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Surgery Clerkship - Procedures > Mastectomy > Flashcards

Mastectomy Flashcards

1
Q

What is a (total) simple mastectomy?

A

Removal of breast and nipple without removal of nodes

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2
Q

What is a modified radical mastectomy?

A

Removal of the breast, nipple, and axillary lymph nodes (no muscle removed)

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3
Q

What is a lumpectomy with radiation?

A

Removal of breast mass and axillary lymph nodes; normal surrounding breast tissue is spared. patient then undergoes post-operative radiation treatments

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4
Q

What four nerves must the surgeon be aware of during an axillary dissection?

A
  1. Long thoracic
  2. Thoracodorsal
  3. Medial pectoral
  4. Lateral pectoral
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5
Q

Describe the location of the long thoracic nerve and what muscle it innervates.

A

Courses along the lateral chest wall in the mid-axillary line on the serratus anterior muscle

Innervates serratus anterior

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6
Q

Describe the location of the thoracodorsal nerve and what muscle it innervates.

A

Courses latearl to the long thoracic nerve on the latissimus dorsi muscle

Innervates lattisimus dorsi

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7
Q

Describe the location of the medial pectoral nerve and what muscle it innervates.

A

Runs lateral to or through the pectoral minor muscle, actually lateral to the lateral pectoral nerve

Innervates pectoral minor and major

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8
Q

Describe the location of the lateral pectoral nerve and what muscle it innervates.

A

Runs medial to the medial pectoral nerve (names describe orientation from the brachial plexus)

Innervates pectoral major

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9
Q

What is the name of the deformity if you cut the long thoracic nerve in this area?

A

Winged scapula

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10
Q

What is the name of the cutaneous nerve that crosses the axilla in a transverse fashion (many surgeons try to preserve this nerve)?

A

Intercostobrachial nerve

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11
Q

What is the name of the large vein that marks the upper limit of the axilla?

A

Axillary vein

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12
Q

What is the lymphatic drainage of the breast?

A

Lateral: axillary LNs
Medial: parasternal nodes that run with internal mammary arery

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13
Q

What are the levels of the axillary LNs?

A 
Level I (low): lateral to pectoral minor
Level II (middle): deep to pectoral minor
Level III (high): medial to pectoral minor
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14
Q

In breast cancer, what level of axillary LN has the worst prognosis?

A

Level III (but the level of involvement is less important than the number of positive nodes)

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15
Q

What are Rotter’s nodes?

A

Nodes between the pectoralis major and minor muscles; not usually removed unless they are enlarged or feel suspicious intraoperatively

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16
Q

What are the suspensory breast ligaments called?

A

Cooper’s ligaments

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17
Q

Which hormone is mainly responsible for breast milk production?

A

Prolactin

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18
Q

What is the incidence of breast cancer?

A

12% lifetime risk

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19
Q

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

A

75%

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20
Q

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

A

~2%

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21
Q

What are the major breast cancer susceptibility genes?

A

BRCA1 and BRCA2

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22
Q

What option exists to decrease the risk of breast cancer in women with BRCA?

A

Prophylactic bilateral mastectomy

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23
Q

What is the most common motivation for medicolegal cases involving the breast?

A

Failure to diagnose a breast carcinoma

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24
Q

What is the triad of error for misdiagnosed breast cancer?

A
  1. Age <45 years
  2. Self-diagnosed mass
  3. Negative mammogram

(>75% of cases of misdiagnosed breast cancer have these 3 characteristics)

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25
Q

What are the historical risk factors for breast cancer?

A

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)
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26
Q

What are physical/anatomic risk factors for breast cancer?

A

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)

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27
Q

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

A

No

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28
Q

What are the possible symptoms of breast cancer?

A 
No symptoms
Mass in the breast
Pain (most are painless)
Nipple discharge
Local edema
Nipple retraction
Dimple
Nipple rash
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29
Q

Why does skin retraction occur?

A

Tumor involvement of Cooper’s ligaments and subsequent traction on ligaments pull skin inward

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30
Q

What are the signs of breast cancer?

A 
Mass (1 cm is usually the smallest lesion that can be palpated on exam)
Dimple
Nipple rash
Edema
Axillary/supraclavicular nodes
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31
Q

What is the most common site of breast cancer?

A

~50% develop in the upper outer quadrants

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32
Q

List the different types of invasive breast cancer.

A
  1. Infiltrating ductal carcinoma (~75%)
  2. Medullary carcinoma (~15%)
  3. Infiltrating lobular carcinoma (~5%)
  4. Tubular carcinoma (~2%)
  5. Mucinous carinoma (colloid) (~1%)
  6. Inflammatory breast cancer (~1%)
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33
Q

What is the most common type of breast cancer?

A

Infiltrating ductal carcinoma

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34
Q

DDx - breast cancer?

A 
Fibrocystic disease of the breast
Fibroadenoma
Intraductal papilloma
Duct ectasia
Fat necrosis
Abscess
Radial scar
Simple cyst
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35
Q

Describe the appearance of the edema of the dermis in inflammatory carcinoma of the breast.

A

Peau d’orange (orange peel)

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36
Q

What are the radiographic tests for breast cancer?

A

Mammography and breast U/S, MRI

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37
Q

What is the classic picture of breast cancer on mammogram?

A

Spiculated mass

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38
Q

What is the best initial test to evaluate a breast mass in a woman <30 years?

A

Breast U/S

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39
Q

What are the methods for obtaining tissue for pathologic examination?

A

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)

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40
Q

Indications for biopsy?

A 
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
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41
Q

What is the process of performing a biopsy when a non-palpable mass is seen on mamogram?

A

Sterotactic (mammotome) biopsy or needle localization biopsy

42
Q

What is needle localization biopsy?

A

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

43
Q

What is a mammomtome biopsy?

A

Mammogram-guided computerized steroetactic core biopsies

44
Q

What is done first - mammogram or biopsy?

A

Mammogram; otherwise, tissue extraction may alter the mammogram findings (FNA can be done prior)

45
Q

What would be suspicious mammogram findings?

A

Mass, microcalcifications, stellate/spiculated mass

46
Q

What is a radial scar seen on mammogram?

A

Spiculated mass with central lucency, +/- microcalcifications

47
Q

What tumor is associated with a radial scar?

A

Tubular carcinoma

48
Q

What is the work-up for a breast mass?

A

Clinical breast exam
Mammogram or breast U/S
FNA, core biopsy, or open biopsy

49
Q

How do you proceed if the mass appears to be a cyst?

A

Aspirate with a needle

50
Q

Is the fluid from a breast cyst sent for cytology?

A

Not routinely; blood fluid should be sent

51
Q

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

A

Second cyst recurrence
Bloody fluid in the cyst
Palpable mass after aspiration

52
Q

What is the pre-operative staging work-up in a patient with breast cancer?

A 
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
53
Q

What hormone receptors must be checked for in the biopsy specimen and why?

A

Estrogen and progesterone receptors - key for determining adjuvant treatment

54
Q

What staging system is used for breast cancer?

A

TMN (Tumor/Mets/Nodes)

55
Q

Stage I?

A

Tumor 2 or fewer cm in diameter without mets, no nodes

56
Q

Stage IIA?

A

Tumor 2 or fewer cm in diameter with mobile axillary nodes

OR

Tumor 2-5 cm in diameter, no nodes

57
Q

Stage IIB?

A

Tumor 2-5 cm in diameter with mobile axillary nodes

OR

Tumor >5 cm with no nodes

58
Q

Stage IIIA?

A

Tumor >5 cm with mobile axillary nodes

OR

Any size tumor with fixed axillary nodes, no mets

59
Q

Stage IIIB?

A

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

60
Q

Stage IIIC?

A

Any size tumor, no distant mets

POSITIVE: supraclavicular, infraclavicular, or internal mammary LN

61
Q

Stage IV?

A

Distant mets (including ipsilateral supraclavicular nodes)

62
Q

What are the sites of mets (most common)?

A 
LN (most common)
Lung/pleura
Liver
Bones
Brain
63
Q

What are the major treatments of breast cancer?

A

Modified radical mastectomy
Lumpectomy and radiation + sentinel LN dissection

Both can have +/- postop chemo/tamoxifen

64
Q

Indications for radiation therapy after a modified radical mastectomy?

A 
IIA
IIIB
Pectoral muscle/fascia invasion
Positive internal mammary LN
Positive surgical margins
4+ positive axillary LNs post-menopause
65
Q

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

A

Stage I and II (tumors <5 cm)

66
Q

What approach may allow a patient with stage IIIA cancer to have breast-conserving surgery?

A

NEO-adjuvant chemo (pre-op chemo shrinks the tumor)

67
Q

What is the treatment of inflammatory carcinoma of the breast?

A

Chemo first; then often followed by radiation, mastectomy, or both

68
Q

What is lumpectomy and radiation?

A

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

69
Q

What are other contraindications to lumpectomy and radiation?

A

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)

70
Q

What is a modified radical mastectomy?

A

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

71
Q

Where are the drains placed with an MRM?

A 
Axilla
Chest wall (breast bed)
72
Q

When should the drains be removed?

A

<30 cc/day drainage

73
Q

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

A

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

74
Q

What is a sentinel node biopsy?

A

Instead of removing all the axillary LNs, the primary draining LN is removed

75
Q

How is the sentinal LN found?

A

Inject blue dye and/or technetium-labeled sulfur colloid

76
Q

What follows a positive sentinel node biopsy?

A

Removal of the rest of the axillary LNs

77
Q

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?

A

Sentinel LN dissection

78
Q

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

A

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

79
Q

How does tamoxifen work?

A

Binds estrogen receptors

80
Q

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

A

Salvage mastectomy

81
Q

Can tamoxifen prevent breast cancer?

A

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

82
Q

Common options for breast reconstruction?

A

TRAM (Transverse Rectus Abdominus Myocutaneous) flap, implant, latissimus dorsi flap

83
Q

Side effects of tamoxifen?

A

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

84
Q

What is DCIS?

A

Ductal carcinoma in situ (aka intraductal carcinoma)

Cancer cells in the duct without invasion

85
Q

Mammographic findings of DCIS?

A

Microcalcifications

86
Q

Most aggressive DCIS histologic type?

A

Comedo

87
Q

What is the risk of LN mets with DCIS?

A

<2%

88
Q

What is the major risk with DCIS?

A

Subsequent development of infiltrating ductal carcinoma in the same breast

89
Q

Rx DCIS?

A

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)

90
Q

When must a simple mastectomy be performed for DCIS?

A

Diffuse breast involvement, >1cm, and contraindication to radiation

91
Q

What is the role of axillary node dissection with DCIS?

A

No role in true DCIS; some perform a sentinel LN dissection for high-grade DCIS

92
Q

What is adjuvant Rx for DCIS?

A

Tamoxifen if ER+

Post-lumpectomy XRT

93
Q

What is LCIS?

A

Lobular Carcinoma In Situ (carcinoma cells in the lobules of the breast without invasion)

94
Q

Mammographic findings of LCIS?

A

None

95
Q

What is the major risk of LCIS?

A

Carcinoma of EITHER breast -> equal risk!

96
Q

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

A

~30% in the 20 years after dx of LCIS

97
Q

What type of invasive breast cancer do patients with LCIS develop?

A

Most commonly, infiltrating ductal carcinoma, with equal distribution in both breasts

98
Q

Rx LCIS?

A

Close follow-up or bilateral simple mastectomy in high-risk patients

99
Q

Most common cause of bloody nipple discharge in a young woman?

A

Intraductal papilloma

100
Q

Most common breast tumor in patients <30 years?

A

Fibroadenoma

101
Q

Paget’s disease of the breast?

A

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

Surgery Clerkship - Procedures (17 decks)

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