Surgery - Breast Flashcards
US for breast best to detect masses of what size?
> 1cm in diameter
Acute mastitis
- causes
- description
- tx
Usually due to S. aureus. It is a cellulitis (vs breast abscess needing drainage)
Need to r/o breast cancer!
Dicloxacillin
Cephalosporins
Cont breast feeding as can dec progression of mastitis to breast abscess
Mammo guidelines
- Should start at age 40
- DO NOT DO before 20 (breast too dense) or lactation (all is milk)
Fibroadenoma
- description
- management
Young women (< 35 yo)
Firm, mobile, rubbery mass
Increase size/tenderness with menstruation
FNA
Sonogram
OPTIONAL removal
Giant juvenile fibroadenomas
- description
- management
Young adults
Rapid growth
YES remove
To avoid deformity and distortion of breast
Cystosarcoma phyllodes
- description
- management
30-50 yo
LARGE bulky mass that is mobile and arises from lobular tissue
Most benign, but can turn malignant
Core or incisional bx
YES remove
Fibrocystic disease
- description
- management
30s-40s Tender + grow w/ menstrual cycle Usually not increase risk of carcionma Diff histo types: - fibrosis - cystic - sclerosing adenosis (microcalcificatiosn on mammo) - epithelial hyperplasia
Mammo if no dominant or persistent mass
If persistent mass –> aspiration (not FNA)
If aspiration doesn’t disappear –> formal bx needed
Intraductal papilloma
- description
- management
Young women
Grows in lactiferous ducts
No increased cancer risk
Bloody nipple discharge
Mammogram to ID other lesions – will not show papilloma b/c too tiny
Galactogram (dx and for surgery resection)
Breast abscess
- description
- management
In lactating women
I & D
Bx of abscess wall
Treatment for breast cancer during pregnancy
No radiation
No chemo in 1st trimester
OK to keep pregnancy
DCIS
- description
- management
Can’t mets
Usually looks like microcalcifications on mammo
comedo has highest malignant potential
Diffuse lesions: Total simple mastectomy + Sentinel node bx
1 lesion: Lumpectomy + radiation
Breast cancer – resectable
- what do you do?
How about if not resectable?
Resectable:
Lumpectomy + axillary sampling + postop rad
Modified radical mastectomy + axillary sampling (sentinel lymph nodes)
Not resectable:
Chemo
Breast Cancer mets
- where does it go?
- dx?
- Tx?
Brain
<3 vertebral pedicles
Tx breast cancer in premenopausal? postmen?
Pre = tamoxifen
Post = anastrozole
Breast Cancer stage I
Tumor ≤ 2cm in diam
(-) mets
(-) nodes
Breast Cancer stage IIA
Tumor ≤ 2cm in diam + mobile axillary nodes
OR
Tumor 2-5 cm in diam, (-) nodes
Breast Cancer stage IIB
Tumor 2-5cm in diam + mobile axillary nodes
OR
Tumor > 5 cm, (-) nodes
Breast Cancer stage IIIA
Tumor > 5cm + mobile axillary nodes
OR
Any size + fixed axillary nodes, (-) mets
Breast Cancer stage IIIB
Peau d’orange OR Chest wall invasion/fixation OR Inflammatory cancer OR Breast skin ulceration OR Breast skin satellite mets OR Any tumor + ipsilateral internal mammary lymph nodes
Breast Cancer stage IIIC
Any size tumor, (-) mets
+ supraclavicular, infraclavicular, or internal mammary lymph nodes
Breast Cancer stage IV
Distant mets (including ipsilateral supraclavicular nodes) - Loves: lymph nodes, lung/pleura, liver, bones, brain
Metastatic breast cancer to bone - test to dx?
MRI
Mammo results w/ strong correlation with breast cancer
(1) breast calcifications that are
(a) smaller than 2 mm,
(b) punctate, microlinear, or branching,
(c) clustered along ducts or concentrated in clusters >5 calcifications per square centimeter;
(2) stellate-shaped lesions;
(3) masses with ill-defined borders or nodular contours;
(4) solitary dominant masses that are significantly larger than any other mass in either breast; and
(5) areas of increased noneffacing tissue density or distorted breast architecture.
What do breast cysts look like on mammo?
How do you confirm the nature of theses cysts?
Round, well-circumscribed densities
Confirm w/ breast US
Breast cyst suspicion - what do you do?
Aspirate and cytologic exam of cyst fluid
If lesions don’t disappear w/ aspiration —> excise
BRCA 1 and 2 - associations
BRCA 1 - breast + ovarian
BRCA 2 - breast
Breast cancer screening for non-high risk pts
Monthly breast self exam @20
Mammo @ 40 q 1-2 yrs until 50
Mammo @ 50 q 1 year
Breast cancer screening for high risk pts
Initial mammo at 30 q 1-2 yrs until 40
Mammo @ 40 q 1 year
Diffuse + multicentric DCIS - tx?
Simple masectomy w/ or w/o reconstruction
Small breast lesion - cancer - tx?
Wide excision
+
Radiotherapy
LCIS - chance to develop into invasive cancer over 20 years?
15-20%
It is incidental finding in histopath
It is a malignant disease marker
Tx LCIS
close observation
Exam + mammo q 6 months for the next several years
What things are essential to est in breast cancer?
Dx
Completely eradicate primary tumor
Determine if lymph node involvement
Determine if mets present
Arterial supply to breast
Venous return
Internal mammary
Lateral thoracic artery
Veins:
- axillary
- internal mammary veins
What is a modified radical mastectomy
Remove
- breast tissue
- skin
- axillary lymph nodes
Spares
- pec major
Simple masectomy
Removes:
- breast tissue
- nipple-areolar complex
- skin
Borders of the breast for masectomy
Superior - clavicle Inferior - inframammary fold Medial - sternum Lateral - latissimus dorsi Posterior - pec major
Borders of axilla
Superior - axillary v
Posterior - Long thoracic N
Lateral - latissius dorsi
Medial - pec minor
Levels of axillary lymph nodes
1 - lateral to pec minor
2 - deep to pec minor
3 - medial to pec minor
higher level of involvement, worse prognosis
How do you evaluate sentinel node?
INject blue vital dye or
Technetium - 99 labeled sulfur colloid
around primary tumor - will go to axillary lymph nodes
Gammaprobe will ID radiotracer
Contraindications to reconstructiton after mastectomies
Primary lesions involving chest wall
Extensive local or regional disease
Stage 3 or 4 cancer
Tx Stage 0, 1 (< 1cm) stage tumors
Lumpectomy
axillary sampling
Radiation
Tx Stage 1 w/ larger tumors (1-2 cm)
Lumpectomy
axillary sampling
post-op radiation
adjuvant therapy (based on ER status and menopause)
Tx Stage 2 cancer
Lumpectomy
axillary sampling
post-op radiation
adjuvant therapy (based on ER status and menopause)
OR
modified radical masectomy
Development of coma in pt w/ hx of breast cancer - what should you be suscpicious abotu?
Hyperacalcemia!!!
Who gets offered chemotherapy?
Stage 2 or greater
they ahve a 33-44% risk of recurrence of disease at 20 years w/ locoregional control only
Usually do”
- 5-FU/doxorubicin/cyclophosphamide
- Taxol
- trastuzumab
How long do you give antiestrogen therapy for pts w/ ER or PR + tumors?
5 years
What are the benefits of neoadjuvant therapy? Does it make a difference?
This is chemo before surgery
Improvements in breast conservation rate + better cosmetic results
NO shown survival difference
Tamoxifen s/e
uterine cancer
DCIS vs invasive ductal - what is difference?
Both from ductal hyperplasia
But DCIS is without basement membrane penetration
Both are more likely to be unilateral breast (vs bilateral in lobular)
Paget’s disease
Eczematous patches on nipple
Usually has undelrying DCIS
Reasons for gynecomastia in men
Hyperestogenism
- cirrhosis
- testicular tumor
- puberty
Kleinfelter’s
Drugs: SDCAK Spironolactome Digitalis Cimetidine Alcohol Ketoconazole
Steroids
Tx inflammatory carcinoma of breast
Chemo first
Then radiation + masectomy
Causes of bloody nipple discharge
Next step
Intraductal papilloma
Ductal ectasia
Carcionma
–> B/l mammo + US
Ddx of nipple discharge (all kinds)
Pregnancy Infections (mastitis/abscess) Pituitary adenoma Meds (metoclopramide, TCAs, OCPs) Hypothyroidism Fibrocystic changes Intraductal papilloma (usually unilateral) Diffuse papillomatosis (serous discharge, increased risk of cancer) Carcionma
Can use ductogram for some to figure out if the etiology is in duct!
How do you tell if there is a bit of blood in a discharge?
Hemoccult test
When can you do a ductogram?
ONLY if they have active discharge
IF abnormal, need surgical bx
If normal, may suggest underlying carcionma
Most common factor increasing risk of breast cancer
having 1 or more 1st degree relatives who have had breast cancer
Atypical ductal hyperplasia
- characteristics
- management
Hyperplasia of ducts of lobules
Looks like DCIS
Assoc cancer risk is 4-5x higher
Management:
- core bx –> shows atypical ductal hyperplasia –> needle loc + excision
