Breast

CHAPTER 11
Breast


Christine Du and Daniel Barnas


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%


Image


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%


Image


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. 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


Image


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. 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:

Aug 13, 2019 | Posted by in ABDOMINAL MEDICINE | Comments Off on Breast
Premium Wordpress Themes by UFO Themes