Breast

Question 1

Serratus anterior

Answer 1

Long thoracic nerve (winged scapula), lateral thoracic artery

Question 2

Medial pectoral (thoracic) nerve

Answer 2

Pec major and minor

Question 3

Lateral pectoral nerve

Answer 3

Pec major – injured during level III node takedown

Question 4

MCC of primary axillary adenopathy

Answer 4

Lymphoma

Question 5

Intercostobrachial nerve

Answer 5

MC nerve injured during mastectomy
-Numbness and pain of UPPER INNER ARM

Question 6

MCC of breast abscess

Answer 6

-breast feeding  MC staph aureus. 1st line treatment is FNA.
- Can continue breast feeding

Brest infections: lactational vs non-lactational; both S aureus
-Recurrent unresolving mastitis -> skin bx to r/o inflammatory breast CA

Question 7

Poland syndrome

Answer 7

– hypoplasia of chest wall mm. Congenital absence of pectoralis, serratus, and latissimus dorsi muscles
- Associated with fused fingers, dextrocardia, amastia, hypoplastic shoulder

Question 8

Periductal mastitis

Answer 8

Periductal mastitis – non-cyclical mastodynia.
- This is due to ectasia of lactiferous ducts
- Tender mass behind nipple, creamy nipple discharge, nipple retraction, mammary fistula
- Risk factors: Breast feeding, SMOKING!!, nipple piercing
- Can get Subareolar abscesses
- Path  dilated mammary ducts, inspissated secretions
- Can form abscesses and fistula
- Dx: FNA
- Non-breast-feeding associated Tx:  if typical creamy discharge, no blood or nipple retraction abx and reassure
- If not, recurs, or > 2 weeks  excision of duct ectasia and fistula if present
- Breast feeding  Same as above but continue breast feeding

-Mastitis: caused by Staphylococcus aureus; common in initial 4-6 weeks of breastfeeding or during weaning; ducts poorly drain -> bacteria proliferate -> cellulitis (fever,pain, erythema, swelling) -> 1st line= abx, breastfeeding warm compresses; if continues after 10-14 day abx -> r/o abscess w US; if abscess= percutaneous US-guided aspiration w 18-gauge needle (thicker/more viscous= 14-gauge)
-When skin is intact, repeated aspiration preferred; if skin is not intact, I&D (small incision)

-Non-lactational: smoking and ductal ectasia; abx, I&D if abscess

Question 9

Mastodynia

Answer 9

MC location, upper outer quadrant.
MCC of continuous Mastodynia = infectious
Cyclical mastodynia = cyclical mastalgia = occurs with menses = MC premenopausal = bilateral = Do H&P  Tx: reassurance
Non-cyclical Mastodynia = MC post-menopausal
- Tx: 1st line is reassurance, OTC, change bra, support garment
- 2nd line = tamoxifen or danazole. Avoid nicotine, caffeine, OCP.
- Evening primrose oil  studies show no effects

-Mastodynia management
-Mild/moderate: conservative therapy; NSAID, acetaminophen, topical diclofenac (patch/gel)
-Severe 1st line: tamoxifen; SERM; use < 6 mo; contraindicated in pregnancy; SE= vaginal dryness, hot flashes, blood clot risk, strokes; inc risk of uterine CA; dec risk of osteoporosis + fxs
-Severe 2nd line: danazol; antigonadotropin agent with mild androgenic effect; contraindicated in pregnancy; SE= acne, voice changes, weight gain, hot flashes, menstrual irregularities; administered during the luteal phase of the menstrual cycle
-Severe 3rd line: bromocriptine; dopaminergic agent; inhibits release of prolactin from anterior pituitary gland; SE= HA, dizziness, n
-Cyclic= menstrual cycle- during late luteal phase
-Non-cyclic after menopause; if over 40 -> evaluate w mammogram

Question 10

Mondor’s disease

Answer 10

Mondor’s disease – MC location lower outer quadrant. Superficial vein thrombophlebitis. Lateral thoracic vein. Tx: NSAIDS

-Mondor’s dz/thrombophlebitis: lateral thoracic or superior thoraco epigastric vein; tender,palpable subcutaneous cord; associated with hypercoagulable state, surgery, trauma, inflamm process; benign/ self-limited; tx= NSAIDS, warm compress
-If over 35 w Mondor dz= mammogram to r/o malignancy (rare association)

Question 11

Breast MRI is indicated

Answer 11

Breast MRI is indicated if there is known nodal mets, and US and mammogram are negative for mass

Question 12

Gynecomastia

Answer 12

Gynecomastia
In kids  no treatment
In adults can try tamoxifen or danozol

-Gynecomastia: benign proliferation of male glandular breast tissue; rubber or firm mass extending concentrically from the nipple; can be unilateral
-Vs carcinoma: asymmetric, eccentric to nipple, non-tender, firm, fixed, skin dimpling, nipple retraction, discharge, lymphadenopathy
-MOA: dec in androgen production; inc in estrogen or availability of estrogen precursors for peripheral conversion to estrogen; androgen receptor blockade & dec free testosterone due to inc binding of androgen sex hormone-binding globulin
-Can be associated with cimetidine, spironolactone, marijuana;digoxin, thiazides, estrogens, phenothiazines, theophylline
-If present for several years less likely to regress as fibrosis likely present -> surgical excision of glandular tissue and liposuction of surrounding adipose tissue

Question 13

Breast cyst

Answer 13

Breast cyst
Most are benign.
Mammography cannot distinguish cyst from mass.
Dx: US is best.
Simple cyst: anechoic with posterior acoustic shadowing and no septations (solid component)
- No further management needed
- FNA only performed here if has signs of infection (abscess)
- Never send for cytology unless bloody
Complex cyst: septations, solid component
- This needs a core needle biopsy. Never do FNA here
Can repeat FNA for recurrence. If recurs a 3rd time  excisional biopsy
If cyst looks benign, do not even need to aspirate it and don’t need follow up imaging

Question 14

Fibroadenoma

Answer 14

Fibroadenoma
Rubbery, mobile, and painless masses on physical exam. Ultrasound will demonstrate a well-circumscribed hypoechoic mass.
Prominent fibrous tissue compressing epithelial cells, Large course calcifications (popcorn calcification).
Teenagers > 5 cm = Juvenile fibroadenoma = excision
<30 y/o breast mass. Start with ultrasound. If US consistent with fibroadenoma  can follow with imaging in 6 months
>30 years old  BL mammogram and US, then all need CNBx or straight to excisional biopsy
Indications for surgical excision: Symptoms (pain), growth, patient preference (anxiety), no size cut off but generally > 3 cm

-Fibroadenoma: MCC of breast mass in women >30; stromal + epithelial elements; soft, firm, mobile, rubbery, painless; mammogram- well-circumscribed solid mass; develop calcifications as degenerate (coarse calcifications)
-Grow during increase hormonal influence- menses, pregnancy
-Giant fibroadenoma: > 6 cm, difficult to distinguish from phyllodes
-Complex= sclerosing adenosis, papillary apocrine hyperplasia, cysts, epithelial calcifications; risk for carcinoma
-Tubular adenoma: tightly packed epithelial component with sparse connective tissue; variant of peri canalicular fibroadenoma w adenosis-like epithelial proliferation; benign
-Degenerating fibroadenoma with coarse (A arrow) and popcorn (B) calcifications

Surgical indications for fibroadenoma:
-Large size at presentation (typically > 3 cm)
-Symptomatic (pain with menstruation)
-Interval growth
-Inability to exclude other premalignant lesions
-Patient prefence/ anxiety

Question 15

Breast mass work up

Answer 15

<30 y/o breast mass. Start with US. Get a mammography if concerning for cancer. CNBx.
>30 years old  BL mammogram and US, then all need CNBx or straight to excisional biopsy
- Palpable abnormalities that you are working up, all need US (determine if cyst or solid)

Question 16

Nipple discharge

Answer 16

Nipple discharge
Most are benign, MC hyperprolactinemia, meds,
Work up: Prolactin level, TSH, pregnancy test
- If there is a mass  normal breast mass work up  mammogram, US
Benign if it’s: Bilateral, arises from multiple ducts, is provoked, milky or dark green
- MC caused by breast feeding, pregnancy, medications
- Does not require work up other than H&P
Pathological discharge: unilateral, from a single duct, spontaneous, is serous (clear, yellow, orange), or bloody
- MCC by #1 intraductal papilloma #2 benign duct ectasia #3 cancer
- Work up: 1st Mammogram and Ultrasound  CNBx if there is a lesion
- If above is normal (unable to localize duct) next step is MRI
- Ductoscopy and galactography have fallen out of favor
- Surgical excision required for all pathological nipple discharge
- Intra-ductal papilloma (usually single duct)– use lacrimal probe (methylene blue) intra-op to excise single duct
If nipple discharge yellow/green, cyclical, non-spontaneous  fibrocystic disease  reassure

-Bloody nipple discharge: central duct excision or subareolar resection if duct cannot be identified; preserve breastfeeding galactography/ ductoscopy (minimally helpful) -> excise single duct; suspicious discharge: unilateral, single duct, spontaneous -> mammogram/US; if lesion, then CNB
-Pathologic: intraductal papilloma (MCC), duct ectasia, fibrocystic breast disease
breast carcinoma
-Benign: galactorrhea, glandular secretions, pregnancy, medications, physiologic stimulation-Pregnancy test, TSH/prolactin level, US, mammogram
-Green/yellow/brown discharge: usually fibrocystic disease; should have lumpy breast tissue consistent with fibrocystic dz
-Serous discharge: worrisome for cancer, esp if only 1 duct or spont
-Usually no cytology because still need surgical bx

Question 17

Intraductal papilloma

Answer 17

Intraductal papilloma
MCC of pathologic and bloody nipple discharge
NO risk of malignancy within itself, but can harbor neighboring DCIS
No mass is found on exam or imaging
Mammogram and US cannot dx, but need this for work up
Dx: US, mammogram and then CNBx
Tx: Single Duct excision

-Papilloma: most commonly found in major subareolar ducts; “branching fibrovascular core with overlying epithelial and myoepithelial layers”

Question 18

DCIS

Answer 18

Cluster Calcifications
Premalignant, MC get invasive ductal CA
50% risk of CA to ipsilateral breast if not resected

Tx: lumpectomy with 2 mm margin and whole breast XRT; Can go for Re-excision X 1
tamoxifen (premenopausal)/anastrozole (aromatase inhibitor, postmenopausal) X 5 years post op if ER positive

-XRT reduces risk of recurrence by 50% but does not affect overall survival

-Comedo DCIS: central necrosis, many mitotic figures, large pleomorphic nuclei; more aggressive; likely to recur/progress to invasive ductal carcinoma; tx: simple mastectomy + adjuvant hormone therapy; also need SLNB (last chance to sample nodes if it turns out to be CA)

Simple mastectomy with SLNB for: (No post mastectomy radiation)
- Males
- Comedo
- High grade
- Paget’s that lead to DCIS
- Multicentric (located in different quadrants) = relative contraindication to BCT. Multifocal (numerous lesion in same vicinity) = OK to do BCT
- Inability to get negative margins after RE-RESECTION
- DCIS recurrence
- Diffuse malignant appearing calcifications
- Previous XRT

-SLNB performed for DCIS: lumpectomy in upper & outer quadrant which may affect lymphatic drainage, mastectomy, or more aggressive subtype of DCIS (comedo); large (>2-2.5 cm), high-grade ductal carcinoma, palpable mass

Question 19

LCIS

Answer 19

LCIS
40% risk of CA Bilaterally, No calcifications.
The lesion itself is not premalignant, it is a marker for cancer risk = No SLNBx or radiation
Have equal risk of getting ductal or lobular carcinoma bilaterally
This is found incidentally on biopsy. IT IS NOT SEEN ON IMAGING
MC premenopausal women
Don’t need negative margins
Treatment:
-Options observe with US &/or mammogram imaging q6 months for a year + tamoxifen or excise then tamoxifen if not classic
- Pleomorphic or florid LCIS (non-classic LCIS) all need excisional biopsy then tamoxifen; pleomorphic & atypical LCIS need 2 mm margins
- Tamoxifen (premenopausal) or raloxifene post op (post menopausal) X 5 years = BIG for LCIS
- Prophylactic bilateral subcutaneous mastectomy  No longer supported

-LCIS: small uniform cells confined to the lumen of the lobule (not penetrated BM); tx= wire localized excision & tamoxifen (premenopausal) or raloxifene (postmenopausal); if positive margin, no re-excision

Question 20

Need excisional biopsy for

Answer 20

Need excisional biopsy for: (Do NOT need negative margin, just need to resect all of it if seen on mammogram)
- Atypical ductal/lobular hyperplasia – Give tamoxifen after excision to reduce risk of CA
- These are like lobular carcinoma in situ, just increases risk of CA but not pre-malignant
- Columnar cell hyperplasia with atypia
- Radial scar = Stellate arrangement with central fibroelastic core
- Papillary lesions
- Complex sclerosing lesion
- Flat epithelial atypia
- Intraductal papilloma

-Breast bx indication: BI-RADS 4 & 5; complex cysts, suspicious solid or indeterminate masses, persistence of mass after aspiration; bloody fluid w malignant cells on FNA
-Fluid from a simple cyst will always show atypical cells on cytology, which is not a cause for concern; therefore, fluid should only be sent for culture unless it is frankly bloody–in which case both cytology and culture should be performed.
-CNB: gives architecture (Histology)
-FNA: gives cytology (just cells)
-Breast lesions identified on CN biopsy:
* Atypical ductal/ lobular hyperplasia: surgical excisional bx
* Lobular carcinoma in situ: excise vs observation
* Pleomorphic lobular carcinoma in situ: excise
* Fibroepithelial lesions w concern for phyllodes; phyllodes tumors: surgical excisional bx
* Complex sclerosing lesion or radial scar: surgical excisional bx
* Desmoid: wide local excision; benign but infiltrative, recurrence is high
* Pseudoangiomatous stromal hyperplasia: observation
* Other indications for excisional bx: columnar cell hyperplasia w atypia, papillary lesion, lack of concordance, nondiagnostic

Columnar cell lesions with atypia= frequent association with tubular carcinomas

Question 21

Atypical ductal hyperplasia

Answer 21

Found after CNBx of calcifications on mammogram
- Confers 30% risk of breast cancer in bilateral breast in 25 years when found
- Has many similar features of DCIS on histology, it’s difficult to distinguish the two.
- Tx: excisional bx then give tamoxifen post op as chemoprevention

-Atypical ductal hyperplasia: 4-5-fold increased risk of invasive CA; Dx= CNB; tx= excisional bx (negative margins not required); 9-30% incidence of DCIS on excisional bx; 3% chance of IDC

Question 22

Sclerosing adenosis and apocrine metaplasia

Answer 22

don’t need to excise. No treatment necessary

-Sclerosing adenosis: microcalcifications; CNB; not CA precursor; if no atypia & concordant w imaging= observe

Question 23

Anatomy

Answer 23

Question 24

Axillary LN levels

Answer 24

-1: lateral to pec minor
-2: posterior to pec minor
-3: medial to pec minor

-Breast cancer: removal of level 1 & 2 LNS
-Melanoma: levels 1-3 excised

-Axillary LN dissection boundaries:
-Medial: serratus anterior
-Lateral: anterior border of latissimus dorsi muscle
-Inferior: tail of breast
-Superior: level of axillary vein

-Anatomical axilla boundaries:
-Apex: posterior clavicle border
-Anterior: pec major & minor
-Medial*: serratus anterior muscle overlaying 1st 4 ribs & chest wall
-Lateral: anterior border of latissimus dorsi muscle
-Posterior: subscapularis muscle
Rotter’s nodes – Level II nodes between pec minor and major
Sappey nodes – Subareolar nodes, principle for lymphatic mapping

-Axillary LN status= most important predictor of prognosis

-Clinically palpable nodes should not be treated with SLNB -> axillary lymph node dissection

Question 25

Axillary dissection nerve injured

Answer 25

-Winged scapula: long thoracic innervating serratus anterior o Shoulder pain, inability to raise arms above shoulder level -Weakness in pullups & arm adduction (move towards midline): thoracodorsal nerve innervating latissimus dorsi -Sensory deficits to medial arm & axilla: intercostobrachial nerve= lateral cutaneous branch of 2nd intercostal nerve -Right-sided "winging"

Question 26

Gail Model

Answer 26

-Gail Model: calculates a woman’s risk of developing breast cancer within the next 5 years and within her lifetime -Age, age of first period, age of first birth, FHx of breast CA (mom, sister, daughter), number of past breast biopsies, number of breast bx showing atypical hyperplasia, race/ ethnicity -Underestimates risk for patients with strong family history (BRCA), personal hx of DCIS, LCIS, or invasive CA

Question 27

BI-RADS

Answer 27

0 – Needs additional imaging 1 – negative (no mass or lesions), routine screening 2 - benign finding, routine screening 3 - probably benign, short interval follow up mammogram 3-6 months 4 – suspicious for cancer (indeterminant calcifications) → get core needle biopsy. If CNBx benign and concordant  If 4a f/u in 3-6 months, If 4b or 4c  excisional biopsy 5 - highly suggestive of cancer -> get core needle biopsy. If any other finding than CA on CNBx then needs EBx

Question 28

BRCA

Answer 28

BRCA (Tumor suppressor gene) – Autosomal domoninant BRCA 1 – tends to be poorly differentiated (High grade) and triple receptor negative. - 60% breast, 40% ovarian, 1% male breast BRCA 2 – well differentiated and hormonal receptor positive - 60% breast, 20% ovarian, 10% male breast - Increased risk of prostate cancer, pancreatic cancer, melanoma First line prophylaxis: BRCA 1 who do not wish to have children and are age 35 – 40 years old for and 40-45 for BRCA2 should be offered: - Bilateral salpingo-oopherectomy and bilateral total mastectomy - Prophylactic surgery – Can do skin or nipple sparing BL mastectomy. No SNLBx, no axillary dissection Second line prophylaxis – If patient’s refuse the above surgery then: - Give tamoxifen/raloxifene and at 25 y/o yearly mammogram, breast MRI, pelvic exam, pelvic (ovarian) US, CA-125 Yearly MRI screening in addition to mammography for: - BRCA positive - > 20% lifetime risk of breast cancer - History of mantle radiation - 1st degree relative of BRCA positive who is untested

Question 29

Invasive Ductal CA

Answer 29

MC type of breast cancer 70% Small ovoid cells with little cytoplasm in a single file pattern Will see spiculation (calcifications) on mammography and US DCIS is a precursor -Ductal CA: most common; tx= MRM or BCT (no ink on tumor) with postop XRT -Medullary: smooth borders, inc lymphocytes; more favorable prognosis -Tubular: small tubule formations; more favorable prognosis -Mucinous (colloid): mucin, more favorable -Cirrhotic: worse prognosis

Question 30

Invasive Lobular CA

Answer 30

Will not see calcifications. Usually hard to palpate and difficult to see on imaging -Lobular CA: doses not form calcifications; extensively infiltrative; inc bilateral, multifocal, multicentric; tx= MRM or BCT with postop XRT -Signet cells: worse prognosis

Question 31

Types of mastectomies:

Answer 31

Radical mastectomy (Halsted) – remove all breast, skin, nipple and areola complex, pec minor and major, Leve I, II, III nodes - Never used Modified radical mastectomy - removes breast, skin, nipple and areola complex, fascia of pec major, level I and II nodes - For biopsy proven axillary mets - For Patients who do not want reconstruction Simple mastectomy = total mastectomy – remove breast tissue and overlying skin, nipple and areola complex. No nodes or muscles - Used for CA treatment or prophylaxis Skin sparing mastectomy – removes breast and nipple areola complex. Spares the skin. Circular incision around areola. Immediate reconstruction can follow - Mostly used for prophylaxis Nipple sparing mastectomy – removes breast, any biopsy scar, preserves skin and nipple - Mostly used for prophylaxis -Modified radical mastectomy: prevent seroma with JP drain across pec muscle and extending into axilla; remove post op day 2/3 when less than 50 mL/24 hours

Question 33

DCIS vs LCIS

Answer 33

-LCIS= risk factor (not pre-cancerous), bilateral (DCIS is ipsilateral), multicentric

Question 34

Margins

Answer 34

-DCIS: 2 mm -Invasive ductal/ lobular carcinoma: no tumor on ink=clear margin; if invasive ductal carcinoma identified on lumpectomy for DCIS, then sentinel LN bx performed for staging -Lobular carcinoma in situ: no margins -Phyllodes: 1 cm

Question 35

BIRADS

Answer 35

* 0: incomplete; further imaging (diagnostic mammogram) * 1: normal * 2: typically benign; normal follow up * 3: probably benign; short follow up * 4 (suspicious) 5 (highly suspicious): bx o 4 with CNBx; if benign & concordant w mammogram: 6 month f/u o Any other finding for 4 & all 5: need needle localization excisional bx * 6: histologically proven malignancy: excision -Findings on mammography that are concerning for malignancy: irregular borders, spiculated, distortion of breast, or small/thin linear branching calcification

Question 36

Lymphangiosarcoma

Answer 36

previous hx of axillary LN dissection; lymphedema risk factor for lymphangiosarcoma (Stewart-Treves syndrome) in affected extremity; tumor originates in vascular endothelial cells (not lymphatic vessels) Stewart-Treves syndrome tx: wide surgical debridement (3-6 cm margins of normal skin), usually needs amputation

Question 37

Physiology

Answer 37

Development: from ectoderm milk streak -Estrogen: duct development; cyclic changes= inc breast swelling, glandular tissue growth -Progesterone: lobular development; cycl changes= inc maturation of glandular tissue; withdrawal= menses

Question 38

Axilla anatomy

Answer 38

-Medial pectoral nerve: innervates pec major & minor -Lateral pectoral nerve: pec major -Blood supply: internal thoracic (mammary), intercostals, lateral thoracic, thoracoacromial arteries -Batson's plexus: valveles venous plexus that allows direct hematogenous spread to spine -Cooper's ligaments: suspensory ligaments; divides breast into segments

Question 39

Fibrocystic dz

Answer 39

Perimenopausal; sx= breast pain, nipple discharge, lumps that vary w menstrual cycle -Simple cysts: observe -Symptomatic: aspirate -Bloody or recurrent -> cytology (cancer risk if ADH or ALH) -Bloody aspirate, unresolved, recurrent: surgical excision

Question 40

Phyllodes tumors

Answer 40

-Phyllodes tumors: epithelial & stromal overgrowth; resemble rapidly growing, large sized fibroadenomas; malignant potential- based on atypia, mitotic activity, stromal overgrowth; tx= wide local excision to achieve 1-cm margins -Benign, borderline, malignant -Malignant phyllodes: greater potential if >5 mitoses per high power field; behave like sarcomas- metastasize through hematogenous route (axillary staging not recommended) -No adjuvant endocrine or chemotherapy; recurrence treated with resection; radiation if malignant -Histology: "leaf-like" pattern, hypercellular, sarcomatous -Core needle biopsy (white arrow) of well-circumscribed, hypoechoic phyllodes tumor (black arrow)

Question 41

Radial scar

Answer 41

-Radial scar (sclerosing papillary proliferations, benign sclerosing ductal proliferation) -Stellate, irregular spiculated mass; has central fibroelastic core with ducts & lobules radiating outward -2x inc risk of CA -Mammogram appears similar to small, invasive CA -Excisional bx (difficult to distinguish radial scar vs invasive breast carcinoma on CNB) 50% benign. Rest is sarcoma. Based on Mitoses >5/HPF. Path: epithelial AND spindle cell stromal component form a characteristic leaf like projections Clinically and on imaging it is indistinguishable from fibroadenoma Most biopsy reveal “fibroepithelial tissue”, Has mesenchymal tissue. No nodal mets. Mets via hematogenous route, MC mets is lung Dx: Core needle biopsy Tx: Excision with 1 cm margin, no nodes, no node workup

Question 42

Fat necrosis

Answer 42

Fat necrosis: previous trauma, radiation, surgery Non-tender mass -Fluid-filled level (arrow) usually mobile indicating oil cyst -Mammogram findings: spiculated masses, microcalcifications, architectural distortion -Stereotatic bx if inconsistent hx or imaging findings

Question 43

Atypical lobular hyperplasia

Answer 43

-Atypical lobular hyperplasia: less developed but morphologically similar to LCIS; increased risk of CA (not pre-malignant); Dx= CNB; TX= excisional bx -Excisional biopsy to rule out sampling error of core needle bx/ evaluate if cancer is associated with the lesion

Question 44

Male breast cancer

Answer 44

If male diagnosed with breast cancer: all need genetic BRCA testing Adult male with breast mass: mammogram, US, and CNBx No breast conservation therapy. All need mastectomy with SNLBx vs axillary dissection -Male breast cancer risk factors: Klinefelter syndrome, obesity, gynecomastia, exogenous estrogen exposure, BRCA2 mutation; genetic testing for males with breast cancer; usually ductal -Simple mastectomy + sentinel LN bx usually preferred over breast-conserving surgery b/c of small volume of male breast tissue -Genetic testing for all male breast cancer -> if positive, offer prophylactic bilateral mastectomy -Tamoxifen better than anastrozole alone; testicular production of estrogen not inhibited by anastrozole stage-for-stage same prognosis as women but typically present later DCIS and invasive ductal carcinoma; lobular subtype rare likely ER and PR positive; les likely to have HER2 expression

Question 45

Breast CA in pregnant

Answer 45

- Often diagnosed with advanced CA due to delay in Dx - Surgery and chemo safe in 2nd and 3rd trimester - Late 3rd trimester: BCS with SLNBx ONLY then post partum XRT - Methylene blue and isosulfan blue dye CI in pregnant only use radiolabeled sulfur colloid for SLNBx - Never use hormonal therapy in pregnant Mammography can be safely done during pregnancy with shielding -Breast cancer in pregnant patients: radiation & hormonal therapy contraindicated; 1st trimester if continues pregnancy- mastectomy with axillary staging; 2nd trimester- can start adjuvant chemotherapy -> neoadjuvant chemo followed by breast conserving surgery (lumpectomy w low-dose SLNB; postdelivery XRT); late 3rd trimester same as nonpregnant

Question 46

Paget’s of breast

Answer 46

Paget’s of breast – large, round vacuolated cells. 95% have DCIS or ductal CA. - Worse prognosis if Paget’s present - Dx: BL diagnostic mammography then, full thickness punch biopsy of the skin * If there is an underlying mass this must be biopsied too - Two options: Follow treatment algorithms for DCIS or cancer to see which fits * Mastectomy + SNLBx (follow usual guidelines if CA found) = MC treatment to perform * BCT + SLNBx Central lumpectomy (include nipple, areola complex) then radiation - More difficult because you need to take all the skin that is involved -Paget's dz: Cells with clear cytoplasm + enlarged nucleoli; marker of underlying malignancy- DCIS or IDC (generally ER-/PR- and HER2+ ); tx= mastectomy including nipple-areolar complex + SLN

Question 47

Chemotherapy and Hormonal therapy

Answer 47

* Order of post-op chemo-rad and hormone therapy First you give chemotherapy, followed by radiation, then you can start hormonal therapy * If triple negative, > 0.5 cm OR positive nodes breast cancer  all need chemotherapy * If patient got a full course of neoadjuvant chemo, most do not need adjuvant chemo * All patients with hormone receptor positive should get endocrine therapy * If tumor < 0.5 cm, node negative, HER-2 negative, but ER positive endocrine therapy alone suffices. No chemo * If hormone receptor positive, HER-2 negative, node negative, tumor 0.5 – 5 cm use the gene expression profile (Oncotype) recurrence score to determine if the patient should get adjuvant chemotherapy * If postmenopausal and 3 or more lymph nodes involved and did not receive neoadjuvant chemo  patient needs adjuvant chemo

Question 48

Adjuvant chemo indicated for:

Answer 48

Adjuvant chemo indicated for: (TAC, Taxanes, Adriamycin, and cyclophosphamide for 6-12 weeks) - > 0.5 cm - Positive nodes - ER/PR negative

Question 49

Neoadjuvant chemo – breast

Answer 49

- T3 (> 5 cm) and N0-1  trying to shrink tumor for BCT - T4 (inflammatory, skin, chest wall)  followed by MRM - Breast CA in pregnant -Neoadjuvant chemo: Locally advanced/inoperable tumors: inflammatory, N2/N3, T4

Question 50

Indications for XRT

Answer 50

Indications for XRT after mastectomy - 4 or more nodes involved - T3 ( > 5 cm) or T4 (inflammatory CA) - extracapsular nodal invasion - N2 or N3 - Positive margins Radiation decreases risk of local recurrence after lumpectomy -XRT after mastectomy: -Advanced nodal disease (>4 nodes), fixed nodes, internal mammary nodes -Skin/chest wall involvement -Positive margins -T3/T4 tumor, which is greater than 5 cm -Regional node irradiation: - >4 positive lymph nodes: XRT to supraclavicular, infraclavicular, and axillary LN -Tumor central to inner area of breast: internal mammary node radiation -Geriatric radiation: lumpectomy with negative margins plus hormonal therapy WITHOUT radiation in women >70 with clinically negative nodes and ER+ T1 breast CA

Question 51

Z0011 trial

Answer 51

-ACOSOG Z0011 trial: axillary lymph node dissection (ALND) is not needed for women with T1 (<2 cm) or T2 tumors (< 5 cm), clinically node-negative, with only 1 or 2 positive lymph nodes on SLNB, who will receive whole-breast radiation as part of breast-conserving therapy ALND can be avoided only if all of the following criteria are met: * T1 or T2 tumors * Clinically negative nodes (non-palpable) * 1 or 2 positive nodes ONLY on SLNB * Planned breast conserving therapy * Planned whole-breast RT * No neoadjuvant chemotherapy planned

Question 52

Occult Breast Cancer

Answer 52

Occult Breast Cancer – Presentation with adenocarcinoma (breast) of lymph node only If you cannot find breast lesion on mammography and US  Next step is MRI If MRI negative too  Axillary lymphadenectomy and whole breast radiation (better survival) vs MRM -Occult breast cancer: axillary adenopathy w no primary breast lesion; mammogram, MRI, whole body imaging

Question 53

Breast Cancer Screening

Answer 53

-Average risk women: annual screening mammogram starting at 40 - Mammogram sensitivity increases with age as the dense parenchymal tissue is replaced with fat -High risk: 10 years before youngest age of diagnosis in first degree relative; need clinical breast exams q6-12 mo -Hereditary disorders with increased risk: BRCA 1/2, Li-Fraumeni (p53), Cowden syndrome (PTEN), Peutz-Jeghers (STK11), CDH1 -BRCA screening: age 25 with annual mammogram AND MRI + pelvic exam + US and CA-125 -Bilateral salpingo oophorectomy recommended prophylactically for BRCA 1 & 2 to reduce ovarian cancer; BRCA2 also decreased breast cancer risk After a mastectomy, there is no need for screening mammograms. Recurrence risk very low

Question 54

Brest cancer risk factors

Answer 54

ADH, obesity, caucasian, alcohol, dense breast tissue, early menarche, late menopause, delayed childbearing (>30); BRCA strongest RF -Smoking not well-defined risk factor -Protective: breastfeeding, multiparity, exercise, oophorectomy before 35 -BRCA1 cumulative risk: 65% breast; 40% ovary -Inc risk of ovarian, prostate, melanoma, pancreatic, colon cancer -BRCA2 cumulative risk: 45% breast; 10% ovary

Question 55

TNM Staging

Answer 55

* TX: 1ary tumor cannot be assessed * T0: no evidence of 1ary tumor * Tis: ductal carcinoma in situ * T1: tumor <= 20 mm * T2: tumor > 20 mm & <= 50 mm * T3: tumor > 50 mm * T4: direct extension to chest wall or skin; ulceration or macroscopic nodules * CNx: cannot be assessed * CN0: no regional LN mets (imaging or clinical exam) * CN1: mets to movable ipsilateral level I, II axillary LN * CN1mi: micro metastases (0.2-2 mm) * CN2: mets in ipsilateral level I, II * CN3: mets in ipsilateral level III * pNx: cannot be assessed * pN0: no regional LN mets * pN1: micro metastases; mets in 1-3 axillary LN * pN1mi: micro metastases (0.2-2 mm) * pN2: mets in 4-9 axillary LN * pN3: mets in 10(+) axillary LN * M0: no distant mets * C/pM1: distant mets N1 and N2 – Axillary nodes I or II N3 = level III lymph node (infraclavicular) BCT only stage I and stage II Stage I and II  BCT or MRM. Exception is Stage IIb T3N0  If patient wants BCT then Neoadjuvant cehmo 1st then BCT Stage IIIa  MRM. Exception is T3N1  If patient wants BCT then neoadjuvant 1st N2 disease  Cannot do BCT. Needs MRM Stage IIIc (only N3a or N3b)  MRM Stage IIIb (T4)  Neoadjuvant, then MRM, then adjuvant XRT Stage IIIc ONLY N3c (supraclavicular node) and Stage IV = non-operable.  Chemo and hormonal therapy XRT follows chemo Grossly positive Level II nodes are an indication to take Level III nodes

Question 56

Re-excision

Answer 56

Re-excision (when to perform) – (Negative margin = no ink on tumor) For Cancer, a positive margin at the fibroglandular border (skin, pectoralis fascia) does not need re-excision For Cancer, a positive margin on breast tissue should be re-excised LCIS does not require negative margin Need negative margins (no ink on tumor) before starting any XRT for BCT. If < 2 mm margin but no ink on tumor controversial

Question 57

Mammography features concerning for malignancy

Answer 57

Microcalcifications, spiculated lesions, multiple clustered lesions, irregular borders, ductal asymmetry, distortions of breast tissue architecture

Question 58

-Inflammatory CA

Answer 58

-Inflammatory CA: T4 disease; median survival 36 months -Dermal lymphatic invasion/blockage of dermal lymphatics by tumor emboli= peau d'orange lymphedema; erythematous & warm -Dx: full-thickness incisional breast bx including skin -Tx: neoadjuvant chemo, MRM (removes all breast tissue, includes axillary node disection= level 1 &2), adjuvant chemo-XRT Inflammatory breast = A clinical diagnosis (erythema, peau d’orange) You may get ductal or lobular carcinoma on path!! But it is still inflammatory breast CA if it fits above description Sentinal LNBx is contraindicated here Tx  neoadjuvant chemo MRM Post op XRT - Skin biopsy is not sufficient to rule out the diagnosis. Go for CNBx if there is a mass present. *biopsy required to evaluate tissue, but dermal lymphatic involvement is not sufficient by itself to establish diagnosis* T4d

Question 59

-Galactocele/ Galactorrhea

Answer 59

-Galactocele: breast cysts filled with milk; occurs w breastfeeding; aspiration -> I&D -Galactorrhea: inc prolactin (pituitary prolactinoma), OCPs, TCAs, phenothiazine, metoclopramide, alpha-methyl dopa, reserpine

Question 60

Ductal ectasia

Answer 60

-Ductal ectasia: dilation of subareolar duct in peri- and post-menopausal women; cheesy, viscous nipple discharge; excision if sx

Question 61

Absolute Contraindications to BCT

Answer 61

Absolute Contraindications to BCT (BCT requires WHOLE BREAST radiation) - Multicentric (multiple foci in different quadrant) BUT Multifocal (multiple foci in same quadrant) IS NOT CONSIDERED A CONTRAINDICATION - 2 or more primaries in different quadrants - Diffuse malignant appearing micro-calcifications - Persistent positive margin after re-resection (can re-resect once). Can’t do XRT with positive margins  mastectomy - Pregnancy (Can do it if in 3rd trimester after delivery) - Previous XRT to the chest area. Other areas of the body are okay - T3 tumors will cause unacceptable cosmetic result  neoadjuvant chemo 1 st - Scleroderma and lupus is a relative CI

Question 62

Contraindications to SLNBx

Answer 62

Contraindications to SLNBx - Neoadjuvant chemoNOT TRUE. Can still do SLNBx after neoadjuvant - Clinically positive nodesNOT TRUE. Patients with cN1 can downstage to cN0 after neoadjuvant chemotherapy (based on physical exam, not imaging). Then in the OR can do SLNBx and avoid an axillary dissection - T3 (>5cm blocks lymphatics) - T4 (skin, inflammatory) - Previous axillary dissection - Tumor already removed

Question 63

Raloxifene

Answer 63

decreases post-menopausal fractures, less risk of DVT/thrombosis and endometrial CA

Question 64

Anastrozole

Answer 64

fractures 2 X more common, less DVT and endometrial CA vs tamoxifen. If elderly with osteoporosis can consider tamoxifen instead if worried about fractures

Question 65

Tamoxifen

Answer 65

-Selective estrogen receptor modulator; bind to ER causing conformational change= competitive inhibition to estradiol – Less fractures, but more thrombosis, endometrial CA, and cataracts. Give for 5 years for CA - Contraindications: Warfarin use!! - Indicated for women with high risk 5-year Gail risk > 1.67% and LCIS - Stop this if women wants to get pregnant

Question 66

Trastuzumab

Answer 66

Give for 1 year

Question 67

Increase risk of recurrence and mets with

Answer 67

Increase risk of recurrence and mets with: positive nodes, large tumor, negative receptors, poor grade

Question 68

SLNB:

Answer 68

-Sentinel lymph node biopsy: indicated in non-palpable T1–T3 invasive breast cancer with clinically negative axillary node exam Contraindications to SLNB: inflammatory breast cancer; palpable lymphadenopathy; prior axillary surgery, chemotherapy, radiation therapy; multifocal breast cancer

Question 69

Chemotherapy Needed:

Answer 69

-Tumors > 1 cm: exception hormone receptor positive, node negative tumors with favorable oncotype characteristics can receive postop hormonal therapy alone -Positive nodes -Triple negative tumors

Question 70

Most common chemo regiment:

Answer 70

-Most common chemo regiment: TAC -Taxane (Docetaxel); AE = peripheral neuropathy -Adriamycin (Doxorubicin);AE = cardiomyopathy -Cyclophosphamide; AE = Hemorrhagic cystitis; Mesna reduces risk of hemorrhagic cystitis

Question 71

Endocrine therapy:

Answer 71

-Receptor positive better prognosis; more common in post-menopausal -PR+ better prognosis; both better -Tx= 5 years of tamoxifen (pre-menopausal) or aromatase inhibitor (post-menopausal women)

Question 72

HER2/neu:

Answer 72

epidermal growth factor receptor family; transmembrane tyrosine kinase receptor; constitutive activation of cell proliferation when overexpressed; associated w poor differentiation, high proliferative rates, decreased expression of steroid hormone receptors, increased likelihood of having LN metastases; poor disease-free and overall survival (follows LN status for worst prognosis); tx= traztuzumab (Herceptin) for 1 year, SE= heart failure

Question 73

Olaparib

Answer 73

Poly (ADP-ribose) polymerase (PARP) inhibitor; induces synthetic lethality in BRCA1/2-deficient tumor cells through formation of double-stranded DNA breaks -> cannot be repaired; recommended for 1 year for triple-negative breast cancer with BRCA 1 & 2 deficient tumors

Question 74

Most common sites for breast cancer metastases:

Answer 74

bone (MC), lung, brain, liver

Question 75

Consideration for prophylactic mastectomy:

Answer 75

FHx + BRCA or LCIS

Question 76

Most common post mastectomy reconstruction:

Answer 76

transverse rectus myocutaneous flap (superior epigastric vessels) and latissimus dorsi flap (thoracodorsal vessels)

Question 77

Genes associated with breast cancer

Answer 77

Question 78

Radiation-induced angiosarcoma of the breast

Answer 78

-Years after radiation therapy to breast -Erythema and nodules in affected breast; discrete mas not always present -W/u: mammogram, us; dx confirmed with skin biopsy -Tx: mastectomy with excision of overyling skin