SR 56 - Breast Flashcards
What are the boundaries of the axialla?
Superior - axillary vein
Posterior - Long thoracic nerve
Lateral - Latissimus dorsi muscle
Medial boundary - Pectoral minor muscle (lateral, deep or medial to)
What four nerves are at risk during an axillary dissection?
Long thoracic nerve
Thoracodorsal nerve
Medial pectoral nerve
Lateral pectoral nerve
Location of and muscle innervated?
Long thoracic nerve
Lateral chest wall in midaxillary line on serratus anterior muscle
Innervates serratus anterior muscle
Location of and muscle innervated?
Thoracodorsal nerve
Lateral to long thoracic ner on lattisimus dorsi muscle
Innervates lattisimus dorsi muscle
Location of and muscle innervated?
Medial pectoral nerve
Runs laterl to or through th pectoral minor muscle; latearl to lateral pectoral nerve
Inervates pectoral minor and major
Location of and muscle innervated?
Lateral pectoral nerve
Medial to medial pectoral nerve
Innervates pectoral major
What deformity do you get if you cut the long thoracic nerve?
Winged scapula
Name of the cutaneous nerve the crosses the axilla in a transverse fashion?
Intercostobrachial nerve
What is the large vein that akrs the upper limit of the axilla?
Axillary vein
Lymphatic drainage of the breast?
Lateral - axillary LN
Medial - parasternal LN that run with internal mammary artery
What are the levels of axillary LN?
Level I (low) - lateral to pectoral minor Level II (middle) - deep to pectoral minor Level III (high) - medial to pectoral minor
What are Rotter’s nodes?
Between the pectoralis major and minr muscles
Only removed if tehy are enlarged or feel suspicious intraoperatively
suspensory breast ligaments?
Cooper’s ligaments
What is the tail of Spence?
Breast tissue that tapers into the axilla
Which hornome is mainly responsible for breast milk production?
Prolactin
Triad of error for misdiagnosed breast cancer?
Age
History risk factors for breast cancer?
Nulliparity
Age at menarch 55yo
Cancer of the breast (self or family)
Pregnancy with first child >30yo
NAACP
Physical/anatomic risk factors for breast cancer?
Cancer in the breast Hyperplasia Atypical hyperplasa Female Elderly DCIS
LCIS
Inherited genes
Papilloma
Scloering adenosis
CHAFED LIPS
Possible symtoms of breast cancer?
No symptoms Mass in breast (Pain) Nipple discharge Local edema Nipple retraction Dimple Nipple rash
Why does skin retraction occur in breast cancer?
Tumor involvement of Cooper’s ligaments and subsequent traction on ligaments pull skin inwards
What are the signs of breast cancer?
Mass (1cm is smallest palpable) Dimple Nipple rash Edema Axillary/supraclavicular nodes
Different types of invasive breast cancer?
Infiltrating ductal carcinoma (75%) Medullary carcinoma (15%) Infiltrating lobular carcinoma (5%) Tubular carcinoma (2%) Mucinous carcinoma (cooloid) (1%) Inflammatory breast cancer (1%)
Most common type of invasive breast cacner?
Infiltrating ductal carcinoma
DDx of a breast mass?
Fibrocystic disease of the breast Fibroadenoma Intraductal papilloma Ductal ectasia Fat necrosis Abscess Radial scar Simple cyst
Breast exam recommendations?
Self-exam monthly
20-40yo - physician exam every 2-3 years
>40yo - physician exam yearly
Mammogram recommendations?
Baseline mammogram 35-40yo
Biyearly 40-50yo
Yearly >50yo
What is the classic picture of breast canc on mammogram?
Spiculated mass
Indications for a breast biopsy?
Persistent mass after aspiration
Solid mass
Blood in cyst aspirate
Suspicious lesion by mammography, US, MRI
Bloody nipple discharge
Ulcer or dermatitis of nipple
Patient’s concern of persistent breast abnormality
What is a ‘radial scar’ seen on mammogram?
Spiculated mass with central lucency, +/- microcalcifications
Associated with Tubular carcinoma
When do you proceed to open biopsy for a breast cyst?
- Second cyst recurrence
- Bloody fluid in cyst
- Palpable mass after aspiration
Preop staging workup for patient with breast cancer?
Bilateral mammogram CXR LFTs Serum calcium, alkaline phosphate Other tests based on symptoms
Breast cancer - Stage I
Tumor
Breast cancer - Stage IIA
Tumor
Breast cancer - Stage IIB
Tumor 2-5cm Mobile axillary node OR Tumor >5cm No nodes
Breast cancer - Stage IIIA
Tumor >5cm Mobile axillary node OR Any sized tumor Fixed axillary nodes No metastases
Breast cancer - Stage IIIB
Peau d'orange OR Chest wall invasioin/fixation OR Inflammatory cancer OR Breast skin ulceration OR Breast skin satellite metastases OR Any tumor + ipsilateral internal mammary LN
Breast cancer - Stage IIIC
Any size tumor
NO distant mets
Positive - supraclavicular, infraclavicular, internal mammary LN
Breast cancer - Stage IV
Distant mets
Including ipsilateral supraclavicular nodes
Common sites of metastases in breast cancer?
LN Lung/pleura Liver Bone Brain
Major treatment options for breast cancer?
Modified radical mastectomy
Lumpectomy and radiation + sentinel LN dissection
+/- postop chemotherapy or Tamoxifen
Indications for radiation after a modified radial mastectomy?
Stage IIIA/B Pectoral muscle/fascia invasion Positive internal mammary LN Positive surgical margins >4 positive axillary LN postmenopausal
What carcinomas are candidates for breast-conserving therapy?
Stage I/II
Treatment for inflammatory carcinoma of the breast?
Chemo first
Then radiation and/or mastectomy
What is a modified radical mastectomy?
Breast, axillary nodes (level Ii, I) and nipple-areolar complex are removed
Pectoralis msucles are NOT removed
Drains in axilla and chest wall
When do you remove drains after axillary dissection?
Common options for breast reconstruction?
Transverse Rectus Abdominis Myocutaneous flap (TRAM flap)
Implant
Latissimus dorsi flap
AE of Tamoxifen?
Endometrial cancer DVT, PE Cataracts Hot flashes Mood swings
Chemotherapy for breast cancer?
CMF - Cyclophosphamide, Methotrexate, 5-Flurouracil
CAF - Cyclophosphamide, Adriamycin, 5-Fluorouracil
When do you use Tamoxifen?
ER +
Postmenopausal ER -
What make a high risk tumor?
>1cm in size Lymphatic/vascular invasion High nuclear grade High S phase ER negative HER-2/neu overexpression
Most common cause of bloody nipple discharge in a young woman?
Intraductal papilloma
Most common breast tumor in patients younger than 30yo?
Fibroadenoma
Define paget’s disease of the breast
Scaling rash/dermatitis of the nipple
Due to invasion of skin by cells from a ductal carcinoma
Risk factors for male breast cancer?
>65yo Increased estrogens Radiation Gynecomastia from increased estrogen Estrogen therapy Klinefelter's syndrome (XXY) BRCA2 carrier
What is the most common cause of green, straw-colored or brown nipple discharge?
Fibrocystic disease
What is the most common cause of breast mass after breast trauma?
Fat necrosis
What is Mondor’s disease?
Thrombophlebitis of superficial breast veins
What must be ruled out with sponatneous galactorrhea (+/- amenorrhea)?
Prolactinoma
Pregnancy test and prolactin level
What is cystosarcoma phyllodes
Mesenchymal tumor arising from breast lobar tissue
Most are benign
What is a fibroadenoma?
Benign tumor of breast consisting of stromal overgrowth
Collagen arranged in swirls
Solid, mobile, well-circumscribed round breast mass,
What is fibrocystic disease?
Common benign breast condition consisting of fibrous, rubbery and chystic changes in breast
Varies with menstrual cycle
What is the treatment of fibrocystic disease?
Stop caffiene
Pain meds (NSAIDS)
Vit E, primrose oil
Danzol and OCP
What is mastitis? When does it occur?
Superficial infection of the breast
Associated with breast-feeding
Bacteria associated with mastitis?
Staph aureus
Causes of a breast abscess?
Mammary ductal ectasis (stenosis of duct)
Mastitis
Causes of male gynecomastia?
Medications Illicit drugs (marijuana) Liver failure Increased estrogen Decreased testosterone
