Lymph Drainage of the Breast?

Nerve supply to the breast?

Breast Cells
Breast Physio

Usual causative agent of periductal and

pueriperal mastitis?
Which lymph node group receives
>75% of the lymphatic drainage from
the breast?
May provide a route of breast CA mets
to the vertebrate, pelvic bones, skull,
and CNS?
Axillary Lymph Node Groups

Involved Veins in Mondors Dse?

What distinguishes atypical ductal

hyperplasia from carcinoma in situ?
What distinguished lobular hyperplasia
from carcinoma in situ?
What is the most common cause of
bloody nipple discharge in young
women?
Pathognomonic sign of PAGETs DSE of
the nipple?
Most common site specific cancer in
women?
Leading Cause of Death from CA for
Women aged 20-59?
Breast Surgery removal Breast and Skin
Breast Surgery removal Breast, axillary
dissection, LEVEL 1+2 nodes and skin
Breast Surgery removal Breast,
Pectoralis major + minor, overlying
skin, ALL axillary nodes

Lateral quadrants
Anterior axillary GON
Medial quadrants
Internal thoracic ipectoral GON
3rd (SCHWARTs)
4th-6th intercostal nerves (MOOREs)
Sinus Stratified & Ducts Cuboidal
Ducts
Estrogen
Lobes
Progesterone
Prolactin
Lactogenesis
Staph Aureus
Axillary Lymph node

Batsons Vertebral Venous Plexus

LEVEL I = AES
LEVEL II = CI
LEVEL III = S
Lateral Thoracic
Thoracoepigastric
Superficial Epigastric
Irregular intracellular spaces
& variable cell nuclei
Presence of alveolar lumina &
Incomplete distension
Intraductal papillomas

Large, Pale, Vacudated cells (PAGETs

Cells) in the rate pegs of the epithelium
Breast CA
Breast CA
Simple/Total Mastectomy
Modified Radical Mastectomy
Radical Mastectomy

TAMOXIFEN side effects

AROMATASE INHIBITORS side effects

Metastatic involvement of BREAST CA?

Multicentricity of Breast CA?

Multifocality of Breast CA?
Microcalcifications occurring in adjacent
tissues is unique to?
COMEDO growth pattern?

Intraductal papillomas in ductography?

Mammography findings suggestive of
CA

Advantage of UTZ in breast mass?

Comedo growth pattern is usually found
in
Distinctive cellular feature of LCIS
Breast masses that manifest as nipple
discharge?
Palpable dilated subareolar ducts assoc.
with nipple discharge
First symptom of itching or burning of
the nipple + superficial erosion or
ulceration
Refers to disordered growth w/c is
frequently the precursor of malignancy
Change form 1 type of differentiated
tissue to another
Hodgkins Staging E

Vasomotor complaints
Vaginal Discharge Iathrophy
high risk of uterine CA, CVA, &
thromboembolism
Loss of bone density and function
MSK aches, High Cholesterol
Bone
Lung
Pleura
Soft tissues
Liver
2nd CA outside the breast quadrant or @
least 4 cm away
2nd CA in same quadrant or w/in 4cm of
it
Lobular Carcinoma in situ
Increase cell growth + Decrease blood
supply
Necrosis + An anatomic precursor of
invasive ductal carcinoma
Small filling detects surrounded by
contrast
Fine, stipple Calcium around a lesion
Assymetric thickening
Clustered microcalcifications
Solid Mass
differentiates solid from cyctic
DCIS
neighborhood calcification
Duct ectasia
Intraductal Papilloma
Carcinoma
Duct ectasia
Pagets Carcinoma

Dysplasia
Metaplasia
Localized solitary involvement
(extralymphatic and except liver +
bone marrow)
Single discreet site proximal to a

Hodgkins Staging X

Hodgkins Staging B
Hodgkins Staging A
Hodgkins Stage IV

Hodgkins Stage III

Hodgkins Stage II
Hodgkins Stage I
Malignant Cell of Hodgkins Dse?
4 histological subtypes of CLASSICAL
HODGKINs?
2 major forms of HODGKINs dse?
Who are at risk for HODGKINs dse?
Cause of Hodgkins dse?
Stereotactic radio surgery

Proton Therapy

Intensity-modulated radiation therapy

Conformal Radiation Therapy

Brachytherapy

regional involved nodal site (II E)

Limited direct extension for a known
nodal site
Bulky dse: >10cm max diameter of
nodal mass & mediastinal mass >1/3 of
chest diameter
Unexplained wt loss; unexplained fever;
recurrent night sweats
No symptoms
Involvement of extranodal site beyond
E or
>1 extranodal deposit @ any location
any involvement of liver or bone
marrow
2 or more Lymph node or structures on
both sides of the diaphragm
2 or more lymph node or structure on
same side of the diaphragm
Single Lymph node or structure
Reed-Sternberg cell derived from
follicular center B cell
Modular sclerosis (70%); mixed
cellularity (20%); lymphocyte non (35%); lymphocyte depleted (<2%)
Classical & nodular lymphocyte
predominant
Farmers; wood workers; meat workers;
HLA-link disequilibrium; AIDS
unknown
3rd technique that delivers the radiation
dose in a single 1x fraction; for brain
tumors with gamma knife (Cobalt Unit)
or linear accelerator based system
DNA damage secondary to free radicals
produced by this particle; useful when
tumor is near sensitive tissue
Extension of conformal therapy;
considered when target is in close
proximity to important structures; equal
radiation dose given
Geometric shaping of the radiation
beam that conforms with the shape of
the tumor from the perspective of the
beam source
Radiation source is in contact with the
tumor; used in prostate, gynecologic,
oral, oropharynx CA + sarcoma

Electron Beam/External Beam

In radiotherapy, DNA damage is caused

by?
Small molecules that bind to
intracellular domains of a cell surface
receptor + prevents activation of the
intracellular signals that drive cellular
process
Bind to cell surface proteins; high
affinity binding, prevents the normal
ligard from attaching, inhibiting
receptor activation; diminishes
intracellular signal that drives cellular
processes such as angiogenesis + cell
growth
Bind to the tubulin as a polymerized
molecule + prevents disassembly back
into the dimeric form; Act during M
phase
Bind to the tubulin dimer + prevent the
assembly of microtubule filaments +
therefore interfere with fx of the mitosis
spindle + prevent cell division during M
phase
Tubulin Binders
Structurally related to natural
compaounds + inhibit the metabolism
necessary for DNA/RNA or protein
synthesis; most act on S phase
Breaks down strands of DNA + allows
the other strand to pass thru ligate
Intercalating Agents

Intercalate into the DNA major groove

between base pairs of the DNA;
disrupts steric integrity + blocks
replication by targeting topoisomerase
II
Intercalate + disrupt the steric integrity
of the DNA double helix; also form
intrastrand links to alkylating agents
Cannot form cross-links but cause
adducts which inhibit DNA synthesis (S
phase); more mutagenic + carcinogenic

Can treat superficial tumors up to 5cm

deep; for skin lesions; to boost pre-tx
areas with protons
Free Radicals
Kinase inhibitors
Imatinib (BrAbl, C-kit) ; Erlotinib (EGF
receptor); Lapatinib (HER2 + EGF
receptor)
Monoclonal antibodies
Rituximab (CD2O); Bevacizumab
(VEGF); Transtuzumab (HER 2 receptor)

Taxanes
Paclitaxel; Docetaxel

Vinca Alkaloids
Vincristine; vinblastine; vindesine;
vinorelbine

Vinka Alkaloids + Taxanes

Antimetabolites
Methotrexate (antifolate); Gemcitabine
(Pyrimidire analogue); 5-Fluororacil
(Pyrimidire analogue)
Topoisomerase II inhibitors
Etoposide; Teniposide
Platinum Compounds
Anthracyclines
Anthraquinones
Antracyclines
Doxorubicin; Daunorubicin; Epibubicin
Anthraquinones
Mitoxantrene
Platinum Compound
Cisplatin; Carboplatin; Oxaliplatin
Monofunctional Alkylating Agents
Dacarbazine; Temozolomide;
Nitrosureas

Act on more than 1 base of the DNA,

more cytotoxic; form covalent bonds
between 2 different bases which
inhibits DNA synthesis (S phase)
Transfer an alkyl group to the purine
bases of DNA (adenine + guanine)
Prevent DNA strands from becoming
tangled and allowing it to wind or
unwind
Breaks single strand DNA + relieves
tension; inhibitors act in S phase;
prevents relegation, trapping isomerase
I in a covalent complex with DNA
Autologous tissue for conservation
therapy
Arteries and veins supplying the breast?

Thyroid tumors T2
Thyroid tumor T1
Thyroid tumor T0
Thyroid tumor Tx
Tumors of the hypopharynx, cervical
esophagus, + thyroid frequently involve
Retropharyngeal Lymph Nodes

Advanced tumors of the glottis with

subglottic spread may involve
Gold Standard for control of cervical
metastasis (traditionally)
Classic Radical Neck Dissection

Modified Radical neck dissection

(MRND)
Selective Neck Dissection (SND)

LEVEL 1-3 dissection

Supraomohyoid dissection

Bifuncitonal Alkylating Agents

Chlorambucil; Melphalan; Nitrogen
Mustard; Cyclophosphamide
Alkylating Agents
Topoisomerase I/II inhibitors

Topoisomerase I inhibitors
Topotecan; Irinotecan

Transverse Rectus Abdominis

Myocutaneous flap; Lattisimus Dorsi
flap
Thoracic-internal
Intercostal
Axillary
Tumors >2cm-4cm diameter LIMITED to
thyroid
Tumors < 2cm in diameter, LIMITED to
thyroid
No evidence of primary tumor
Primary tumor cannot be assessed
Paratracheal nodal compartment LEVEL
VII
Tumors of the nasopharynx, soft palate,
lateral + posterior walls of oropharynx
+ hypopharynx metastasize into?
Delphian node / a pretracheal lymph
node
Radical Neck Dissection (RND)
Removes LEVEL 1-5 of cervical
lymphatics
SCM, IJV, Spinal Accessory Nerve (CN
XI)
Any modification of the RND that
preserves non lymphatic structures
Neck dissection that preserves
lymphatic compartments normally
removed in classic RND
Supraomohyoid N D
Types of SND typically used with oral
cavity malignancies and removes level
1-3 nodes

Lateral neck dissection

Posterolateral Neck Dissection

Tumors in oropharynx hypopharynx +
larynx commonly spread to?
Malignancies in nasopharynx + thyroid
commonly spread to?
Primary tumors within the oral cavity +
lip metastasis to the nodes in?
NECK LEVEL 1 nodes
NECK LEVEL 1a nodes

NECK LEVEL 1b nodes

NECK LEVEL 2 nodes

NECK LEVEL 2a nodes

NECK LEVEL 2b nodes

NECK LEVEL 3 nodes

NECK LEVEL 4 nodes

NECK LEVEL 5 nodes

NECK LEVEL 5a nodes

NECK LEVEL 6 nodes

Type of SND frequently used for

laryngeal malignancies and removes
LEVEL 2-4 nodes
Type of SND used with TYROIC cancer
removes level 2-5 nodes
LEVELS 2, 3, 4
LEVEL 5 jugular chain nodes level 2, 3,
4
LEVELs 1. 2. 3
submental + submandibular nodes
Submental nodes; medial to the
anterior belly of the digastric muscle
bilaterally, symphysis of mandible
superiorly. And hyoid inferiorly
Submandibular nodes + gland;
posterior to the anterior belly of
digastric; anterior to the posterior belly
of digastric; inferior to the body of the
mandible
Upper jugular chain nodes
Jugulodigastric nodes; deep to SCM
muscle; anterior to posterior border of
the muscle, posterior to posterior
aspect of the digastric belly; superior to
hyoid; inferior to spinal accessory nerve
(CN 9)
Submuscular recess; superior to spinal
accessory nerve to the level of the skull
base
Middle jugular chain nodes; inferior to
the hyoid, superior to cricoid, deep to
SCM muscle, posterior border of the
muscle to the strap muscles medially
Lower jugular chain nodes, inferior to
the level of the cricoid, superior to the
clavicle, deep to SCM muscle from
posterior border of the muscle to the
strap muscles medially
Posterior Triangle Nodes
Lateral to the posterior aspect of SCM
muscle, medial to trapezius, inferior to
SAN and superior to the clavicle
Anterior compartment nodes, inferior to
the hyoid, superior to suprasternal
notch, medial to the lateral extent of

NECK LEVEL 7 nodes

NSCLC STAGE 4 (5 year survival)

NSCLC STAGE 3B (5 year survival)

NSCLC STAGE 3A (5 year survival)

NSCLC STAGE 2B (5 year survival)

NSCLC STAGE 2A (5 year survival)

NSCLC STAGE 1B (5 year survival)

NSCLC STAGE 1A (5 year survival)
NSCLC
NCSLC
NSCLC
NSCLC

STAGE 0
occult carcinoma
M1b
M1a

NSCLC M1
NSCLC M0
NSCLC N3

NSCLC N2
NSCLC N1

NSCLC N0
NSCLC Nx
NSCLC T4

the strap muscles bilaterally

Paratracheal nodes; inferior to the
suprasternal notch in upper
mediastinum
ANY T
ANY N
M1a-M1b
13%
T1a-T3 N3 M0
T4 N2-N3 M0
9%
T1a N2
M0
T3 N1-N2 M0
T4 N0-N1 M0
24%
T2b N1
M0
T3
N0
M0
36%
T2b
N0
M0
T1a-T1b N1
M0
46%
T2a
N0
M0
58%
T1a-T1b
N0
M0
73%
Tis N0 M0
Tx
N0 M0
Distant mets (in extrathoracic organs)
Separate tumor nodules in a
contralateral lobe
Tumor with pleural nodules
Malignant pleural/pericardial effusion
Distant Metastasis
No distant metastasis
Mets in contralateral mediastinal,
contralateral hilar, ipsi or contra
scalene, or supraclavicular lymph node
Mets in ipisilateral mediastinal and or
subcannal lymph node
Mets in ipsilateral peribronchial and or
hilar lymph node + including
involvement in direct extensions
No regional Lymph node mets
Regional lymph node cannot be
assessed
Tumor of any size that invades
mediastinum, esophagus, carina, heart

NSCLC T3

NSCLC T2b
NSCLC T2a
NSCLC T2

NSCLC T1b
NSCLC T1a
NSCLC T1

NSCLC Tis
NSCLC T0
NSCLC Tx

Posterior Mediastinal Nodes

Anterior Mediastinal Nodes

Tracheobronchial lymph nodes

N2 lymph nodes

Lymphatic Sump of Berrie

or any great vessel, trachea, laryngean

nerve, vertebrae, separate tumor
nodules in a different ipsilateral lobe
Tumor >7cm or directly invades any of
chest wall, phrenic nerve, mediastinal
pleura, parietal pericardium; tumor
<2cm distal to canna, tumor with assoc
atelectasis or obstructive pneumonitis
(entire lung); separate tumor in same
lobe
Tumor >57cm
Tumor >3-5cm
Tumor >3cm-7cm with any of ff:
involves main bronchus distal to canna;
invades visceral pleura; assoc with
atelectasis or obstructive pneumonitis
(hilar-not entire lung)
Tumor >2 3cm
Tumor <2cm
<3cm surrounded by lung or visceral
pleura; without bronchoscopic evidence
of invasion more proximal than lobar
bronchus
Carcinoma in situ
No evidence of primary tumor
Primary tumor cannot be assessed;
tumor proven by sputum + bronchial
washing but not visualized by imaging
or bronchoscopy
Includes paraesophageal lymph nodes
with in the inferior pulmonary ligament
+ more superiorly between the
esophagus + trachea near the arch of
the azygos vein
Located in assoc with upper surface of
the pericardium, phrenic nerves,
ligamentum arteriosum, and the left
innominate vein
Made up of 4 subgroups that are
located near the bifurcation of the
trachea
Anterior & Posterior Mediastinal Nodes
Tracheobronchial & Paratracheal lymph
nodes
Constituted by the interlobar lymph
nodes
Drains all of the pulmonary lobes

Lobar nodes
Interlobar nodes

Intrapulmonary or Segmental Nodes

Hilar nodes
2 groups of Lymph Nodes that drain the
lungs
N1 lymph nodes
Paratracheal lymph nodes
Cuff pressure (intubation) is maintained
at?
Most common cause of injury secondary
to tracheal intubation
Approx. how many rings for every 1cm
of tracheal length?
The first tracheal ring is attached
directly into?
C-shaped hyaline cartilaginous
structures and provide rigidity to the
anterior and lateral tracheal walls
Subglottic Space

Lie along the upper, middle, lower lobe

bronchi
Located in the angles formed by the
main bronchi bifurcating into the lobar
bronchi
Lie @ points of division of segmental
bronchi or in the bifurcations of the
pulmonary artery
Located along the main bronchi
Pulmonary Lymph Nodes (N1) &
Mediastinal Lymph Nodes (N2)
Intrapulmonary or segmental, lobar,
interlobar, hilar lymph nodes
In proximity ot the trachea in the
superior mediastinum
<20mmHg
Overinflation of the endotracheal cuff
Approx. 2
Cricoid cartilage
Tracheal Rings

Narrowest part of the trachea

Internal diameter approx. 2cm
From inferior surface of the vocal
chords to the first tracheal ring
Vocal Cords
Originate from the arytenoid cartilages,
and then attach to the thyroid cartilage
Arytenoid Cartilages
Articulates with the posterior cricoid
plate
Cricoid Cartilage
First Complete cartilaginous ring of the
airway
Trachea
Composed of cartilaginous +
membranous portions, beginning with
the cricoid cartilage
NO NON INVASIVE DIAGNOSTIC TEST IS SUFFICIENT TO DEFINE A DISEASE
PROCESS AS CANCER
Type of Lung CA that tends to occur as
Small Cell Carcinoma
a central mass with endobronchial
growth; highly aggressive with rapid
doubling time
Type of Lung CA identical to
NSCLC squamous cell carcinoma
extrapulmonary squamous cell

carcinomas; grows centrally

Type of Lung CA histology with
presence of glands, papillary structure,
bronchoalveolar pattern, cellular mucin,
or solid pattern
A subtype of adenocarcinoma that
grows along the alveoli without
invasion; can present as a single mass
on x-ray (or diffuse multinodular lesion,
or fluffy infiltrate) ground glass on CT
Type of Lung CA that is poorly
differentiated, larger malignant cells
w/o evidence of squamous, glandular,
differentiation or features of SCLC
Positive in >70% of pulmonary
adenocarcinomas + is a reliable
indicator of primary lung cancer
Lung CA histology with scant
cytoplasm, small hyperchromatic nuclei
with a fine (Salt & Pepper) chromatin
pattern + prominent nucleoli
Lung CA histology with infiltrating nest
of tumor cells that lack intercellular
bridges + keratin can usually be seen
Type of Lung CA most common form
occurring in NEVER smokers
3 GENETIC loci for lung cancer risk
Primary cause of lung cancer
Figo staging with carcinoma is strictly
confined to cervix (extension of corpus
should be disregarded)
Figo staging deepest invasion <5mm ;
largest extension <7mm; invasive CA
that can only be diagnosed by
microscopy
Figo staging >3mm deep & >7mm wide
stromal invasion
Fido Staging of clinical lesions confined
to the cervix or preclinical lesions >1a
a. <4cm
b. >4cm
Figo staging 4-5mm deep & <7mm
wide stromal invasion
Figo staging with carcinoma extends
beyond cervix but has not extended to
pelvic wall & involves vagina; not as far
as lower 3rd

Adenocarcinoma

Bronchioalveolar Carcinoma (BAC)

Large Cell Carcinoma (NSCLC)

Thyroid Transcription Factor 1 (TTF-1)

Small Cell Carcinoma

(NSCLC) Squamous Cell Carcinoma

Adenocarcinoma
5p15 15a25 6p21
Tobacco consumption
STAGE 1

STAGE 1a

STAGE 1a1
a. STAGE 1b1
b. STAGE 1b2

STAGE 1A2
STAGE 2A

Figo staging with no obvious

parametrial invasion
a. < 4cm
b. > 4cm
Figo staging with obvious parametrial
involvement
Figo staging has extended to pelvic
wall; no CA-free space between tumor &
pelvic wall on rectal exam; involves
lower 3rd of vagina; with hydronephrosis
or non-functioning kidney
Figo staging with no extension to pelvic
wall ; involvement of lower 3rd of vagina
Figo staging extension to pelvic wall
and/or hydronephrosis or nonf(x) kidney
d/t tumor
Figo staging CA has extended beyond
true pelvis or has clinically involved
mucosa of bladder or rectum
a. Adjacent pelvic organs
b. Distant organs
ANY T
ANY N
M1
T4b
ANY N
M0
T4a ANY N
M0
ANY T
ANY N
M0
T4b
ANY N
M0
T4a N0-N1a M0
T1-T4a
N1b
M0
T1-3
N1a
M0
T2-T3
N0
M0
T1
N0 M0
ANY T
ANY N
M1
T4b

ANY N

M0

T3 N0 M0
T1-T3 N1a
M0
T4a N0-N1a
M0
T1-T4a
N1b
M0
T2
N0
M0
T1

N0

ANY T

M0
ANY N

M1

a. STAGE 2a1
b. STAGE 2a2
STAGE 2 B
STAGE 3

STAGE 3a
STAGE 3b

a. STAGE 4a
b. STAGE 4b

Anaplastic STAGE 4c

Anaplastic STAGE 4b
Anaplastic STAGE 4a
Medullary T-CA STAGE 4C

Medullary T-CA STAGE 4B

Medullary T-CA STAGE 4A
Medullary T-CA STAGE 3
Medullary T-CA STAGE 2
Meduallry T-CA STAGE 1
PTC/FTC staging (>45yo)
STAGE 4C
PTC/FTC staging (>45yo)
STAGE 4B
PTC/FTC staging (>45yo)
STAGE 3
PTC/FTC staging (>45yo)
STAGE 4A
PTC/FTC staging (>45yo)
STAGE 2
PTC/FTC staging (>45yo)
STAGE 1
PTC/FTC staging (<45yo)

ANY T

ANY N

M0

Distant Metastasis
Distant metastasis cannot be assesed
No distant metastasis
Metastasis to unilateral, bilateral, or
contralateral cervical or superior
mediastinal lymph node
Metastasis to level 4 pretracheal,
paratracheal, prelaryngeal/delphian
lymph node
No regional lymph node metastasis
Regional lymph node cannot be
assessed
Tumor invading prevertebral fascia, or
encasing carotid artery or mediastinal
vessels; extrathyroidal anaplastic CA
Any tumor size extending beyond
capsule for invasion or intrathyroidal
anaplastic cancer
Tumor >4cm diameter, limited to
thyroid or any tumor with minimal
extrathyroidal invasion
Markers B2-microglobulins
Marker AFP
Marker CA125

Marker CA 15-3
Marker Calcitonin
Carcinoembryonic Antigen (CEA)

Markers B-HCG

Vibrissae
Basal Cells

Brush Cells

STAGE 2
PTC/FTC staging (<45yo)
STAGE 1
THYROID TUMOR M1
TYROID TUMOR Mx
THYROID TUMOR M0
THYROID TUMOR N1b

THYROID TUMOR N1a

THYROID TUMOR N0
THYROID TUMOR Nx
THYROID TUMOR T4b

THYROID TUMORT4a

THYROID TUMORS T3

Myeloma & Non-Hodgkins

Lymphoma
Non-seminomatous germ cell
tumors
Hepatocellular CA
Lung
Gastrointestinal
Breast
Ovarian Epithelial
Breast CA
Medullary cell CA (THYROID)
Lung
Gastrointestinal
Breast
Colon
Choriocarcinoma
Non seminomatous germ cell
tumor
Seminoma
Nasal hairs
Lungs Histology- mitotically active stem
+ projenitor cells that give rise to the
other epithelial cell types
Lung Histology- chemosensory

Vestibule

Small granule cells

receptors, resembling gustatory cells

Boundary between keratinized
squamous + pseudostratified columnar
in the base
Lung Histology- AKA kulchitsky cells
(3%) part of diffuse neuroendocrine
systems (DNES)