Surgery: The Breast – Flashcards
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Name the boundaries of the axilla for dissection. a. superior boundary b. posterior boundary c. lateral boundary d. medial boundary
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a. axillary vein b. long thoracic nerve c. latissiumus dorsi muscle d. lateral to, deep to, or medial to pectoral minor muscle, depending on level of nodes taken
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What 4 nerves must the surgeon be aware of during an axillary dissection?
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long thoracic nerve thoracodorsal nerve medial pectoral nerve lateral pectoral nerve
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What nerve courses along the lateral chest wall in the midaxillary line, on the serratus anterior muscle? What does it innervate?
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long thoracic nerve innervates serratus anterior muscle
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What nerve courses lateral to the long thoracic nerve, on the latissimus dorsi muscle? What does it innervate?
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thoracodorsal nerve innervates latissimus dorsi muscle
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What nerve runs LATERAL to or through the pectoral minor muscle, actually lateral to the lateral pectoral nerve? What does it innervate?
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medial pectoral nerve • innervates the pectoral minor and pectoral major muscles
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What nerve runs MEDIAL to the medial pectoral nerve? What does it innervate?
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lateral pectoral nerve • innervates the pectoral major • names describe orientation from the brachial plexus
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Damage to which nerve causes "winged scapula"?
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long thoracic nerve "winged scapula" is the name of the deformity if you cut the long thoracic nerve in the axillary
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What is the name of the cutaneous nerve that crosses the axilla in a transverse fashion?
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intercostobrachial nerve • Many surgeons try to preserve this nerve.
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What is the name of the large vein that marks the upper limit of the axilla?
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axillary vein
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What is the lymphatic drainage of the breast (2)?
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lateral - axillary lymph nodes medial - parasternal nodes that run with internal mammary artery
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What are the levels of the axillary lymph nodes? a. Level I (low) b. Level II (middle) c. Level III (high)
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a. lateral to pectoral minor b. deep to pectoral minor c. 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 positive nodes
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What nodes are located between the pectoralis major and minor muscles?
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Rotter's nodes • not usually removed unless they are enlarged or feel suspicious intraoperatively
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What are the suspensory breast ligaments called?
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Cooper's ligaments
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What is the mammary "milk line"?
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the embryological line from shoulder to thigh where "supernumerary" breast areolar and/or nipples can be found
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What is the name of the breast tissue that tapers into the axilla?
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"tail of Spence"
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Which hormone is mainly responsible for breast milk production?
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prolactin
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What is the lifetime risk of breast cancer (the incidence)? What percentage of women with breast cancer have no known risk factor?
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12% 75%
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What are the major breast cancer susceptibility genes (2)?
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BRCA 1 BRCA 2
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What is the "triad of error" for misdiagnosed breast cancer?
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more than 75% of cases of misdiagnosed breast cancer have these characteristics: 1. age < 45 years 2. self-diagnosed mass 3. negative mammogram
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What are the history risk factors for breast cancer?
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"NAACP" Nulliparity Age at menarche (younger than 13) Age at menopause (older than 55) Cancer of the breast (in self or family) Pregnancy with first child (older than 30)
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What are the physical/anatomic risk factors for breast cancer?
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"CHAFED LIPS" Cancer in the breast Hyperplasia Atypical hyperplasia Female Elderly DCIS LCIS Inherited genes (BRCA) Papilloma Sclerosing adenosis
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What is the relative risk of developing breast cancer from hormone replacement therapy?
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1-1.5
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Is fibrocystic disease a risk factor for breast CA?
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No
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What are possible Sxs for breast CA?
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No symptoms, or... mass, pain (most are painless), nipple discharge, local edema, nipple retraction, dimple, nipple rash
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Why does skin retraction occur with breast CA?
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tumor involvement of Cooper's ligaments and subsequent traction on ligaments pull skin inward
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What are the signs of breast cancer?
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Mass (1 cm usually the smallest that can be palpated) dimple nipple rash edema axillary/supraclavicular LAD
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What is the MC site of breast cancer?
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upper outer quadrant
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What are the major types of invasive breast carcinoma?
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invasive ductal carcinoma (90%) invasive lobular carcinoma (10%) inflammatory carcinoma
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What is the MC type of breast cancer?
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Infiltrating ductal carcinoma
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What is the DDx of breast cancer / mass?
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fibrocystic dz of breast fibroadenoma intraductal papilloma duct ectasia fat necrosis absccess radial scar simple cyst
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How does the edema of the dermis in inflammatory carconima of the breast appear?
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Peau d'orange (orange peel)
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What are the screening recommendations for breast cancer? a. breast exam recommendations? b. mammograms?
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a. self-exams monthly; exam every 2-3 years for 20-40 yo; exam annually for those over 40 b. baseline betwen 35-40 years; mammogram annually or every other yr for 40-50 yo; annual after 50
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When is best time for SBEs?
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one week after menstrual period
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What is the classic picture of breast CA on mammogram?
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spiculated mass (stellate)
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Which radiographic option is best to evaluate a breast mass in a women under 30?
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breast ultrasound
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What type of biopsy is performed when a nonpalpable breast mass is seen on mammogram?
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sterotactic (mammotome) biopsy or needle localization biopsy
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What is a needle loc biopsy (NLB)? What is a mammotome Bx?
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needle localization by radiologist, followd by Bx. Checked by mammogram to be sure all of lesion has been excised mammogram-guided computerized sterotactic core biopsies
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Workup for breast mass?
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1. clinical breast exam 2. mammogram or breast U/S 3. FNA, core Bx, or open Bx
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What is the preop staging workup in a pt with breast cancer?
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bilateral mammogram CXR (check for lung mets) LFTs (check for liver mets) serum Ca level, alkaline phos (if they indicate bone mets, do bone scan) head CT if pt has focal neurologic deficits for brain mets
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What hormone receptors must be checked for in the biopsy specimen of suspected breast CA?
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estrogen and progesterone receptors -- this is the key for determining adjuvant treatment ***
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What staging system is used for breast CA? What stage is distant metastases? What stages are candidates for lumpectomy + radiation?
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TMN (tumor, metastases, nodes) IV I, II (tumors < 5 cm)
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What are the sites of breast CA metastasis?
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lymph nodes (MC) lung/pleura liver bones brain
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What are the indications for modified radical postmastectomy radiation therapy?
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> 4 lymph nodes, plus chest wall involvement by tumor
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What is the Tx of inflammatory CA of the breast?
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Chemotherapy first! Then often followed by radiation, mastectomy, or both
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What is the major absolute CI to lumpectomy and radiation?
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pregnancy Others: prior radiation to chest, positive margins, collagen vascular dz, extensive DCIS
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After a mastectomy, at what drainage level are drains removed?
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< 30 cc/day drainage or post op day 14 whichever comes first
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Why shouldn't the pt be paralyzed during an axillary dissection?
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Bc the nerves (long thoracic/thoracodorsal) are stimulated with resultant muscle contraction to help ID them They can be stimulated w/ a forceps, which results in contraction of the latissimus dorsi (thoracodorsal nerve) or anterior serratus (long thoracic nerve)
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What do you do with a mammatome biopsy that returns as atypical hyperplasia?
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Open needle loc Bx as many will have DCIS or invasive CA
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How does tamoxifen work?
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It binds estrogen receptors
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What is the Tx for local reccurrence in breast after lumpectomy and radiation?
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"salvage" mastectomy (axillary dissection already completed)
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Can tamoxifen prevent breast cancer? What are the SEs of tamoxifen?
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Yes In high risk women, tamoxifen for 5 yrs will lower risk by up to 50% (but with an increased risk of endometrial cancer and clots) Endometrial cancer**, DVT, pulmonary embolus, cataracts, hot flashes, mood swings
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What are common options for breast reconstruction? (3)
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TRAM flap (transverse rectus abdominis myocutaneous flap) implant latissimus dorsi flap
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What type of chemo is usually used for breast CA?
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CMF (cyclophosphamide, methotrexate, 5-FU) CAF (cyclophosphamide, adriamycin, 5-FU)
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What makes a breast tumor high risk?
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> 2 cm lymphatic / vascular invasion nuclear grade (high) S phase (high) ER negative
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DCIS... a. What does it stand for? b. What is it also known as? c. Describe it. d. SSx? e. Mammographic findings? f. How is diagnosis made? g. What is the most aggressive histiologic type?
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a. ductal carcinoma in situ b. intraductal carcinoma c. cancer cells in the duct w/o invasion (not penetrating basement membrane) d. usually none (usually nonpalpable) e. microcalcifications f. core or open bx g. comedo
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What is the major risk with DCIS?
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subsequent development of infiltrating ductal carcinoma in the same breast
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What is a total (simple) mastectomy?
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removal of breast and nipple without removal of axillary nodes
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What is adjuvant for DCIS?
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Tamoxifen postlumpectomy XRT
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LCIS... a. What is it? b. SSx? c. Mammographic findings? d. How is Dx made?
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a. Lobular Carcinoma In Situ (CA in lobules of breast) b. none c. none d. found incidentally on biopsy
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DCIS cancer occurs in ____ breast. LCIS cancer occurs in ______.
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same either (equal risk in both breasts)
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What type of invasive breast CA do patients with LCIS develop?
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most commonly, infiltrating ductal carcinoma with equal distrbution in the contralateral and ipsilateral breasts
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What is Tx of LCIS?
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close follow up (or bilateral simple mastectomy in hi risk patients)
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What is the MC cause of bloody nipple discharge in a young woman?
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intraductal papilloma
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What is the MC breast tumor in patients younger than 30 years?
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fibroadenoma
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What is Paget's dz of the breast?
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scaling rash / dermatitis of the nipple caused by invasion of skin by cells from a ductal carcinoma
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List the risk factors for male breast cancer?
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increased estrogen radiation gynecomastia from increased estrogen estrogen therapy Klinefelter's syndrome (XXY) BRCA2 carriers
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What type of breast cancer do men develop?
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ductal carcinoma (men don't usually have breast lobules)
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What is the MC cause of green, straw-colored, or brown nipple discharge?
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fibrocystic disease
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What is teh MC cause of breast mass after breast trauma?
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fat necrosis
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What is Mondor's dz?
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thrombophlebitis of superficial breast veins
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What must be ruled out with spontaneous galactorrhea (+/- amenorrhea)?
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prolactinoma (check pregnancy test and prolactin level)
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Fibroadenoma... a. What is it? b. What is clinical presentation? c. How is it diagnosed? d. Tx? e. what is its claim to fame?
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a. benign tumor of breast consisting of stromal overgrowth, collagen arranged in swirls b. solid, mobile, well-circumscribed** round breast mass, usually < 40 years c. negative needle aspiration looking for fluid; u/s; core Bx d. surgical resection for large or growing lesions; small can be observed closely e. MC breast tumor in women <30yrs old
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Fibrocystic dz a. What is it? b. SSx? c. Dx? d. Tx for symptomatic dz?
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a. common benign condition; fibrous (rubbery) and cystic changes in the breast b. breast pain or tenderness that varies w/ menstrual cycle; cysts; fibrous "nodular" fullness c. breast exam, Hx, aspirated cysts (usually straw-colored or green fluid) d. STOP CAFFEINE! Pain meds (NSAIDs), Vit E, evening primrose oil
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Mastitis... a. What is it? b. In what circumstance does it most often occur? c. What bacteria are MC cause? d. Tx? e. Why closely follow up this pt?
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a. superficial infection of breast (cellulitis) b. breastfeeding c. staph aureus d. stop breastfeeding; use breast pump instead; apply heat; Abx e. to be sure she doesn't have inflammatory breast CA
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What are the causes of breast abscess? What is MC bacteria?
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mammary ductal ectasia (stenosis of breast duct) and mastitis nursing = staph aureus nonlactaing = mixed infection
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What is the Tx of a breast abscess?
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Abx (e.g., dicloxacilln) needle or open drainage with cultures taken resection of involved ducts if recurrent breast pump if breastfeeding
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What is lactational mastitis?
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infection of the breast during breastfeeding - MC caused by S. aureus. Tx with Abx and follow for abscess formation
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What must be ruled out with a breast abscess in an nonlactating woman?
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breast cancer!
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What are the 5 causes of male gynecomastia? What is the major differential diagnosis in the older patient? What is the treatment?
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medications ** illicit drugs (marijuana) liver failure increased estrogen decreased testosterone Male breast cancer Stop medications, correct underlying cause, perform biopsy or SQ mastectomy if refractory to conservative treatment
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Why is mammography more useful diagnostic tool in older women than in younger?
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Breast tissue undergoes fatty replacement with age, making masses more visible. Younger women have more fibrous tissue, which makes mammograms harder to interpret.
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What are the radiographic tests for breast cancer?
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Mammography and breast US MRI
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What are the methods for obtaining tissue for pathologic examination?
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FNA Core biopsy (larger needle core sample) mammotome stereotactic biopsy open biopsy - can be incisional (cutting a piece of the mass) or excisional (cutting out the entire mass)
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What are the indications for a biopsy?
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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
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What is obtained first, the mammogram or the biopsy?
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Mammogram Tissue extraction may alter the mammographic findings FNA may be done prior because the fine needle usually will not affect the mammogram findings
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What would be suspicious mammogram findings?
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Mass Microcalcifications Stellate/spiculated mass
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How do you proceed if the mass appears to be a cyst?
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Aspirate it with a needle
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Is the fluid from a breast cyst sent for cytology?
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Not routinely, bloody fluid should be sent for cytology
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When do you proceed to open biopsy for a breast cyst?
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1. in the case of a second cyst recurrence 2. bloody fluid in cyst 3. palpable mass after aspiration
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What stage of breast cancer? Tumor < or equal to 2 cm in diameter without metastases, no nodes
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Stage I
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What stage of breast cancer? Tumor < or equal to 2 cm in diameter with mobile axillary nodes or tumor 2-5 cm in diameter, no nodes
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Stage II A
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What stage of breast cancer? Tumor 2-5 cm in diabeter with mobile axillary nodes or tumor >5 cm with no nodes
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Stage II B
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What stage of breast cancer? Tumor >5 cm with mobile axillary nodes or tumor > 5 cm with fixed axillary nodes, no mets
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Stage III A
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What stage of breast cancer? Peau d'orange or chest wall invasion/fixation or inflammatory CA or breast skin ulceration or breast skin satelite mets or any tumor and + ipsilateral internal mammary lymph nodes
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Stage III B
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What stage of breast cancer? Distant mets including ipsilateral supraclavicular nodes
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Stage IV
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What are the major txs of breast cancer?
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Modified radical mastectomy Lumpectomy and radiation (both treatments either with or without postop chem/tamoxifen)
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What breast carcinomas are candidates for lumpectomy and radiation?
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Stage I and II, tumors <5 cm
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Where are the drains placed with an MRM?
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1. axilla 2. chest wall (breast bed)
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What are the potential complications after a MRM?
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Ipsilateral arm lymphedema, infection, and injury to nerves, skin flap necrosis, hematoma/seroma, phantom breast syndrome
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How can the long thoracic and thoracodorsal nerves be identified during an axillary dissection?
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The nerves can be stimulated with forceps which results in contraction of the latissimus dorsi (thoracodorsal) and anterior serratus (LTN)
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What is a "sentinel" node biopsy?
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Instead of removing all the axillary lymph nodes, the primary draining or sentinel lymph node is removed
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How is the sentinel lymph node found?
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Inject blue dye or techetium labeled sufur colloid
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What follows a positivie sentinel node bx?
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Removal of the rest of the axillary lymph nodes
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What is the tx for DCIS 1 cm?
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Remove with 1 cm margins +/- XRT Perform lumpectomy with 1 cm margins and radiation or total mastectomy (no axillary dissection)
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What is the role of axillary node dissection with DCIS?
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No role in true DCIS (without microscopic invasion), some perform a sentinel node dissection for high-grade DCIS
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What are the common options for breast reconstruction after a mastectomy?
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Saline implant TRAM flap
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a. What is the incidience of BRCA in men? b. What is the average age at diagnosis? c. What are the s/sx? d. Most common presentation? e. How is it diagnosed?
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a. <1% b. 65yrs c. Breast mass (most painless), breast skin changes, nipple discharge d. painless breast mass e. biopsy and mammogram
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What is the treatment of BRCA in men?
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1. mastectomy 2. sentinel LN dissection of clinically negative axilla 3. axillary dissection if clinically positive axillary LN
