CHAPTER 11
Breast
Test Taking Tips
1. Know the contraindications for breast conservation. This is a commonly missed area. Most people are aware that breast conservation is the preferred treatment, so they tend to pick breast conservation as the answer.
2. Surgical management of breast cancer after neoadjuvant therapy is another frequently missed topic. If the patient doesn’t have contraindications to breast conservation, they may choose either breast conservation or mastectomy. This is based on the residual disease not on the original tumor size.
3. Know the anatomic levels of the axilla. The pectoralis minor muscle divides the axilla into 3 levels.
ANATOMY/PHYSIOLOGY
The embryologic structure from which the breast forms:
Ectodermal thickenings termed mammary ridges or milk lines
Name the function of the following hormones:
Estrogen: branching differentiation and duct development in the breast
Progesterone: lobular development of the breast
Name the muscle the artery supplies:
Lateral thoracic artery
Serratus anterior muscle
Thoracodorsal artery
Latisimus dorsi
Name the nerve that innervates the following muscles:
Serratus anterior muscle
Long thoracic nerve
Latissimus dorsi
Thoracodorsal nerve
Pectoralis minor
Medial pectoral nerve
Pectoralis major
Lateral and medial pectoral nerves
Name the complication if the following nerves were injured:
Long thoracic nerve: Winged scapula
Thoracodorsal nerve: Weak arm adduction/pull-ups
Name the arterial supply to the breast:
Branches derived from the intercostal arteries, internal thoracic artery, lateral thoracic artery, and thoracoacromial artery
The valveless venous plexus responsible for direct hematogenous spread of breast cancer to the spine:
Batson plexus
Suspensory ligaments that divide the breast into segments:
Cooper ligaments
What percentage of lymphatic drainage of the breast is to:
The axillary nodes: 97%
The internal mammary nodes: 1% to 2%
FIGURE 11-1. Axillary lymph node groups. Level I includes lymph nodes located lateral to the pectoralis minor (PM) muscle; level II includes lymph nodes located deep to the PM; and level III includes lymph nodes located medial to the PM. Arrows indicate the direction of lymph flow. The axillary vein with its major tributaries and the supraclavicular lymph node group are also illustrated. (This article was published in Romrell LJ, Bland KI. Anatomy of the breast, axilla, chest wall, and related metastatic sites. In: Bland KI, Copeland EM III, eds. The Breast: Comprehensive Management of Benign and Malignant Diseases. Philadelphia: WB Saunders; 1998:19. Copyright © Elsevier 1998.)
Anatomic description for Levels I, II, and III nodes in the breast?
Level I: Lateral to the pectoralis minor muscle
Level II: Beneath the pectoralis minor muscle
Level III: Medial to the pectoralis minor muscle
What are Rotter nodes?
Nodes between the pectoralis minor and major muscles
What are the boundaries of the axilla?
Superior: Axillary vein
Posterior: Long thoracic nerve
Lateral: Latissimus dorsi muscle
Medial: Pectoralis minor
Nerves to be aware of in an ALND:
Long thoracic nerve
Thoracodorsal nerve
Medial pectoral nerve
Lateral pectoral nerve
Intercostobrachial nerve
Potential complications of ALND:
Axillary vein thrombosis
Infection
Nerve injury
Lymphedema
Lymphatic fibrosis
Lymphangiosarcoma
Most likely cause of sudden, painful, early postop swelling of the ipsilateral arm after an axillary dissection:
Axillary vein thrombosis
Most likely cause of slow, painless, progressive swelling of the ipsilateral arm after an axillary dissection:
Lymphatic fibrosis
Most likely cause of hyperesthesia of the inner upper aspect of the ipsilateral arm after an axillary dissection:
Injury to the second intercostobrachiocutaneous nerve
Incidence of lymphedema after axillary node dissection:
15% to 30%
Incidence of lymphedema after sentinel node biopsy:
2% to 4%
SCREENING/IMAGING
Sensitivity and specificity of mammography:
90% for both
How large must a mass be to be detected on mammography?
5 mm or greater
Best time for a breast self-exam:
1 week after menstrual period
General population screening recommendations for breast cancer:
Initial screening mammogram at age 40 and annual mammograms after age 40
Screening recommendations for a patient at high risk for breast cancer:
Mammogram 10 years before the youngest age of diagnosis of breast cancer in a first-degree relative
What percentage of breast cancers have a negative mammogram and ultrasound?
10%
FIGURE 11-2. Breast cancer. Craniocaudal mammographic view of a palpable mass (arrows). (Reproduced from Brunicardi FC, Andersen DK, Billiar TR, et al. Schwartz’s Principles of Surgery. 9th ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)
Suspicious findings seen on mammography for breast cancer?
Asymmetric density
Distortion of architecture
Ductal asymmetry
Irregular borders
Multiple clusters
Linear, small, thin, and/or branching calcifications
Spiculation
What does BIRADS stand for?
Breast Imaging Reporting and Data System
What is the assessment and recommendation for each BIRADS category?
BIRADS 0: Incomplete; follow-up imaging necessary
BIRADS 1: Negative; routine screening
BIRADS 2: Definite benign finding; routine screening
BIRADS 3: Probably benign; 6-month short-interval follow-up
BIRADS 4: Suspicious abnormality; biopsy should be considered
BIRADS 5: Highly suspicious of malignancy; appropriate action should be taken
BIRADS 6: Known biopsy-proven malignancy; ensure that treatment is completed
FIGURE 11-3. Breast cancer. Ultrasound image demonstrating a solid mass with irregular borders (arrows) consistent with cancer. (Reproduced from Brunicardi FC, Andersen DK, Billiar TR, et al. Schwartz’s Principles of Surgery. 9th ed. http://www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)
BREAST CANCER
Most aggressive subtype of ductal carcinoma in situ (DCIS):
Comedo pattern
Risk of lymph node metastasis with DCIS:
<2%
Surgical treatment for a < 1 cm low-grade DCIS?
Excision with 2- to 3-mm margins ± radiation
Surgical treatment for a >1 cm DCIS?
Lumpectomy and radiation with 2- to 3-mm margins or total mastectomy without axillary dissection
Indications to perform a simple mastectomy for DCIS:
Contraindications to radiation, high grade, and diffuse breast involvement
In which breast does invasive cancer arise in the setting of DCIS?
Usually the ipsilateral breast
What percentage of patients get cancer in the ipsilateral breast with unresected DCIS?
50% to 60%
What percentage of patients get cancer in the contralateral breast with unresected DCIS?
5% to 10%
What percentage of patients develop cancer in either breast with lobular carcinoma in situ (LCIS)?
40%
How much does atypical lobular hyperplasia increase the chance of developing breast cancer?
4-fold
How much does atypical lobular hyperplasia in the setting of a strong family history of breast cancer increase the chance of developing breast cancer?
9-fold
How much does LCIS increase the chance of developing breast cancer?
9-fold
In which breast does invasive cancer arise in the setting of LCIS?
Carcinoma can arise in either breast.
True or False: LCIS is a premalignant lesion:
False; considered a marker for the development of breast cancer but not premalignant
True or False: LCIS needs to be excised to negative margins:
False; negative margins are not required.
What is the most likely type of breast cancer to develop in a patient with LCIS?
Ductal carcinoma (70%)
What is the percentage of finding a synchronous breast cancer at the time of diagnosis of LCIS?
5%
Treatment for LCIS:
Close-interval follow-up, treatment with tamoxifen, or bilateral simple mastectomy
What is the incidence of breast cancer?
1 in 8 women; 12% lifetime risk
What is the breast cancer risk in a patient with no risk factors?
4% to 5%
What percentage of women with breast cancer have no known risk factors?
75%
Name factors that place a patient at greatly increased risk for breast cancer:
2 primary relatives with bilateral or premenopausal breast cancer
BRCA gene in a patient with family history of breast cancer DCIS or LCIS
Fibrocystic disease with atypical hyperplasia
Name factors that place a patient at moderately increased risk for breast cancer:
Early menarche (<12 years)
Late menopause (>55)
Nulliparity (or first birth after age 30)
Environmental risk factor (high-fat diet/obesity)
Family history of breast cancer (excluding BRCA gene)
Two primary relative with bilateral or premenopausal breast cancer
Previous breast cancer
Radiation
What is the median survival for a patient with untreated breast cancer?
2 to 3 years
What is the most common site of breast cancer?
Upper outer quadrant (~50%)
What is the most important prognostic staging factor for breast cancer?
Nodal status
Approximate 5-year survival for a patient with breast cancer with:
0 positive nodes: 75%
1 to 3 positive nodes: 60%
4 to 10 positive nodes: 40%
According to AJCC cancer staging, what is a:
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