breast

Question 1

fibroadenoma

Answer 1

-MC benign in young females < 30
-<5cm usually
-50s-60s- giant fibroadenoma
-mobile, round, rubbery, firm (cyst is non-firm), non-tender
-can be multiple and bilateral
-does NOT change with period

DX
-to DX- core biopsy (with needle) via US!!!!
-US to r/o or in cyst
-phyllodes tumor would be bigger
-dense tissue -> acoustic shadowing
-hypoechoic -> not fluid
-FNA
-TX
-excision depends on if pt is symptomatic
-potential excision is usually >3cm or pt preference

Question 2

metastasis

Answer 2

-vertebral veins drain into the batson plexus -> this plexus has no valves
-lymphatics and veins drain breasts
-can go up and down with breathing - from brain to sacrum
-bone pain?
-pain over spine?
-changes in vision?
-seizures? -> brain tumor

Question 3

ductal carcinoma in situ (DCIS)

Answer 3

-MC non invasive breast cancer- 80%
-non palpable
-begins in milk ducts and invades surrounding tissue
-not invasive yet
-asymptomatic

dx:
-detected via screening - microcalcifications
-biopsy
-tx- excision
-Usually hormone receptor positive and HER 2 negative

Question 4

invasive ductal carcinoma

Answer 4

MCC breast cancer: 80% -> MC TYPE: 70% estrogen/progesterone +, HER 2 -
-nests and cords of tumors cells assoc with gland formation

Subclass: medullary breast cancer:
* MC: young women with BRCA 1 mutation
* sheet-like growth and high lymphocytic infiltrate
* typically triple-negative with favorable prognosis

Subclass: inflammatory breast cancer
* rare and aggressive - high likelihood of metastasis at dx
* Sx:
○ Redness, swelling, warmth, and pain in the breast. Ddx with mastitis but without lactation
○ Peau d’orange (orange peel texture) appearance due to dermal lymphatic invasion.
○ Often presents without a distinct lump, making it harder to detect on traditional imaging.
* Dx: SKIN BX - cancer cells in dermal layer: dermal lymphatic invasion.
* Tx:
○ Need NEOADJUVANT CHEMO to reduce tumor size and control spread
○ Radiation after
Targeted threapy

S&S
-breast/axillary lump
-asymmetry
-swelling
-abnormal nipple discharge
-nipple retraction
-skin changes- dimpling
-mastalgia

Question 5

INVASIVE LOBULAR CARCINOMA (ILC)

Answer 5

-5-10%
-MC: older women; postmenopausal!
-diffuse
-bilateral
-at dx usually large
-usually incidental finding
-Almost always estrogen and progesterone receptor positive -> good for medication therapy

Question 6

anatomy of breast

Answer 6

-superior-clavicle
-inferior- rectus sheath
-medial-sternum
-lateral- lat dorsi
-beware of serratus anterior nerve -> long thoracic

Question 7

breast dimpling

Answer 7

-shortening of suspensory ligaments
-cancer
-inflammation
-fat fibrosis 2ndary to trauma
-has it always been there?

Question 8

fat necrosis

Answer 8

-caused by acute inflammatory response due to trauma (including surgery): adipose tissue replaced by scar tissue
-asymptomatic usually -> can have lump, fluid discharge, skin dimpling, pain, nipple inversion
-can progress to chronic fibrotic change -> solid irregular lump
-due to calcified irregular, speculated mass -> must biopsy to r/o cancer
-tx- self limiting

Question 9

lymphatics

Answer 9

-axillary nodes in tail of spence
-subclavicular
-mediastinal nodes
-areolar nodes

Question 10

mastitis/breast abscess

Answer 10

-commonly occurs during breast feeding
-if you see in pt without lactation -> think inflammatory breast carcinoma (can have it secondary to trauma with hematoma)
-pain, swelling, induration, redness
-smoking- damage to subareolar duct walls -> bacteria
-bleeding/discharge
-staph aureus MC

tx:
-gram + abx: dicloxacillin, analgesics; CONTINUE TO BREAST FEED
-US needle aspiration
-or operative (I&D) -> can cause fistula
-IF NOT GETTING BETTER R/O CANCER/fungal

Question 11

zuska’s disease (periductal mastitis)

Answer 11

-periductal mastitis: rare, chronic inflammation of the breast, typically around the ducts near the nipple

Presentation:
-abscess within the duct
-nipple discharge - purulent or bloody
-reoccurring
-behind the
-risk factor: smoking

tx:
-antibiotics + drainage
-resection for management
-+/- terminal ducts removed depending on pt to stop recurrence

Question 12

hidradenitis suppurativa

Answer 12

Chronic skin condition characterized by painful lumps, often in areas with sweat glands like the armpits and under the breasts
-no cure
-accessory gland of Montgomery involved here
-clindamycin DOC
-biologics
-surgical approach - unroofing areas where there are tracts -> grafting
-obesity associated -> wt loss helpful

Question 13

mondor’s disease

Answer 13

-veins - lateral thoracic, thoracoepigastric, superficial epigastric vein
-thrombophlebitis
-pain over vein, redness, dimpling
-cord like on palpation
-arm elevation creates a groove in the breast

tx:
-anti-inflammatory meds and warm compress
-resolves 4-5 weeks
-can be refractory to therapy -> segment of involved vein is to be surgically removed

Question 14

cystosarcoma phyllodes

Answer 14

-30-40s (but can happen in any age)
-huge, rapid growth
-dont invade tissue locally
-normal architecture
-RESECT with clear margins: even if benign they can undergo malignant transformation 1/3)

Dx:
-core needle bx needed!! -> bc inflammation and necrosis present
-FNA is inaccurate
-10% chance of reoccurrence

Question 15

mammary dysplasia/fibrocystic disease/cystic mastitis

Answer 15

-MC benign in child bearing age women
-mastodynia- PAIN in breast tissue
-clear nipple discharge
-dx 3-5 days after period -> lumpiness from period will go down
-fluctuation dependent on period
-lumpy breast, multiple
-50% of females, very common
-DX-
-US to eval: anechoic and smooth walls
-green/dark brown fluid when aspirated (FNA)
-TX-
-if mass is still there or bloody after aspiration -> biopsy

Question 16

simple cysts vs complex cysts

Answer 16

simple:
- well defined, anechoic on US
- posterior enhancement with thin walls (due to increased brightness behind cyst due to fluid inside)
- benign and no tx unless sx

complex:
- internal echos, debris inside: protein, blood, inflammation
- may need aspiration, bx to r/o malignancy

Question 17

intraductal papilloma

Answer 17

-MCC of bloody nipple discharge
-clear or bloody discharge
-40-50yo
-not always assoc with cancer (50% of time)

Dx:
-mammogram to exclude cancer
-dense breast -> MRI
-galactogram/ductogram- dye -> view lesions/deformity
-17-20% are cancerous
-biopsy to r/o ductal carcinoma (not from his slides)

tx:
-depends on how big it is and how many are present, pts risk factors -> more likely cancer -> remove

Question 18

lobular carcinoma in situ (LCIS)

Answer 18

-lesions of secretory lobules
-contained within basement membrane
-more risk for invasive breast cancer
-bilateral mirror image
-asymptomatic - incidental finding during bx
-tx- low grade- monitor
-less likely to have nodal metastasis then DCIS
-bilateral prophylactic mastectomy in BRCA pts

Question 19

noninvasive in situ carcinoma

Answer 19

-80% ductal
-10% lobular

Question 20

risk factors for breast cancer

Answer 20

-Advancing age and female sex are the most common risk factors.
-BRCA 1 and 2, account for about 10% of breast cancers.
-History of DCIS.
-High BMI.
-First birth at age > 30 years or nulliparity.
-Early menarche (before age 13).
-Family history of breast or ovarian cancer.
-Late menopause
-Postmenopausal hormone therapy use (white women, normal BMI, dense breasts).
-Prior Chest wall radiation
-longer exposure to estrogen -> more risk

Question 21

classification breast cancer

Answer 21

-by region/origination -> lobular or ductal
-hormonal receptivity and human epidermal growth factor receptor 2 (HER-2) expression

Question 22

hormone receptivity

Answer 22

-Refers to the presence or absence of estrogen and progesterone receptor expression in the malignancy.
-Hormone receptor positive breast cancer, especially when non-metastatic, is amenable to hormone-blocking therapy -> tamoxifen
-HER-2 positive malignancies are generally responsive to HER-2 directed monoclonal antibodies.
-Hormone receptor positive (er/pr), HER-2 negative is the most common expression status of breast cancer.

Question 23

triple negative breast cancer

Answer 23

-low levels of estrogen and progesterone receptor, and HER2 neg
-12% of women with breast cancer
-more common in non-Hispanic black women
-any age
-dx at earlier ages than other subtypes
-More likely to be dx at later stage (stage III or IV).
-Tend to be higher grade and more aggressive than hormone receptor positive HER-2 negative disease
-tx- chemo before surgery
-radiation

Question 24

different types of breast cancer

Answer 24

-ductal carcinoma in situ (DCIS)- heterogenous category of noninvasive noninfiltrating malignancies that are localized inside mammary ducts
-sometimes invasive ductal carcinoma (IDC) will have mammographic or histologic evidence of DCIS
-DCIS -> further classified depending on morphology, location, cytological characteristics
-DCIS and LCIS are usually hormone receptor positive and HER2 neg
-IDC is MC type
-70% of women with IDC will be hormone receptor positive and HER2 neg
-Medullary breast cancer
-Inflammatory breast cancer
-Mammary Paget disease is an adenocarcinoma affecting the nipple and areola -> dry and flakey
-Tubular, papillary, and mucinous breast cancers
-Phylloides tumors are less common cancers

Question 25

medullary breast cancer

Answer 25

-more common in younger women who carry a BRCA 1 mutation!
-rare
-aggressive
-usually triple neg- hormone and HER2 -> but better prognosis bc less likely to metastasize to axilla!!!
-chemo and surgery

Question 26

clinical assessment and differentials

Answer 26

-Palpable breast mass is evident in about 30%
-Visible signs include:
-Dimpling (peau d’orange)
-Erythema
-Edema
-Blistering
-Excoriations
-Sanguineous nipple discharge
-Nipple retraction.
-**Skin changes such as peau d’orange and blistering are strongly associated with inflammatory breast CA
-Remember to rule out malignancy in pts being treated for mastitis or a breast abscess that is not improving clinically!!!!! -> could also be fungal or not staph aureus

Question 27

DDx of breast mass

Answer 27

-Benign conditions such as:
-Fibroadenoma
-Breast cyst
-Intraductal papilloma
-Fibrocystic changes
-**Once a mass has been palpated, the next steps are to refer the patient for a diagnostic mammogram and ultrasound

Question 28

diagnosing cancer- when to get MRI

Answer 28

-Initial Imaging:
-Mammography
-Ultrasound
-MRI:
-Dense breasts
-Hx of breast CA
-Evaluation of contralateral disease- lobular (bilateral)
-High cancer risk
-Surgical planning
-Identifying skin changes skin involvement
-breast implants

Question 29

findings in invasive breast cancer

Answer 29

-Irregularly shaped mass
-Spiculation
-Pleomorphic microcalcifications
-Anatomical distortion around it
-Axillary lymphadenopathy
-Posterior acoustic shadowing - from dense tissue
-Breast Imaging and Reporting Data System (BI-RADS)- staging

Question 30

BI-RADS classification

Answer 30

0 → incomplete assessment, need additional imaging or prior exams
1 → negative, routine screening
2 → benign, routine screening
3 → probably benign, risk of malignancy is < 2%, US imaging or control mammography imaging and exam within 6 months
4 → suspicious, risk of malignancy is 2-94%, further cytology or pathohistology investigation is necessary
5 → highly suspicious, risk of malignancy is >94%, referral to surgeon

4- core biopsy, aspiration
-standard- mammo every two years at age 40 and continue until age 74

Question 31

confirmation of breast cancer

Answer 31

-Confirmation by tissue biopsy:
-Percutaneous US guided core needle biopsy, excisional biopsy
-Stereotactic biopsy
-MRI-guided biopsy
-**Preferred method for most is US guided large-bore core needle biopsy with or without a vacuum-assisted device.

Question 32

tissue biopsy results

Answer 32

-Contain information about:
-Tumor grade, based on cell differentiation
-Low-grade tumors (grade 1) are well differentiated
-High-grade (grade 4) tumors are undifferentiated
-Immunohistology, based on hormone receptivity and HER-2 expression.
-Oncotype DX Breast Recurrence Score tell you if you need neoadjuvant chemotherapy and risk of recurrence in patients with early stage breast cancer -> 25-100

Question 33

more testing after dx of breast cancer

Answer 33

-Increased risk in Cowden syndrome and Li-Fraumeni syndrome.
-Patients with a family history of:
-Cancer of the breast
-Ovary
-Pancreas
-Prostate
-Colon
-Thyroid,
-Endometrium
-Should undergo more extensive genetic testing!
-send to geneticist

Question 34

tumor staging- who gets BRCA testing

Answer 34

-Breast cancer is staged using the TNM (tumor, nodes, metastasis) classification system
-Most women with a biopsy-proven malignancy should undergo genetic testing for BRCA 1 and 2 mutations:
-breast malignancy dx at age 50 or younger
-bilateral breast malignancy
-personal or family hx of breast of ovarian cancer
-multiple breast malignancies in pt family
-male breast cancer in family
-ashkenazi jewish heritage

Question 35

treatment decision

Answer 35

-Tx of breast cancer, including surgery, depends on the size of the lesion, hormone receptivity and histologic markers (differentiated/undifferentiated), presence or absence of metastatic or contralateral disease, patient age, and patient preference

Question 36

surgical options for breast cancer

Answer 36

-Lumpectomy
-Mastectomy, and bilateral mastectomy
-Breast-conserving surgery (lumpectomy) *preferred intervention for most pts with unilateral disease, but many patients still opt for mastectomy
-many do mastectomy with immediate reconstruction (flap surgery)
-lumpectomy requires radiation of breast and axillary nodes after
-Sentinel lymph node biopsy preferred over wide lymph node dissection if no evidence of axillary lymph node involvement
-preserve skin and nipple
-With lymph node involvement, expert consensus remains mixed as to whether axillary node dissection has clinical benefit.
-antibiotics, drains, foley, doppler signals for good perfusion
-get attending IMMEDIATELY if there is a problem

Question 37

chemotherapy

Answer 37

-Hormone reception status.
-HER-2 status.
-Presence or absence of metastatic disease.
-Oncotype DX recurrence score.
-Locally advanced disease and triple negative breast cancer usually are treated with presurgical neoadjuvant chemotherapy
-doxorubicin
-cyclophosphamide
-paclitaxel

Question 38

chemo meds complications

Answer 38

-Doxorubicin:
-Nausea, vomiting
-Diarrhea, and fatigue
-Discoloration of their nails
-Reddish discoloration of urine, tears, and sweat
-alopecia
-HEART failure!
-do echo prior to starting
-Cyclophosphamide:
-Neutropenia
-Alopecia
-Nausea and vomiting
-hemorrhagic cystitis!!
-kidney toxicity
-Paclitaxel:
-Neutropenia,
-Alopecia
-Arthralgias
-Myalgias
-Peripheral neuropathy!!
-Mucositis
-CNS toxicity
-decrease bone marrow

Question 39

adjunctive chemo

Answer 39

-Aromatase inhibitors and selective estrogen receptor modulators (SERMs): nonmetastatic estrogen and progesterone receptor positive breast cancer
-HER-2 positive breast cancer can be responsive to HER-2 blockers such as pertuzumab and trastuzumab
-Neoadjuvant and adjuvant anthracycline-based chemotherapy (doxo, pac, cyclo), in addition to HER-2 blocking monoclonal antibodies, has shown clinical superiority.

Question 40

HER2 blockers

Answer 40

-pertuzumab
-trastuzumab:
-monitor ejection fraction before and after tx
-Primary resistance in >30% of pts, and secondary resistance occurs in >70% of pts

Question 41

selective estrogen receptor modulators (SERMS) and aromatase inhibitors

Answer 41

SERMs:
- are used in PREMENOPAUSAL pts + hormone receptor +
-hormone receptor + breast cancer: use a SERM for 5 years -> then an aromatase inhibitor for 5 years
-causes premature menopause
-high risk pts (< 35 yo with positive nodes, high-grade, or large tumors) with hormone receptor + and HER-2 neg may benefit from using:
-Tamoxifen is the MC used SERM!

aromatase inhibitor:
- Used in postmenopausal women or premenopausal women undergoing ovarian suppression
- exemestane, anastrozole
-chemical ovarian suppression with a gonadotropic releasing hormone agonist (leuprolide/lupron or goserelin) OR
-oophorectomy OR
-ovarian radiation

Question 42

tamoxifen

Answer 42

-SERM
-Tamoxifen associated with endometrial hyperplasia and carcinoma
-Any new abnormal uterine bleeding must be reported to gynecologist
-bone pain
-hypercalcemia
-Avoid co prescribing paroxetine, fluoxetine, bupropion, and duloxetine, because these medications are strong inhibitors of CYP2D6 and may lower tamoxifen’s effectiveness
-Escitalopram, citalopram, sertraline, and desvenlafaxine are moderate inhibitors of CYP2D6.
-Venlafaxine seems to have a negligible effect on CYP2D6

Question 43

aromatase inhibitors: overview and side effects

Answer 43

-Use in natural and surgically induced menopause
-work in periphery in fat
-Postmenopausal: Age 60 years or older
-Oophorectomy
-Under age 60 years with amenorrhea for at least 12 months without any exogenous medications that could alter ovarian function
-< 60 years and taking a SERM, but has serum estradiol (low) and/or FSH (high) that are consistent with menopause

side effects:
-Experience accelerated bone loss, so monitor bone density.
-Consider bisphosphonates in postmenopausal women with hormone receptor positive breast cancer to help prevent further bone loss from aromatase inhibitor therapy.
-Can cause significant joint pain -> NSAIDs and acetaminophen.
-Some relief from physical therapy, acupuncture, exercise, and other complementary therapies

Question 44

triple negative subtype tx

Answer 44

-combination of doxorubicin, cyclophosphamide, and paclitaxel

Question 45

radiation therapy

Answer 45

-Either before or more commonly after surgery.
-Whole-breast and targeted nodal radiation -> “gold standard”.
-Typically receive radiation therapy 5x/week for 4 - 7 weeks.
-A “boost” of lower radiation may be considered in women at high risk of recurrence.
-Accelerated partial breast irradiation may be considered in women > 50 years who are node-negative, hormone receptor positive, and BRCA-negative.
-Women who undergo breast-conserving surgery (lumpectomy) receive postsurgical radiation of the breast and axilla (bc nodes are here and can have undetected spread there)
-Women with positive lymph nodes and tumors > 5 cm, radiation may be used on the axilla (axillary), supraclavicular areas (subclavicular), and sternum (substernal)

Question 46

radiation precautions

Answer 46

-Avoid use of deodorants, antiperspirants, and underwire bras.
-Topical creams, lotions, and ointments.
-Thicker applications could affect the radiation dose received.
-Heavily perfumed lotions and creams on the breast,
-Use only specific topical products (such as aloe vera and hydrocortisone)

Question 47

ADRs radiation

Answer 47

-Fatigue.
-Pain
-bone marrow suppression
-Breast discoloration.
-Women with large breasts are also at risk of developing a candida dermatitis under the breast.

if you use deodorant, perfumed lotions, topical creams: burns, decreased radiation effectiveness

Question 48

USPSTF recommendations (didnt talk ab it)

Answer 48

-US Preventive Services Taskforce (USPSTF) recommends screening mammography in women ages 50 to 74 years.
-Women ages 40 to 49 years should have a screening regimen based on the best-available evidence, including the patient’s risk factors, through shared decision-making.
-Annual mammography is not recommended for average-risk women in any age group, and the benefit of screening in women over age 75 years has not been established.
-The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of adjunctive screening for breast cancer using breast ultrasonography, magnetic resonance imaging, DBT, or other methods in women identified to have dense breasts on an otherwise negative screening mammogram (Dense Breasts).

Question 49

breast self exam and clinical breast exam

Answer 49

-Monthly breast self-examinations are NOT explicitly recommended by any professional organization.
-Clinical breast examination recommendations vary by professional organization:
-ACOG and the National Comprehensive Cancer Network recommend clinical breast examinations every 1 to 3 years.
-American Cancer Society and the USPSTF do not recommend clinical breast examinations

Question 50

deep inferior epigastric perforator (DIEP)

Answer 50

-breast reconstruction: preserves ab muscles, takes abdominal skin and fat below belly buttom
-corrective DIEP flap
-muscle transplant
-anastomose deep inferior epigastric perforator - preserves ab strength, decreases risk of hernias, natural feel

Question 51

TRAM candidates vs bad candidates

Answer 51

TRAM: transversus rectus abdominus myocutaneous (TRAM) flap
-Are not a candidate for implant reconstruction.
-Have had failed reconstruction using a breast implant.
-Have had radiation administered to your chest wall.
-Have sufficient tissues in your lower abdomen to create one or both breasts.
-Have never had surgery on your abdomen.
-Prefer to reconstruct one or both breasts using your own tissue

NOT GOOD CANDIDATES:
-Are obese.
-Cannot tolerate prolonged general anesthesia.
-Do not want a lower abdominal scar.
-Have an overly large abdominal pannus (hanging flap of tissue).
-Have diabetes mellitus.
-Have had abdominal surgery (e.g. an abdominoplasty).
-Lack sufficient lower abdominal tissue to create acceptable breast volume.
-Smoke (or quit smoking only recently).

note: TRAM weakens ab muscles -> hernia risk but ppl like the tummy tuck effect

Question 52

other breast reconstruction options

Answer 52

-Deep inferior epigastric perforator(DIEP) flap: Uses tissue from the lower abdomen.
-Latissimus dorsi flap: Uses tissue from the upper back.
-Superficial inferior epigastric artery (SIEA) flap: Uses tissue from the lower abdomen.
-Superior or inferior gluteal artery perforator (SGAP/IGAP) flap: Uses tissue from the buttocks.
-Transverse upper gracilis (TUG) flap: Uses tissue from the inner thigh and underlying gracilis muscle

Question 53

vioptix

Answer 53

-transcutaneous oxygen level monitoring
-target is what the O2 was at in the surgical room
-notify attending immediately if it waivers
->70% O2
-give aspirin bc of the anastomosis

Question 54

breast cysts

Answer 54

-fluid filled
-lobules become distended due to blockage
-perimenopausal
-smooth, soft, can be painful
-dx- US- def dx
-mammo - halo shape
-tx-
-aspiration if persisting, symptomatic, unknown dx
-if there is blood or lump does not disapear after aspiration -> RO cancer

Question 55

mammary duct ectasia

Answer 55

-dilation and shortening of lactiferous ducts with subareolar periductal inflammation

presentation:
-perimenopausal; 40s-50s
-green/yellow nipple discharge** (oregon ducks)
-palpable mass
-nipple retraction/inversion
-seen on mammo
-bx- multiple plasma cells

tx- no tx unless you cant r/o cancer
-is nipple discharge is severe -> duct excision
-atkins microdochectomy

Question 56

paget’s disease of nipple

Answer 56

-adenocarcinoma!
-rough, scaling, ulcerating, eczematous change to nipple
-underlying neoplasm 85% of the time
-itching, red
-flaking, thick skin
-painful, sensitive
-flattened nipple
-yellow or bloody discharge
-does NOT spare the nipple (eczema does- only areola)

dx-
-bx
-US, mammo, MRI

tx- surgery

Question 57

inflammatory breast cancer

Answer 57

-rare but aggressive- worser prognosis
-swelling
-red
-warm
-SKIN changes- dimple, thickened, blistering
-pain
-dx-
-US, Mammo
-!!!!skin biopsy NOT breast biopsy -> dermal lymphatic invasion by tumor cells is hallmark
-Tx-
-chemo before surgery
-radiation after
-targeted therapy if possible

Question 58

when do we get MRI

Answer 58

-dense breast
-breast implants
-involvement of skin

Question 59

Batsons plexus

Answer 59

• Can participate in distribution of metastatic lesions -> can go through here and can go up and down and seep into vertebral bodies -> feed the brain and the sacrum
  Potential area of transmission of breast cancer metastacies