Breast 1

Question 0

Typical breast cancer patient?

Answer 0

White wealthy, single obese woman, with late full-term pregnancy and the history of breast cancer

Question 1

Strong risk factors for breast cancer (more than 4x increase in relative risk)

Answer 1

1. Old age
2. Previous history of cancer
3. Family history of premenopausal bilateral breast cancer

Question 2

Differences in breast cancer screening in high-risk versus low-risk patients?

Answer 2

Breast exam twice yearly starting at 25 versus every 2-3 years from age 20-39

Initial mammogram at age 40 versus 30

Mammograms every 1-2 until age 50 (Then yearly) versus mammograms every 1-2 years until age 40 (then yearly)

Question 3

Mortality reduction in mammograms in women over 50 years of age?

Answer 3

30%

Question 4

Risks of mammograms?

Answer 4

1. Radiation exposure (2-6 times CXR)

2. False-negative rate (10-20%), higher in young women

Question 5

Types of mammographic abnormalities?

Answer 5

1. Masses
2. Asymmetric densities
3. Microcalcifications

Question 6

Causes of asymmetric density on the mammogram?

Answer 6

1. Cancer
2. Previous surgery
3. Previous radiation
4. Previous infection

Question 7

Suspicious finding on mammogram – next step?

Answer 7

Core-needle biopsy

Question 8

Patient’s mammogram shows 1 cm area of pleomorphic microcalcifications with no associated mass. Suspicious for? Next step?

Answer 8

Ductal carcinoma in situ

1. Stereotactic-guided core needle biopsy (especially if indeterminate or less suspicious)
2. localization and open surgical biopsy (Especially for highly suspicious lesion, because it may provide adequate therapy with one procedure)
3. FNA maybe nondiagnostic and should not be used

Question 9

Patient has a mammogram which reveals amorphous calcifications. Has stereotactic core biopsy. Management if biopsy shows ductal carcinoma in situ? Should you node section?

Answer 9

1. Simple mastectomy for diffuse and multicentric DCIS
2. Wide excision and radiotherapy for smaller visions if pathology-free margins
3. Node section is not necessary unless comedo variant (then use sentinel node approach)

Question 10

Risk of infiltration at time of excision? mortality if untreated?DCIS histologic pattern with highest malignant potential?

Answer 10

10-20% of DCIS lesions have infiltrative component at excision.

30% mortality over 10 years

Comedo (Unlike other variants, may have axillary metastasis)

Question 11

Lobular carcinoma in situ – usual discovered how? Management? Risk of malignant disease? Risk of of axillary metastasis?

Answer 11

Incidental finding at histopathology (not apparent on mammography)

Close observation, with mammography every six months .7 years (if high-risk, bilateral simple mastectomies)

15-20% chance of developing invasive disease

Almost no risk of axillary metastasis

Question 12

Sclerosis adenosis - usually manifests as? Work up? Management?

Answer 12

Clustered microcalcifications on mammography

Core Biopsy

Routine follow-up

Question 13

Atypical ductal hyperplasia – risk of cancer? Management?

Answer 13

4-5 times higher

Needle localization and excision

Question 14

Relatively high-risk (8-10x) for invasive breast carcinoma? Moderate (4-5x) risk? Slightly increased (1.5-2x) risk? No increased risk?

Answer 14

High risk – LCIS and DCIS

Moderately increased risk – atypical ductal hyperplasia/atypical lobular hyperplasia

Slightly increased risk – sclerosing adenosis, papilloma, hyperplasia

No risk – apocrine change, ductal ectasia, mild epithelial hyperplasia

Question 15

Postmenopausal women with breast mass – likely diagnosis? Work up?

If woman is aged 35-60?

If woman is younger than 30?

Answer 15

Carcinoma

1. Mammogram affected and contralateral breast
2. Ultrasound if cystic (if positive, aspiration)
3. Biopsy if solid (wide excision)

Same as above

Increased benign lesions and higher risk of radiation from mammography

1. Ultrasound before mammogram for cystic lesion (if positive aspirate)
2. If solid, suspect fibroadenoma (observe or elective removal without prior core biopsy)
3. Mammography if clinical examination or US suggest cancer
4. If lump appears physiologic, can observe patients for 1-2 menstrual cycles
5. If Mass persists, larges, or appears suspicious, core needle biopsy

Question 16

35 y/o woman with tender breasts before menstrual periods. Complains of lumps – likely diagnosis? management?

Answer 16

fibrocystic disease of the breast

1. Eliminate caffeine, and supplement of vitamin E
2. If dominant painful cyst, aspirate
3. If diagnosis is unclear, biopsy

Question 17

20-year-old woman presents with 1.5 cm mass that is firm, rubbery, nontender, and freely movable. Opposite breast and axillae are normal. Likely diagnosis? Management?

Answer 17

Fibroadenoma

1. Excisional biopsy
2. Observation for small lesions

Question 18

20-year-old woman presents with 14 cm mass that is firm, rubbery, nontender, and freely movable. Opposite breast and axillae are normal. Likely diagnosis? Other physical findings that will help distinguish from other types of masses? Management?

Answer 18

Cystosarcoma phyllodes/Giant cell fibroadenoma

Occasional ulceration of overlying skin

1. Local excision with generous margins that are free of disease

Question 19

Patient with bloody nipple discharge – likely diagnosis? Management?

Answer 19

Intraductal papilloma

1 Examined for mass or mammographic abnormality

2. Surgical biopsy (cannulate duct, and excise)
3. Can use ductogram (radiographic dye in duct) to localize affected duct and define extent of process