1. Pimp Session: Breast
By James Lee, MD

2. What muscle does the lateral thoracic artery supply?

3. What muscle does the lateral thoracic artery supply?
 Serratus anterior

4. What muscle does the thoracodorsal artery supply?

5. What muscle does the thoracodorsal artery supply?
Latissimus dorsi

6. What percentage of lymphatic drainage of the breast is to the axillary nodes?

7. What percentage of lymphatic drainage of the breast is to the axillary nodes?
97%

8. What percentage of lymphatic drainage of the breast is to the internal mammary nodes?

9. What percentage of lymphatic drainage of the breast is to the internal mammary nodes?
1-2%

10. Describe what levels I, II and III nodes are in the breast?

11. Describe what levels I, II and III nodes are 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

12. What are the boundaries of an axillary lymph node dissection?

13. What are the boundaries of an axillary lymph node dissection (ALND)?
Superior - axillary vein Posterior - long thoracic nerve Lateral - latissimus dorsi muscle Medial - pectoralis minor

14. What nerves do you have to be aware of in an ALND?.

15. What nerves do you have to be aware of in an ALND?
Long thoracic nerve
Thoracodorsal nerve
Medial pectoral nerve
Lateral pectoral nerve

16. What is the most likely cause of sudden, painful, early postop swelling of the ipsilateral arm after an axillary dissection?

17. What is the most likely cause of sudden, painful, early postop swelling of the ipsilateral arm after an axillary dissection?
Axillary vein thrombosis

18. What is the most likely cause of slow, painless, progressive swelling of the ipsilateral arm after an axillary dissection?

19. What is the most likely cause of slow, painless, progressive swelling of the ipsilateral arm after an axillary dissection?
Lymphatic fibrosis

20. What is the most likely cause of hyperesthesia of the inner upper aspect of the ipsilateral arm after an axillary dissection?

21. What is the most likely cause of hyperesthesia of the inner upper aspect of the ipsilateral arm after an axillary dissection?
Injury to the second intercostobrachiocutaneous nerve

22. What is the incidence of lymphedema after axillary node dissection?

23. What is the incidence of lymphedema after axillary node dissection?
15-30%

24. What is the indicence of lymphedema after sentinel node biopsy?
2-4%

25. What is the most common breast abnormality?

26. What is the most common breast abnormality?
Accessory nipple

27. What is the most common cause of bloody nipple discharge?

28. What is the most common cause of bloody nipple discharge?
Intraductal papilloma

29. What is the dose of evening primrose oil to treat mastodynia?

30. What is the dose of evening primrose oil to treat mastodynia?
3-4 grams daily

31. What is the most aggressive subtype of ductal carcinoma in situ?

32. What is the most aggressive subtype of ductal carcinoma in situ?
Comedo pattern

33. What is the Risk of lymph node metastasis with DCIS?

34. What is the Risk of lymph node metastasis with DCIS?
< 2%

35. What is the surgical treatment for a < 1 cm low grade DCIS?

36. What is the surgical treatment for a < 1 cm low grade DCIS?
Excision with 1 cm margins +/- radiation

37. What is the surgical treatment for a > 1 cm DCIS?
Lumpectomy and radiation with 1 cm margins or total mastectomy without axillary dissection

38. What are the indications to perform a simple mastectomy for DCIS?
Contraindications to radiation, DCIS > 1cm, and diffuse breast involvement

39. Which breast does invasive cancer arise in the setting of DCIS?

40. Which breast does invasive cancer arise in the setting of DCIS?
Usually the ipsilateral breast

41. Which breast does invasive cancer arise in the setting of LCIS?

42. Which breast does invasive cancer arise in the setting of LCIS?
Carcinoma can arise in either breast

43. What is the assessment and recommendation for each BI-RADS category?

44. What is the assessment and recommendation for each BI-RADS category?
BI-RADS 0: Incomplete; follow-up imaging necessary
BI-RADS 1: Negative; routine screening
BI-RADS 2: Definite benign finding; routine screening
BI-RADS 3: Probably benign; 6 month short interval follow-up
BI-RADS 4: Suspicious abnormality; biopsy should be considered
BI-RADS 5: Highly suspicious of malignancy; appropriate action should be taken
BI-RADS 6: Known biopsy proven malignancy; assure that treatment is completed

45. How large must a mass be to be detected on mammography?

46. How large must a mass be to be detected on mammography?
5 mm or greater

47. What are the general population screening recommendations for breast cancer?

48. What are the general population screening recommendations for breast cancer?
Initial screening mammogram at age 40 and annual mammograms after age 40

49. What are the screening recommendations for a patient at high risk for breast cancer?

50. What are the 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

51. What percentage of breast cancers have a negative mammogram and ultrasound?

52. What percentage of breast cancers have a negative mammogram and ultrasound?
10%

53. Which subtype of ductal carcinoma with the worse prognosis?

54. Which subtype of ductal carcinoma with the worse prognosis?
Scirrhotic carcinoma

55. How long does it take for a single malignant cell to become a 1-cm tumor?

56. How long does it take for a single malignant cell to become a 1-cm tumor?
5-7 years

57. What are indications for radiation after mastectomy?

58. What are indications for radiation after mastectomy?
4 nodes, extracapsular nodal invasion, fixed axillary nodes (N2) or internal mammary nodes (N3), inflammatory cancer, positive margins, skin/chest wall involvement, tumor > 5 cm

59. What is the treatment for male breast cancer?

60. What is the treatment for male breast cancer?
Modified radical mastectomy

61. What is removed with a modified radical mastectomy?

62. What is removed with a modified radical mastectomy?
Breast, nipple-areolar complex, and axillary nodes (level I, II)

63. What is the chance of local recurrence after mastectomy?

64. What is the chance of local recurrence after mastectomy?
5% (4-8%)

65. What is the standard dosage of Tamoxifen in regards to adjuvant treatment for breast cancer?

66. What is the standard dosage of Tamoxifen in regards to adjuvant treatment for breast cancer?
20 mg daily for 5 years

67. What percentage of cystosarcoma phyllodes are malignant based on > 5-10 mitoses/HPF?

68. What percentage of cystosarcoma phyllodes are malignant based on > 5-10 mitoses/HPF?
10%

69. What is the most common bacteria to cause mastitis?

70. What is the most common bacteria to cause mastitis?
Staphylococcus aureus

71. What are indications for neoadjuvant therapy in breast cancer?

72. What are indications for neoadjuvant therapy in breast cancer?
Primary tumors >5 cm, fixed or matted axillary nodes, and inflammatory breast carcinoma.

73. What are contraindications to radiation therapy?

74. What are contraindications to radiation therapy?
Previous radiation therapy to breast, severe collagen vascular disease, pregnancy