Describe the anatomical location of the breast
Anterior surface of the thorax, overlying and attached to the pectoral muscles at the level of the 2nd to the 6th rib
Describethe composition of each mammary gland and be able to label each part on a diagram
Mammary glands are modified sweat glands that are composed of 15-20 lobes. There are ducts, areola, ligaments, fat, lymph nodes, a nipple, etc.
How many lobes aer in each mammary gland?
State the primary pathway of lymphatic drainage for the breast.
Which lymph nodes lie deep in the axillary fascia in close association with the major blood vessels?
What drains the upper extremities, chest wall, and breast?
How are the axiallary lymph nodes divided up?
- into 3 levels
- Low axillary level 1 (which is always treated)
- mid axillary level 2
- high axillary level 3
The lobes of the mammary glands are seperated from each other by _____ and _____
dense connective and adipose tissues
The dense connective and adipose tissues support the glands and attach them to the ______ ______ _______
underlying pectoral muscles
What are the connective tissues that form dense strands that help support the weight of the breast?
Cooper's Ligaments (suspensory)
The breast parenchymal tissue that extends into the axilla through an opening in the axillary fascia is called
axiallry tail of Spence
What extends from the nipple like spokes on a wheel?
Under the areola, each duct has a dilated portion called the_______ ______ in which milk accumulates during lactation
Where does milk accumulate during lactation?
How are the mammary glands drained?
via the lactiferous or alveolar (epithelial ducts) which opens to the nipple
How is the breast drained?
axillary, internal mammary and the intercostal veins
Direct venous communication exists between the breast and what 3 things?
superior vena cava, the vertegral venous plexus, and the portal venous system.
What explains why breast CA spreads to the lungs, liver and bones of the axial skeleton?
The venous communication between the superior vena cava, the vertegral venous plexus, and the portal venous system.
List the lymph groups of the breast and locate each group
- Axillary lymph nodes which consists of, low axillary level 1, mid-axillary level 2, High axillary level 3 and then there are Brachial axillary nodes, Supraclavicular nodes, internal mammary lymph nodes (4 on each side), pectoral lymph nodes, brachial axillary
Where do the internal mammary nodes lie
at the edge of the sternum and at the 1st-3rd intercostal space (2cm deep)
which 2 hormones control the development of the breast during puberty and also play an important role in the lactation?
estrogen and progesterone
What stimulates milk production
Prolactin from the pituitary
Where does the main blood supply to the breast come from?
Internal mammary artery
List 3 common sites of spread of breast cancer
Lung, bone, liver
Where does the breast receive an additional supply of blood besides the main supply via the internal mammary artery?
from the branches of the axillary artery and the aorta
Discuss the incidence of breast cancer in the US and contrast it to the incidence in other countries.
- Caucasian and European women have higher
- incidence than other nationalities. Developed countries show more malignancies than others but that could be
- because developing countries do not have the resources, equipment, or screening abilities that the US and well developed countries have. The US also has a
- higher in fat diet that may be linked to increased breast cancer.
Why is knowing the lymphatic system of the breast so critical?
Because of the clinical importance in the spread of breast cancer.
State the most common disease of the breast
Anatomically, where does breast cancer
most often present?
- In the left breast
- 50% in the upper outer quadrant
- 10% in the lower outer quadrant
- 5% in the lower inner quadrant
- 15% in the upper inner quadrant
- 15% in the sub areola
List potential risk factors for breast
- Female, age, family history (BRCA1 and
- BRCA2), Oral contraceptives, HRT, Alcohol and tobacco use, nulliparous, early menarche and late menopause, radiation exposure during adolescence.
State the most common symptom of breast
State how most breast cancers are
90% are found by BSE, breast self-exam
Discuss the virtues of physical exams vs
mammography and give the accuracy rate of mammography and the guidelines for
- BSE effective and should be done at the same time every month. 90% of lesions are found through women doing their own BSE.
- Clinical exams are just like BSE except
- the doc performs them in the office
- Mammograms are baseline done at age 35, every other year at age 40 and every year after age 50. But the mammograms can miss 10-15 % of all lesions so they are only 80-85% accurate.
Describe the symptoms of advanced breast cancer
- The 1st sign is a palpable lump about .5cm
- Nipple discharge, retraction, or pain
- Skin changes and/or alterations like dimpling, warmth, irritation, or ulcerations.
Discuss the types of biopsy used for breast cancer
- Fine Needle- the use of a tiny needle to eject blood and/or tissue to be tested
- Core Needle- the use of a larger needleto aspirate a core of tissue from the breast mass to be tested
- Incisional- involves the partial removal of a breast mass to make a histological diagnosis
- Excisional- removes the entire mass with or without a surrounding portion of normal tissue.
List the most common type of breast cancer
Ductal or infiltrating ductal carcinoma
Discuss inflammatory carcinoma, its prognosis and treatment
- This is the most aggressive that occurs when cancer cells block the lymph vessels in the skin. Very poor prognosis.
- This is treated by combining chemo therapy, radiation therapy, and surgery.
State which type of breast cancer is most likely to present as bilateral disease.
Discuss the factors which determine the stage of breast cancer
- Tis- Carcinoma in situ (earliest stages)
- T1- 2cm or less
- T2-more than 2 cm but no more than 5cm
- T3-greater than 5cm
- T4-any size with direct extension to chestwall or skin
Differentiate between mastectomy and lumpectomy
Mastectomy removes the whole breast and the lumpectomy only removes the tumor
State the cases for which lumpectomy are not recommended
- Depending on the size, if the cancer is in multiple places of the breast, women who have had a lumpectomy before with radiation, if there are cancers in multiple places in the body, if the tumor has attached itself to the chestwall or other structures, pregnancy because a
- woman would not be able to have the needed radiation after, or just prior radiation to the chest area
Describe hormonal therapy as it applies to the management of breast cancer
- Estrogen or Progesterone test. They test to see if the tumor is positive for estrogen or progesterone and if it is, it means that the tumor is growing because of hormones and they can give you tamoxifen or femara which are hormone suppression drugs which will starve your
- tumor. Her-2/neu is a protein called human epidermal growth factor receptor 2 which promotes the growth of cancer cells. If you test positive for this test it is bad because it means your tumor is aggressive and not responsive to the hormone therapy, however there are a few other drugs that are effective.
Describe the treatment fields commonly used for RT of the breast
Still trying to work on this answer
Describe the time dose fractions used in treatment of the breast
- Tangents (breast or chestwall)
- Breast is treated with photons,
- chestwall can be treated with photons or abutting electrons
- 4500-5000 cGY fractionated about 25
- treatments of about 180-200 cGY
- And then a boost of 1000-1600 cGY to the
- spot of the tumor directly so in total the breast will have 6000-6600 cGY
- SCV supraclavicular gets 4500-5000 cGY
- PAB posterior axiallary boost midline to 4500-5000 cGY
- Internal mammary nodes get 4500-5000 cGY
Discuss the use of electrons in the treating of breast
These are used to treat superficial tumors like skin cancers. They do not travel very far through tissue so they can only treat very superficially.
List and discuss the possible complications of RT
- Skins changes- peak about 2-3 weeks after treatment
- Dryness and redness (after 3000 cGY)
- Dry desquamation (after 4000 cGY) like a peeling from sunburn
- Moist desquamation (after 4000 cGY) like skin sore
- Cardiac effect because you may have to include part of the heart when radiating the breast
- Pulmonary effects which is like radiation pneumonitis and they need a steroid to treat
- Brachial plexopathy (numbness in hand
- etc) The brachial plexus is a network of nerves supplying the upper extremities originating between C5 and T1 and extends downward over the 1st rib,
- behind the middle clavicle and into the axilla. Damage to these nerves from radiation is what will cause the numbness, pain or weakness.
- Myelopathy, some nerve damage due to spinal cord exposure
- Osteoradionecrosis which is radiation induced bone death, brittle bones
- Hyperpigmentation which is where you will still see the treatment field years later
- Telangiectasia which is like spider veins where the blood vessels break
- Rib fractures due to brittle bones
How many women will develop breast cancer?
1 in 8
The incidence of breast cancer increases with age and peak is about _____
1 in how many women at the age of 60 will have breast ca
1 in how many women at 30 will have breast ca
What is the leading cause of death in 40-55 year olds?
What % of breast cancer patients have no evidence of risk factors?
______ of recurrences will happen in 3 years
Only ___ of diagnosed cases are men and the disease is ____ _____
Which breast CA starts in the duct but hasn't left yet?
Ductal carcinoma in situ (DCIS)
Which breast ca starts out in the duct bu leaves and goes into the fat and tissue
ductal or infiltrating ductal carcinoma
Which breast cancer is the most common?
Ductal or infiltrating ductal carcinoma
Which one can present bilateral
Which breast ca is the most aggressive
Which breast ca starts in the breast and then infiltrates to the skin
What is the overall survival rate for women that had breast cancer and are still alive 5 years later?
What is the overall survival rate for women that had breast cancer and are still alive 5 years later but originally had regional spread/lymph nodes involved ?
What is the overall survival rate for women that had breast cancer and are still alive 5 years later but originally had mets involved ?
the 5 year survival is not the best indicator because breast cancer can lay dormant for up to _____ after treatment because of its systemic nature
The tumor will grow locally involving ____ and adjacent tissues and local or regionl lymph nodes
Nodes are present in tumors in about how many cases?
Can breast ca recur locally, in lymph nodes or at distace metastatic sites?
Distant mets are an invasion of blood vessels: Where does it generally metastasize to
Bone ( which is the most common) and brain, and lung
How big is the lump before it is palpable?
What is Tis
- Staging for a carcinoma in situ
- the earliest one
What is T2
more than 2cm but not more than 5cm
What is T3
Greater than 5cm
What is a tumor of any size with direct extension to chestwall or skin
What is a sentinel node biopsy
Inject radioactive tracer into tumor and if it goes to a specific node just remove that specific one instead of all the nodes.
What is axillary dissection
remove all of the axillary lymph nodes
Which 2 drugs are typically used for chemotherapy
- CAF cytoxan, adriamycin, 5FU 5-fluorouacil (common to lost hair)
- CMF cytoxan, 5-fluorouracil, methotrexate
What is endocrine therapy
hormonal therapy in which if you test positive for the progesterone/or estrogen test then you will be a candidate for endocrine therapy.
What drugs are used for endocrine therapy?
- Tamoxifen which will cause you to gain weight
- or Femara
How do you position a patient
- Arms above head in immolization device. breast boards may be used
- Supine position straight on table (including feet)
- Head turned to the contralateral side