1.

A 72£year-old woman has invasive lobular cancer, (ER/PR+, HER2 positive) with matted axillary
nodes. She requires an axillary dissection. What would be the result of an injury to the nerve
that runs parallel to the chest wall? A. Winged scapula

Modified Radical Mastectomy A modified radical mastectomy preserves the pectoralis major muscle
with removal of levels I, II, and III (apical) axillary lymph nodes.293 The operation was first described by
David Patey, a surgeon at St Bartholomew’s Hospital London, who reported a series of cases where he
had removed the pectoralis minor muscle allowing complete dissection of the level III axillary lymph
nodes while preserving the pectoralis major and the lateral pectoral nerve. A modified radical
mastectomy permits preservation of the medial (anterior thoracic) pectoral nerve, which courses in the
lateral neurovascular bundle of the axilla and usually penetrates the pectoralis minor to supply the
lateral border of the pectoralis major. Anatomic boundaries of the modified radical mastectomy are the
anterior margin of the latissimus dorsi muscle laterally, the midline of the sternum medially, the
subclavius muscle superiorly, and the caudal extension of the breast 2 to 3 cm inferior to the
inframammary fold inferiorly. Skin-flap thickness varies with body habitus but ideally is 7 to 8 mm
inclusive of skin and telasubcutanea (Fig. 17-35). Once the skin flaps are fully developed, the fascia of
the pectoralis major muscle and the overlying breast tissue are elevated off the underlying musculature,
which allows for the complete removal of the breast (Fig. 17-36).

Subsequently, an axillary lymph node dissection is performed. The most lateral extent of the axillary vein
is identified, and the areolar tissue of the lateral axillary space is elevated as the vein is cleared on its
anterior and inferior surfaces. The areolar tissues at the junction of the axillary vein and the anterior
edge of the latissimus dorsi muscle, which include the lateral and subscapular lymph node groups (level
I), are cleared. Care is taken to preserve the thoracodorsal neurovascular bundle. The dissection then
continues medially with clearance of the central axillary lymph node group (level II). The long thoracic
nerve of Bell is identified and preserved as it travels in the investing fascia of the serratus anterior
muscle. Every effort is made to preserve this nerve because permanent disability with a winged
scapula and shoulder weakness will follow denervation of the serratus anterior muscle. Patey divided
the pectoralis minor and removed it to allow access right up to the apex of the axilla. The pectoralis
minor muscle is usually divided at the tendinous portion near its insertion onto the coracoid process
(Fig. 17-37 inset), which allows dissection of the axillary vein medially to the costoclavicular (Halsted’s)
ligament. Finally, the breast and axillary contents are removed from the surgical bed and are sent for
pathologic assessment. In his modified radical mastectomy, Patey removed the pectoralis minor muscle.
Many surgeons now divide only the tendon of the pectoralis minor muscle at its insertion onto the
coracoid process while leaving the rest of the muscle intact, which still provides good access to the apex
of the axilla.

2. A postmenopausal woman has undergone Breast Conservation Surgery for @ 1.5- cn-estrogen
receptor—negative, progesterone receptor—negative, human epidermal growth factor receptor
2—positive invasive ductal carcinoma with negative sentinel nodes. Adjuvant treatment would
involve which of the following? C. Radiation, chemotherapy, and trastuzumab
 3. This breast pathology is characterized by chronic eczematoid eruptions of the nipple? Paget's
disease

Paget’s disease of the nipple was described in 1874. It frequently presents as a chronic, eczematous
eruption of the nipple, which may be subtle but may progress to an ulcerated, weeping lesion. Paget’s
disease usually is associated with extensive DCIS and may be associated with an invasive cancer. A
palpable mass may or may not be present. A nipple biopsy specimen will show a population of cells that
are identical to the underlying DCIS cells (pagetoid features or pagetoid change). Pathognomonic of this
cancer is the presence of large, pale, vacuolated cells (Paget cells) in the rete pegs of the epithelium.
Paget’s disease may be confused with superficial spreading melanoma. Differentiation from pagetoid
intraepithelial melanoma is based on the presence of S-100 antigen immunostaining in melanoma and
carcinoembryonic antigen immunostaining in Paget’s disease. Surgical therapy for Paget’s disease may
involve lumpectomy or mastectomy, depending on the extent of involvement of the nipple-areolar
complex and the presence of DCIS or invasive cancer in the underlying breast parenchyma.

4. A 46-year old female came in due to a 6 month history of a 4x5 cm nontender left breast mass,
bringing with her a mammogram reading of BIRADS 4A. What is the appropriate way to get a
histologic diagnosis of the said mass? Core needle biopsy

Less invasive, can use image guidance

5. A 39 y/o female noticed a 2cm hard mass on left breast 2 years ago, progressively enlarging to
its present size of 12x10cm, ulcerating weeping. The left axilla appears to be free of clinically
palpable nodes. The microscopic picture showed leaf-like pattern of complexity branching
spaces invaginated by fibrous stroma. What is the recommended treatment? Wide excision

Phylloides Tumor – recurrence is the problem

Phyllodes Tumors The nomenclature, presentation, and diagnosis of phyllodes tumors (including
cystosarcoma phyllodes) have posed many problems for surgeons.371 These tumors are classified as
benign, borderline, or malignant. Borderline tumors have a greater potential for local recurrence.
Mammographic evidence of calcifications and morphologic evidence of necrosis do not distinguish
between benign, borderline, and malignant phyllodes tumors. Consequently, it is difficult to differentiate
benign phyllodes tumors from the malignant variant and from fibroadenomas.

Phyllodes tumors are usually sharply demarcated from the surrounding breast tissue, which is
compressed and distorted. Connective tissue composes the bulk of these tumors, which have mixed
gelatinous, solid, and cystic areas. Cystic areas represent sites of infarction and necrosis. These gross
alterations give the gross cut tumor surface its classical leaf-like (phyllodes) appearance. The stroma of
a phyllodes tumor generally has greater cellular activity than that of a fibroadenoma. After
microdissection to harvest clusters of stromal cells from fibroadenomas and from phyllodes tumors,
molecular biology techniques have shown the stromal cells of fibroadenomas to be either polyclonal or
monoclonal (derived from a single progenitor cell), whereas those of phyllodes tumors are always
monoclonal. Most malignant phyllodes tumors (Fig. 17-38) contain liposarcomatous or
rhabdomyosarcomatous elements rather than fibrosarcomatous elements. Evaluation of the number of
mitoses and the presence or absence of invasive foci at the tumor margins may help to identify a
malignant tumor. Small phyllodes tumors are excised with a margin of normal-appearing breast tissue.
When the diagnosis of a phyllodes tumor with suspicious malignant elements is made, reexcision of the
biopsy specimen site to ensure complete excision of the tumor with a 1-cm margin of normal-appearing
breast tissue is indicated. Large phyllodes tumors may require mastectomy. Axillary dissection is not
recommended because axillary lymph node metastases rarely occur

6. The following are the nerves that are spared in doing Modified Radical Mastectomy except? one
of the above

long thoracic nerve Thoracodorsal nerve Medial pectoral nerve

A modified radical mastectomy permits preservation of the medial (anterior thoracic) pectoral
nerve, which courses in the lateral neurovascular bundle of the axilla and usually penetrates the
pectoralis minor to supply the lateral border of the pectoralis major

The long thoracic nerve of Bell is identified and preserved as it travels in the investing fascia of the
serratus anterior muscle. Every effort is made to preserve this nerve because permanent disability
with a winged scapula and shoulder weakness will follow denervation of the serratus anterior
muscle.

Care is taken to preserve the thoracodorsal neurovascular bundle.

7. A 43-year old female patient with a 1 cm palpable mass of the right breast for 5 years
underwent core-needle biopsy which revealed invasive ductal carcinoma. Breast conserving
therapy was done. Lymph nodes were negative for cancer cells. ER and PR tests were also
negative. What is the appropriate next step? Adjuvant chemotherapy

Breast Conserving Therapy - wide excision + ALN sampling surgery + RT

1cm mass ER/PR neg, if px can tolerate it, give chemotherapy