benign and malignant ds of breast

Question 1

physical exam

Answer 1

overall shape, symmetry
palpable lump-note location, size, mobility, shape
nipple discharge
skin changes-dimpling, retraction, erythema, crusting of nipple, peau d’orange (sign of edema)
lymph nodes-axillary, supraclavicular and cervical

Question 2

breast lump

Answer 2

every palpable mass needs eval, 85% lumps found by pts are benign or normal tissue.

Question 3

screening mammography

Answer 3

yearly ages 50-75. screening during 40s and after 75 at discretion. if high risk patient, start screening 10 years earlier than age at which youngest relative diagnosed

Question 4

diagnostic mammogram

Answer 4

screening mammogram abnormal, clinical exam finding-mass, pain, discharge. BIRADS score 1-4 based on level of suspicion.

Question 5

ultrasound

Answer 5

adjunt to diagnostic mammo, primary tool in pts

Question 6

MRI

Answer 6

high risk pts-previous cancer, dense breasts, significant family history. evaluate ipsilateral and/or contralateral breast in ca pts. all abnormal imaging needs either short-term follow-up or bx.

Question 7

atypical ductal hyperplasia

Answer 7

precursor to invasive carcinoma 4-5 x increased risk. requires excision with clear margins. no further therapy, annual mammograms

Question 8

fibrocystic changes

Answer 8

normal change that occurs in the breast in response to hormones. sxs: lumpy breasts, tender-especially at menstruation, may have significant non-cyclic pain. pathology: macro and mircroscopic cysts, fibrosis, ductal hyperplasia. treatment: reassurance, NSAIDS for pain, change or cessation of OCPs, vit b complex, evening primrose oil, fish oil

Question 9

fibroadenoma

Answer 9

most common solid mass found in reproductive aged women. benign, may be multiple and recurrent. firm, round, well circumscribed mobile mass. diagnose by US appearance and or needle bx.

Question 10

nipple discharge

Answer 10

usually benign. bilateral milky may be galactorrhea-check for pg or elevated prolactin levels. clear or greenish is normal-related to underlying duct ectasia/inflammation. bloody- usually due to intraductal papilloma-benign growth, rarely due to ca.

Question 11

mastitis causes

Answer 11

pg/lactation, injury, nipple piercing.

Question 12

symptoms mastitis

Answer 12

pain, swollen, erythematous breast

Question 13

treatment of mastitis

Answer 13

abx-dicloxacillin, clindamycin, bactrim (if MRSA suspected)

Question 14

risk factors for breast ca

Answer 14

• early menarche
• first birth after age 30 or nulliparity
• family hx
• atypical hyperplasia
• lobular carcinoma in situ
• known carrier of BRCA 1 or 2
• personal hx of ovarian, colon, or uterine ca
• horomone replacement therapy- especially if started at young age.
• radiation exposure

Question 15

LCIS

Answer 15

not cancer, is a risk factor for developing invasive ductal cancer. treatment is close observation, bilateral prophylactic mastectomy, possibly tamoxifen

Question 16

DCIS (ductal carcinoma in situ)

Answer 16

usually presents as abnormal appearing microcalicifications. proliferation of malignant cells within duct. (stage 0 breast ca). treatment is lumpectomy/radiation therapy, mastectomy if multifocal or diffuse, no lymph node dissection, no chemo, +/- tamoxifen. BASEMENT MEMBRANE IN TACT

Question 17

invasive ductal/lobular carcinoma

Answer 17

invades beyond the normal duct/lobule into surrounding tissue. lobular carcinoma can be more diffuse and difficult to detect by mammography. lymphatic spread. LLBB METASTASIS (lung, liver, bone, brain)

Question 18

treatment of invasive ductal/lobular carcinoma

Answer 18

all pts need axillary lymph node bx for staging. lumpectomy and radiation. mastectomy. chemo/hormone replacement therapy

Question 19

inflammatory breast cancer

Answer 19

stage IIIb disease, poor prognosis. signs: swollen, usually nontender breast, erythema, peau d’orange, may not have dominant mass. treatment is peroperative chemo, mastectomy and axillary lymph node dissection, radiation, hormone therapy

Question 20

paget’s disease

Answer 20

eczematous changes of the nipple. assocaited with underlying invasive cancer. dx with nipple biopsy. usually treated with mastectomy, if underlying ca identified can do central lumpectomy

Question 21

surgical bx

Answer 21

incisional bx=removing a piece of the suspicious mass for diagnosis only.
excisional bx=completely excising mass for dx, if clear margins may be adequate cancer surgery

Question 22

lumpectomy

Answer 22

terminology reserved for treatment of cancers, not benign lesions. also called partial or segmental mastectomy.

Question 23

mastectomy

Answer 23

excision of breast tissue, pectoralis fascia, and overlying skin (including the nipple/areolar complex) modified radical mastectomy includes axillary lymph nodes

Question 24

poor prognostic factors breast ca

Answer 24

positive lymph nodes, size > 2 cm, high grade, estrogen receptor negative, Her-2 positive

Question 25

herceptin

Answer 25

adjuvant therapy in tumors with Her2 gene overexpression. Her2 controls cell growth and death. binds to her2 receptors rendering them ineffective.

Question 26

Tamoxifen

Answer 26

competitive inhibitor of estrogen receptors. adjunt to chemo. side effects include risk of uterine ca, thrombotic events, hot flashes, weight gain.

Question 27

aromatase inhibitors (arimidex)

Answer 27

inhibits production of estrogen by adrenal glands. effective only for post-menopausal women.

Question 28

indications for radiation

Answer 28

• lumpectomy
• mastectomy with tumor > 5cm
• chest wall involvement or positive margins.
• positive axillary lymph n
• +/-women over 70 with good prognositc factors.

Question 29

factors indicating increased risk of a genetic cancer

Answer 29

bilateral cancers in paired organs
multiple primary cancers
multifocal cancers (4 tumors in one breast)
early age of onset

Question 30

cowden syndrome

Answer 30

hamartomas, breast, GI, and thyroid cancers

Question 31

Li Fraumeni syndrome

Answer 31

breast, brain or adrenal cancer, sarcoma, leukemia.

Question 32

BRCA 1 related ca

Answer 32

breast, ovarian, prostate, fallopian tube, colon ca

Question 33

BRCA 2 related ca

Answer 33

breast, ovarian, pancreatic, prostate, melanoma, colon

Question 34

appropriate pts for genetic counseling

Answer 34

breast or ovarian ca before age 50
male breast ca
bilateral breast ca
breast and ovarian ca
family hx