Breast

• Intercostobrachial nerve (off 2nd intercostal n.) sensation to medial arm; can sacrifice
• Long thoracic n. to serratus anterior, injury = winged scapula
• Thoracodorsal n. to latissiumus dorsi, injury = weak arm adduction/pull ups
• Medial pectoral n. to pec major and minor; Lateral pec n to pec minor only
• Batson's Plexus: valveless vertebral veins, allow direct mets to spine
• Poland syndrome: amastia, hypoplastic shoulder, no pectoralis
• Mastodynia: Rx with danazol, OCP, evening primrose oil, tamoxifen (?); Vit E not useful
• Mondor's disease: thrombophlebitis of superficial vein of breast. Cord like mass laterally.  Rx: Nsaids
• T1 < 2cm; T2 2-5cm; T3 >5cm; T4 skin of chest wall involvement 'grave signs' - peau d' organe, inflam
• N1 + ax nodes; N2 matted or fixed nodes, N3 internal mammary nodes
• State I T1; II up to T2 N1 or T3 N0; III T4 or N2; IV Mets (includes supraclav node, unlike lung CA)
• Breast mets: to bone, lung, brain
• Her 2 neu: a marker for breast CA, implies worse prognosis. Herceptin now available for Rx
• Erb B 2, p53, cathepsin all indicate worse prognosis
• 1 cm tumor is ~ 5 yrs old
• Tamoxifen reduces risk 50% in high risk but increases endometrial CA, DVT
• Atypical Hyperplasia raises risk x 4 (only finding in fibrocystic disease that increases risk)
• ER + PR+ is better than ER - PR + which is better than ER + PR - which is better than ER - PR -
• DCIS 50% develop invasive carcinoma, is a precursor. Usually lumpectomy +RT, but mastectomy for high grade/large tumor/poor margins.  50% of DCIS recurrence is invasive
• LCIS 30-40% develop invasive carcinoma (either breast); is a marker of risk. Treatment options: nothing, tamoxifen, or bilateral mastectomy
• Comedo Breast CA: likely multicentric, do mastectomy.  Poor Rx
• Paget's disease of the breast: eczematous lesions on nipple, there is underlying DCIS or Ductal CA
• Cystosarcoma Phyllodes or 'Phyllodes tumor' since only 10% malignant. Large. Rare nodal mets. As with other sarcomas, spread is hematogenous, not lymphatic. Rx is wide local excision, rarely mastectomy, no axillary node dissection
• BRCA 85% have CA by 70. BRCA I associated with ovarian CA (50%), II associated with male breast CA
• Indications for RT after mastectomy: >4 nodes, skin or chest wall involvement, + margins
• Stewart Treves: lymphangiosarcoma in lymphedematous limb; presents with purplish mass on arm ~ 10yrs s/p MRM
• Intraductal Papilloma: no risk of CA. #1 cause of bloody nipple discharge (although 1/2 are serous)

Return to Absite Review