Breast

Question 1

DCIS

Answer 1

Involves ducts. Risk of invasive cancer in ipsilateral breast
Often unilateral and unicentric

Local tx w/ mastectomy or breast-conserving therapy (BCT; lumpectomy) + adjuvant rads

2mm margin

Question 2

LCIS

Answer 2

Involves lobules
Cancer can be ductal or lobular
Marker of elevated risk of invasive cancer, up to 40% in either breast
Often bilateral and multi centric

Tx: excisional biopsy Tamoxifen/antiestrogen modulators reduce risk of subsequent invasive, hormone-positive breast cancer

Question 3

Inflammatory breast CA

Answer 3

edema, erythema, dimpling (Peau d’orange)

rapid onset without underlying breast mass

Bx: dermal lymphovascular invasion

Question 4

Paget disease of breast

Answer 4

scaly, eczematous, raw, vesicular, ulcerated lesion. begins on nipple, spreads to areola

Bx: malignant, intraepithelial adenocarcinoma cells (Paget cells) single or in small groups within epidermis of nipple. Cells have pale/clear cytoplasm, oval nuclei, prominent nucleoli b/w normal keratinocytes

assoc w/ underlying carcinoma (DCIS or IDC)

tx: total mastectomy w/ wide excision of nipple-areolar complex and SLNBx

Question 5

Fat necrosis

Answer 5

Benign
2/2 breast trauma/surgery
Bx: lipid-laden MPs

Question 6

Infiltrating lobular carcinoma

Answer 6

No mass
Lack of E-cadherin staining

Bx: small cells, infiltrate mammary stroma & adipose individually and in single-file pattern, grow in target-like configuration, around normal breast ducts

Question 7

Phyllodes tumor

Answer 7

Breast mass/abnormal mammo findings, smooth, multinodular, well-defined, firm, mobile, painless mass, rapidly growing.

similar to fibroadenomas but phyllodes have malignant potential 2/2 increased cellularity, invasive margins

Bx: leaf-like architecture, elongated ductal elements & cleft-like spaces, papillary projections of epithelial-lined stroma

Tx: wide local surgical excision w/ 1cm tumor free margins. rarely mets to LNs. recurrence -> resect.

Question 8

Mastitis

Answer 8

lactating or nonlactating

lactating - caused by staph aureus. MC in first 4-6 weeks of breastfeeding or during weaning. Tx: Abx, cont breast feeding.

Epidemic puerperal mastitis - caused by MRSA. purulent nipple drainage. Tx: Abx, stop breastfeeding

Question 9

RFs for Breast Cancer

Answer 9

Low risk: age monarche <12, age menopause >55, nulliparity, obesity, hormone replacement therapy

mod risk: age at first birth >30, mother or sis w/ breast CA, previous breast CA, radiation exposure

high risk: BRCA1/2 mutation, age >70

Question 10

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

Answer 10

Most of epithelial tissue in upper outer quadrant
MC site of both benign and malignant breast disease
Most benign and malignant breast lesions are derived from epithelial tissue

Question 11

Inflammatory breast cancer recon options

Answer 11

Following surgery these patients need post mastectomy radiation.

Delayed autologous recon is preferred to prevent delay of adjuvant radiation and avoid complications w/ irradiating reconstructed breast

Question 12

Radial scar

Answer 12

Nonpalpable lesion, benign

Histo: central fibroelastosis w/ radiating ducts & lobules w/ atypia, micro cysts, epithelial hyperplasia, adenosis

Tx: excisional bx (r/o cancer)

Question 13

Breast lesions that require excisional bx following CNBx

Answer 13

Atypical lobular hyperplasia
LCIS
Radial scar
Papillary lesions
Phyllodes tumor

Question 14

Breast lesions that require mastectomy following CNBx

Answer 14

DCIS

invasive cancer

Question 15

Intraductal papilloma

Answer 15

MCC pathological nipple discharge

Tx: surgical excision

Question 16

BRCA 1/2 mutation cancer risks

Answer 16

BRCA 1

• tumor suppressor gene mutation on chrom 17
• Breast cancer risk: 55-70%
• Ovarian 40%
• Male breast cancer 1%
• Prostate 15-20%
• Pancreatic 2-4%

BRCA 2

• tumor suppressor gene mutation on chrom 13
• Breast CA 45-70%
• Ovarian 15%
• Male breast 8%
• Prostate 30-40%
• Pancreatic 5%

Question 17

Hereditary breast cancer syndrome

Answer 17

mutation TSG located on chrom 17 or 13
pt w/ mutation has 70% chance of breast cancer
PPx bilateral mastectomy offered (decreases risk of breast CA ~90% for pts w/ BRCA1/2 mutations)

Surveillance if nonop desired:

• Monthly self-breast exams at 18
• MRI at 25
• Annual mammograms at 30
• Ovarian CA screen w/ transvag US & CA 125 q6 mo at 30

Question 18

RFs for Male breast cancer

Answer 18

Klinefelter syndrome
Obesity
Gynecomastia
Exogenous estrogen exposure
BRCA 2 mutation

Same prognosis for Male vs Female breast CA stage-for-stage. Male usually have pectoral involvement at time of Dx

Question 19

Risk of atypical ductal hyperplasia for cancer

Answer 19

3- to 5- fold increase risk of cancer in both breasts

Excisional biopsy is recommended when CNBx shows ADH due to 20% rate of DCIS

Question 20

Breast Angiosarcoma

Answer 20

Dark, violaceous mass, vascular tumors
Histo: distorted vessels (endothelial cells), pleomorphism, mitoses
Hx of radiation (breast-conserving therapy)

Primarily in breast parenchyma
Secondarily in dermis of breast after radiation - fatal w/ medial survival of 2 years (dark, purple nodule in field of prior radiation); 2nd MC etiology of secondary angiosarcoma is chronic lymphedema (Stewart-Treves syndrome)

Route of spread: hematogenous to lung/bone

tx: total mastectomy + adjuvant chemo (extends survival)

Question 21

Long thoracic nerve injury

Answer 21

Winged scapula

Innervates serratus

Question 22

Thoracodorsal nerve injury

Answer 22

Weakness of extension, adduction, internal rotation of arm at shoulder

Innervates lattisimus

Question 23

Medial pectoral nerve injury

Answer 23

Weakness of extension, adduction, internal rotation of arm at shoulder

Innervates pec major & minor

Question 24

Lateral pectoral nerve injury

Answer 24

Weakness of flexion of arm at shoulder

Innervates pec major

Question 25

Intercostobrachial nerve injury

Answer 25

Hypoesthesia of upper inner arm

Innervates skin