Breast

High Yield Anatomy

• What are the surgical boundaries of the axillary lymph nodes?
• Level I - Lateral to pec minor
• Level II - Posterior to pec minor
• Level III - Medial to pec minor Figure 1. Surgical Levels of The Axillary Lymph Nodes
• Name the nerve that can be injured during an axillary dissection based on the clinical sequela
• Results in winged scapula:
• Long thoracic innervating the serratus anterior
• Results in weakness in pullups and arm adduction:

• Thoracodorsal nerve innervating the latissimus dorsi

• This nerve results in sensory deficits to the medial arm:
• Intercostobrachial
• What nerve innervates both pec major and pec minor:
• Medial pectoral nerve

• Lateral pectoral nerve only innervates pec major Lateral pectoral nerve only innervates pec major

• What is the blood supply to the breast?
• Internal thoracic (aka mammary)
• Intercostals
• Lateral thoracic
• Thoracoacromial arteries
• What is Batson’s plexus?
• Valveless venous plexus that allows direct hematogenous spread to the spine Benign Breast Disease
• Breast Pain
• Common, self-limited in most cases
• Most frequent during the late luteal phase of the menstrual cycle
• Treatment
• Reassurance
• For severe pain, the following have been studied with variable results:
• danazol, bromocriptine, tamoxifen, primrose oil, vitamin E
• What is Mondor’s disease and what is the treatment?

• Superficial thrombophlebitis of the lateral thoracic vein or a tributary

• MC secondary to recent surgery, trauma, or other inflammatory process
• Rarely associated with carcinoma
• Presentation: tender, palpable subcutaneous cord
• Treatment: NSAIDs
• Fibrocystic disease
• Most common in perimenopausal women
• Symptoms: breast pain, nipple discharge, lumps that vary throughout menstrual cycle
• Treatment:
• Simple cysts → observe
• Symptomatic → aspirate
• If aspirate is bloody or recurrent → cytology
• Bloody aspirate → surgical excision
• Unresolved after aspiration → surgical excision
• Recurrence → surgical excision
• Is there a risk of cancer?
• If cytology demonstrates atypical ductal or lobular hyperplasia
• Fibroadenoma and Phyllodes tumors
• Presentation: dominant mass
• Dx:
• Imaging
• If <35 yo → ultrasound (density of breast tissue)
• If >35 yo → mammography
• If findings are consistent with a benign fibroadenoma AND no risk factors → bi-annual ultrasound
• If any uncertainty → core needle biopsy (CNB)
• What if the mass continues to enlarge?
• Need excisional biopsy

• Fibroadenoma variants

• Giant fibroadenoma

• 6 cm, can be difficult to distinguish from phyllodes tumor

• Complex fibroadenoma = risk for developing carcinoma
• Fibroadenoma with sclerosing adenosis, papillary apocrine hyperplasia, cysts, or epithelial calcifications
• Tubular adenoma = benign
• Variant of peri canalicular fibroadenoma with adenosis- like epithelial proliferation
• Phyllodes tumor
• Subclassifications: benign, borderline, malignant
• 10% become malignant (greater potential if >5 mitoses per high power field)
• Rare hematogenous metastasis (does not go to nodes, so no sentinel lymph node biopsy (SLN) or Axillary dissection)
• Treatment: Wide local excision (1 cm margins)
• Do you need to perform SLN or axillary dissection?
• No . Hematogenous metastasis (rare)
• Nipple discharge
• What is the MC cause of bloody nipple discharge?
• Intraductal papilloma (not premalignant)
• What findings are more concerning for malignancy?
• Bloody, spontaneous, persistent, unilateral
• <40 yo → 3% associated with cancer

• 60 yo → 32% associated with malignancy

• Diagnosis:
• Ductal fluid cytology, contrast ductogram, ductoscopy - minimally helpful
• Best diagnostic test = Duct excision

• Treatment: subareolar resection of involved duct and papilloma

• Duct Ectasia
• Dilation of the subareolar duct in peri- and post- menopausal women
• Symptoms: cheesy, viscous nipple discharge
• Treatment:
• Asymptomatic → observe
• Symptomatic → duct excision
• Breast Infections
• What are the most common bacteria to cause both breast abscesses and mastitis?
• Staphylococcus aureus
• 2 groups:
• Lactational - Most likely from blockage of the lactiferous ducts
• If no abscess → antibiotics alone, continue breastfeeding
• If abscess → aspiration and antibiotics, continue breastfeeding
• I&D if does not resolve promptly
• AE = concern for development of milk fistula
• Nonlactational - Periductal infections associated with smoking and ductal ectasia
• Tx: antibiotics, I&D if abscess present
• Patient presents with recurrent, unresolving mastitis . What else do you need to do?
• Biopsy of the skin to rule out inflammatory breast cancer
• Sclerosing Adenosis
• Presentation: microcalcifications
• Diagnosis: core needle biopsy

• Treatment: if no atypia and concordant with imaging → observe

• Not a precursor to cancer
• Radial Scar
• Alternate names: sclerosing papillary proliferations, benign sclerosing ductal proliferation
• Diagnosis: mammogram - appears similar to small, invasive cancer
• Treatment: excisional biopsy
• Associated with a small increased risk of cancer and the difference between invasive breast carcinoma may be difficult to determine on core biopsy alone High Risk Breast Lesions
• Atypical lobular hyperplasia (ALH)
• Less well developed but morphologically similar to LCIS
• Not pre-malignant, but marker of increased risk
• 8-12-fold greater lifetime risk, or ~1% per year
• Diagnosis: CNB
• Treatment: excisional biopsy
• Why excise if not pre-malignant?
• Discordant finding as these lesions are often incidental to the radiographic abnormality that prompted the biopsy
• Atypical ductal hyperplasia (ADH)
• Associated with a 4-5-fold increased risk of invasive cancer
• Diagnosis: CNB
• Treatment: Excisional biopsy
• 9-30% incidence of DCIS on excisional biopsy

• 3% chance of invasive ductal carcinoma (IDC)

• Lobular carcinoma in situ (LCIS)
• Multifocal and bilateral, genetic predisposition
• 90% ER/PR+ and HER2-
• What is the malignancy risk?
• Marker for 40% risk of CA development in EITHER breast
• What type of cancer do they develop?
• Ductal carcinoma
• Treatment:
• Wire localized excision
• What if there is a positive margin?
• No re-excision, adjuvant hormonal therapy
• Pleomorphic LCIS = variant that is treated like DCIS No re-excision needed for LCIS when margin comes back positive
• Ductal carcinoma in situ (DCIS)
• Malignant cells of the ductal epithelium without invasion of the basement membrane (premalignant lesion)
• What is the malignancy risk?
• 50% in ipsilateral breast
• 5% in contralateral breast
• Presentation: majority are non-palpable
• Diagnosis: Mammography, CNB
• Treatment:
• Breast conserving therapy (BCT) = lumpectomy (1 cm margins) with adjuvant radiation (XRT)
• Post op whole breast XRT reduces risk of local recurrence by 50% but does not affect overall survival

• Large, multiquadrant, or contraindication to BCT → simple mastectomy + SLN

• Up to 25% DCIS may show invasive component on final pathology, so SLN sampling required before removing all breast tissue
• Skin and nipple-sparing procedures with immediate reconstruction are options
• Adjuvant therapy
• Premenopausal → tamoxifen
• Postmenopausal → aromatase inhibitor (anastrazole)
• What is the most aggressive subtype of DCIS?
• Comedo
• Characterized by necrosis
• Treatment: simple mastectomy + adjuvant hormone therapy DCIS excision need 2mm margin Breast Cancer
• Screening
• When should you start screening mammography?
• Low risk: Age 40 every 2-3 years → annually after age 50
• High risk: 10 years before youngest age of diagnosis in first-degree relative
• Hereditary disorders with increased risk: BRCA 1/2, Li-Fraumeni (p53), Cowden syndrome (PTEN), Peutz- Jeghers (STK11), CDH1
• BRCA 1/2 mutations → 10-20-fold increased risk → 30-60% risk by age 60
• Screening age 25 with annual mammogram AND MRI + pelvic exam and CA-125
• Findings on mammography that are concerning for malignancy: irregular borders, spiculated, distortion of breast, or small/thin linear branching calcification
• BIRADS classification

Risk Management Incomplete Further imaging Negative Routine follow-up Benign Routine follow-up Probably Benign 6 month follow-up Suspicious for Malignancy Biopsy Highly Suggestive of Malignancy Biopsy Biopsy-Confirmed Malignancy Excision

• Gail Model
• Prediction model that calculates a woman’s risk of developing breast cancer within the next 5 years and within her lifetime .
• Variables:
• Age
• Age at first period
• Age at the time of the birth of a first child (or has not given birth)
• Family history of breast cancer (mother, sister or daughter)
• Number of past breast biopsies
• Number of breast biopsies showing atypical hyperplasia
• Race/ethnicity
• Underestimates risk for patients with strong family history (BRCA), personal hx of DCIS, LCIS, or invasive CA
• Invasive breast cancer
• NCCN staging pearls T1 0-2 cm N1 1-3 nodes T2 2-5 cm N2 4-9 nodes T3 >5 cm N3 >10 nodes or supra/ infraclavicular T4 Chest wall or skin involvement

Stage 1 Small tumor, no nodes (T1N0M0) Surgery + Adjuvant chemoXRT if indicated Stage 2 Larger tumor, minor nodal involvement (T3N0 or T2N1) Surgery + Adjuvant chemoXRT if indicated Stage 3a/3b Local invasion or more nodes (T4N0 or T3N2) Surgery first vs neoadjuvant therapy Stage 3c Clavicular nodes (Any T, N3, M0) Neoadjuvant + surgery if responds Stage 4 Distal mets Definitive chemotherapy

• Categories of breast cancer
• What is the most common type of breast cancer?
• Ductal carcinoma
• What type of breast cancer is less common and does not typically form calcifications?
• Lobular
• Which subtype has the worse prognosis?
• Signet ring cells
• Inflammatory breast cancer
• What is the typical presentation?
• Inflamed, angry breast that is erythematous and warm
• Characterized by rapid diffuse involvement of entire breast with cutaneous erythema and peau d’orange changes in the breast skin
• What is the hallmark biopsy result?
• Dermal lymphatic invasion
• Staging: T4d by definition = at least Stage IIIb
• Treatment = Neoadjuvant chemotherapy → modified radical mastectomy → adjuvant chemoXRT

• NO BCT

• What are you concerned about if a patient presents with eczematous changes with scaling and ulceration of the skin and nipple?
• Paget’s disease
• What are the hallmarks of this disease?
• Cells with clear cytoplasm and enlarged nucleoli
• Marker of underlying malignancy - DCIS or IDC (generally ER-/PR- and HER2+
• Treatment = Mastectomy including nipple-areolar complex + SLN
• Breast CA in men
• <1% of breast CA, usually ductal
• Risk factors: family history, Klinefelter’s, BRCA 2 (15% of breast CA in men)
• What is the procedure of choice for a male with breast cancer?
• Modified radical mastectomy
• Usually poor prognosis due to late presentation (same prognosis as women at similar stages)
• Breast CA in pregnancy
• Treatment in 1st trimester = modified radical mastectomy
• Late 2nd and 3rd trimester = BCT is an option
• SLN with modified isotope dosing, post-op chemotherapy, and post-delivery breast radiation
• Treatment Options
• Breast conserving (BCT): lumpectomy + whole breast irradiation
• “No ink on tumor” = negative lumpectomy margin
• Contraindications
• Absolute

• Pregnant and would require radiation during pregnancy

• Multi-centric disease
• Positive pathologic margins after re-excision
• Relative - previous radiation, active connective tissue disease, tumors >5cm For lumpectomy only margin needed is no ink on tumor
• Simple mastectomy
• BCT equivalent to simple mastectomy
• Chemotherapy
• Who gets chemotherapy?
• For the ABSITE:
• Tumors >1cm
• Exception = hormone receptor positive, node negative tumors with favorable oncotype characteristics can receive postop hormonal therapy alone
• Positive nodes
• Triple negative tumors
• What is the most common chemotherapy regimen?
• TAC
• Taxane (Docetaxel) → AE = peripheral neuropathy
• Adriamycin (Doxorubicin) → AE = cardiomyopathy
• Cyclophosphamide → AE = Hemorrhagic cystitis
• Mesna reduces risk of hemorrhagic cystitis
• Who is a candidate for neoadjuvant chemotherapy?
• Locally advanced/inoperable tumors: inflammatory, N2/N3, T4
• If tumor is too large relative to rest of breast for BCT and patient desires BCT

• Radiotherapy

• Whole breast irradiation decreases local recurrence and improves survival
• After lumpectomy whole breast irradiation with boost to tumor bead is strongly recommended
• What are the indications for XRT after mastectomy?
• Advanced nodal disease (>4 nodes), fixed nodes, internal mammary nodes
• Skin/chest wall involvement
• Positive margins
• T3/T4 tumor, which is greater than 5cm
• Regional node irradiation

• 4 positive lymph nodes → XRT to supraclavicular, infraclavicular, and axillary LN

• Tumor central to inner area of breast → internal mammary node radiation
• 1-3 positive LN → grey zone, depends on individual characteristics
• Radiation is given AFTER chemotherapy
• Radiation in older adults
• NCCN guidelines allow for the use of lumpectomy with negative margins plus hormonal therapy WITHOUT radiation in women >70 with clinically negative nodes and ER+ T1 breast CA
• Endocrine therapy
• For Estrogen/Progesterone receptor (ER/PR) positivity
• Which has better prognosis receptor positive or receptor negative patients?
• Receptor positive
• More common in post-menopausal women
• Which has the better prognosis, ER or PR+?
• PR+

• Both is even better!

• Treatment = 5 years of tamoxifen (pre-menopausal) or aromatase inhibitor (post-menopausal women)
• HER2 targeted therapy
• With HER2/neu receptor, is prognosis better or worse if positive?
• Worse
• Treatment = traztuzumab (Herceptin) for 1 year
• Axillary staging
• What is the most prognostic factor in staging of breast cancer?
• Nodal status
• 0 positive nodes → 75% 5-year survival
• 4-10 nodes → 40% 5-year survival
• SLN indicated for all invasive tumors
• ACOSOG Z0011 Trial = RCT comparing SLN to axillary dissection
• Women > 18yo with T1/T2 tumors, <3 positive SLN, BCT + whole breast XRT
• No difference in local recurrence, disease free survival, overall survival at median follow up of 6 .3 years Z11 is critical especially for oral boards If T1-T2 with < 3 positive SLN AND patient is going to receive whole-breast radiation No benefit to axillary dissection
• Axillary dissection recommended for:
• Clinically positive nodes confirmed by FNA or CNB
• Sentinel nodes not identified
• What nodes do you take?
• Level 1 and 2
• What nodes do you take in an axillary dissection for melanoma?
• Levels 1-3

Quick Hits

• Patient presents with a dominant breast mass . Next step?
• IMAGING — Bilateral mammography and/or U/S
• Concerning lesion on mammography - core needle biopsy returns normal?
• Excisional biopsy for discordant findings
• Most common sites for breast cancer metastases?
• Bone, lung, brain, and liver
• Isolated tumor cell deposits (<0 .2mm) do NOT constitute metastatic disease
• Valveless venous system responsible for bony metastasis to spine?
• Batson’s plexus
• What is the cumulative risk of breast and ovarian CA with BRCA1 and BRCA2?
• BRCA1 - 65% breast, 40% ovary
• BRCA2 - 45% breast, 10% ovary
• Side effects of tamoxifen?
• Thromboembolism
• Increased risk of uterine CA
• Chronic lymphedema for 10 years following axillary dissection, now with dark purple lesion on upper arm?
• Stewart-Treves Syndrome (lymphangiosarcoma)
• What is Poland’s syndrome?
• Hypoplasia of the chest wall, amastia, hypoplastic shoulder, no pectoralis muscle
• What are the nodes between the pectoralis major and minor called?
• Rotter’s nodes

Figures