Breast

Question 1

Boundaries of axillary dissection

Answer 1

1. Axillary vein (superior)
2. Long thoracic nerve (posterior)
3. Lat dorsi (lateral)
4. Pec minor (medial)

Question 2

4 nerves of concern in axillary dissection

Talk about each

Answer 2

1. Long thoracic nerve (midax line, along serratus anterior, which it innervates)
2. Thoracodorsal nerve (courses lat dorsi, which it innervates)
3. Medial pectoral nerve (lateral of lateral pec, innervates pec minor and major)
4. Lateral pectoral nerve (medial of medial pec, innervates pec major)

Question 3

Injury to long thoracic nerve results in?

Answer 3

Winged scapula (d/t weakness of serratus anterior)

Question 4

Cutaneous nerve that traverses axilla?

Answer 4

Intercostobrachial nerve

Question 5

Lymphatic drainage of the breast?

Answer 5

Lateral: axillary lymph nodes
Medial: parasternal nodes that run with internal mammary artery

Question 6

Levels of axillary lymph nodes?

Answer 6

I: lateral to pec minor
II: deep to pec minor
III: medial to pec minor

Question 7

What are Rotter’s nodes?

Answer 7

Nodes in between pec major and minor

Generally not removed

Question 8

What are suspensory ligaments of the breast called?

Answer 8

Cooper’s ligaments

Question 9

Mammary milk line?

Answer 9

Embryo line from shoulder to breast where extra nipples can be found

Question 10

Tail of Spence?

Answer 10

Tail of breast tissue that extends into axilla

Question 11

Hormone for production vs. expulsion?

Answer 11

Production = prolaction
Letdown = oxytocin

Question 12

Incidence of breast cancer?

Answer 12

12% lifetime risk
(2% occurs in younger than 30)
(33% occurs in older than 70)

Question 13

Triad of error for misdx (false pos)?

Answer 13

Age <45
Self dx’d mass
Negative mammo

Question 14

Biggest risk factors for breast CA?

Answer 14

NAACP
Nulliparidy
Age at menarche (<13)
Age at menopause (>55)
Cancer of the breast (history)
Pregnancy with first child (>30)

Question 15

Mech of skin retraction?

Answer 15

Tumor involvement of Cooper’s

Question 16

Best test for mass in woman <30?

Answer 16

Breast ultrasound

Question 17

Options for bx?

Answer 17

FNA
Core biopsy (bigger needle)
Steriotactic
Open (incisional, excisional)

Question 18

Spiculated mass with central lucency +/- calcifications on mammo?

Answer 18

Radial scar

Associated with tubular carcinoma

Question 19

Staging workup?

Answer 19

Bilateral mammo
CXR (lung)
LFTs (liver)
Calcium, alk phos (bone)
Neuro eval (brain)

Question 20

What is a modified radial mastectomy?

Answer 20

Breast, nipple, and I/II axillary nodes removed
Spares pec major and minor
Drains in axilla and chest wall

Question 21

When do you remove drains?

Answer 21

<30cc per day

Question 22

Potential complications after MRM?

Answer 22

Ips arm lymphedema
Infection, nerve injury
Skin flap necrosis
hematoma/seroma

Question 23

Sentinel biopsy?

Answer 23

Blue dye or tech labeled dye to identify primary draining node

Question 24

Breast reconstruction options?

Answer 24

TRAM flap (transverse rectus abdominus myocutaneous)
Lat dorsi flap
Implant

Question 25

Blood supply to breast parenchyma

Answer 25

``` Internal mammary perforators Thoracoacromial artery Vessels to serratus anterior Lateral thoracic artery 3-8 terminal intercostals ```

Question 26

Lumpectomy

Answer 26

Total removal of mass with wide, clear margins Rel CI: Small breast, large tumor (>5cm), collagen dz Abs CI: multifocal dz, hx of CA, pregnancy

Question 27

DCIS

Answer 27

Cancer cells in duct without invasion through BM

Question 28

Most aggresive subtype?

Answer 28

Comedo

Question 29

Risk of LN met in DCIS?

Answer 29

<2%

Question 30

DCIS <1cm tx?

Answer 30

Remove with 1cm margins | XRT

Question 31

DCIS >1cm tx?

Answer 31

Lumpectomy with 1cm margins with XRT or Total mastectomy, no axillary dissection

Question 32

Diffuse DCIS tx?

Answer 32

Total mastectomy | SN for aggressive cancer