Sabiston Ch 34 Flashcards
What is the name of the fibrous bands in the breast?
Suspensory ligaments of Cooper
Define the axillary lymph nodes by level (anatomically):.
I - Lateral to the lateral border of Pectoralis Minor
II - Posterior to the Pectoralis Minor Muscle
III - Medial to the Pectoralis Minor Muscle, also include subclavicular nodes
What percentage of lymphatic drainage goes to the axilla?
75% (remainder Internal Mammary)
What nerve innervates the serratus anterior?
Long Thoracic
Injury to what nerve causes a winged scapula?
Long Thoracic
What nerve innervates the latissimus dorsi?
Thoracodorsal
What nerve innervates the pectoralis major muscle?
Medial Pectoral
What nerves supply sensation to the undersurface of the upper part of the arm and skin of the chest wall along the posterior margin of the axilla?
Brachial Cutaneous Nerves
What are the 3 principle tissue types of the breast?
1) Glandular epithelium
2) Fibrous stroma and supporting structures
3) Adipose tissue
What layer is maintained in DCIS (to differentiate from invasive breast cancer)?
Basement membrane layer of breast ducts
What are lymph nodes called in the space between the pec major and minor?
Rotter’s nodes (or Interpectoral group)
How does the breast composition change with age?
Pre-Puberty: Dense fibrous stroma
Post-Menopausal: Largely adipose tissue
Name features of nipple discharge concerning for malignancy.
Bloody or serous
Spontaneous
Unilateral (especially if coming from a single duct)
What is the treatment of galactocele?
Needle aspiration
Surgery only if cannot be aspirated or becomes infected
What are hallmarks of inflammatory breast carcinoma?
Peau d’orange (edema of the skin), and tenderness, warmth, and swelling of breast
Describe Paget’s disease.
Changes within dermis of the nipple
Commonly associated with underlying breast cancer
Nipple first, then extends to areola.
Name two scenarios when FNA biopsy is indicated in breast work-up.
1) Evaluating second suspicious lesion in ipsilateral breast in presence of known malignancy (to confirm multifocality)
2) Evaluate suspicious lymph node
What is the method of choice to sample breast lesions?
Core needle biopsy (under Ultrasound, stereotactic, or MRI guidance) with biopsy clip left behind
When ADH is found on breast core biopsy, what percentage of cases will have DCIS or IDC
20%
What is the treatment for cellular fibroadenoma on core needle biopsy?
Excisional biopsy to rule out Phyllodes tumor
What are the USPSTF and ACS recommendations for screening mammography?
USPSTF: Biennial screening mammography for women 50 - 74 years old
ACS: Annual screening mammography for women > 40 years old
ACS Indications for Breast MRI Screening
HIGH LIFETIME RISK of Breast Cancer (MRI screening indicated starting at age 30)
1) Known BRCA1 or BRCA2 gene mutation
2) 1st degree relative w/ BRCA1 or BRCA2
3) Lifetime risk of breast cancer >20-25%
4) Radiation therapy to chest b/w age 10-30
5) Li-Fraumeni or Cowden syndrome (or 1st degree relative with either)
MODERATELY INCREASED LIFETIME RISK of Breast Cancer (MRI screening up for discussion)
1) Lifetime risk of breast cancer 15-20%
2) Personal h/o Breast cancer, DCIS, LCIS, ADH, or atypical lobular hyperplasia
3) Extremely dense or unevenly dense breast tissue on mammograms
Describe BIRADS system
BI-RADS 0 - Incomplete assessment
BI-RADS 1 - Negative (nothing to comment on)
BI-RADS 2 - Benign, rec annual screening
BI-RADS 3 - Probably Benign, short-interval f/u
BI-RADS 4 - Suspicious Abnormality, consider biopsy
BI-RADS 5 - Highly suggestive of Malignancy, take action
BI-RADS 6 - Proven malignancy
Treatment options for LCIS.
1) Close observation
2) Chemoprevention w/ tamoxifen or raloxifene
3) Bilateral Mastectomy
Which BRCA genetic mutation is associated with male breast cancer?
BRCA2
Name typical histopathological features of BRCA-1 associated breast cancers.
High Grade
Hormone receptor negative
Aneuploid
Increased S-phase fraction
Name two selective estrogen receptor modulators (SERM).
Tamoxifen (TMX, Nolvadex, Genox, Tamifen, etc)
Raloxifene (Evista)
Name aromatase inhibitors.
Anastrozole (Arimidex) Letrozole (Femara) Exemestane (Aromasin) Vorozole (Rivizor) Formestane (Lentaron) Fadrozole (Afema)
What is the most common breast tumor in women younger than 30 years old?
Fibroadenoma
What is the most common bacteria causing breast infections?
Staph aureus
Name 2 risk factors for breast infections in non-lactating women.
Smoking and diabetes
What is the initial treatment of a breast abscess?
Needle aspiration and antibiotics (I&D reserved for abscesses that do not resolved with aspiration and antibiotics)
What are the two most common types of breast cancer?
1) Invasive Ductal Carcinoma (50-70%)
2) Invasive Lobular Carcinoma (10%)
then Mixed Ductal/Lobular
Name 2 subtypes of invasive ductal carcinoma. Which one carries a better/worse prognosis?
Mucinous - usually low grade
Medullary - usually high grade, usually triple negative
What is the defining feature of Metaplastic Carcinoma?
Most are node negative, but have a high potential for metastatic spread.
What humanized monoclonal antibody is an effective treatment for Her-2 positive breast cancer?
Trastuzumab (Herceptin)
What is an Oncotype DX assay?
A 21-gene test run on tumor material from breast surgical specimens, which provides a recurrence score for ER+ breast cancer to determine if adjuvant chemotherapy is recommended
What is MammaPrint?
Multigene assay for determining breast cancer prognosis used on ER+ or ER- tumors.
Adjuvant tamoxifen reduces the risk for a second breast cancer in the unaffected breast by what percent?
47% (Early Breast Cancer Trialists’ Collaborative Group EBCTCG)
What is a Phyllodes Tumor?
Breast tumor with biphasic proliferation of stroma and mammary epithelium. Usually benign. Show on mammogram as round density with smooth borders. Differ from fibroadenomas by larger size, faster growth, and occurrence in older patients.
Malignant if –> increasing cellularity, an invasive margin, and sarcomatous appearance.
What margin is desired on a Phyllodes tumor?
1cm to prevent local recurrence
How do malignant Phyllodes tumors spread?
Hematogenously - most often lung, bone, abdominal viscera, and mediastinum
Name a secondary malignancy of the breast. What populations are at risk?
Angiosarcoma
Prior breast irradiation increases risk in breast
Lymphedema increases risk in upper extremity
(can also arise de novo)
Describe the staging for Breast Cancers.
Stage 0 - in situ cancer
Stage I - <2cm AND micromets only in LN
Stage II - more positive LNs allowed if smaller tumor
Stage III - T4 (invasion into chest wall or skin changes)
Stage IV - distant mets
Most common sites of metastasis of breast cancer?
Liver
Lung
Bone
Contraindications to Radiation?
- Pregnancy
- Systemic scleroderma
- Lupus
- Prior radiation
- Severe pulmonary or cardiac disease (if left sided)
- Inability to be positioned for radiation (supine, arm abducted)
- p53 mutation
Requirements for breast conserving therapy.
Can be excised with clear margins and acceptable cosmesis
What is the required margin on for invasive breast carcinoma?
no ink on tumor
Name two indications for more strongly considering oncoplastic reconstruction in lumpectomy?
> 20-30% of total breast volume to be excised AND tumors lying directly under nipple-areolar complex or inferior to NAC
What is the occurrence of lymphedema in SLNB vs ALND?
SLNB - 5%
ALND - 15-20%
What did the Z0011 trial change? What population is it applicable to?
ALND was not justified in all patients with early-stage breast cancer with 1-2 positive sentinel nodes.
- T1 or T2
- clinically node-negative breast cancer
- Lumpectomy + Radiation
- No neoadjuvant
What special subset of patient undergoing lumpectomy do NOT need adjuvant radiation?
- Age > 70 years
- ER-positive
- Stage I
- Undergoing adjuvant hormonal therapy
Name features of breast cancer that make it a suitable candidate for partial breast irradiation (according to American Society for Radiation Oncology).
- ER positive Invasive ductal carcinoma
- Age >60 years
- Tumor < 2cm (T1) with >2mm margins
- Unicentric
- Negative LNs
- No neoadjuvant chemotherapy
What is the principle cause of death from breast cancer?
Metastatic Disease
What breast cancer biomarker statuses are associated with WORSE prognosis?
ER-
PR-
Her2+
What are the main side effects for breast cancer chemotherapy?
Anthracyclines - Cardiomyopathy
Taxanes - Peripheral Neuropathy
What is Trastuzumab?
Brand Name: Herceptin
Humanized monoclonal antibody developed to target the extracellular domain of the Her-2 receptor.
What are common side effects of Tamoxifen?
Hot flashes or vasomotor symptoms
Rare: VTE, uterine cancer
What is the duration of Tamoxifen therapy?
Treat for 5 years. If patient is still pre-menopausal, offer an additional 5 years.
In what patient group are Aromatase Inhibitors contraindicated?
Pre-menopausal or Peri-menopausal women
What is the pathogenesis of Inflammatory Breast Cancer?
Tumor involvement of dermal lympathic channels within the breast and overlying skin causing erythema, edema, and warmth of breast.
What breast cancer population s/p lumpectomy may NOT require radiation?
>70 years old ER+ <2cm Negative LNs Receiving hormonal therapy (CALGB trial, equivalent breast cancer-specific survival)
What is the treatment of Paget disease?
Mastectomy w/ axillary staging
OR
wide local excision of the nipple-areolar complex w/ axillary staging and radiation
How does Paget disease appear clinically?
Scaling skin and erythema of the nipple-areolar complex. Associated with pruritus. May progress to crusting/ulceration.
