breast Flashcards
clustered pleomorphic calcifications
DCIS
may advance in a segmental manner with gaps between disease areas
DCIS
five architecture types of DCIS
papillary, micro papillary, solid, cribriform, comedo (necrosis)
Surgical treatment for DCIS
surgical excision alone (partial mastectomy) w/margins of greater than 2 mm and adjuvant radiation
Surgical treatment for multicentric DCIS
total simple mastectomy
why do adjuvant radiation after partial mastectomy for DCIS?
decrease rate of local recurrence
Does adjuvant radiation improve survival benefit for DCIS?
No
For pure DCIS do you need adjuvant chemotherapy?
No
When do you use adjuvant chemotherapy for DCIS?
if ER positive use tamoxifen or anastrozole
most common histology types of invasive breast cancer
infiltrating ductal
infiltrating lobular
medullary
mucinous
tubular
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
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
Who gets a total (simple) mastectomy w/SLNB?
patients w/clinically negative axilla
what is a skin sparing mastectomy?
form of total (simple) mastectomy where you preserve the skin envelope and infra mammary ridge
what is the follow up after mastectomy?
every 3-6 months for 3 years
every 6-12 months for next 2 years
then annually
Does BCT w/SLND have similar survival and recurrence rates to those w/MRM?
Yes
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
what are the most common complications after ALND?
infections and serum
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
Unilateral nipple discharge and mammogram shows no suspicious lesion, what is the treatment?
terminal duct excision
if someone has unilateral nipple discharge and mammogram shows suspicious lesion and is malignant on core needle biopsy what is the treatment?
cancer treatment
spiculated mass w/central necrosis
radial scar
proliferation of both stromal and epithelial contents
benign solid tumors w/glandular and fibrous tissue
fibroadenoma
excise only if symptomatic
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
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?
NO
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?
AD
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?
AD
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?
2
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
13
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
