BREAST Flashcards
Can you do SLN in pregnant pt?
Yes just can only use radioactive sulfur colloid
Tx of pregnant pt 1st trimester with breast CA
Mastectomy + axillary staging
Adjuvant chemo 2nd trimester
+/- adjuvant XRT post partum
+/- adjuvant endocrine post partum
Tx of pregnant pt late 2nd trimester/early 3rd trimester with breast CA
Mastectomy OR BCT + axillary staging
OR
preoperative chemo, mastectomy or BCT + axillary staging
(+/- adjuvant RT post partum +/- adjuvant endocrine post partum)
Tx of pregnant pt late 3rd trimester with breast CA
Mastectomy + axillary staging
Adjuvant chemo
+/- adjuvant RT post partum +/- adjuvant endocrine post partum
Whcih chemo is contra indicated in pregnancy?
Herceptin
Coarse eggshell calcification on mammogram
fat necrosis
Tx of true gynecomastia
Direct surgical excision of glandular tissue + liposuction
Tx for malignant phyllodes
Excision with 1 cm margins
When is XRT indicated for malignant phyllodes
Close margins <1 cm
Fascial/chest wall involvement
Tumors > 5 cm
How much increased risk with atypical lobular hyperplasia?
4 fold
Stain to differentiate ALH from ADH
E-cadherin. ALH stains negative
Relative CI to BCT
Systemic scleroderma, lupus, severe cardiac dz (left sided tumors), inability to abduct arm on affected side, p53 mutation, severe pulm disease
NEoadjuvant chemo for inflammatory breast CA
anthracyclines (doxorubicin) + taxanes (paclitaxel)
Breast feeding pt - MCC mastitis?
S. aureus
What mutation in bladder, breast, and colorectal CA?
CHEK2. Serine/threonine kinase involved in DNA damage repair and apoptosis. Also increase in male breast CA.
BRCA1 protein function
Complexes with RNA polymerase in transcription
BRCA2 protein function
bind directly to DNA to repair damage
p53 assoc with
Li Fraumeni
breast brain lung and hematologic malignancies
sarcoma
adrenal cortical carcinoma
Tx for lymphangiosarcoma
Wide local excision 3-6 cm margins
Prognostic indicator in Stewart Treves
Tumor size (<5 cm is better)
Tumor cells with a high mitotic rate, large pleomorphic nuclei, lymphoplasmacytotic infiltrate
Medullary CA (subtype of invasive ductal)
Malignant epithelial cells confined by the basement membrane of the ductal-lobular interface
DCIS
Pale cytoplasm, prominent nucleoli in the epidermis
Paget disease
Whorled stromal cells, epitheliall ined clefts
phyllodes
Adenosis, microcysts, central sclerosis, distortion of surrounding architecture
Radial scar
MC site of mets in phyllodes tumors
Lungs (bones, brain)
Luminal A subtype
ER or PR +
HER2 -
Ki <14%
Luminal B subtype
ER or PR +
HER2 -
Ki >14%
Endocrine + adjuvant chemo
Basal subtype
Triple negative
When to excise radial scar
If >6 mm
When to excise ADH
If >6 mm
When to excise LCIS
If suspicious findings or pleomorphic subtype
Boundaries of ax dissection
Apex: posterior border of clavicle Anterior: pec major and minor** mm Posterior: subscapularis Medial: serratus anterior Lateral: lat dorsi
Bilateral SOO in premenopausal BRCA1 - breast and ovarian CA risk reduction
80% RR ovarian CA
4% RR breast CA
4% RR breast CA
Bilateral SOO in premenopausal BRCA2- breast and ovarian CA risk reduction
79% RR ovarian CA
82% RR breast CA
82% RR breast CA
Which abx should be avoided in breast feeding?
Ciprofloxacin, tetracycline, chloramphenicol
Risk of CA or CA in situ in surgical excision for ADH?
15-30%
Dilation of ducts with lipid material
Ductal ectasia. Often present with fever and localized tenderness. Not due to underlying infection. May resolve to leave subareolar nodule
Tx for refractory mastodynia
SERM. Cyclical (toremifine) or non cyclical (ormeloxifene)
Columnar cells with atypia on core biopsy
Up to 80% have tubular CA
Tx of lymphangiosarcoma if no evidence of mets
Amputation if possible
MC met of lymphangiosarcoma
Spreads lymphatically or hematogeneously. MC mets to lungs
Tx of metastatic lymphangiosarcoma
Single agent doxorubicin or paclitaxel. XRT reduces local recurrence but no improvement in overall survival
Chance of malignancy in Phyllodes
10%
Phyllodes CA spread via?
Hematogenous
HER2 subtype breast CA
Tend to be higher grade due to p53 mutations, 5-10% of breast CA,
Gail model
Age
Race or ethnicity
History of breast disease but NOT CA, DCIS or LCIS
Age at menses onset
Family hx but not high risk gene mutations
Age at first live birth
MC benign finding for microcalcs on CNBx
Sclerosing adenosis
Complex sclerosing lesion AKA?
Radial scar
Excisional bx needed!
CHEK2 mutation a/w which CA
Breast, colorectal, bladder
CHEK2 mutation protein function
serine/threonine kinase involved in DNA damage
PALB2 mutation protein function
genome maintenance (repair of double strand DNA breaks)
PALB2 mutation assoc CA
breast, pancreatic
p53 mutation protein function
regulates cell division
p53 mutation a/w which CA
LI FRAUMENI
Breast
Brain
Lung
Sarcoma
Adrenal cortical carcinoma
Wilms
Phyllodes!
Pancreatic
Leukemia
Neuroblastoma
PTEN mutation protein function
phosphatase involved in cell cycle regulation
CDH mutation protein function
involved in cell adhesion
PTEN mutation a/w which CA
Breast
thyroid
GU tract
Endometrium
Margin goals in Stewart Treves
3-6 cm
Where do tumor cells originate from in Stewart Treves
Dermal vascular endothelium
First line pharmacologic in severe cyclical breast pain
SERM (tamoxifen) < 6 months, 10-20 mg daily
Only FDA approved pharmacologic for mastalgia
Danazol –200 mg during luteal phase of menstrual cycle
Considered 2nd line pharmacologic
Side effects f Danazol
antigonadotropin agent (mild androgenic effects) – acne, voice changes, weight gain, hot flashes ,menstrual irregularities
CONTRAINDICATED in pregnancy
Anatomic boundaries of axilla
Apex: posterior border of clavicle
Anterior: pec major and minor
Posterior: subscapularis
Medial: serrates anteriorr
Lateral: anterior border of lat dorsi
p16/CDK4 assoc with?
familial melanoma
Melanoma, pancreatic CA, dysplastic nevi, atypical moles
APC mutation a/w
CRC
duodenal and gastric neoplasms
medulloblastomas
osteomas
