Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + TEST TAKING TIPS Download Section PDF Listen +++ ++ Test Taking Tips 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. 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. Know the anatomic levels of the axilla. The pectoralis minor muscle divides the axilla into 3 levels. + ANATOMY/PHYSIOLOGY Download Section PDF Listen +++ +++ 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.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ 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 Download Section PDF Listen +++ +++ 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.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ 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.) Graphic Jump LocationView Full Size||Download Slide (.ppt) + BREAST CANCER Download Section PDF Listen +++ +++ 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: ++ T1 breast lesion: ≤2 cm T2 breast lesion: 2 to 5 cm T3 breast lesion: >5 cm T4 breast lesion: Skin/chest wall involvement (excluding pectoral muscles) Peau d'orange: Inflammatory breast cancer +++ According to AJCC cancer staging, what are N1, N2, and N3 nodal status in breast cancer? ++ N1- Ipsilateral axillary nodes N2- Fixed ipsilateral axillary nodes N3- Ipsilateral internal mammary nodes +++ According to AJCC cancer staging, what is M1 disease in breast cancer? ++ Distant metastasis including ipsilateral supraclavicular nodes +++ AJCC cancer staging: ++ Stage 0 breast cancer? Tis, N0, M0 Stage I breast cancer? T1, N0, M0 Stage IIa breast cancer? T0-1, N1, M0 or T2, N0, M0 Stage IIb breast cancer? T2, N1, M0 or T3, N0, M0 Stage IIIa breast cancer? T0-3, N2, M0 or T3, N1-2, M0 Stage IIIb breast cancer? Any T4 or N3 tumors Stage IV breast cancer? M1 +++ Most common type of breast cancer: ++ Infiltrating ductal carcinoma +++ Name in dications for breast biopsy: ++ Blood in cyst aspirate, bloody nipple discharge Dermatitis/ulceration of nipple Patient concern of persistent breast abnormality Persistent mass after aspiration Solid mass Suspicious lesion by imaging studies +++ What are central/subareolar tumors at an increased risk for? ++ These tumors are usually multicentric. +++ How long does it take for a single malignant cell to become a 1-cm tumor? ++ 5 to 7 years +++ What are the sites of metastasis for breast cancer? ++ Lymph nodes (most common) Brain Bones Liver Lung/pleura +++ Estrogen receptor (ER)- and progesterone receptor (PR)-positive tumors are associated with? ++ Better overall prognosis and prognosis following surgery Better response to chemotherapy and hormone manipulation More well-differentiated tumor +++ Most common place for distant metastasis for breast cancer: ++ Bone +++ Name malignant tumors with a well-circumscribed, benign appearance: ++ Phyllodes tumor, medullary carcinoma, and adenoid cystic carcinoma +++ What percentage of phyllodes tumors are malignant? ++ 10% +++ What is the treatment of a Pyllodes tumor? ++ Wide local excision with 1-cm margin without axillary dissection +++ Name benign conditions that can mimic breast cancer: ++ Fat necrosis, fibromatosis, granular cell tumor, radial scar +++ Incidence of male breast cancer: ++ <1% of all breast cancer cases +++ Risk factors for male breast cancer: ++ BRCA2 carrier, estrogen therapy, gynecomastia (from increased estrogen), increased estrogen, Klinefelter syndrome (XXY), radiation +++ The type of breast cancer that males develop: ++ Ductal carcinoma +++ True or False: The prognosis for breast cancer is poorer in men than in women, stage for stage? ++ False; prognosis is the same stage for stage (overall prognosis is poorer secondary to men presenting at a later stage). +++ Approximate risk of ovarian cancer with BRCA1 versus BRCA2 mutation: ++ 40% versus 20% +++ Approximate percentage of males with BRCA2 mutations that develop breast cancer: ++ 6% +++ How are BRCA1 and BRCA2 transmitted? ++ Autosomal dominant transmission +++ True or False: The germ-line mutations BRCA1 and BRCA2 are completely penetrant. ++ False; they are incompletely penetrant and some carriers may not develop cancer. +++ Population with the highest incidence of BRCA mutations: ++ Ashkenazi Jews (1%–3%) +++ What kind of protein does the human epidermal growth factor receptor-2 (HER-2) encode for? ++ Transmembrane tyrosine kinase receptor with potent growth-stimulating activity +++ Inherited breast cancer syndrome associated with an increased incidence of adrenocortical cancers, brain tumors, leukemias, soft tissue, and osteosarcomas in the same family: ++ Li-Fraumeni syndrome +++ Treatment for male breast cancer: ++ Modified radical mastectomy +++ Causes of male gynecomastia: ++ Medications (cimetidine, ketoconazole, spironolactone, TCAs), androgen insensitivity, gonadal failure, decreased testosterone, increased estrogen, illicit drugs (marijuana), liver failure +++ Treatment for male gynecomastia: ++ Stop/change medications, correct any hormonal imbalances/underlying cause; if refractory to time and conservative measures, perform a biopsy versus simple mastectomy +++ Define a simple/total mastectomy: ++ Excision of breast and nipple-areolar complex without removal of axillary nodes +++ What is removed with a modified radical mastectomy? ++ Breast, nipple-areolar complex, and axillary nodes (level I, II) +++ Potential complications after modified radical mastectomy: ++ Hematoma/seroma, infection, ipsilateral arm lymphedema, nerve injury, Phantom breast syndrome, skin flap necrosis +++ Considerations for prophylactic mastectomy: ++ Family history and BRCA+ or LCIS with one of the following: High patient anxiety Lesion difficult to follow on exam/mammography Poor access for follow-up Patient preference for mastectomy +++ What are indications for radiation after mastectomy? ++ Tumor >5 cm 4 or more positive lymph nodes Extracapsular nodal invasion Fixed axillary nodes (N2) or internal mammary nodes (N3) Inflammatory cancer Positive margins Skin/chest wall involvement +++ List complications of breast irradiation: ++ Cardiac toxicity, contralateral breast cancer, edema, erythema, pneumonitis, rib fractures, sarcoma, ulceration +++ Absolute contraindications for breast-conserving therapy in invasive carcinoma: ++ An area with a history of prior therapeutic irradiation Diffuse malignant-appearing microcalcifications Persistent positive margins after surgery Pregnancy (except in 3rd trimester, can give radiation after delivery) Two or more primary tumors in separate quadrants of the breast +++ List relative contraindications for breast-conserving therapy in invasive carcinoma: ++ Extensive gross multifocal disease in the same quadrant History of scleroderma or active systemic lupus erythematosus Large tumor in a small breast if it would result in unacceptable cosmesis Genetic predisposition to breast cancer +++ What breast cancers can be treated with lumpectomy and radiation? ++ Tumors <5 cm (stage I and II) +++ Chance of local recurrence after lumpectomy with radiation: ++ 10%, usually within 2 years of the first operation +++ Treatment for local recurrence of breast cancer after lumpectomy, axillary dissection, and radiation: ++ Salvage mastectomy +++ Chance of local recurrence after mastectomy: ++ 5% (4%–8%) +++ What is the false-negative rate for sentinel node biopsy? ++ 4% to 12% +++ What are the usual chemotherapeutic regimens for breast cancer? ++ AC (adriamycin and cyclophosphamide) followed by pacitaxel, TAC (adriamycin, cyclophosphamide, and docetaxel), TC (docetaxel and cyclophosphamide), or CMF (cyclophosphamide, methotrexate, 5-fluorouracil) +++ Standard dosage of tamoxifen in regards to adjuvant treatment for breast cancer: ++ 20 mg daily for 5 years +++ For which patient population is Arimidex/Femara (aromotase inhibitors) useful? ++ Postmenopausal women +++ Name alternative hormonal/chemotherapy options for breast cancer: ++ Aminoglutethimide, anastrozole/letrozole (aromatase inhibitors), androgenic steroid, bilateral oophorectomy, megace +++ Risk of blood clots with the use of tamoxifen: ++ 1% +++ Risk of endometrial cancer with the use of tamoxifen: ++ 0.10% +++ What is the increased relative risk of breast cancer with 5 years of hormone replacement therapy? ++ 1.35 (26% increased risk) +++ Recommendation for adjuvant therapy for: ++ Node negative, low-risk breast cancer? No treatment or endocrine therapy if ER+ Node negative, higher risk ER+ breast cancer? Chemotherapy + endocrine therapy or endocrine therapy Node negative, higher risk ER− breast cancer? Chemotherapy Node positive, ER+ breast cancer in a premenopausal pt.? Chemotherapy + endocrine therapy Node positive, ER+ breast cancer in a postmenopausal pt.? Chemotherapy + endocrine therapy or endocrine therapy alone Node positive, ER− breast cancer? Chemotherapy +++ What is the treatment of HER-2–positive breast cancer? ++ Chemotherapy plus Trastuzumab (Herceptin) +++ Treatment for breast cancer in pregnancy: ++ 1st trimester: modified radical mastectomy 2nd trimester: modified radical mastectomy 3rd trimester: If late, can perform lumpectomy with ALND and postpartum radiation; otherwise modified radical mastectomy +++ Indications for neoadjuvant therapy: ++ Primary tumors >5 cm, fixed or matted axillary nodes, and inflammatory breast carcinoma +++ Contraindications to radiation therapy: ++ Previous radiation therapy to breast or severe collagen vascular disease, pregnancy +++ What is the mechanism of action of tamoxifen versus aromatase inhibitors? ++ Tamoxifen is a selective estrogen receptor (ER) modulator and binds to and inhibits ER signaling in the breast. It produces antiestrogen effects in the breast. In postmenopausal women, the primary source of estrogen is from the conversion of androstenedione to estrone and testosterone to estradiol in peripheral tissues such as breast, skin, and adipose tissue by aromatase. The aromatase inhibitors block this conversion, explaining why they are only effective in postmenopausal women. +++ What are the side effects to aromatase inhibitors? ++ Osteoporosis, joint disorders, hypercholesterolemia +++ What other cancers are associated with BRCA1 and BRCA2 mutations? ++ Prostate cancer is associated with both mutations. BRCA-1: ovarian and endometrial. Consider prophylactic TAH-BSO. BRCA-2: male breast cancer, colon, pancreatic, stomach, gallbladder, melanoma. +++ What type of breast cancer is associated with BRCA1 and BRCA2 mutations? ++ BRCA1: poorly differentiated, receptor-negative BRCA2: well-differentiated, receptor-positive +++ What is Paget disease (of the breast)? ++ Dermatitis/scaling rash of the nipple caused by invasion of the skin by ductal carcinoma cells +++ If Paget disease is confined to the nipple, how can it be treated? ++ Excision with sentinel lymph node (SLN) biopsy and radiation. + MISCELLANEOUS Download Section PDF Listen +++ +++ What is Stewart-Treves syndrome? ++ Lymphangiosarcoma secondary to chronic lymphedema following axillary dissection +++ Term for thrombophlebitis of superficial breast veins: ++ Mondor disease +++ How do you treat Mondor disease? ++ Nonsteroidal anti-inflammatory drugs (NSAIDs) +++ Term for a benign tumor of the breast found with collagen arranged in swirls and consisting of stromal overgrowth: ++ Fibroadenoma +++ Term for a cellulitis/superficial infection of the breast: ++ Mastitis +++ Most common bacteria to cause mastitis: ++ Staphylococcus aureus +++ Treatment for mastitis: ++ Antibiotics, continue breast-feeding, heating packs, utilization of breast pumps +++ Why should a patient with mastitis have close follow-up? ++ To rule out inflammatory breast cancer +++ Most common breast abnormality: ++ Accessory nipple +++ Name of the syndrome associated with absence of the pectoralis muscle, amastia, hypoplasia of the chest wall, and hypoplastic shoulder? ++ Poland syndrome +++ Condition in which the nipple is present, but the breast mound is absent: ++ Amastia ++ FIGURE 11-4. Ductogram. Craniocaudal mammographic view demonstrates a mass (arrow) posterior to the nipple and outlined by contrast, which also fills the proximal ductal structures. (Courtesy of Dr. Barbara G. Steinbach.) Graphic Jump LocationView Full Size||Download Slide (.ppt) +++ Most common cause of bloody discharge from the nipple: ++ Intraductal papilloma +++ Treatment for an intraductal papilloma: ++ Resection (subareolar resection) +++ Most common cause of brown-, green-, or straw-colored nipple discharge: ++ Fibrocystic disease +++ Treatment for mastodynia: ++ Evening primrose oil, danazol, OCP +++ Dose of evening primrose oil to treat mastodynia: ++ 3 to 4 g daily +++ Most common breast lesion in adolescents and young adults: ++ Fibroadenoma + MAKE THE DIAGNOSIS Download Section PDF Listen +++ +++ Biopsy of a breast lesion shows prominent fibrous tissue compressing epithelial elements: ++ Fibroadenoma +++ Biopsy of a breast lesion shows nests of epithelial cells invading stroma in a random fashion with the suggestion of tubule formation: ++ Infiltrating ductal carcinoma +++ Biopsy of a breast lesion shows a uniform population of cells distorting, expanding, and filling the lobules: ++ LCIS +++ Biopsy of a breast lesion shows an ectatic duct with a single- or double-cell layer (epithelial or myoepithelial): ++ Fibrocystic disease +++ Fine-needle aspiration (FNA) of a breast lesion with the histologic appearance of poorly cohesive intact cells with variation in nuclear size with nuclear crowding, prominent nucleoli, clumping of chromatin, and radial dispersion in a highly cellular, monmorphic pattern: ++ Breast carcinoma +++ FNA of a breast lesion with the histologic appearance of broad sheets of cohesive cells with nuclei in uniform size and shape: ++ Fibroadenoma