Professional Documents
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Chapter 56 Breast
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What are the levels o axillary Level I (low): lateral to pectoral minor
lymph nodes? Level II (middle): deep to pectoral minor
Level III (high): medial to pectoral minor
In breast cancer, a higher level of
involvement has a worse prognosis, but
the level of involvement is less
important than the number of positive
III
nodes (T ink: Levels I, II, and III are in
the same inferior–superior anatomic
I order as the Le Fort facial fractures and
II the trauma neck zones; I dare you to
forget!)
Caro tid
III III
II III
II
I II I
I
Ne c k zo ne s Le Fo rte Axillary
frac ture lymph no de s
What are Rotter’s nodes? Nodes between the pectoralis major and
minor muscles; not usually removed
unless they are enlarged or feel suspicious
intraoperatively
What is the “tail o Spence”? “ ail” of breast tissue that tapers into the
axilla
BREAST CANCER
What is the incidence o breast 12%li etime risk
cancer?
What are the major breast BRCA1 and BRCA2 (easily remembered:
cancer susceptibility genes? BR BReast and CA CAncer)
LCIS
Inherited genes (BRCA I and II)
Papilloma (1.5 )
Sclerosing adenosis (1.5 )
What are the signs o breast Mass (1 cm is usually the smallest lesion
cancer? that can be palpated on examination)
Dimple
Nipple rash
Edema
Axillary/supraclavicular nodes
What is the most common site Approximately one half of cancers develop
o breast cancer? in the upper outer quadrants
What are the methods or Fine needle aspiration (FNA), core biopsy
obtaining tissue or pathologic (larger needle core sample), mammotome
examination? stereotactic biopsy, and open biopsy, which
can be incisional (cutting a piece of the
mass) or excisional (cutting out the entire
mass)
Is the f uid rom a breast cyst Not routinely; bloody uid should be sent
sent or cytology? for cytology
How can the long thoracic Nerves can be stimulated with a forceps,
and thoracodorsal nerves be which results in contraction of the
identi ed during an axillary latissimus dorsi (thoracodorsal nerve) or
dissection? anterior serratus (long thoracic nerve)
How is the sentinel lymph node Inject blue dye and/or technetium-labeled
ound? sulfur colloid (best results with both)
What ollows a positive sentinel Removal of the rest of the axillary lymph
node biopsy? nodes
What do you do with Open needle loc biopsy as many will have
a mammotome biopsy DCIS or invasive cancer
that returns as “atypical
hyperplasia”?
DCIS
What does DCIS stand or? Ductal Carcinoma In Situ
What is the role o tamoxi en amoxifen for 5 years will lower the risk
in DCIS? up to 50%, but with increased risk of
endometrial cancer and clots; it must be an
individual patient determination
What is a memory aid or the Cancer arises in the same breast as DCIS
breast in which DCIS breast (T ink: DCIS Directly in same breast)
cancer arises?
Chapter 56 / Breast 419
LCIS
What is LCIS? Lobular Carcinoma In Situ (carcinoma
cells in the lobules of the breast without
invasion)
Lo bular
No rmal c arc ino ma
lo bule in s itu
Which breast is most at risk Equal risk in both breasts! (T ink of LCIS
or developing an invasive as a risk marker for future development of
carcinoma? cancer in either breast)
What medication may lower amoxifen for 5 years will lower the risk
the risk o developing breast up to 50%, but with an increased risk of
cancer in LCIS? endometrial cancer and clots; it must be an
individual patient determination
420 Section II / General Surgery
MISCELLANEOUS
What is the most common Intraductal papilloma
cause o bloody nipple
discharge in a young woman?
What type o breast cancer do Nearly 100% of cases are ductal carcinoma
men develop? (men do not usually have breast lobules)
What are the signs/symptoms Breast mass (most are painless), breast skin
o breast cancer in men? changes (ulcers, retraction), and nipple
discharge (usually blood or a blood-tinged
discharge)
What must be ruled out with Prolactinoma (check pregnancy test and
spontaneous galactorrhea prolactin level)
( / amenorrhea)?
CYSTOSARCOMA PHYLLODES
What is it? Mesenchymal tumor arising from breast
lobular tissue; most are benign (Note:
“sarcoma” is a misnomer, as the vast
majority are benign; 1% of breast cancers)
422 Section II / General Surgery
What is the usual age o the 35–55 years (usually older than the patient
patient with this tumor? with broadenoma)
What are the signs/ Mobile, smooth breast mass that resembles
symptoms? a broadenoma on exam, mammogram/
ultrasound ndings
FIBROADENOMA
What is it? Benign tumor of the breast consisting of
stromal overgrowth, collagen arranged in
“swirls”
FIBROCYSTIC DISEASE
What is it? Common benign breast condition
consisting of brous (rubbery) and cystic
changes in the breast
Chapter 56 / Breast 423
What are the signs/symptoms? Breast pain or tenderness that varies with
the menstrual cycle; cysts; and brous
(“nodular”) fullness
MASTITIS
What is it? Super cial infection of the breast (cellulitis)
Why must the patient with o make sure that she does not have
mastitis have close ollow-up? in ammatory breast cancer!
BREAST ABSCESS
What are the causes? Mammary ductal ectasia (stenosis of breast
duct) and mastitis
MALE GYNECOMASTIA
What is it? Enlargement of the male breast
Chapter 57 Endocrine
ADRENAL GLAND
Anatomy
Where is the drainage o the Le renal vein
lef adrenal vein?
Cushing’s Syndrome
What is Cushing’s syndrome? Excessive cortisol production (T ink:
Cushing’s Cortisol
Ac ne
I’m we ak
Hirs utis m
I’m de pre s s e d Buffalo
hump
Hig h blo o d
pre s s ure
Purple
s triatio ns 200
Trunc al
o be s ity
Eas y
bruis ing