Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
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
|