Mastectomy Flashcards
What is a (total) simple mastectomy?
Removal of breast and nipple without removal of nodes
What is a modified radical mastectomy?
Removal of the breast, nipple, and axillary lymph nodes (no muscle removed)
What is a lumpectomy with radiation?
Removal of breast mass and axillary lymph nodes; normal surrounding breast tissue is spared. patient then undergoes post-operative radiation treatments
What four nerves must the surgeon be aware of during an axillary dissection?
- Long thoracic
- Thoracodorsal
- Medial pectoral
- Lateral pectoral
Describe the location of the long thoracic nerve and what muscle it innervates.
Courses along the lateral chest wall in the mid-axillary line on the serratus anterior muscle
Innervates serratus anterior
Describe the location of the thoracodorsal nerve and what muscle it innervates.
Courses latearl to the long thoracic nerve on the latissimus dorsi muscle
Innervates lattisimus dorsi
Describe the location of the medial pectoral nerve and what muscle it innervates.
Runs lateral to or through the pectoral minor muscle, actually lateral to the lateral pectoral nerve
Innervates pectoral minor and major
Describe the location of the lateral pectoral nerve and what muscle it innervates.
Runs medial to the medial pectoral nerve (names describe orientation from the brachial plexus)
Innervates pectoral major
What is the name of the deformity if you cut the long thoracic nerve in this area?
Winged scapula
What is the name of the cutaneous nerve that crosses the axilla in a transverse fashion (many surgeons try to preserve this nerve)?
Intercostobrachial nerve
What is the name of the large vein that marks the upper limit of the axilla?
Axillary vein
What is the lymphatic drainage of the breast?
Lateral: axillary LNs
Medial: parasternal nodes that run with internal mammary arery
What are the levels of the axillary LNs?
Level I (low): lateral to pectoral minor Level II (middle): deep to pectoral minor Level III (high): medial to pectoral minor
In breast cancer, what level of axillary LN has the worst prognosis?
Level III (but the level of involvement is less important than the number of positive nodes)
What are Rotter’s nodes?
Nodes between the pectoralis major and minor muscles; not usually removed unless they are enlarged or feel suspicious intraoperatively
What are the suspensory breast ligaments called?
Cooper’s ligaments
Which hormone is mainly responsible for breast milk production?
Prolactin
What is the incidence of breast cancer?
12% lifetime risk
What percentage of women with breast cancer have no known risk factors?
75%
What percetnage of all breast cancers occur in women younger than 30 years?
~2%
What are the major breast cancer susceptibility genes?
BRCA1 and BRCA2
What option exists to decrease the risk of breast cancer in women with BRCA?
Prophylactic bilateral mastectomy
What is the most common motivation for medicolegal cases involving the breast?
Failure to diagnose a breast carcinoma
What is the triad of error for misdiagnosed breast cancer?
- Age <45 years
- Self-diagnosed mass
- Negative mammogram
(>75% of cases of misdiagnosed breast cancer have these 3 characteristics)
What are the historical risk factors for breast cancer?
NAACP
Nulliparity Age at menarche (<13 years) Age at menopause (>55 years) Cancer of the breast (in self or family) Pregnancy with first child (>30 years)
What are physical/anatomic risk factors for breast cancer?
CHAFED LIPS
Cancer in the breast (3% synchronous contralateral cancer) Hyperplasia (moderate/florid -> 2x risk) Atypical hyperplasia (4x risk) Female (100x the risk of males) Elderly DCIS
LCIS
Inherited genes
Papilloma (1.5x)
Sclerosing adenosis (1.5x)
Is run of the mill fibrocystic disease a risk factor for breast cancer?
No
What are the possible symptoms of breast cancer?
No symptoms Mass in the breast Pain (most are painless) Nipple discharge Local edema Nipple retraction Dimple Nipple rash
Why does skin retraction occur?
Tumor involvement of Cooper’s ligaments and subsequent traction on ligaments pull skin inward
What are the signs of breast cancer?
Mass (1 cm is usually the smallest lesion that can be palpated on exam) Dimple Nipple rash Edema Axillary/supraclavicular nodes
What is the most common site of breast cancer?
~50% develop in the upper outer quadrants
List the different types of invasive breast cancer.
- Infiltrating ductal carcinoma (~75%)
- Medullary carcinoma (~15%)
- Infiltrating lobular carcinoma (~5%)
- Tubular carcinoma (~2%)
- Mucinous carinoma (colloid) (~1%)
- Inflammatory breast cancer (~1%)
What is the most common type of breast cancer?
Infiltrating ductal carcinoma
DDx - breast cancer?
Fibrocystic disease of the breast Fibroadenoma Intraductal papilloma Duct ectasia Fat necrosis Abscess Radial scar Simple cyst
Describe the appearance of the edema of the dermis in inflammatory carcinoma of the breast.
Peau d’orange (orange peel)
What are the radiographic tests for breast cancer?
Mammography and breast U/S, MRI
What is the classic picture of breast cancer on mammogram?
Spiculated mass
What is the best initial test to evaluate a breast mass in a woman <30 years?
Breast U/S
What are the methods for obtaining tissue for pathologic examination?
FNA, core biopsy (larger needle core sample), mammotome stereotactic biopsy, and open biopsy, which can be incisional (cut a piece of the mass) or excisional (cutting out the entire mass)
Indications for biopsy?
Persistent mass after aspiration Solid mass blood in cyst aspirate Suspicious lesion by mammography/U/S/MRI Bloody nipple discharge Ulcer or dermatitis of nipple Patient's concern of persistent breast abnormality
What is the process of performing a biopsy when a non-palpable mass is seen on mamogram?
Sterotactic (mammotome) biopsy or needle localization biopsy
What is needle localization biopsy?
Needle localization by radiologist, followed by biopsy; removed breast tissue must be checked by mammogram to ensure all of the suspicious lesion has been excised
What is a mammomtome biopsy?
Mammogram-guided computerized steroetactic core biopsies
What is done first - mammogram or biopsy?
Mammogram; otherwise, tissue extraction may alter the mammogram findings (FNA can be done prior)
What would be suspicious mammogram findings?
Mass, microcalcifications, stellate/spiculated mass
What is a radial scar seen on mammogram?
Spiculated mass with central lucency, +/- microcalcifications
What tumor is associated with a radial scar?
Tubular carcinoma
What is the work-up for a breast mass?
Clinical breast exam
Mammogram or breast U/S
FNA, core biopsy, or open biopsy
How do you proceed if the mass appears to be a cyst?
Aspirate with a needle
Is the fluid from a breast cyst sent for cytology?
Not routinely; blood fluid should be sent
When do you proceed to open biopsy for a breast cyst?
Second cyst recurrence
Bloody fluid in the cyst
Palpable mass after aspiration
What is the pre-operative staging work-up in a patient with breast cancer?
Bilateral mammogram CXR (lung mets) LFTs (liver mets) Serum calcium level, alk phos (if these test indicate bone mets or if their is bone pain, proceed to bone scan) Other tests depending on signs/symptoms
What hormone receptors must be checked for in the biopsy specimen and why?
Estrogen and progesterone receptors - key for determining adjuvant treatment
What staging system is used for breast cancer?
TMN (Tumor/Mets/Nodes)
Stage I?
Tumor 2 or fewer cm in diameter without mets, no nodes
Stage IIA?
Tumor 2 or fewer cm in diameter with mobile axillary nodes
OR
Tumor 2-5 cm in diameter, no nodes
Stage IIB?
Tumor 2-5 cm in diameter with mobile axillary nodes
OR
Tumor >5 cm with no nodes
Stage IIIA?
Tumor >5 cm with mobile axillary nodes
OR
Any size tumor with fixed axillary nodes, no mets
Stage IIIB?
Peu d’orange (skin edema)
OR
Chest wall invasion/fixation
OR
Inflammatory cancer
OR
Breast skin ulceration
OR
Breast skin satellite mets
OR
Any tumor and +ipsilateral internal mammary LNs
Stage IIIC?
Any size tumor, no distant mets
POSITIVE: supraclavicular, infraclavicular, or internal mammary LN
Stage IV?
Distant mets (including ipsilateral supraclavicular nodes)
What are the sites of mets (most common)?
LN (most common) Lung/pleura Liver Bones Brain
What are the major treatments of breast cancer?
Modified radical mastectomy
Lumpectomy and radiation + sentinel LN dissection
Both can have +/- postop chemo/tamoxifen
Indications for radiation therapy after a modified radical mastectomy?
IIA IIIB Pectoral muscle/fascia invasion Positive internal mammary LN Positive surgical margins 4+ positive axillary LNs post-menopause
What breast carcinomas are candidates for lumpectomy and radiation (breast-conserving therapy)?
Stage I and II (tumors <5 cm)
What approach may allow a patient with stage IIIA cancer to have breast-conserving surgery?
NEO-adjuvant chemo (pre-op chemo shrinks the tumor)
What is the treatment of inflammatory carcinoma of the breast?
Chemo first; then often followed by radiation, mastectomy, or both
What is lumpectomy and radiation?
Lumpectomy (segmental mastectomy - removal of a part of the breast), axillary node dissection, and a course of radiation AFTER operation over a period of several weeks
What are other contraindications to lumpectomy and radiation?
Previous radiation to the chest
Positive margins
Collagen vascular disease (eg, scleroderma)
Extensive DCIS (often seen as diffuse microcalcification)
Relative contraindications:
-Lesion cannot be seen on mammograms
Very small breast (no cosmetic advantage)
What is a modified radical mastectomy?
Breast, axillary nodes (level II, I), and nipple-areolar complex removed
Pectoralis major and minor muscles NOT removed (Auchincloss modification)
Drains placed to drayn lymph fluid
Where are the drains placed with an MRM?
Axilla Chest wall (breast bed)
When should the drains be removed?
<30 cc/day drainage
How can the long thoracic and thoracoorsal nerves be identified during an axillary dissection?
Nerves can be stimulated with a forceps, which results in contraction of the latissimus dorsi (thoracodorsal) or anteiror serratus (long thoracic)
What is a sentinel node biopsy?
Instead of removing all the axillary LNs, the primary draining LN is removed
How is the sentinal LN found?
Inject blue dye and/or technetium-labeled sulfur colloid
What follows a positive sentinel node biopsy?
Removal of the rest of the axillary LNs
What is now considered the standard of care for LN evaluation in women with T1 or T2 tumors (stages I and IIA) and clinically negative axillary LNs?
Sentinel LN dissection
What do you do with a mammotome biopsy that returns as “atypical hyperplasia”?
Open needle localization biopsy as many will have DCIS or invasive cancer
How does tamoxifen work?
Binds estrogen receptors
What is the treatment for local recurrence in breast after lumpectomy and radiation?
Salvage mastectomy
Can tamoxifen prevent breast cancer?
Yes - in the breast cancer prevention trial of 13,000 women at increased risk of developing breast cancer, tamoxifen reduced risk by ~50% across all ages
Common options for breast reconstruction?
TRAM (Transverse Rectus Abdominus Myocutaneous) flap, implant, latissimus dorsi flap
Side effects of tamoxifen?
Endometrial cancer (2.5x RR), DVT, PE, cataracts, hot flashes, mood swings
What is DCIS?
Ductal carcinoma in situ (aka intraductal carcinoma)
Cancer cells in the duct without invasion
Mammographic findings of DCIS?
Microcalcifications
Most aggressive DCIS histologic type?
Comedo
What is the risk of LN mets with DCIS?
<2%
What is the major risk with DCIS?
Subsequent development of infiltrating ductal carcinoma in the same breast
Rx DCIS?
Tumor <1 cm (low grade) - remove with 1 cm margins and XRT
Tumor >1 cm - lumpectomy with 1 cm margins and radiation OR total mastectomy (no axillary dissection)
When must a simple mastectomy be performed for DCIS?
Diffuse breast involvement, >1cm, and contraindication to radiation
What is the role of axillary node dissection with DCIS?
No role in true DCIS; some perform a sentinel LN dissection for high-grade DCIS
What is adjuvant Rx for DCIS?
Tamoxifen if ER+
Post-lumpectomy XRT
What is LCIS?
Lobular Carcinoma In Situ (carcinoma cells in the lobules of the breast without invasion)
Mammographic findings of LCIS?
None
What is the major risk of LCIS?
Carcinoma of EITHER breast -> equal risk!
What % of women with LCIS develop an invasive breast carcinoma?
~30% in the 20 years after dx of LCIS
What type of invasive breast cancer do patients with LCIS develop?
Most commonly, infiltrating ductal carcinoma, with equal distribution in both breasts
Rx LCIS?
Close follow-up or bilateral simple mastectomy in high-risk patients
Most common cause of bloody nipple discharge in a young woman?
Intraductal papilloma
Most common breast tumor in patients <30 years?
Fibroadenoma
Paget’s disease of the breast?
Scaling rash/dermatitis of the nipple caused by invasion of skin by cells from a ductal carcioma
