history of breast cancer has bone pain, swelling, erythema
Metastatic flare: XRT can help, and is good for bone mets
Woman presents with breast cancer in axilla but cannot find primary
Occult breast cancer
Tx: MRM (70% are found to have breast cancer)
Woman with scaly skin lesion on nipple; dx and tx
Paget’s disease: biopsy shows paget cells
-Patients have DCIS or ductal CA in breast
Tx: MRM if cancer present, otherwise simple mastectomy (must include nipple areolar xomplex with Paget’s)
Large tumor with stromal and epithelial elements (mesenchymal tissue)
Cystosarcoma phylloides
- 10% malignant, based on mitoses per hpf (> 5-10)
- Hematogenous spread rare; NO nodal mets
- Resembles giant fibroadenoma; can be large
Tx: WLE with negative margins; NO ALND
Dark purple nodule or lesion on arm 5-10 years after ALND
Stewart-Treves syndrome: Lymphangiosarcoma from chronic lymphedema following axillary dissection
Breast mass in pregnancy
-US (although both mammogram and US do not work as well during pregnancy)
- If cyst -> drain, send FNA for cytology
- If solid -> core needle biopsy or FNA
-Equivocal biopsy -> excisional biopsy
Breast cancer in pregnancy
- Tends to present late -> worse prognosis
- No XRT while pregnant; no breastfeeding after delivery
1st trimester: MRM
2nd trimester: MRM
3rd trimester: MRM or if late can perform lumpectomy with ALND and postpartum XRT
