24: Breast Flashcards
1
Q
What percent of lymphatic drainage from the breast goes to the axillary nodes?
A
97%
[2% goes to the internal mammary nodes]
2
Q
What complication of axillary lymph node dissection should be suspected in a patient who develops slow swelling over 18 months?
A
Lymphatic fibrosis
3
Q
What is the relative risk of developing breast cancer in a patient with Fibrocystic disease with atypical hyperplasia?
A
Greatly increased risk (relative risk > 4)
[UpToDate: Atypical hyperplasias (ADH and ALH), especially multifocal lesions, confer a substantial increase in the risk of subsequent breast cancer (relative risk [RR] 3.7 to 5.3). AH is associated with an increased risk of both ipsilateral and contralateral breast cancer and thus provides evidence of underlying breast abnormalities that predispose to breast cancer. In a report from the Nurses’ Health Study, only 56 percent of cancers that developed in women with AH occurred in the ipsilateral breast. The cumulative incidence of breast cancer over 30 years approached 35 percent. Some studies have shown that the risk of developing breast cancer is higher with ALH than ADH; however, the data on this are conflicting. There is a higher risk of subsequent breast cancer when the ALH involves both lobules and ducts (RR 6.8) as compared with lobules alone (RR 4.3) or ducts alone (2.1).]
4
Q
What is the relative risk of developing breast cancer in a patient with DCIS or LCIS?
A
Greatly increased risk (relative risk > 4)
[DCIS: ipsilateral breast at risk. LCIS: both breasts have same high risk.]
5
Q
What is the most common organism responsible for infectious mastitis?
A
Staph aureus
[Associated with breastfeeding]
6
Q
Is having very large or pendulous breasts an absolute contraindication or a relative contraindication to breast-conserving therapy in invasive carcinoma if reproducibility of patient setup and adequate dose homogeneity cannot be ensured?
A
Relative contraindication
7
Q
Breast abscesses are usually associated with what risk factor?
A
Breast feeding
8
Q
What should be ruled out in a nonlacting woman with assumed infectious mastitis?
A
Necrotic cancer
[In nonlactating women, infectious mastitis can be due to chronic inflammatory diseases (eg actinomyces) or autoimmune disease (eg SLE)]
(requires incisional biopsy including the skin)
9
Q
What percentage of U.S women develop breast cancer in their lifetimes?
A
12% (1 in 8 women)
[5% in women with no risk factors.]
10
Q
True or false: almost all women with breast cancer recurrence die of disease?
A
True
[Increased recurrences and metastases occur with positive nodes, large tumors, negative receptors, and unfavorable subtypes.]
11
Q
What is the definition of a N3 breast tumor according to TNM classification?
A
Metastases in 10 or mor axillary nodes
or
In infraclavicular nodes
or
In internal mammary (IM) nodes in the presence of one or more positive axillary nodes
or
In more than 3 axillary nodes with IM metastases
or
In supraclavicular nodes
12
Q
Are persistent positive margins after reasonable surgical attempts an absolute contraindication or a relative contraindication to breast-conserving therapy in invasive carcinoma?
A
Absolute contraindication
13
Q
What is the definition of a Tis breast tumor according to TNM classification?
A
Carcinoma in situ, ductal, or lobular, or Paget’s disease of the nipple with no tumor
14
Q
What is the most common site for distant metastasis of breast cancer?
A
Bone
[Lung, liver, and brain also common]
15
Q
What is the chance of local recurrence following breast conserving therapy and XRT?
A
10%
[Usually happens within 2 years of 1st operation. Need to restage with recurrence and need salvage modified radical mastectomy for local recurrence.]
16
Q
Is a history of scleroderma or active systemic lupus erythematosus an absolute contraindication or a relative contraindication to breast-conserving therapy in invasive carcinoma?
A
Relative contraindication
17
Q
What is the risk of blood clots and endometrial cancer with tamoxifen use?
A
- Blood clot risk: 1%
- Endometrial cancer risk: 0.1%
18
Q
Male breast cancer is associated with which risk factors?
A
- Steroid use
- Previous XRT
- Family history
- Klinefelter’s syndrome
[Male breast cancer has an increased risk of pectoral muscle involvement. It has a poorer prognosis because of late presentation. Male breast cancer is usually ductal. Treatment is modified radical mastectomy.]
19
Q
What is the approach to a breast cyst in a pregnant woman?
A
Drain it and send FNA for cytology
20
Q
What is the treatment for inflammatory breast cancer?
A
Neoadjuvant chemo, then modified radical mastectomy, then adjuvant chemo-XRT
[UpToDate:
- For patients with non-metastatic IBC, we recommend neoadjuvant chemotherapy followed by locoregional treatment (Grade 1B). The optimal neoadjuvant chemotherapy regimen, including the sequence of agents and duration of treatment, is undefined, though anthracycline- and taxane-based chemotherapy regimens are typically recommended. Trastuzumab is indicated for human epidermal growth factor receptor 2 (HER2)-positive disease.
- Additional treatment considerations are similar to non-inflammatory breast cancer, including the use of endocrine therapy for hormone receptor-positive disease, the use of HER2-directed therapy for HER2-overexpressing disease, and the use of systemic agents for metastatic cancer. These issues are discussed in detail elsewhere.
- For patients with IBC, we suggest modified radical mastectomy rather than breast-conserving surgery, even for those with a complete clinical response (Grade 2C).
- For patients with IBC (including patients who achieve pathologic complete response to neoadjuvant chemotherapy), we recommend postmastectomy radiation therapy (Grade 1B).
- Although IBC is associated with a particularly poor prognosis and high risk of early recurrence, there is evidence that outcomes have improved with neoadjuvant chemotherapy followed by locoregional treatment.]
21
Q
Which breast pathology is usually not palpable and has no calcifications?
A
lobular carcinoma in situ (LCIS) of the breast
[Primarily found in premenopausal women. Usually an incidental finding; multifocal disease is common.]
22
Q
What complication of axillary lymph node dissection should be suspected in a patient who develops hyperesthesia of the inner arm and lateral chest wall?
A
Intercostal brachiocutaneous nerve injury
[Most commonly injured nerve after mastectomy; no significant sequelae.]
23
Q
What are the 7 indications for XRT following a mastectomy?
A
- > 4 positive nodes
- Skin or chest wall involvement
- Positive margins
- Tumor > 5 cm (T3)
- Extracapsular nodal invasion
- Inflammatory cancer
- Fixed axillary nodes (N2) or internal mammary nodes (N3)
24
Q
What is the lifetime risk of the following cancers in a patient with a BRCA I gene?
- Female breast cancer
- Ovarian cancer
- Male breast cancer
A
- Female breast cancer: 60% lifetime risk
- Ovarian cancer: 40% lifetime risk
- Male breast cancer: 1% lifetime risk
[BRCA II: Female breast cancer: 60% lifetime risk, Ovarian cancer: 10% lifetime risk, Male breast cancer: 10% lifetime risk.]
25
Is having two or more primary tumors in separate quadrants of the breast an absolute contraindication or a relative contraindication to breast-conserving therapy in invasive carcinoma?
Absolute contraindication
26
What percent of breast cancer is negative for both progesterone and estrogen receptors?
10%
27
What is the lifetime risk of the following cancers in a patient with a BRCA II gene?
1. Female breast cancer
2. Ovarian cancer
3. Male breast cancer
1. Female breast cancer: 60% lifetime risk
2. Ovarian cancer: 10% lifetime risk
3. Male breast cancer: 10% lifetime risk
[BRCA I: Female breast cancer: 60% lifetime risk, Ovarian cancer: 40% lifetime risk, Male breast cancer: 1% lifetime risk.]
28
When is a sentinel lymph node biopsy indicated for a breast mass?
In malignant tumors \> 1 cm (well suited for small tumors with low risk of axillary metastases)
[Not indicated in patients with clinically positive nodes as they need an axillary lymph node dissection.]
[UpToDate:
1. The status of the axillary lymph nodes is one of the most important prognostic factors in women with early-stage breast cancer. Histologic examination of removed lymph nodes is the most accurate method for assessing spread of disease to these nodes. Evaluation of the axilla is required for treatment decisions in patients with invasive breast cancer, and axillary lymph node dissection (ALND) remains the standard approach for women who are clinically node-positive.
2. For patients with early-stage breast cancer who are clinically node-negative, we recommend initial axillary evaluation with sentinel lymph node biopsy (SLNB) rather than ALND (Grade 1B).
3. For patients with ductal carcinoma in situ (DCIS) undergoing breast-conserving surgery, we recommend not performing surgical evaluation of the axilla (Grade 1A). For patients with extensive DCIS undergoing a mastectomy, we suggest SLNB (Grade 2B). Patients with DCIS extensive enough to require a mastectomy have a 20 percent chance of having occult invasive disease. If invasive disease is found and an SLNB has not been performed, the patient will require an ALND.
4. When an SLNB is not successful or when clinically suspicious nodes are present after all sentinel lymph nodes have been removed, an axillary dissection should be performed.
29
What is the treatment for lobular breast cancer?
Modified radical mastectomy or breast conserving therapy with postop XRT
[UpToDate: The surgical approach to early-stage breast cancer depends on the size of the tumor, whether or not multifocal disease is present, and the size of the breast. The options include breast-conserving therapy (breast-conserving surgery plus radiation therapy [RT]) or mastectomy (with or without RT). Both approaches result in equivalent cancer-specific outcomes. Most patients with locally advanced, inoperable breast cancer should receive neoadjuvant systemic therapy rather than proceeding with primary surgery. These patients are usually not candidates for breast conservation at their initial presentation. Neoadjuvant treatment improves the rate of breast conservation without compromising survival outcomes.]
30
What percentage of cystosarcoma phyllodes of the breast is malignant?
10%
[Based on mitoses per high-power field (\> 5-10).]
[UpToDate: Metastatic disease has been reported in 13 to 40 percent of patients with phyllodes tumors of the breast. Metastases most frequently involve the lungs. After the development of metastases, mean overall survival is 30 months. As with other soft tissue sarcomas, resection of pulmonary metastases is indicated when technically feasible.]
31
What percentage of all breast cancer is ductal cancer?
85%
32
What results in atrophy of breast tissue after menopause?
Lack of estrogen and progesterone
33
What is Stewart-Treves syndrome?
Lymphangiosarcoma from chronic lymphedema following axillary dissection
34
What is the workup for a breast cyst in a patient \> 40 years old?
Cyst excisional biopsy if bloody, if clear and recures, or if a complex cyst
[UpToDate:
1. Simple cysts, clustered microcysts, and cysts with thin septa are considered benign and no intervention is needed. Fine needle aspiration (FNA) can be performed if the cyst is symptomatic (painful) or obscures adjacent breast tissue.
2. If a symptomatic simple breast cyst recurs several times after aspiration, another mammogram and ultrasound should be performed to evaluate the area again. Excision is reserved for suspicious lesions or for patients who no longer desire repeat aspirations.
3. Complicated cysts are rarely malignant, but should be aspirated to confirm diagnosis or followed with imaging and examination every six months for two years to document stability. Image-guided FNA or biopsy is indicated if the lesion increases in size or changes in characteristics on repeat imaging.
4. Complex cysts should be biopsied, particularly those with thickened cyst walls and/or septa, and solid components.
5. Surgical intervention is indicated for complex cysts that are not amenable to core needle biopsy and when pathology results from a core biopsy are discordant, atypical, indeterminate, or reveal a malignancy.]
35
Which artery supplies the latissimus dorsi muscles?
Thoracodorsal artery
36
What is the relative risk of developing breast cancer in a patient who is obese, uses alcohol, or is on hormone replacement therapy?
Low increased risk (relative risk \<2)
37
What is the relative risk of developing breast cancer in a patient with prior breast cancer or prior radiation exposure?
Moderately increased risk (relative risk 2-4)
38
Are intraductal papilloma lesions premalignant?
No
39
What is the approach to a fibroadenoma in a patient \< 40 years old?
Observation if all 3 of the below criteria are met
* Mass feels clinically benign (firm, rubbery, rolls, not fixed)
* Ultrasound or mammogram consistent with fibroadenoma
* FNA or core needle biopsy shows fibroadenoma
[If all 3 criteria are not met, needs excisional biopsy. if fibroadenoma continues to enlarge during period of observation, then need excisional biopsy. Avoid resection of breast tissue in teenagers and younger children because it can affect breast development.]
[UpToDate: If a presumed fibroadenoma increases in size or is symptomatic, then excision is mandated to rule out malignant change and confirm the diagnosis. Rapid growth of a lesion raises the suspicion for a phyllodes tumor, unusual fibroepithelial tumors which require more extensive surgical resection, and in some cases may require radiation treatment as well.]
40
What is the 5-year survival in a breast cancer patient with 0 positive axillary lymph nodes?
75%
[American Cancer Society: Breast cancer survival rates, by stage
1. The 5-year relative survival rate for women with stage 0 or stage I breast cancer is close to 100%.
2. For women with stage II breast cancer, the 5-year relative survival rate is about 93%.
3. The 5-year relative survival rate for stage III breast cancers is about 72%.
4. Metastatic, or stage IV breast cancers, have a 5-year relative survival rate of about 22%.]
41
A scaly skin lesion on the nipple is most likely what?
Paget's disease of the breast
[Biopsy shows Paget's cells. Patients will likely have DCIS or ductal breast cancer.]
42
What is the treatment for a breast abscess?
1. Percutaneous or incision and drainage
2. Discontinue breastfeeding
3. Continue breast pumping
4. Antibiotics
[UpToDate:
* In the setting of nonsevere infection in the absence of risk factors for methicillin-resistant S. aureus (MRSA), outpatient therapy may be initiated with dicloxacillin (500 mg orally four times daily) or cephalexin (500 mg orally four times daily), pending culture results. In the setting of beta-lactam hypersensitivity, clindamycin (300 to 450 mg orally three times daily) may be used.
* In the setting of nonsevere infection with risk for MRSA, outpatient therapy with trimethoprim-sulfamethoxazole (1 to 2 tabs orally twice daily) or clindamycin (300 to 450 mg orally three times daily) may be initiated.
* In the setting of severe infection (eg, hemodynamic instability, progressive erythema), empiric inpatient therapy with vancomycin (15 to 20 mg/kg/dose every 8 to 12 hours, not to exceed 2 g per dose) should be initiated; therapy should be tailored to culture and sensitivity results. Gram stain results demonstrating gram-negative rods should prompt empiric antibiotic therapy against these organisms with a third-generation cephalosporin or a combination beta-lactam–beta-lactamase agent.]
43
What is the appropriate treatment for breast cancer in a woman in her
1. 1st trimester
2. 2nd trimester
3. 3rd trimester
1. 1st trimester: Modified radical mastectomy
2. 2nd trimester: Modified radical mastectomy
3. 3rd trimester: Modified radical mastectomy (unless late in which case breast conserving therapy with axillary lymph node dissection and postpartum XRT are an option.)
[No XRT during pregnancy. No breastfeeding after delivery.]
[UpToDate:
1. In general, pregnant women with breast cancer should be treated according to guidelines for nonpregnant patients, with some modifications to protect the fetus.
2. Either breast-conserving surgery or mastectomy is a reasonable option in the pregnant woman with breast cancer. A choice between them is guided by tumor characteristics and patient preferences.
3. Women with breast cancer during pregnancy should undergo an axillary node dissection. The safety of sentinel lymph node biopsy has not been established.
4. For women who require adjuvant radiation therapy (RT), we recommend adjuvant RT be administered after delivery rather than during pregnancy (Grade 1C).
5. For women in whom chemotherapy is recommended, we initiate treatment after the first trimester.
6. Chemotherapy should be avoided for three to four weeks before delivery to avoid transient neonatal myelosuppression and potential complications of sepsis and death.]
44
An axillary lymph node dissection must take what level of nodes?
Level I and level II
[Complications include infection, lymphedema, and lymphangiosarcoma.]
45
What percent of lymphatic drainage from the breast goes to the internal mammary nodes?
2%
[Any quadrant can drain to the internal mammary nodes]
46
Ductal carcinoma in situ (DCIS) of the breast is defined as malignant cells of the ductal epithelium without what?
Invasion of the basement membrane
[This is a premalignant lesion]
47
What is the most common breast lesion in adolescents and young women?
Fibroadenoma
[10% are multiple.]
48
What are 5 clinical features of breast cancer?
1. Distortion of normal architecture
2. Skin/nipple retraction or distortion
3. Hard
4. Tethered
5. Indistinct borders
49
What is the treatment for ductal breast cancer?
Modified radical mastectomy or breast conserving therapy with postop XRT
[UpToDate: The surgical approach to early-stage breast cancer depends on the size of the tumor, whether or not multifocal disease is present, and the size of the breast. The options include breast-conserving therapy (breast-conserving surgery plus radiation therapy [RT]) or mastectomy (with or without RT). Both approaches result in equivalent cancer-specific outcomes. Most patients with locally advanced, inoperable breast cancer should receive neoadjuvant systemic therapy rather than proceeding with primary surgery. These patients are usually not candidates for breast conservation at their initial presentation. Neoadjuvant treatment improves the rate of breast conservation without compromising survival outcomes.]
50
What is stage 1 based on the breast TNM classification?
T1 N0 M0
51
What is the treatment for mastodynia (breast pain)?
1. Danazol
2. OCPs
3. NSAIDs
4. Evening primrose oil
5. Bromocriptine
[Discontinue caffeine, nicotine, methylxanthines]
52
Which nerve innervates the latissimus dorsi muscles?
Thoracodorsal nerve
[Injury results in weak arm pull-ups and adduction.]
53
What is the definition of a T0 breast tumor according to TNM classification?
No evidence of primary tumor
54
Which 2 solutions can be injected into the tumor area to identify the sentinel node?
Lympazurin blue dye
Radiotracer
[Type I hypersensitivity reactions have been reported with lympazurin blue dye.]
55
What is the workup for a breast mass in a patient \> 40 years old?
Bilateral mammograms, ultrasound, and core needle biopsy
[If core needle biopsy or FNA is indeterminate, non-diagnostic, or non-concordant with exam findings/imaging studies then an excisional biopsy in required. Clinically indeterminate or suspicious solid masses will eventually need excisional biopsy unless cancer diagnosis is made prior to that.]
56
Which hormone promotes lobular development of the breast?
Progesterone
57
What is the most important prognostic staging factor in breast cancer?
Axillary nodes (survival is directly related to the number of positive nodes)
[Other important staging factors are tumor size, tumor grade, progesterone and estrogen receptor status.]
58
What are the 8 findings on core needle biopsy of the breast that are an indication for surgical biopsy?
1. Atypical ductal hyperplasia
2. Atypical lobular hyperplasia
3. Radial scar
4. Lobular carcinoma in situ
5. Columnar cell hyperplasia with atypia
6. Papillary lesions
7. Lack of concordance between appearance of mammographic lesion and histologic diagnosis
8. Nondiagnostic specimen
59
What is the treatment for ductal carcinoma in situ (DCIS) of the breast?
Lumpectomy and XRT with 1 cm margins and possibly tamoxifen (no sentinel lymph node biopsy or axillary dissection is necessary)
[Simple mastectomy if high grade (eg comedo type, multicentric, multifocal), or if it is large and not amenable to lumpectomy, or if not able to get good margins. Again no axillary lymph node dissection.]
[UpToDate:
1. Local therapy for DCIS consists of mastectomy or breast-conserving therapy (BCT). BCT for DCIS includes lumpectomy, generally followed by RT, and results in breast cancer-specific survival rates comparable to mastectomy, although the rate of local recurrence is higher with BCT.
2. Candidates for BCT include patients with DCIS whose disease is localized to one quadrant and can be resected with negative margins in a cosmetically acceptable manner, taking into account the size of disease relative to the breast size. Re-excision(s), mastectomy, or radiation boost should be performed if close or positive margins are present.
3. For patients who are candidates for BCT, we suggest BCT over mastectomy (Grade 2B). We recommend that most women undergoing BCT receive RT in addition to lumpectomy (Grade 1B).
4. For patients with very small foci of low-grade DCIS, breast-conserving surgery only (ie, omission of RT) with widely negative margins (ideally 10 mm) is an option. However, prospective randomized evidence to support the omission of adjuvant radiation is limited, even in selected low-risk cases.
5. For most patients with DCIS, we recommend not performing surgical evaluation of the axilla (Grade 1A). However, we suggest sentinel lymph node biopsy (SLNB) in patients who do not meet criteria for BCT and thus require mastectomy (Grade 2B).]
60
What is stage IV based on the breast TNM classification?
Any T Any N M1
61
What are 4 contraindications to XRT in breast conserving therapy?
1. Scleroderma (results in severe fibrosis and necrosis)
2. Previous XRT and would exceed recommended dose
3. SLE (relative contraindication)
4. Active rheumatoid arthritis (relative contraindication
62
Breast abscesses are most commonly due to which bacteria?
Staph aureus
[Strep is common too]
63
What is the most common breast anomaly?
Accessory nipples
[Can be found from the axilla to the groin]
64
What are the 4 subtypes of ductal breast cancer?
Medullary: More favorable prognosis
Tubular: More favorable prognosis
Mucinous: More favorable prognosis
Scirrhotic: Worse prognosis
65
What percentage of patients with ductal carcinoma in situ (DCIS) of the breast get cancer if it is not resected?
50%
[5% get cancer in the contralateral breast]
66
Which has a better prognosis: Progesterone receptor-positive tumors or estrogen receptor-positive breast tumors?
Progesterone receptor positive
[Tumors that are both progesterone receptor and estrogen receptor positive have the best prognosis.]
67
What is the sensitivity/specificity of mammography?
90%
[Sensitivity increases with age as the dense parenchymal tissue is replaced with fat.]
68
Which surgical option removes all breast tissue including the nipple areolar complex and includes an axillary node dissection (level I nodes)?
Modified radical mastectomy
[UpToDate: A modified radical mastectomy (MRM) is complete removal of the breast and the underlying fascia of the pectoralis major muscle along with the removal of the level I and II axillary lymph nodes. Several randomized trials documented equivalent survival rates with MRM as compared with radical mastectomy, with less morbidity. The equivalent survival outcome of the two procedures was further confirmed in an analysis of 3236 women enrolled in four randomized trials. Modified radical mastectomy is utilized in patients requiring or desiring mastectomy who have biopsy-proven axillary metastases.]
69
Breast tumors in which 2 locations have increased risk of multicentricity?
1. Central
2. Subareolar
70
Which artery supplies the serratus anterior muscles?
Lateral thoracic artery
71
What is the definition of a T1 breast tumor according to TNM classification?
Tumor 2 cm or less in greatest dimension
72
What is stage IIA based on the breast TNM classification?
* T0 N1 M0
* T1 N1 M0
* T2 N0 M0
73
What is stage IIIB based on the breast TNM classification?
* T4 N0 M0
* T4 N1 M0
* T4 N2 M0
74
Receptor-positive breast tumors are more common in pre- or post-menopausal women?
Post-menopausal
75
Is a history of prior therapeutic irradiation to the breast region of concern that would result in retreatment to an excessively high radiation dose an absolute contraindication or a relative contraindication to breast-conserving therapy in invasive carcinoma?
Absolute contraindication
76
What are the boundaries of node levels in axillary nodes?
* Level I: Inferior and lateral to pectoralis minor muscle
* Level II: Beneath the pectoralis minor muscle and below the axillary vein
* Level III: medial to pectoralis minor muscle against the chest wall
[In an axillary dissection, one must take level I and level II nodes (take level III nodes only if grossly involved).]
77
How does pregnancy affect timing of presentation and screening modalities of a breast mass?
Tends to present late (leading to worse prognosis) and mammography and ultrasound do not work as well during pregnancy
[Try to use ultrasound to avoid radiation.]
78
Branches of which 4 arteries supply the breast?
1. Internal thoracic (internal mammary) artery
2. Intercostal arteries
3. Thoracoacromial artery
4. Lateral thoracic artery
79
Which mammography findings are suggestive of cancer?
1. Irregular borders
2. Spiculated
3. Multiple, clustered, small, thin, linear, crushed-like and/or branching calcifications
4. Ductal asymmetry or distortion of architecture
80
What are some complications of XRT in breast conserving therapy?
* Edema
* Erythema
* Rib fractures
* Pneumonitis
* Ulceration
* Sarcoma
* Contralateral breast cancer
81
What is the most common cause of bloody nipple discharge?
Intraductal papilloma
[Usually small, nonpalpable, and close to the nipple]
82
Which kind of breast cancer is automatically considered T4 disease and is very aggressive?
Inflammatory breast cancer
[UpToDate: It is important to rule out inflammatory breast cancer if a suspected breast infection does not respond to antibiotics.]
83
When is chemotherapy indicated in a patient with a breast mass that is \> 1 cm but has negative lymph nodes?
Everyone with gets chemotherapy except women with positive estrogen receptors
[Post menopausal women with positive estrogen receptors can get hormonal therapy with anastrazole (aromatase inhibitor). Pre-menopausal women with positive estrogen receptors can get hormonal therapy with tamoxifen.]
84
Which types of fibrocystic change carry a cancer risk?
Atypical ductal or lobular hyperplasia
[These lesions need to be resected. Negative margins are not necessary with atypical hyperplasia; just remove all suspicious areas (ie calcifications) that appear on mammogram.]
85
What percentage of all breast cancer is lobular cancer?
10%
86
Which hormone cyclically increases breast swelling and growth of glandular tissue?
Estrogen
87
What are the indications for considering prophylactic mastectomy?
* Family history + BRCA gene
* LCIS
In the setting of one of the following
* High patient anxiety, poor patient access for follow-up exams and mammograms, difficult lesion to follow on exam or with mammograms, or patient preference for mastectomy
[UpToDate: Based upon a prospective study of 745 women with breast cancer and a family history of breast and/or ovarian cancer undergoing a CPM, the risk-reduction of a contralateral breast cancer (CBC) was approximately 96 percent. In this cohort, the risk reduction following a CPM for women less than age 50 years (n = 388) was 94.4 percent and 96.0 percent for women 50 years of age and older.]
88
Breast pain, nipple discharge (usually yellow to brown), lumpy breast tissue that varies with hormonal cycles are symptoms consistent with what?
Fibrocystic disease of the breast
[Many types: Papillomatosis, sclerosing adenosis, apocrine metaplasia, duct adenosis, epithelial hyperplasia, ductal hyperplasia, and lobular hyperplasia.]
89
What is the approach to a solid breast mass in a pregnant woman?
Core needle biopsy or FNA
[If core needle and/or FNA is equivocal, need to get ecisional biopsy.]
[UpToDate:
1. Pregnant or postpartum women with breast cancer usually present similarly to nonpregnant women, with a mass or thickening in the breast. Rarely, a nursing infant has refused a breast that harbors an occult carcinoma, leading to an early diagnosis of breast cancer; this has been named the milk rejection sign.
2. The index of suspicion for cancer must be high in pregnant women with a breast mass. A breast mass that persists for more than two weeks should be investigated, although the majority (80 percent) of breast biopsies performed in pregnant women will prove to be benign. The differential diagnosis of a breast mass in a pregnant or lactating woman includes epithelial breast cancer, a lactating adenoma, fibroadenoma, cystic disease, lobular hyperplasia, milk retention cyst (galactocele), abscess, lipoma, hamartoma, and rarely, leukemia, lymphoma, phyllodes tumors, sarcoma, neuroma, or tuberculosis.
3. Mammography is not contraindicated in pregnancy as the average glandular dose to the breast for a two-view mammogram (200 to 400 millirad) provides a negligible radiation dose to the fetus, as long as abdominal shielding is used. Abdominal shielding is recommended, although there is no clinical data comparing fetal radiation exposure with or without shielding.]
90
During a sentinel lymph node biopsy for a breast mass, what must be done if no radiotracer or dye is found?
Need to do a formal axillary lymph node dissection
[UpToDate: When an SLNB is not successful or when clinically suspicious nodes are present after all sentinel lymph nodes have been removed, an axillary dissection should be performed.]
91
What percentage of breast cancers have a negative mammogram and a negative ultrasound?
10%
92
What is the treatment for periductal mastitis?
1. If typical creamy discharge is present that is not bloody and not associated with nipple retraction, give antibiotics and reassure
2. If not or if it recurs, need to rule out inflammatory carcinoma with an incisional biopsy including the skin
[UpToDate: Usually a chronic problem. In the setting of purulent nipple discharge, Gram stain and culture should be obtained. Approximately half of the cases resolve with antibiotic therapy together with needle aspiration or incision and drainage of any associated abscess. Patients with repeated episodes of periareolar infection warrant surgical treatment with excision of diseased ducts.
Empiric antibiotic therapy for periductal mastitis consists of amoxicillin-clavulanate (875 mg orally every 12 hours). Reasonable alternative regimens include dicloxacillin or cephalexin (with metronidazole if anaerobes are suspected). If risk for methicillin-resistant Staphylococcus aureus (MRSA) is high, trimethoprim-sulfamethoxazole or doxycycline is an appropriate regimen. In the setting of beta-lactam hypersensitivity, clindamycin (300 to 450 mg orally three times daily) is a reasonable alternative. Therapy should be tailored to results of Gram stain and culture results when available.
Smoking cessation is helpful for reducing the risk of repeat infection.]
93
What margins are needed in breast conserving therapy prior to starting XRT?
1 cm negative margins
[UpToDate: The appropriate macroscopic margin of normal breast tissue to resect around the tumor for women undergoing BCT should be 0.5 to 1.0 cm of grossly normal breast tissue, which will usually result in histologically negative margins (ie, no tumor at ink) in the majority of patients. Larger resections may be necessary for invasive carcinomas with an extensive intraductal component (EIC) or for infiltrating lobular carcinomas.]
94
How does cystosarcoma phyllodes of the breast spread?
Hematogenously (metastasis is rare however)
[No nodal metastases.]
95
What is the treatment for Paget's disease of the breast?
Modified radical mastectomy if cancer is present
[If no cancer present, simple mastectomy will suffice (need to include the nipple-areolar complex with Paget's).]
96
By what percentage does having a first-degree relative with bilateral, premenopausal breast cancer increase the risk of developing breast cancer?
50%
97
Is one's ability to lactate frequently compromised after a breast reduction?
Yes
98
Breast cancer with positive supraclavicular nodes is considered which N stage in TNM staging?
N3 disease
99
What complication of axillary lymph node dissection should be suspected in a patient who develops sudden, early, postop swelling?
Axillary vein thrombosis
100
What is the definition of a N1 breast tumor according to TNM classification?
* Metastasis to 1-3 axillary nodes
or
* In internal mammary (IM) nodes with microscopic disease detected by sentinel node biopsy, which is not clinically apparent
101
What is metastatic flare?
Pain, swelling, erythema in metastatic areas
[XRT can help. XRT is good for bone metastases.]
102
Which hormone cyclically increases maturation of glandular tissue, and causes menses when withdrawn?
Progesterone
103
What is the preferred chemotherapy regimen for breast cancer?
Taxanes (docetaxel, paclitaxel), adriamycin, and cyclophosphamide (TAC) for 6-12 weeks
[After chemo, patients positive for estrogen receptors should receive appropriate hormonal therapy. Post-menopausal = anastrazole. Pre-menopausal = tamoxifen.]
[UpToDate:
1. For patients in whom chemotherapy is recommended, the choice of regimen (ie, single-agent or a combination) and selection of a specific therapy depends on multiple factors, including the tumor burden (both in tumor volume and the presence of disease-related symptoms), general health status, prior treatments and toxicities, and patient preferences. These factors can help in the formulation of an individualized treatment plan in the first- or later-line setting.
2. For patients with a limited tumor burden and/or limited or minimal cancer-related symptoms, we suggest single-agent chemotherapy administered sequentially rather than combination chemotherapy (Grade 2B). Taxanes and anthracyclines are most the commonly administered single agents, especially in the first-line treatment of metastatic breast cancer.
3. For select patients with symptomatic disease due to the location of specific metastatic lesions (eg, right upper quadrant pain due to expanding liver metastases, or dyspnea related to diffuse lung metastases) and a large tumor burden, we suggest a combination regimen rather than a single-agent (Grade 2B). Combination therapy results in a greater likelihood of a response compared with single-agent therapy, which may be of a sufficient benefit to justify the risks of treatment.
104
Which hormone promotes duct development of the breast?
Estrogen
105
By what percentage does tamoxifen decrease risk of breast cancer?
50%
106
What is stage IIIA based on the breast TNM classification?
* T0 N2 M0
* T1 N2 M0
* T2 N2 M0
* T3 N1 M0
* T3 N2 M0
107
What is the treatment for cystosarcoma phyllodes of the breast?
Wide local excision with negative margins and no axillary lymph node dissection (it does not spread to the lymph nodes)
[Can often be large tumors that resemble giant fibroadenomas with stromal and epithelial elements (mesenchymal tissue).]
[UpToDate: A complete surgical excision is the standard of care for a phyllodes tumor. Based upon a retrospective review of 164 patients, surgical approach should include a wide local excision with histologic margins negative for malignant cells. Other studies suggest a histologic margin of at least 1 cm, which is much larger than what is required for invasive or in situ breast cancer. Unfortunately, local excision without attention to margins is often performed, particularly since phyllodes tumors are often misdiagnosed as fibroadenomas preoperatively. Recurrence rates are unacceptably high following either local excision or enucleation without negative margins. In a multivariate survival analysis that included 172 patients with phyllodes tumors, a positive surgical margin was associated with an almost fourfold risk of a tumor-related event (eg, local recurrence, distant disease) (hazard ratio [HR] 3.9, 95% CI 1.1-14.3).]
108
What is the relative risk of developing breast cancer in a patient with _\>_ 2 primary relatives with bilateral or premenopausal breast cancer?
Greatly increased risk (relative risk \> 4)
109
What is the approach to a fibroadenoma in a patient \> 40 years old?
Excisional biopsy to ensure diagnosis
110
What is the definition of a N0 breast tumor according to TNM classification?
No regional node metastases histologically, no additional examination for isolated tumor cells (ITCs)
111
Which intervention (other than for breast cancer) should be considered in BRCA families with a history of breast cancer?
Total abdominal hysterectomy (TAH) and bilateral salpingoopherectomy (BSO)
[UpToDate: Studies have demonstrated that bilateral salpingo-oophorectomy reduces ovarian cancer risk (hazard ratio [HR] 0.28, 95% CI 0.12-0.69) and mortality, and also substantially reduces breast cancer risk [HR 0.54, 95% CI 0.37-0.79] and mortality when performed in premenopausal women. Postmenopausal women do not appear to derive a strong benefit from salpingo-oophorectomy with respect to breast-cancer-risk reduction, but they do reduce their ovarian cancer risk. Thus, mutation carriers who have undergone this procedure, either for prophylaxis or for other medical reasons, substantially reduce their cancer risk.]
112
Radiotherapy usually consists of how many rad when being used in conjunction with breast conserving therapy?
5,000 rad
113
What are the 6 contraindications to a sentinel lymph node biopsy?
1. Pregnancy
2. Multicentric disease
3. Neoadjuvant therapy
4. Clinically positive nodes
5. Prior axillary surgery
6. Inflammatory or locally advanced disease
[UpToDate: The use of sentinel node biopsy in special circumstances, including patients with locally advanced disease, patients undergoing neoadjuvant chemotherapy, pregnant patients, and those who have had prior breast or axillary surgery remains controversial. Inflammatory breast cancer is one of the few absolute contraindications to SLNB.]
114
Is most nipple discharge benign or malignant?
Benign
[All cases need a history, breast exam, and bilateral mammogram. Try to find trigger point or mass on exam.]
[UpToDate: Nipple discharge is categorized as normal (lactation), benign (physiologic), or pathologic based on the characteristics of presentation. Most nipple discharge is benign in origin. Pathologic discharge is characterized by spontaneous, persistent, unilateral discharge limited to one duct (uniductal). The discharge can be either serous (straw-colored or clear), sanguineous (bloody), or serosanguineous (blood-tinged). An intraductal papilloma is the cause of pathologic discharge in over half the cases, while underlying malignancy is the cause of nipple discharge in 5 to 10 percent of cases.]
115
Are diffuse malignant-appearing microcalcifications an absolute contraindication or a relative contraindication to breast-conserving therapy in invasive carcinoma?
Absolute contraindication
116
What is the definition of a T3 breast tumor according to TNM classification?
Tumor more than 5 cm in greatest dimension
117
What is the relative risk of developing breast cancer in a patient with proliferative benign disease?
Low increased risk (relative risk \<2)
118
Which two hormones cause ovum release during the menstruation cycle?
FSH and LH surge
119
What is the #1 cause of primary axillary adenopathy?
Lymphoma
120
Which breast mass is usually painless, slow growing, well circumscribed, firm, and rubbery?
Fibroadenoma
[Often grows to several cm in size and then stops. Giant fibromas can be \> 5 cm (treatment is the same). Can change in size with menstrual cycle and can enlarge in pregnancy.]
121
What are the suspensory ligaments of the breast that divide the breast into segments called?
Cooper's ligaments
[Breast cancer involving these strands can dimple the skin]
122
When is chemotherapy indicated in a patient with a breast mass and positive lymph nodes?
Everyone with positive lymph nodes gets chemotherapy except postmenopausal women with positive estrogen receptors
[Post menopausal women with positive estrogen receptors can get hormonal therapy with anastrazole (aromatase inhibitor).]
123
What is the difference between the yield of a core needle biopsy vs an FNA?
* CNBx: Gives architecture
* FNA: Gives cytology (just the cells)
124
What are the 5 BI-Rads classifications of mammographic abnormalities?
* Category 1: assessment negative (recommendation: routine screening)
* Category 2: Benign finding (recommendation: routine screening)
* Category 3: Probably a benign finding (recommendation: Short interval follow-up mammogram)
* Category 4: suspicious abnormality like indeterminate calcifications or architecture (recommendation: Core needle biopsy to rule out cancer. If benign then 6 month follow up. If insufficient then need needle localization excisional biopsy)
* Category 5: highly suggestive of cancer such as suspicious caclifications or architecture (recommendation: Core needle biopsy to rule out cancer. If malignancy not found then need needle localization excisional biopsy.)
[Core needle biopsy without excisional biopsy allows appropriate staging with sentinel lymph node biopsy since the mass is still present and allows for one-step surgery (avoids 2 surgeries) for patients diagnosed with breast cancer.]
125
What is the treatment for an intraductal papilloma?
Subareolar resection of the involved duct and papilloma
[Get contrast ductogram to find papilloma, then needle localization]
[UpToDate: Intraductal papillomas consist of a monotonous array of papillary cells that grow from the wall of a cyst into its lumen. Although they are not concerning in and of themselves, they can harbor areas of atypia or ductal carcinoma in situ (DCIS). Papillomas can occur as solitary or multiple lesions. The standard approach to a papilloma diagnosed by core needle biopsy (CNB) is to perform a surgical excision, particularly if atypical cells are identified. In a meta-analysis of 34 studies that included 2236 non-malignant breast papillary lesions, 346 (15.7 percent) were upgraded to malignancy following a surgical excision. Because of a risk of malignancy, these require surgical excision.]
126
Which type of breast cancer has dermal lymphatic invasion which causes a peau d'orange lymphedema appearance of the breast that is erythematous and warm?
Inflammatory breast cancer
127
What is stage 0 based on the breast TNM classification?
Tis N0 M0
128
What is the relative risk of developing breast cancer in a patient with early menarche, late menopause, or nulliparity?
Low increased risk (relative risk \<2)
129
The risk of recurrence of ductal carcinoma in situ (DCIS) of the breast is higher with lesions of what size?
Lesions \> 2.5 cm
[UpToDate:
1. Ductal carcinoma in situ (DCIS) of the breast represents a heterogeneous group of neoplastic lesions confined to the breast ducts and lobules. Its diagnosis has increased dramatically with the introduction of breast cancer screening mammography.
2. The risk of DCIS increases with age. It is uncommon in women younger than 30 and is as high as 88 per 100,000 in women aged 50 to 64 years.
3. The risk of cancer-related death in women with DCIS is low, estimated at 1.9 percent within 10 years.
4. Most cases of DCIS are detected only on imaging studies (most commonly by the presence of mammographic microcalcifications).
5. Percutaneous core biopsy under stereotactic or ultrasound guidance is preferred in the evaluation of mammographically-identified microcalcifications. Fine needle aspiration biopsy is inadequate for the diagnosis of DCIS, as it cannot distinguish between invasive and in situ disease. In technically challenging stereotactic cases, wire localization biopsy may be preferable.]
130
Which nerve innervates the serratus anterior muscles?
Long thoracic nerve
[Injury results in winged scapula]
131
What is the 5-year survival in a breast cancer patient with 4-10 positive axillary lymph nodes?
40%
[American Cancer Society: Breast cancer survival rates, by stage
1. The 5-year relative survival rate for women with stage 0 or stage I breast cancer is close to 100%.
2. For women with stage II breast cancer, the 5-year relative survival rate is about 93%.
3. The 5-year relative survival rate for stage III breast cancers is about 72%.
4. Metastatic, or stage IV breast cancers, have a 5-year relative survival rate of about 22%.]
132
What is the treatment for lobular carcinoma in situ (LCIS) of the breast?
No treatment necessary vs trial of tamoxifen vs bilateral subcutaneous mastectomy without axillary dissection
[Do not need negative margins.]
[UpToDate:
1. For patients with a high-risk proliferative breast lesion (eg, atypical hyperplasia, flat epithelial atypia, lobular carcinoma in situ) identified by a core needle biopsy, we perform a wide excision of the lesion as an attempt to identify a malignancy.
2. For patients with a high-risk proliferative breast lesion (eg, flat epithelial atypia, atypical hyperplasia, lobular carcinoma in situ) identified by an excisional biopsy, we recommend no further resection of the lesion (Grade 1C).
3. For patients with pleomorphic LCIS (PLCIS), we suggest a wide excision with negative margins for local control and to exclude malignancy (Grade 2C). The nuclear features, necrosis, and calcifications can make the differentiation from DCIS challenging, and the behavior of PLCIS is uncertain. (Grade 2C).]
133
What percentage of patients with lobular carcinoma in situ (LCIS) of the breast get cancer (either breast)?
40%
[lobular carcinoma in situ (LCIS) of the breast is considered a marker for the development of cancer rather than being premalignant itself.]
[UpToDate:
1. When first described, LCIS was assumed to be malignant since it was sometimes found in association with an invasive cancer, and therefore, believed to be best managed with mastectomy. Subsequent data suggested that LCIS is an indolent lesion with very low malignant potential, but that it conveys a risk for ipsilateral as well as contralateral invasive breast cancer.
2. LCIS is a risk factor for invasive carcinoma, and may be a direct precursor lesion. Retrospective series report a higher risk of developing ipsilateral than contralateral invasive breast cancer and a greater likelihood of developing invasive lobular carcinoma rather than invasive ductal carcinoma, suggesting that LCIS represents more of a precursor lesion than previously suspected. Observational studies identified infiltrating lobular carcinoma in 23 to 49 percent of subsequent cancers in women previously diagnosed with LCIS, compared with 5 to 13 percent incidence observed among breast cancer patients in general.
3. The relative risk of developing an invasive cancer in women with LCIS is approximately two-fold higher than for women without LCIS. The absolute risk is approximately 1 percent per year and appears to be life-long.]
134
What is stage IIIC based on the breast TNM classification?
Any T N3 M0
135
What is the definition of a Nx breast tumor according to TNM classification?
Nodes cannot be assessed
136
Where are Rotter's nodes located?
Between the pectoralis major and pectoralis minor muscles
137
Noncyclical mastodynia, erythema, nipple retraction, and creamy discharge from the nipple that is sometimes associated with sterile or infected subareolar abscesses are symptoms of what?
Periductal mastitis (mammary duct ectasia or plasma cell mastitis)
[Risk factors are smoking and nipple piercings. biopsy demonstrates dilated mammary ducts, inspissated secretions, and marked periductal inflammation.]
138
Which nerve innervates only the pectoralis major?
Lateral pectoral nerve
139
What is the median survival in patients with untreated breast cancer?
2-3 years
140
What is the treatment for a galactocele (breast cyst filled with milk)?
Aspiration vs incision and drainage
141
What is the definition of a T4 breast tumor according to TNM classification?
Tumor of any size with direct extension to the chest wall (not including pectoralis muscle), skin edema, skin ulceration, satellite skin nodules, or inflammatory carcinoma
142
By what percentage does screening for breast cancer reduce mortality?
25%
143
What is the definition of a Tx breast tumor according to TNM classification?
Primary tumor cannot be assessed
144
What is the definition of a T2 breast tumor according to TNM classification?
Tumor more than 2 cm but not more than 5 cm in greatest dimension
145
What causes neonatal breast enlargement?
Circulating maternal estrogens
[It will spontaneously regress.]
146
What percentage of patients with lobular carcinoma in situ (LCIS) of the breast who develop breast cancer develop ductal carcinoma?
70%
[5% risk of having synchronous breast cancer at the time of diagnosis of LCIS (most likely ductal carcinoma).]
147
Is the breast formed from endoderm, mesoderm, or ectoderm?
Ectoderm
[It is formed from the ectoderm milk streak]
148
Is pregnancy an absolute contraindication or a relative contraindication to breast-conserving therapy in invasive carcinoma?
Absolute contraindication (Because XRT cannot be utilized)
[When cancer is diagnosed in the third trimester; it may be possible to perform breast-conserving surgery and treat the patient with irradiation after delivery.]
149
What is the current recommendation for mammography screening?
1. Every 2-3 years beginning at age 40
2. Yearly after age 50
[High risk screening mammogram 10 years before the youngest age of diagnosis of breast cancer in a first-degree relative. No mammography in patients \< 40 years of age unless high risk (mammograms in younger women are hard to interpret because of dense parenchyma and expose women to radiation at a young age).]
[UpToDate:
1. The benefit of screening increases as women age (eg, the absolute benefit is more for women in their 50s and 60s than 40s). Screening should be available to all women over age 40 who opt to be screened after shared decision-making. For healthy women over age 40, we suggest that decisions about screening for breast cancer be individualized, based on discussion of the benefits and harms of screening and personal values and preferences; we do not encourage women to begin screening at age 40. We suggest breast cancer screening with mammography for women aged 50 to 74 years (Grade 2B).
2. We suggest that women over the age of 74, and younger women who have comorbid medical problems, be offered screening only if their life expectancy is at least 10 years (Grade 2C).
3. We recommend that screening be performed with mammography, rather than other modalities, when a decision is made to screen (Grade 1B).
4. The ideal interval for screening mammography is not known. We suggest screening every two years (Grade 2B). Alternative intervals for younger women may be preferred by some clinicians, patients, or national policies.]
150
What is occult breast cancer and what is the treatment?
Breast cancer that presents as axillary metastases with an unkown primary
[Treatment is modified radical mastectomy (70% are found to have breast cancer).]
151
Is a large tumor in a small breast that would result in cosmesis unacceptable to the patient an absolute contraindication or a relative contraindication to breast-conserving therapy in invasive carcinoma?
Relative contraindication
152
What is Poland's syndrome?
1. Hypoplasia of the chest wall
2. Amastia
3. Hypoplastic shoulder
4. No pectoralis muscle
153
Approximately how long does it take to go from a single malignant cell to a 1-cm tumor?
5-7 years
154
What is the workup for a breast mass in a patient \< 40 years old?
Ultrasound and core needle biopsy (consider FNA)
[If clinical exam or ultrasound is indeterminate or if suspicious for cancer then a mammogram is indicated (although in general one should avoid excess radiation in this group).]
155
What is the relative risk of developing breast cancer in a patient with a first-degree relative with breast cancer?
Moderately increased risk (relative risk 2-4)
156
What is Batson's plexus?
Valveless vein plexus that allows direct hematogenous metastasis of breast cancer to spine
157
What histological finding confers a worse prognosis in lobular breast cancer?
Signet ring cells
158
What has prominent fibrous tissue compressing epithelial cells on pathology and can have large, coarse calcifications (popcorn lesions) on mammography from degeneration?
Fibroadenoma
159
What is the most common location for polythelia (accessory breast tissue) to occur?
The axilla
160
Which breast pathology is usually not palpable and presents as a cluster of calcifications on mammography?
Ductal carcinoma in situ (DCIS) of the breast
[Can have solid, cribriform, papillary, and comedo patterns.]
[UpToDate:
1. Most cases of DCIS are detected only on imaging studies (most commonly by the presence of mammographic microcalcifications).
2. Percutaneous core biopsy under stereotactic or ultrasound guidance is preferred in the evaluation of mammographically-identified microcalcifications. Fine needle aspiration biopsy is inadequate for the diagnosis of DCIS, as it cannot distinguish between invasive and in situ disease. In technically challenging stereotactic cases, wire localization biopsy may be preferable.]
161
What is the relative risk of developing breast cancer for a patient with a BRCA gene mutation and a family history of breast cancer?
Greatly increased risk (relative risk \> 4)
162
Cyclic mastodynia (breast pain) most commonly represents what?
Fibrocystic disease
163
What is the relative risk of developing breast cancer in a patient who's age was \> 35 when first giving birth?
Moderately increased risk (relative risk 2-4)
164
Gynecomastia may be associated with which compounds/drugs?
1. Cimetidine
2. Spironolactone
3. Marijuana
[Most often it is idiopathic.]
165
What is the definition of a N2 breast tumor according to TNM classification?
* Metastases in 4-9 axillary nodes
or
* In clinically apparent internal mammary (IM) nodes in the absence of axillary node metastasis
166
Continuous mastodynia (breast pain) most commonly represents what?
Acute or subacute infection
[Continuous mastodynia is more refractory to treatment than cyclic mastodynia.]
167
Match the character of breast discharge with the most common cause:
1. Green discharge
2. Bloody discharge
3. Serous discharge
4. Spontaneous discharge
5. Nonspontaneous discharge
1. Green discharge: Fibrocystic change
2. Bloody discharge: Intraductal papilloma (occasionally ductal cancer)
3. Serous discharge: Worrisome for cancer (especially if only from 1 duct)
4. Spontaneous discharge (occurs without pressure): Worrisome for cancer
5. Nonspontaneous discharge (occurs with pressure): Less worrisome
168
Which nerve innervates both the pectoralis major and pectoralis minor muscles?
Medial pectoral nerve
169
What is the 5-year survival in a breast cancer patient with 1-3 positive axillary lymph nodes?
60%
[American Cancer Society: Breast cancer survival rates, by stage
1. The 5-year relative survival rate for women with stage 0 or stage I breast cancer is close to 100%.
2. For women with stage II breast cancer, the 5-year relative survival rate is about 93%.
3. The 5-year relative survival rate for stage III breast cancers is about 72%.
4. Metastatic, or stage IV breast cancers, have a 5-year relative survival rate of about 22%.]
170
What is the median survival of a patient with inflammatory breast cancer?
36 months
[UpToDate: Inflammatory breast cancer (IBC) is associated with a particularly poor prognosis and high risk of early recurrence, although with proper primary and adjuvant therapies, the survival rate is much higher than in the past. Poor prognostic features include triple-negative receptor status, four or more involved lymph nodes prior to therapy, and lack of response to neoadjuvant chemotherapy. Human epidermal growth factor receptor 2 (HER2)-positive IBC may have an equivalent or marginally better prognosis compared with HER2-negative IBC, unlike in the case of non-inflammatory breast cancer.]
171
What is the most aggressive subtype of ductal carcinoma in situ (DCIS) of the breast?
Comedo pattern
[It has necrotic areas with high risk for multicentricity, microinvasion, and recurrence. Treatment is simple mastectomy.]
172
When is a subcutaneous mastectomy (simple mastectomy) useful?
In patients with DCIS or LCIS
[UpToDate: A total or simple mastectomy is removal of the entire breast, with preservation of the pectoral muscles and the axillary contents. The difference between MRM and a simple mastectomy is that the former includes axillary dissection (level I and level II axillary dissection being the standard procedure). With the emergence of sentinel node biopsy, simple mastectomy is performed more frequently than in the past.]
173
What is Mondor's disease?
Superficial vein thrombophlebitis of the breast (feels cordlike, can be painful)
[Associated with trauma and strenuous exercise. Usually occurs in the lower outer quadrant. Treatment is NSAIDs.]
174
Which nerve provides sensation to the medial arm and axilla?
Intercostobrachial nerve (lateral cutaneous branch of the 2nd intercostal nerve)
[Encountered just below axillary vein when performing axillary dissection. Can transect without serious consequences.]
175
Which hormone can cause galactorrhea?
Prolactin
[May be increased as a result of pituitary prolactinoma and is often associated with amenorrhea. Other causes of galactorrhea are OCPs, TCAs, phenothiazines, metoclopramide, alpha-methyl dopa, reserpine]
176
What syndrome presents as dark purple nodules or lesions on the arm 5-10 years after breast surgery with an axillary lymph node dissection?
Stewart-Treves syndrome
[This is defined as lymphangiosarcoma from chronic lymphedema following axillary lymph node dissection.]
177
When is chemotherapy indicated in a patient with a breast mass that is \< 1 cm and has negative lymph nodes?
No chemotherapy is indicated
[Hormonal therapy is indicated if the tumor is estrogen receptor positive.]
178
What is stage IIB based on the breast TNM classification?
* T2 N1 M0
* T3 N0 M0
179
A breast mass needs to be greater than what size to be detected on mammography?
_\>_ 5 mm
