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170 Cards in this Set

  • Front
  • Back
name the boundaries of the axilla for dissection
superior: axillary vein, posterior: long thoracic nerve, lateral: latissimus dorsi, medial: lateral to/deep to/medial to pectoral minor muscle (depending on # of nodes taken)
what 4 nerves must the surgeon be aware of during an axillary dissection
long thoracic nerve, thoracodorsal nerve, medial pectoral nerve, lateral pectoral nerve
long thoracic nerve: position and function
courses along lateral chest wall in midaxillary line on serratus anterior; innervates serratus anterior
thoracodorsal nerve: position and function
courses lateral to long thoracic nerve on latissimus dorsi; innervates latissimus dorsi
medial pectoral nerve: position and function
runs lateral to or through pectoral minor muscle (is actually LATERAL to the lateral pectoral nerve); innervates the pectoral minor and pectoral major muscles
lateral pectoral nerve
runs medial to the medial pectoral nerve (name describes orientation from the brachial plexus); innervates the pectoral major
what is the name of the deformity if you cut the long thoracic nerve in an axillary dissection?
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 lymph nodes; medial: parasternal nodes that run w/internal mammary artery
what are the levels of axillary lymph nodes?
level I (low): lateral to pectoral minor; level II (middle): deep to pectoral minor; level III (high): medial to pectoral minor. in breast cancer, a higher level of involvement has a worse prognosis, but the level of involvement is less important than the # of + nodes
what are rotter's nodes?
nodes b/w 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
what is the mammary milk line?
the embryological line from shoulder to thigh where supernumerary breast areolar and/or nipples can be found
what is the tail of spence?
the tail of breast tissue that tapers into the axilla
which hormone is mainly responsible for breast milk?
prolactin
what is the incidence of breast cancer?
12% lifetime risk
what percentage of women w/breast cancer have no known risk factor?
75%
what percentage of all breast cancers occur in women younger than 30yo?
~2%
what % of all breast cancers occur in women older than 70yrs?
33%
what are the major breast cancer susceptibility genes?
BRCA1 and BRCA2
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 <45yo, self-diagnosed mass, negative mammogram. >75% of misdiagnosed breast cancer have these 3 characteristics
what are the hx risk factors for breast cancer?
NAACP: nulliparity, age at menarche (<13yo), age at menopause (>55yo), cancer of the breast (self or family), pregnancy w/1st child (>30yo)
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), female (100x male risk), elderly, DCIS, LCIS, inherited genes (BRCAI and II), papilloma (1.5x), sclerosing adenosis (1.5x)
what is the relative risk of hormone replacement tx?
1-1.5x
is run of the mill fibrocystic disease a risk factor for breast cancer?
no
what are the possible sx of breast cancer?
no sx, 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 (1cm usually smallest lesion that can be palpated on exam), dimple, nipple rash, edema, axillary/supraclavicular nodes
what is the most common site of breast cancer?
upper outer quadrant (~1/2 of all breast ca)
what are the major types of invasive carcinoma?
invasive ductal carcinoma (90%), invasive lobular carcinoma (10%), inflammatory carcinoma
what is the most common type of breast cancer?
infiltrating ductal carcinoma
what is the DDx of 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
what are the screening recommendations for breast exams?
self-exam monthly, ages 20-40yo breast exam q2yrs by physician, >40yo annually by physician
screening recommendations for mammograms
controversial, but most experts say: baseline mammogram b/w 35-40yo, mammogram every other yr or every yr 40-50yo, mammogram yearly >50yo
when is the best time for breast self-exams
1 wk post menstrual period
why is mammography a more useful diagnostic tool in older women than in younger women?
breast tissue undergoes fatty replacement w/age, making masses more visible. younger women have more fibrous tissue, making mammograms harder to interpret
what are the best radiographic tests for breast cancer?
mammography and breast ultrasound, MRI
what is the classic picture of breast cancer on mammogram?
spiculated mass
which option is best to evaluate a breast mass in woman younger than 30yo
breast ultrasound
what are the methods for obtaining tissue for pathologic exam?
fine needle aspiration (FNA), core biopsy (larger needle core sample), mammotome stereotactic biopsy, open biopsy. open biopsy can be incisional or excisional.
what are the indications for biopsy?
persistent mass after aspiration, solid mass, blood in cyst aspirate, suspicious lesion my mammography/US/MRI, bloody nipple discharge, ulcer or dermatitis of nipple, patient's concern of persistent breast abnormality
what is the process for performing a biopsy when a nonpalpable mass is seen on mammogram
sterotactic (mammotome) bx or needle localization bx
what is a needle loc biopsy (NLB)?
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 mammotome biopsy?
mammogram-guided computerized sterotatic core biopsies (mammatome)
what is obtained first, the mammogram or the biopsy?
the mammogram is obtained 1st; o/w tissue extraction (core or open) may alter the ammographic findings. (FNA may be done prior to the mammogram b/c the fine needle usually will not affect the mammographic findings)
what would be suspicious mamographic findings?
mass, microcalcifications, stellate/spiculated mass
what is the w/u for a breast mass?
1. clinical breast exam, 2. mammogram or breast ultrasound, 3. fine needle aspiration, core biopsy, or open biopsy
how do you proceed if the mass appears to be a cyst?
aspirate it w/a needle
is the fluid from a breast cyst sent for cytology?
not routinely. bloody fluid should be sent for cytology
when do you proceed to open biopsy for a breast cyst?
1. in the case of a 2nd cyst recurrence. 2. bloody fluid in the cyst. 3. palpable mass after aspiration
what is the preop staging w/u in a patient w/breast cancer?
bilateral mammogram, CXR (check for lung mets), LFTs (check for liver mets), serum calcium level/alk phos (proceed to bone scan if abnormal), other tests depending on signs/sx (e.g., head CT if focal neurological signs present)
what hormone receptors must be checked for in the bx specimen?
estrogen and progesterone receptors --> this is key for determining adjuvant tx (this info must be obtained on all specimens, including fine needle aspirates)
what staging system is used for breast cancer?
TMN (tumor/metastases/nodes)
stage I breast cancer
tumor <= 2 cm in diameter w/o mets, no nodes
stage IIa breast cancer
tumor <= 2 cm in diameter w/mobile axillary nodes or tumor 2-5cm in diameter and no nodes
stage IIb breast cancer
tumor 2-5cm in diameter w/mobile axillary nodes or tumor >5cm w/o nodes
stage IIIa breast cancer
tumor >5 cm w/mobile axillary nodes or any size tumor w/fixed axillary nodes, no mets
stage IIIb breast cancer
peau d'orange (skin edema) or chest wall invasion/fixation or inflammatory cancer or breast skin ulceration or breast skin satellite metastases or any tumor and + ipsilateral internal mammary lymph nodes
stage IIIc breast cancer
any size tumor, no distant mets, POSITIVE: supraclav, infraclav, or internal mammary lymph nodes
stage IV breast cancer
distant metastases (including ipsilateral supraclavicular nodes)
what are the sites of breast cancer mets?
lymph nodes (most common), lung/pleura, liver, bones, brain
what are the major treatments of breast cancer?
modified radical mastectomy, lumpectomy and radiation + sentinel lymph node dissection; both treatments either +/- postop chemotx/tamoxifen
what are the indications for radiation tx after a modified radical mastectomy
stage IIIa breast cancer, stage IIIb breast cancer, pectoral muscle/fascia invasion, positive internal mammary LN, positive surgical margins, >=4 + axillary LNs postmenopausal
what breast carcinomas are candidates for lumpectomy and radiation (breast-conserving tx)?
stage I and stage II tumors (<5cm)
what approach may allow a patient w/stage IIIa cancer to have breast-conserving surgery
neoadjuvant chemotherapy --> if preop chemo shrinks the tumor
what is the treatment of inflammatory carcinoma of the breast?
chemotherapy first! then often followed by radiation, mastectomy, or both
what is a lumpectomy and radiation?
lumpectomy (segmental mastectomy/removal of part of the breast); axillary node dissection; and a course of radiation therapy after operation over a period of several weeks
what is the major absolute contraindication to lumpectomy and radiation?
pregnancy
what are contraindications to lumpectomy and radiation?
pregnancy, previous radiation to the chest, positive margins, collagen vascular disease (e.g., scleroderma), extensive DCIS (often seen as diffuse microcalcification). relative contraindications: lesion that cannot be seen on mammograms (early recurrence will be missed on follow-up mammograms), very small breast (no cosmetic advantage)
what is a modified radical mastectomy?
breast, axillary nodes (level II, I), and nipple-areolar complex are removed, pectoralis major and minor muscles no removed (auchincloss modification), drains are placed to drain lymph fluid
where are the drains placed w/an MRM?
axilla, chest wall (breast bed)
when should drains be removed w/MRM?
<30cc/day drainage
what are the potential complications after a modified radical mastectomy?
ipsilateral arm lymphedema, infection, injury to nerves, skin flap necrosis, hematoma/seroma, phantom breast syndrome
during an axillary dissection, should the patient be paralyzed?
NO, b/c the nerves (long thoracic/thoracodorsal) are stimulated w/resultant muscle contraction to help identify them
how can the long thoracic and thoracodorsal nerves be identified during an axillary dissection?
nerves can be stimulated w/a forceps, which results in contraction of latissimus dorsi (thoracodorsla nerve) or anterior serratus (long thoracic nerve)
when do you remove the drains after an axillary dissection?
when there is <30cc of drainage per day or on POD #14 (whichever comes 1st)
what is a sentinel node biopsy?
instead of removing all axillary lymph nodes, the primary draining (sentinel) lymph node is removed
how is the sentinel lymph node found?
inject blue dye and/or technetium-labeled sulfur colloid (best results w/both)
what follow a positive sentinel node biopsy?
removal of the rest of the axillary lymph nodes
what is considered standard of care for lymph node evaluation in women w/T1 or T2 tumors (stages I and IIa) and clinically negative axillary lymph nodes?
sentinel lymph node dissection
what do you do w/a mammotome biopsy that returns as atypical hyperplasia
open needle loc bx, as many will have DCIS or invasive cancer
how does tamoxifen work?
it 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 breast cancer prevention trial of 13,000 women at increased risk of developing breast cancer, tamoxifen reduced risk by ~50% across all ages)
what are common options for breast reconstruction?
TRAM flap, implant, latissimus dorsi flap
what is a TRAM flap?
transverse rectus abdominus myocutaneous flap
what are side effects of tamoxifen?
endometrial cancer (2.5x relative risk), DVT, pulm embolus, cataracts, hot flashes, mood swings
in high-risk women, is there a way to reduce the risk of developing breast cancer?
yes. tamoxifen for 5 yrs will lower the risk by up to 50% (but w/an increased risk of endometrial cancer and clots, it must be an individual patient determination)
adjuvant therapy for patient w/breast cancer that is premenopausal, node +, ER -
chemotx
adjuvant therapy for patient w/breast cancer that is premenopausal, node +, ER +
chemotx and tamoxifen
adjuvant therapy for patient w/breast cancer that is postmenopausal, node +, ER +.
tamoxifen, +/- chemotherapy
adjuvant therapy for patient w/breast cancer that is postmenopausal, node +, ER -.
chemotherapy +/- tamoxifen
what type of chemotherapy is usually used for breast cancer?
CMF (cyclophosphamide, methotrexate, 5-FU) or CAF (cyclophosphamide, adriamycin, 5-FU)
chemotherapy for high risk tumors w/negative lymph nodes should be considered. what makes a tumor high risk?
>1cm in size, lymphatic/vascular invasion, nuclear grade (high), s phase (high), ER negative, HER-2/neu overexpression
what does DCIS stand for? what is it also known as? describe it.
ductal carcinoma in situ. also called intraductal carcinoma. cancer cells in the duct w/o invasion.
signs/sx of DCIS
usually none, usually nonpalpable
mammographic findings of DCIS
microcalcifications
how is the dx of DCIS made?
core or open biopsy
what is the most aggressive type of DCIS?
comedo
what is the risk of lymph node mets w/DCIS
<2% (usually when microinvasion is seen)
what is the major risk w/DCIS?
subsequent development of infiltrating ductal carcinoma in the same breast
what is the tx for DCIS if tumor <1cm (low grade)?
remove w/1cm margins +/- XRT
what is the tx for DCIS if tumor >1cm?
perform lumpectomy w/1cm margins and radiation or total mastectomy (no axillary dissection)
what is a total (simple) mastectomy?
removal of the breast and nipple w/o removal of the axillary nodes (always remove nodes w/invasive cancer)
what is the role of axillary node dissection w/DCIS?
no role in true DCIS (i.e., w/o microinvasion); some perform a sentinel lymph node dissection for high grade DCIS
when must a simple mastectomy be performed for DCIS
diffuse breast involvement (e.g., diffuse microcalcifications), >1cm and contraindication to radiation
what is adjuvant for DCIS?
tamoxifen, postlumpectomy XRT
what is the role of tamoxifen in DCIS?
tamoxifen for 5 yrs will lower risk up to 50% but w/increased risk of endometrial cancer and clots; must be an individual patient determination
w/DCIS, which breast does the cancer arise?
same breast as dcis (D for directly in same breast)
what is LCIS?
lobular carcinoma in situ (carcinoma cells in the lobules of the breast w/o invasion)
what are the signs/sx of LCIS?
there are none
mammographic findings of LCIS
there are none
how is the dx of LCIS made?
incidentally on biopsy
what is the major risk assoc w/LCIS?
carcinoma of EITHER breast
which breast is most at risk for developing an invasive carcinoma in LCIS?
equal risk in both breasts. (think of LCIS as a risk marker for future devt of cancer)
what % of women w/LCIS develop an invasive breast carcinoma?
~30% in the 20 yrs after dx of LCIS
what type of invasive breast cancer do patients w/LCIS develop?
most commonly, infiltrating ductal carcinoma, w/equal distribution in the contralateral and ipsilateral breasts
what medication may lower the risk of developing cancer in LCIS?
tamoxifen for 5 yrs will lower risk up to 50% but w/increased risk of endometrial cancer and clots; must be an individual patient determination
what is the tx of LCIS?
close follow-up (or b/l simple mastectomy in high risk patients)
what is the major difference in the subsequent devt of invasive breast cancer w/DCIS and LCIS
LCIS cancer develops in either breast; DCIS cancer develops in ipsilateral breast
what is the most common cause of bloody nipple discharge in a young woman?
intraductal papilloma
what is the most common breast tumor in patients younger than 30yo
fibroadenoma
what is paget's disease of the breast?
scaling rash/dermatitis of the nipple caused by invasion of skin by cells from a ductal carcinoma
what are the common options for breast reconstruction after a mastectomy?
saline implant, TRAM flap
what is the incidence of breast cancer in men?
<1% of all breast cancer cases (1/150)
what is the avg age of dx of breast cancer in men?
65yo
what are the risk factors for male breast cancer?
increased estrogen, radiation, gynecomastia from increased estrogen, estrogen therapy, klinefelter's syndrome (XXY), BRCA2 carriers
is benign gynecomastia a risk factor for male breast cancer?
no
what type of breast cancer do men develop?
nearly 100% of cases are ductal carcinoma (men do not usually have breast lobules)
what are the signs/sx of breast cancer in men?
breast mass (most are painless), breast skin changes (ulcers, retraction), and nipple discharge (blood or blood-tinged usually)
what is the most common presentation of male breast cancer?
painless breast mass
how is breast cancer in men diagnosed?
biopsy and mammogram
what is the tx of male breast cancer?
1. mastectomy 2. sentinel LN dissection of clinically negative axilla 3. axillary dissection if clinically + axillary LN
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 w/spontaneous galactorrhea (+/- amenorrhea)
prolactinoma (check pregnancy test and prolactin level)
what is cystosarcoma phyllodes?
mesenchymal tumor arising from breast lobular tissue; most are benign (sarcoma is a misnomer)
what is the usual age of a patient w/cystosarcoma phyllodes?
35-55yo (older than the usual patient w/fibroadenoma)
signs/sx of cystosarcoma phyllodes
mobile, smooth breast mass that resembles a fibroadenoma on exam, mammogram/ultrasound findings
how is cystosarcoma phyllodes diagnosed?
through core biopsy or excision
tx of cystosarcoma phyllodes
if benign, wide local excision; if malignant, simple total mastectomy
what is the role of axillary dissection w/cystosarcoma phyllodes tumor?
only if clinically palpable axillary notes, as malignant form rarely spreads to nodes (most common site of metastasis is the lung)
is there a role for chemotx w/cystosarcoma phyllodes?
consider chemotx if large tumor >5cm and stromal overgrowth
what is a fibroadenoma?
benign tumor of the breast consisting of stromal overgrowth, collagen arranged in swirls
what is the clinical presentation of a fibroadenoma?
solid mobile well-circumscribed round breast mass, usually <40yo
how is fibroadenoma diagnosed?
negative needle aspiration looking for fluid; ultrasound; core bx
what is the tx for fibroadenoma?
surgical resection for large or growing lesions; small fibroadenomas can be observed closely
what is fibrocystic disease?
common benign breast condition consisting of fibrous (rubbery) and cystic changes in the breast
signs/sx of fibrocystic disease
breast pain or tenderness that varies w/the menstrual cycle; cysts; fibrous (nodular) fullness
how is fibrocystic dz diagnosed?
through breast exam, history, and aspirated cysts (usually straw-colored or green fluid)
what is the tx for symptomatic fibrocystic disease?
STOP CAFFEINE. pain meds (NSAIDs); vitamin E, evening primrose oil (danazol and OCP as last resort)
what is done if patient has a breast cyst
needle drainage: if aspirate is bloody or a palpable mass remains after aspiration, an open bx is performed. if aspirate is straw colored or green, the patient is followed closely; then, if there is a recurrence, a 2nd aspiration is performed. re-recurrence usually requires open bx
what is mastitis?
superficial infection of the breast (cellulitis)
in what circumstance does mastitis most often occur?
breast feeding
what bacteria are the most common cause of mastitis
staphylococcus aureus
how is mastitis treated?
stop breast-feeding and use a breast pump instead; apply heat; administer antibx
why must the patient w/mastitis have close follow up?
make sure she does not have an inflammatory breast cancer!
what are the causes of a breast abscess?
mammary duct ectasia (stenosis of breast duct) and mastitis
what is the most common bacteria in breast abscess
nursing: staphylococcus aureus. non-lactating: mixed infection
what is the tx of breast abscess?
antibiotics (e.g., dicloxacillin), needle or open drainage w/cultures taken, resection of involved ducts if recurrent, breast pump if breast feeding
what is lactational mastitis?
infection of the breast during breast-feeding; most commonly caused by s. aureus; treat w/antibiotics and follow for abscess formation
what must be ruled out w/a breast abscess in a nonlactating woman?
breast cancer
what is gynecomastia?
enlargement of the male breast
what are the causes of gynecomastia?
MEDICATIONS, illicit drugs (marijuana), liver failure, increased estrogen, decreased testosterone
what is the major DDx of male gynecomastia in the older patient?
male breast cancer
what is the tx of male gynecomastia?
stop or change medications; correct underlying cause if there is a hormonal imbalance; perform bx of subQ mastectomy (i.e., leave nipple) if refractory to conservative measures and time