breast Flashcards by Rosalynn Nguyen

clustered pleomorphic calcifications

DCIS

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may advance in a segmental manner with gaps between disease areas

DCIS

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five architecture types of DCIS

papillary, micro papillary, solid, cribriform, comedo (necrosis)

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Surgical treatment for DCIS

surgical excision alone (partial mastectomy) w/margins of greater than 2 mm and adjuvant radiation

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Surgical treatment for multicentric DCIS

total simple mastectomy

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why do adjuvant radiation after partial mastectomy for DCIS?

decrease rate of local recurrence

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Does adjuvant radiation improve survival benefit for DCIS?

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For pure DCIS do you need adjuvant chemotherapy?

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When do you use adjuvant chemotherapy for DCIS?

if ER positive use tamoxifen or anastrozole

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most common histology types of invasive breast cancer

infiltrating ductal
infiltrating lobular
medullary
mucinous
tubular

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What is a radical (Halsted) mastectomy?

total mastectomy
complete ALND (level I, II, III)
removal of pectorals major and minor muscles
removal of all overlying skin
rarely performed in practice

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what is a modified radial mastectomy?

total mastectomy
ALND
indicated for patients w/clinically positive lymph nodes or positive axillary node based on previous SLNB or FNAB

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Who gets a total (simple) mastectomy w/SLNB?

patients w/clinically negative axilla

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what is a skin sparing mastectomy?

form of total (simple) mastectomy where you preserve the skin envelope and infra mammary ridge

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what is the follow up after mastectomy?

every 3-6 months for 3 years
every 6-12 months for next 2 years
then annually

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Does BCT w/SLND have similar survival and recurrence rates to those w/MRM?

Yes

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how many lymph nodes are needed for a ALND?

10 nodes or more
patients with 4 or more positive lymph nodes should undergo adjuvant radiation to axilla

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what are the most common complications after ALND?

infections and serum

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if someone has unilateral nipple discharge and mammogram shows suspicious lesion but is benign on core needle biopsy, what is most likely to be and how to you treat it?

intraductal papilloma
excisional biopsy

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Unilateral nipple discharge and mammogram shows no suspicious lesion, what is the treatment?

terminal duct excision

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if someone has unilateral nipple discharge and mammogram shows suspicious lesion and is malignant on core needle biopsy what is the treatment?

cancer treatment

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spiculated mass w/central necrosis

radial scar

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proliferation of both stromal and epithelial contents
benign solid tumors w/glandular and fibrous tissue

fibroadenoma
excise only if symptomatic

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fat disruption, lipid laden macrophages, chronic inflammation

fat necrosis
can be mixed up with cancer of radiology, must get biopsy to confirm dx
excision not necessary if dx confirmed

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increased central cellularity w/lobules and intact my-epithelial contents -increased fibrous tissue and interspersed glandular cells

sclerosing adenosis no treatment is needed

rapidly growing breast mass mixed connective tissue and epithelium marked stromal overgrowth and hypercellularity

phyllodes tumor

what is the treatment for phyllodes tumor?

excision with at least 1 cm margin to decrease risk of recurrence

if you have calcifications on mammography and LCIS on biopsy what is the treatment?

excisional biopsy and tamoxifen (because you have discordant findings on imaging and biopsy)

do you need negative margins for excisional biopsy of LCIS?

LCIS has a loss of ?

E-cadherin

what are your treatment options for LCIS after excisional biopsy?

lifelong surveillance bilateral mastectomies w/reconstruction (those with high risk factors) no ALND or SLND tamoxifen

cells with clear cytoplasm and oval nuclei located between normal keratinocytes of the nipple epidermis

Paget disease of the breast

what is the treatment for Paget disease of the breast

total mastectomy and SLNB

when can you do BCT for Paget disease of the breast?

cases where nipple areolar resection and WLE of the malignancy can be achieved w/good cosmetic and oncologic result (not big tumors)

what genetic mutation is associated with osteosarcoma, breast cancer?

TP53 Li-Fraumini syndrome tumor suppressor gene MC breast cancer and rhabdomyosarcoma

Is Li-Fraumini syndrome AD or AR?

What must you need to diagnose Li-Fraumini?

be diagnosed with sarcoma before 45 YO have 1st degree relative with any cancer before 45 YO have another 1st or 2nd degree relative w/sarcoma at any age

why is the upper outer quadrant the most frequent site of both benign and malignant breast disease?

most epithelial tissue of the breast is found there

What is Cowden syndrome associated with?

facial skin lesions breast cancer family hx of thyroid cancer

what germline mutation is associated with Cowden syndrome?

PTEN tumor suppressor gene increased risk of breast, thyroid, and endometrium benign hamartomas

is Cowden syndrome AD or AR?

What mutation is associated with diffuse breast cancer?

CDH1

what other cancer is associated with CDH1

gastric cancer

what is the treatment for breast cancer found in the 1st trimester

mastectomy and ALND BCT avoided d/t tech 99

what is the treatment for breast cancer found in the 2nd trimester

mastectomy and ALND adjuvant chemotherapy is safe in 2nd and 3rd trimesters

what is the treatment for breast cancer found in the 3rd trimester

mastectomy or BCT radiation should be delayed until post partum

when do you need excisional biopsy after core needle biopsy?

ADH/ALH radial scar LCIS columnar cell hyperplasia w/atypia papillary lesions phyllodes tumor lack of concordance between imaging and biopsy non diagnostic specimen on core needle (like when no calcifications on radiology when biopsy shows calcifications)

fibroelastic core with entrapped ducts and surrounding adenosis

radial scar

infiltrating cells of small glands lined by single row of bland epithelium

ductal carcinoma

lesion with mixed stromal and glandular elements

fibroadenoma

lobular lesions w/increased fibrous tissue and glandular cells

sclerosing adenosis

central radiolucency with surrounding architectural distortion

radial scar

how many positive sentinel nodes can you have before ALND is needed?

does DCIS increase risk of ipsilateral breast cancer or either?

ipsilateral

does LCIS increase risk of ipsilateral breast cancer of either

either

If LCIS develops into breast cancer is it usually unilateral or bilateral?

bilateral

is DCIS usually unicentric or multicentric

unicentric

is LCIS usually unicentric or multicentric

multicentric

in patients older than 65 years old with low grade tumors should you give adjuvant radiation?

Generally no

which BRCA mutation increases risk for ovarian cancer

BRCA 2

when do you offer a prophylactic bilateral salpingo-oopherectomy for someone with BRCA 2?

age 35-50

what chromosome is BRCA 2 on

when you find out someone has hereditary breast cancer positive for BRCA 2 what should you offer them

prophylactic bilateral mastectomy

what other cancers do you have to worry about with BRCA mutations

ovarian (more with BRCA 1) male breast (more with BRCA 2) prostate (more with BRCA 2) pancreatic (more with BRCA 2)

what percentage of fat necrosis is due to trauma, radiation, previous surgery, infection?

<50% most idiopathic

patients are high risk for a TRAM flap if they

are obese smoke

gynecomastia presents as

hypo echoic mass

what meds are associated with gynecomastia

digoxin thiazides estrogens theophylline phenothiazines spironolactone TCA reserpine methyldopa finasteride

what has a greater role on risk for breast cancer, family hx of breast cancer or ADH

ADH (3-5 times)

well circumscribed non fluid filled mass with coarse calcifications

fibroadenoma

stellate spiculated mass

radial scar

non-calcified mass with focal asymmetry

pseudoangiomatous stromal hyperplasia

tamoxifen is metabolized by

CYP2D6

which drugs should be stopped before starting tamoxifen

SSRI (CYP2D6 inhibitor, decreased active metabolite of tamoxifen)

risk factors for male breast cancer

klinefelter syndrome obesity gynecomastia exogenous estrogen exposure BRCA 2

When to stop breast feeding when patient has mastitis after a baby

if having purulent nipple discharge

what margins are needed for DCIS

2 mm

If you do a lumpectomy for DCIS that is ER positive, but have 1 mm positive margins what is the treatment?

re-excision to get 2 mm margins, radiation, and adjuvant endocrine therapy

best reconstruction for inflammatory breast cancer undergoing MRM and radiation

delayed autologous breast reconstruction Deep inferior epigastric perforator flap (DIEP flap)

mammary findings of a highly suspicious lesion

spiculated, irregular, or asymmetric mass with linear or segmental calcifications

What are the margins for invasive breast cancer getting BCT?

no tumor touching the inked specimen margins

What do inflammatory and triple negative breast cancers all get?

neoadjuvant chemo

what is the treatment for triple negative breast cancer

neoadjuvant chemo surgery based on size/stage adjuvant chemo and radiation

what is the treatment for locally advanced breast cancer (T3, T4, N2, and/or N3 clinical disease)

bone scan CT C/A/P non inflammatory LABC: neoadjuvant chemo (cyclophosphamide, anthracycline, taxane), followed by surgery, and radiation, may need additional adjuvant chemo

A patient has erythema and firmness over prior scar for DCIS done 3 years ago. What is the next step?

Scar biopsy and mammogram

what is the tumor recurrence rate after BCT?

1% per year

what only disorder has a clear associated between gynecomastia and breast cancer?

Klinefelter's syndrome

what is an aggressive variant of a fibro epithelial lesion in the breast?

phyllodes tumor

what is a not aggressive variant of fibre epithelial lesion in the breast?

fibroadenoma

which vessels do TRAM flaps rely on?

superior epigastric vessels

which vessels do latissimus doors flaps rely on?

thoracodorsal vessels

absolute contraindications for BCT are?

radiation therapy during pregnancy, diffuse malignant appearing micro calcification, wide spread disease involving more than 1 quadrant, positive pathological margin

relative contraindications for BCT?

previous radiation, active connective tissue disease, tumor >5 cm, diffusely positive margin

Adjuvant radiation is recommended for

T3/T4 and N2/N3 disease, extra capsular invasion, chest wall involvement, inflammatory breast cancer, 4 positive nodes, >5 cm

MCC mastitis

staph aureus

adjuvant radiation is considered in stage II disease when?

extra capsular extension, lymphovascular invasion, age 40 or younger, close surgical margins, nodal positivity ratio of 20% or greater, pts who have undergone less than a standard I or II axillary dissection