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ABSITE > Fiser Chapter 24 BREAST > Flashcards

Fiser Chapter 24 BREAST Flashcards

1
Q

Breast develops from what

A

Ectoderm milk streak

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2
Q

Estrogen, progesterone, and prolactin in breast development

A

Estrogen -> duct development (double layer of columnar cells)

Progesterone -> lobular development

Prolactin -> synergizes estrogen and progesterone

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3
Q

Cyclic hormone changes in breast

A

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

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4
Q

Long thoracic nerve

A

Serratus anterior; injury causes winged scapula

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5
Q

Blood and nerve supply to serratus anterior

A

Long thoracic nerve

Lateral thoracic artery

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6
Q

Thoracodorsal nerve

A

Latissimus dorsi; injury causes weak arm pull-ups and adduction

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7
Q

Blood and nerve supply to latissimus dorsi

A

Thoracodorsal nerve

Thoracodorsal artery

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8
Q

Pectoralis muscle nerves

A

Pectoralis major: medial pectoral nerve, lateral pectoral nerve

Pectoralis minor: medial pectoral nerve

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9
Q

Intercostobrachial nerve

A

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

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10
Q

Breast blood supply

A

Branches of internal thoracic artery, intercostal arteries, thoracoacromial artery, and lateral thoracic artery

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11
Q

Batson’s plexus

A

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

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12
Q

Breast lymphatic drainage

A

97% to axillary nodes

2% to internal mammary nodes (any quadrant can drain to internal mammary nodes)

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13
Q

Primary axillary adenopathy

A

1 is lymphoma

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14
Q

Breast cancer with positive supraclavicular nodes

A

N3 disease

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15
Q

Cooper’s ligaments

A

Suspensory ligaments; divide breast into segments

Breast CA involving these strands can dimple the skin

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16
Q

Breast abscess most common bacteria

A

Staph aureus; strep

Usually associated with breastfeeding

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17
Q

Breast abscess tx

A

Perc or I&D; discontinue breast feeding; breast pump, antibiotics

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18
Q

Infectious mastitis most common bacteria

A

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

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19
Q

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

A

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
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20
Q

Lactating woman with breast cyst filled with milk

A

Glactocele

Tx: Aspiration or I&D

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21
Q

Causes of galactorrhea

A
  • Increased prolactin (pituitary prolactinoma)
  • OCPs
  • TCAs
  • Phenothiazines
  • Metoclopramide
  • Alpha-methyl dopa
  • Reserpine

-Often associated with amenorrhea

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22
Q

Gynecomastia causes

A
  • Cimetidine
  • Spironolactone
  • Marijuana
  • Most are idiopathic
  • 2-cm pinch
  • Tx: will likely regress; may need to resect if cosmetically deforming or causing social problems
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23
Q

Neonatal breast enlargement due to what

A

Circulating maternal estrogens; will regress

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24
Q

Accessory breast tissue (most common in axilla)

A

Polythelia

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25
Q

Most common breast anomaly

A

Accessory nipples (can be found from axilla to groin)

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26
Q

Side effect of breast reduction

A

Compromised lactation

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27
Q

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

A

Poland’s syndrome

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28
Q

Mastodynia workup, tx

A

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

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29
Q

Superficial vein thrombophlebitis of breast; feels cordlike; can be painful

A

Mondor’s disease

  • Associated with trauma and strenuous exercise
  • Usually in lower outer quadrant

Tx: NSAIDs

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30
Q

Breast pain, nipple discharge (yellow-to-brown), lumpy breast tissue, varies with hormonal cycle; dx and cancer risk?

A

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
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31
Q

Most common cause of bloody nipple discharge; dx; cancer risk?

A

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

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32
Q

Most common breast lesion in adolescents and young women

A

Fibroadenoma

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33
Q

Young woman with painless, slow growing, well circumscribed, firm, rubbery lesion, changes in size with menstrual cycle

A

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

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34
Q

Nipple discharge

A
  • 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
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35
Q

Green nipple discharge

A

Fibrocystic disease: if cyclical and nonspontaneous, reassure patient.

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36
Q

Bloody nipple discharge

A

Most commonly intraductal papilloma, but occasionally ductal CA: need ductogram and EXCISION of that ductal area

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37
Q

Serous nipple discharge

A

Worrisome for cancer, especially if coming from only 1 duct or spontaneous: EXCISIONAL biopsy of that ductal area

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38
Q

Spontaneous nipple discharge

A

No matter what color or consistency, is worrisome for CA: EXCISIONAL biopsy of duct area causing the discharge

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39
Q

Nonspontaneous nipple discharge (only with pressure, tight garments, exercise, etc)

A

Not as worrisome but may still need excisional biopsy (eg if bloody)

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40
Q

Cluster of calcifications on mammography, pathology shows malignant cells of ductal epithelium without invasion of BM

A

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
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41
Q

DCIS treatment

A

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

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42
Q

LCIS

A

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
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43
Q

Indications for surgical biopsy after core biopsy

A
  • 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)
44
Q

Breast cancer epidemiology

A
  • 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
45
Q

Clinical features of breast CA

A
  • Distortion of normal architecture
  • Skin/nipple distortion or retraction
  • Hard, tethered, indistinct borders
46
Q

Symptomatic breast mass workup

A

<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
47
Q

Difference between CNBx and FNA

A

CNBx gives architecture

FNA gives cytology (just the cells)

48
Q

Mammography sensitivity, specificity, cancer features

A

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

49
Q

BI-RADS classification of mammographic abnormalities

A
  1. Negative -> routine screening
  2. Benign finding -> routine screening
  3. Probably benign finding -> short interval follow-up
  4. Suspicious abnormality (eg indeterminate calcifications or architecture) -> Definite probability of CA; get CNBx
  5. Highly suggestive of CA (suspicious calcifications or architecture) -> High probability of CA; get CNBx
50
Q

CNBx shows non-diagnostic, indeterminate, or benign but non-cordinant with mammogram -> next step?

A

Needle localization excisional biopsy

Benign and concordant with BI-RADS 4 mammo, then 6 month follow-up

51
Q

What’s the point of CNBx in BI-RADS 4 and 5?

A

Allows appropriate staging with SLNBx (mass still present) and one-step surgery (avoids 2 surgeries) for patients diagnosed with breast Ca

52
Q

Breast cancer screening

A

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

53
Q

Node levels

A

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)

54
Q

Most important prognostic staging factor in breast cancer?

A

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

55
Q

Most common site for distant metastasis in breast disease

A

Bone

Other: lung, liver, brain

56
Q

Breast cancer T staging

A

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

57
Q

Breast cancer N staging

A

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

58
Q

Breast cancer M staging

A

M1 distant metastasis = Stage IV

59
Q

Who has greatly increased breast cancer risk (relative risk >4)?

A
  • 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
60
Q

Who has moderately increased breast cancer risk (relative risk 2-4)?

A
  • Prior breast cancer
  • Radiation exposure
  • First-degree relative with breast cancer
  • Age > 35 first birth
61
Q

Who has lower increased breast cancer risk (relative risk <2)?

A
  • Early menarche
  • Late menopausea
  • Nulliparity
  • Proliferative benign disease
  • Obesity
  • Alcohol use
  • Hormone replacement therapy
62
Q

BRCA I and II (+ family history of breast cancer) and lifetime cancer risk

A

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

63
Q

BRCA families with history of breast cancer, what is treatment?

A
  • Consider total abdominal hysterectomy and bilateral salpingooophorectomy
  • Consider prophylactic mastectomy
64
Q

Who should consider prophylactic mastectomy?

A
  • 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
65
Q

Breast cancer receptors

A
  • 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
66
Q

Male breast cancer: what type is it? prognosis? associations? treatment?

A

-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

67
Q

What percentage of breast cancer is ductal versus lobular?

A

85% ductal, 10% lobular

68
Q

Ductal breast cancer subtypes

A
  • Medullary
  • Tubular
  • Mucinous
  • Scirrhotic
69
Q

What kind of breast cancer has smooth borders, increased lymphocytes, bizarre cells

A

-Medullary (ductal cancer)

70
Q

What kind of breast cancer has small tubule formations?

A

-Tubular (ductal)

71
Q

What kind of breast cancer produces an abundance of mucin?

A

-Mucinous/colloid (ductal)

72
Q

What kind of breast cancer has a bad prognosis?

A

Scirrhotic (ductal)

73
Q

Breast cancer tx

A

MRM or BCT with postop XRT

74
Q

What kind of breast cancer does not form calcifications?

A

Lobular breast cancer: no calcs, extensively infiltrative, more often bilateral, multifocal and multicentric

-Signet ring cells confer worse prognosis

75
Q

What kind of breast cancer has dermal lymphatic invasion?

A

Inflammatory breast cancer: considered T4 disease, very aggressive (median survival 36 months)

-Peau d’orange lymphedema appearance on breast; erythematous and warm

76
Q

Tx of inflammatory breast cancer

A

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

77
Q

Surgical options for breast cancer

A
  1. Subcutaneous mastectomy (simple mastectomy): leaves 1-2% of breast tissue, preserves nipple; ONLY FOR DCIS AND LCIS (not breast cancer)
  2. Breast-conserving therapy = lumpectomy, quadrectomy, etc. plus ALND or SLNB; combined with postop XRT; need 1 cm margin (?)
  3. Modified radical mastectomy: removes all breast tissue including nipple areolar complex; includes ALND (level I nodes)
78
Q

Contraindications to BCT in invasive carcinoma

A

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
79
Q

Advantages of SLN over ALND

A
  • Fewer complications

- Usually find 1-3 nodes; 95% of the time, the sentinel node is found

80
Q

SLNB indications

A
  • 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
81
Q

SLNB contraindications

A
  • 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
82
Q

SLNB procedure

A

Lymphazurin blue dye or radiotracer is injected directly into tumor area

-Lumphazurin blue dye has had Type I Hypersensitivity reactions reported

83
Q

ALND procedure (what nodes are taken?)

A

Level I and II nodes

84
Q

Complications of MRM

A

Infection

Flap necrosis

Seromas

85
Q

Complications of ALND

A
  • Infection
  • Lymphedema
  • Lymphangiosarcoma
  • Axillary vein thrombosis
  • Lymphatic fibrosis
  • Intercostal brachiocutaneous nerve injury
86
Q

Sudden, early, postop swelling after ALND

A

Axillary vein thrombosis

87
Q

Slow swelling over 18 months after ALND

A

Lymphatic fibrosis

88
Q

Hyperesthesia of inner arm and lateral chest wall after ALND

A

Intercostal brachiocutaneous nerve injury: most commonly injured nerve after mastectomy; no significant sequelae

89
Q

Breast cancer XRT

A

-5,000 rad for BCT and XRT

90
Q

Complications of XRT

A
  • Edema
  • Erythema
  • Rib fractures
  • Pneumonitis
  • Ulceration
  • Sarcoma
  • Contralateral breast cancer
91
Q

Contraindications to breast cancer XRT

A
  • Scleroderma, SLE, active rheumatoid arthritis

- Previous XRT and would exceed recommended dose

92
Q

Indications for XRT after mastectomy

A

> 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 (?)

93
Q

BCT with XRT methods

A

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

94
Q

Breast cancer recurrence (in same site) after BCT, what is treatment?

A

Salvage MRM (must also re-stage)

95
Q

Breast cancer chemotherapy indications

A

-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

96
Q

Chemotherapy used for breast cancer

A

TAC for 6-12 weeks

  • Taxanes (docetaxel, paclitaxel)
  • Adriamycin
  • Cyclophosphamide
97
Q

Tamoxifen effect on recurrence; side effects

A

Decreases by 50%

Side effects:

  • blood clots (1%)
  • endometrial cancer (0.1%)
98
Q

Who has increased recurrences and metastases?

A
  • Positive nodes
  • Large tumors
  • Negative receptors
  • Unfavorable subtype
99
Q

Woman with history of breast cancer has bone pain, swelling, erythema

A

Metastatic flare: XRT can help, and is good for bone mets

100
Q

Woman presents with breast cancer in axilla but cannot find primary

A

Occult breast cancer

Tx: MRM (70% are found to have breast cancer)

101
Q

Woman with scaly skin lesion on nipple; dx and tx

A

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)

102
Q

Large tumor with stromal and epithelial elements (mesenchymal tissue)

A

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

103
Q

Dark purple nodule or lesion on arm 5-10 years after ALND

A

Stewart-Treves syndrome: Lymphangiosarcoma from chronic lymphedema following axillary dissection

104
Q

Breast mass in pregnancy

A

-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

105
Q

Breast cancer in pregnancy

A
  • 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

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