BREAST

Question 1

HER-2 neu CHEMO

Answer 1

Trastuzumab is a highly effective therapy for breast cancer patients with

Question 2

Regarding women known to be at increased risk of breast cancer development Bilateral salpingo-oophorectomy decreases breast cancer risk by

Answer 2

50%.

Question 3

Regarding women known to be at increased risk of breast cancer development Bilateral prophylactic mastectomy decreases breast cancer risk by

Answer 3

90–95% by removing the majority of the breast tissue. It does not completely eliminate breast cancer risk.

Question 4

Regarding women known to be at increased risk of breast cancer development Tamoxifen decreases breast cancer risk by

Answer 4

50% and is an effective chemoprevention agent.

Question 5

Regarding women known to be at increased risk of breast cancer development The American Cancer Society (ACS) guidelines state that annual MRI for screening is recommended for women whose lifetime risk of breast cancer development is

Answer 5

20–25% or higher. ACS recommends the use of the BRCAPRO, Claus, or Tyrer-Cuzick models to calculate lifetime risk.

Question 6

Anastrozole use is limited to use with what patient population

Answer 6

postmenopausal patients with breast cancer.

Question 7

63-year-old woman undergoes a lumpectomy for a 1.2-cm invasive ductal carcinoma of the breast resected to negative margins. One of 2 sentinel lymph nodes is found to be positive. Which of the following is the most appropriate initial management option

Answer 7

NO axillary disection - just “whole breast radiation”

no difference in in-breast recurrence, axillary recurrence, 5-year disease-free survival or 5-year overall survival between women undergoing axillary lymph node dissection and those women who did not!

Question 8

Currently in the clinical practice, ALND can be avoided for patients who meet ALL of the following criteria:

Answer 8

1 No neoadjuvant chemotherapy
2 Breast conservation
3 Clinical T1 or T2 and N0 tumor
4 1 or 2 positive SLNs
5 Whole breast radiation, not for patients receiving partial breast radiation

Question 9

Life-threatening anaphylactic reactions have been reported in 1% of cases with use of

Answer 9

isosulfan blue

LYMPHAZURIN™

Question 10

isosulfan blue can interfere with

Answer 10

pulse oximetry, resulting in falsely lowered peripheral oxygen saturation readings.

Question 11

in ecurrent breast cancer where should lymp mapping agent be injected

Answer 11

peritumoral injection is recommended.

Question 12

SLN surgery is used when

Answer 12

male breast cancer,
multifocal breast cancer,
multicentric breast cancer,
patients after neoadjuvant chemotherapy with clinically negative nodes at presentation.

Question 13

Patients at an increased risk of local recurrence after breast conservation include those with

Answer 13

a young age at diagnosis (<40 years).

HER2 positive

Question 14

breast cancers, with a lower local recurrence rate

Answer 14

estrogen receptor positive breast cancer.

Question 15

Multicentric breast cancer, recurrence rate with the use of partial breast radiation for the appropriate patients.

Answer 15

lesions in different quadrants of the breast,

longstanding indication for mastectomy.

Question 16

multifocal disease breast cancer

effect on local recurrence

Answer 16

lesions within the same quadrant of the breast,

not suggest increased
can be resected with breast conservation without any evidence of increased local recurrence after breast conservation with adjuvant radiation therapy.

Question 17

Histological subtype of breast cancer between lobular and ductal affect local recurrence rates

Answer 17

not signifcant

Question 18

Regarding a 55-year-old patient with a 2-cm intermediate-grade ductal carcinoma in situ who undergoes surgical resection, what is management besides lumpectomy

Answer 18

Adjuvant breast radiation

decreases local recurrence rates after lumpectomy for ductal carcinoma in situ (DCIS).

tamoxifen and is used to decrease the risk of
recurrence or new primary in the ipsilateral or contralateral breast.

SLNB ONLY if:

Question 19

when is post op radiation recommended in breast surgery

Answer 19

after lumpectomy for ductal carcinoma in situ (DCIS).

after lumpectomy for invasive cancer

after MASTECTOMY if:
greater than 5 cm
chest wall invasion
persistent positive margins
positive lymph nodes (classically ≥4 positive lymph nodes and increasingly also for those women with 1–3 positive lymph nodes).

Question 20

post operative treatment after mastectomy less than 5 cm in size resected to negative margins and has negative lymph nodes,

Answer 20

NO radiation

Question 21

Sentinel lymph node (SLN) staging for DCIS

Answer 21

DCIS ONLY when:
greater than 5 cm in size
palpable
associated with microinvasion on biopsy
high nuclear grade 
presence of comedonecrosis, 

or

treated with mastectomy - disrupted lympatics

By definition, DCIS is noninvasive and should not spread to the lymph nodes.

Question 22

Adjuvant therapy for women with DCIS

Answer 22

tamoxifen and is used to decrease the risk of
recurrence or new primary in the ipsilateral or contralateral breast.

Women with DCIS treated with a bilateral mastectomy are not recommended to receive adjuvant endocrine therapy.

Aromatase inhibitors have not been studied in women with DCIS.

Question 23

Partial breast radiation is appropraite for what patients

Answer 23

radiation to the lumpectomy bed and surrounding breast tissue.

guidelines ALL of the following:
invasive ductal carcinoma
ER positive +/-
tumor size 3 cm or smaller
negative margins
node negative
women older than 45 years 

Location of the tumor within the breast is not a limiting factor regarding use of partial breast radiation.

Question 24

annual screening MRI for the detection of breast cancer

Answer 24

lifetime risk of breast cancer of at least 20–25%
known BRCA1 or 2 mutation carriers
untested first-degree relatives of known BRCA1 or 2 mutation carriers.

evaluation of response to neoadjuvant chemotherapy

radiation to the chest between ages 10 and 30 years
Li Fraumeni syndrome
Cowden syndrome.

It is also useful to reconcile differences between findings on clinical examination and mammographic or ultrasound imaging.

workup of patients presenting with axillary metastases thought to be of breast origin where standard imaging (mammogram and ultrasound) does not identify the primary breast tumor.

Routine MRI for evaluation of the contralateral breast before surgery of a known breast cancer is not required.

MRI should be considered in women with dense breast tissue, women with invasive lobular carcinoma, or women presenting with mammographically occult disease.

ACS concluded that there was insufficient evidence to recommend:
atypia (atypical ductal hyperplasia 
atypical lobular hyperplasia)
lobular carcinoma in situ
or
breast cancer!!

Question 25

Chemoprevention with medications are what and decrease the risk of breast cancer development by

Answer 25

tamoxifen, raloxifene, or exemestane can decrease the risk of breast cancer development by 50%.

Anastrozole has NOT been studied as a chemopreventive agent.

Question 26

what is the managemt when LCIS is diagnosed on a stereotactic core biopsy

Answer 26

operative excisional biopsy is indicated to exclude an adjacent invasive breast cancer.

Surgical excisional biopsy has a 20–30% incidence of a malignant lesion near the LCIS.

If invasive breast cancer is not identified on final pathology, the patient is followed with annual mammography and physical examination.

If the needle-localized excisional breast biopsy has LCIS at the margin of excision, repeat excision is not indicated.

Tamozifne -In premenopausal high-risk women, tamoxifen can decrease the risk of developing invasive breast cancer by almost 50%.

chemoprevention drug of choice is tamoxifen, NOT raloxifene.

Question 27

risks of tamoxifen include

Answer 27

thromboembolic disease and uterine malignancy.

Question 28

managment of 3 cm breast abscess in 22 yo

Answer 28

needle aspiration and antibiotics can be used as first-line treatment for simple breast abscesses.

Incision and drainage are reserved for patients who do not resolve with repeated aspirations.

Placement of a drainage catheter is considered for abscesses greater than 5 cm,

Excision of a breast mass identified by ultrasound to be an abscess is not necessary.

Incisional biopsy is performed in patients with a concern for associated malignancy; overall, fewer than 5% of patients with a breast abscess have an associated malignancy.

Patients should undergo repeat imaging approximately 6 weeks after clinical resolution of the infection.

If there is a residual noninflammatory mass, a core biopsy should be performed to evaluate for malignancy.

If the cellulitis and associated breast mass do not improve with antibiotics, malignancy should be suspected and a biopsy should be performed.

Question 29

A 60-year-old, postmenopausal woman has left breast microcalcifications noted on her yearly screening mammogram. She has no family history of breast or ovarian cancer. Stereotactic core needle biopsy reveals atypical ductal hyperplasia. Which of the following is the next most appropriate step?

Answer 29

Needle located excisional biopsy is indicated to exclude invasive carcinoma

If, after excisional biopsy, there is no additional DCIS or invasive cancer that requires treatment, the patient may consider future chemoprevention with tamoxifen.

Although the patient will continue to need annual mammography for screening purposes, a needle-localized excisional biopsy for definitive diagnosis is indicated first.

Question 30

Stereotactic biopsy is used for

Answer 30

diagnosis of nonpalpable masses or microcalcifications noted on mammography.

Question 31

Mondor disease

Answer 31

superficial thrombophlebitis of the subcutaneous veins.

painless, cord-like induration. The cause of Mondor disease is unknown, although it is most commonly associated with trauma. The disease is easily diagnosed by physical examination.

Treatment is reassurance, because this disease is self-limiting.

Although the most common site is the anterolateral thoracoabdominal wall, including the breast, other sites include the antecubital fossa, the penis, and the posterior cervical region

More aggressive treatment is required only for symptoms, which are generally focused on symptom relief rather than resolution of the thrombosis.

Question 32

recommended practice is to treat N1mi disease as

Answer 32

The Joint Commission defined micrometastasis as a cluster of cancer cells 0.2–2.0 mm in size, with the designation of N1mi.

” It defined single tumor cells or clusters 0.2 mm or smaller as “isolated tumor cells,” with the designation of N0(i+). What these findings mean clinically is still being fully determined.”

Although controversial, the recommended practice is to treat N1mi disease as lymph node positive disease requiring hormonal chemotherapy.

Question 33

sentinel lymph node biopsy (SLNB) in DCIS on core needle biopsy

Answer 33

Routine sentinel lymph node biopsy (SLNB) not recommended in all patients with DCIS

selective use of SLNB in patients with DCIS on core needle biopsy is recommended based on predictors of an invasive component.

Strong predictors include the presence of a
palpable mass,
detection of microinvasion on core needle biopsy,
lesion size at least 2 cm on imaging (other q states 5cm).
high nuclear grade
associated with microinvasion on biopsy
presence of comedonecrosis,

or

treated with mastectomy - disrupted lympatics

Question 34

A 47-year-old woman presents with a 2-year history of an 8-cm mass occupying the majority of the right breast. Although there is no skin breakdown, the breast is blue at the apex of the mass, and the nipple is enlarged and excoriated. No palpable adenopathy is present in the axilla. Core biopsy reveals mixed epithelial stromal proliferation. Which of the following is the next step in her management?

Answer 34

Phyllodes tumors - just excise with clear (1cm) margin unless just too damn big

simple mastectomy

surgical excision with a clear margin, regardless of tumor grade

Axillary dissection is not indicated because of the low incidence of lymph node involvement.

Question 35

incidence of lymphedema in patients undergoing sentinel lymph node biopsy was

Answer 35

6.9%

Question 36

where anatomically is the risk of developing Lymphedema with SLNB

Answer 36

specially if the sentinel node is located at the level of the axillary vein

or if combined with axillary radiotherapy.

Weight loss is shown to reduce upper-extremity lymphedema. Some studies have initiated therapy as early as 48 hours after surgery.

Question 37

treated conservatively lymphedema

Answer 37

physical therapy, manual drainage, or pneumatic pump, yield greater volume reduction than compression garments or limb elevation.

low-level laser therapy increases the rate of lymph vessel pumping and promotes lymph vessel regeneration, reduces pain, and softens fibrous tissue and surgical scarring,

Exercise has been shown to significantly reduce severity of symptoms.

Question 38

Any discharge not considered to be galactorrhea is caused by what DDX

Answer 38

a ductal condition, such as ductal ectasia, fibrocystic breast changes, intraductal papilloma, intraductal carcinoma, and invasive ductal carcinoma (usually papillary type).

Question 39

Ductal ectasia is characterized by

Answer 39

dilatation of the major ducts along with inflammation and fibrosis around the ducts.

Discharge is usually dark green or black and guaiac negative.

Surgical therapy is not necessary in women with classic multiduct nonbloody green–black discharge.

If only 1 duct is involved, therapy is usually excision to help diagnose the etiology.

Question 40

Fibrocystic disease typically results in

Answer 40

serous or light-green multiduct discharge.

cyclic breast pain and premenstrual breast lumpiness, and exam reveals a diffuse fine nodularity.

Mammography and ultrasound are confirmatory and show dense breast tissue with nodularity and microcyst formation.

Question 41

The most common cause of bloody uniductal discharge is

Answer 41

intraductal papilloma - including for 75 yo

Question 42

intraductal papilloma findings, w/u, tx

Answer 42

Discharge is usually spontaneous but can be elicited by palpation and comes from a single duct orifice.

Mammography is typically negative, and ultrasound may show a dilated duct with an intraluminal lesion.

Most intraductal papillomas occur near the areolar edge, and galactography is recommended to identify more-peripheral lesions.

Galactography involves cannulation of the duct orifice and injection of radiopaque dye; papillomas are seen as intraluminal filling defects.

Treatment of intraductal papilloma is duct excision.

Question 43

breast cancer associated with nipple discharge

Answer 43

Ductal carcinoma in situ and papillary carcinoma cause most cancer-associated nipple discharges.

Intraductal and invasive ductal carcinoma only rarely associated with nipple discharge in the absence of an abnormal mammogram or palpable mass.

Occasionally, bloody discharge is present in Paget disease—a scaly, raw, vesicular, or ulcerated lesion that begins on the nipple and spreads to the areola.

Lobular carcinoma in situ and phyllodes tumors are not associated with nipple discharge.

Question 44

Hereditary breast and ovarian cancer syndrome refers to

Answer 44

an increased risk of breast and ovarian cancer in people who have inherited a deleterious mutation of the BRCA1 or BRCA2 genes.

These genes confer a 10-fold relative risk of these cancers and increase risk more than any other factor. Female BRCA1 carriers have a lifetime risk of developing breast cancer and ovarian/fallopian tube cancers of approximately 40–80% and 26–46%, respectively. For BRCA2 mutation carriers the risk of developing breast and ovarian/fallopian tube cancers are 30–60% and 10–20%, respectively.
Because the same specific BRCA mutation tends to be conserved within a given BRCA family, it is most efficient to test an affected patient (“the index relative”) to determine whether a BRCA mutation exists and, if a mutation is found, to then test other family members for that same mutation. The National Comprehensive Cancer Network (NCCN) has established guidelines to determine which patients should undergo BRCA 1/2 mutation testing. These guidelines are detailed, but include 4 main categories:
1. People from families with known deleterious BRCA1/2 mutations
2. People with a personal history of cancer and at least 1 of several other risk factors, for example, diagnosis before age 45, Ashkenazi Jewish heritage (1 in 40 Ashkenazi women are BRCA mutation carriers), and 2 breast cancers when the first was diagnosed before age 50 (after age 50, such events are usually sporadic and not an indication for testing)
3. People with certain cancers (e.g., male breast cancer, ovarian/fallopian tube cancers)
4. Certain high-risk family histories.

Question 45

A 55-year-old woman presents to the office with erythema of the right breast. After a 2-week course of oral antibiotics, the erythema is still present, and right breast mammography reveals diffusely increased density. Ultrasonography shows no fluid component. Which of the following would be the most appropriate next step?

Answer 45

Inflammatory breast cancer is not common, comprising approximately 1–5% of all breast cancers.

Diagnostic evaluation with mammogram and ultrasound should be performed early, whether or not there is a palpable breast mass or axillary adenopathy.

If there is a palpable mass on exam or a radiographic abnormality, an incisional biopsy of the mass with attached/involved skin should be performed.

If ultrasound suggests an abscess, drainage should occur, and the patient should be placed on antibiotics.

If no abscess is seen, but skin erythema is subtle, a percutaneous core biopsy of the underlying lesion should be performed.

The 5-year survival for inflammatory breast cancer patients is approximately 40%; further, 20–35% of patients will have distant metastases at the time of presentation, and 60–85% will have nodal metastases.

MRI in the initial workup is neither necessary nor recommended.

Question 46

Atypical ductal hyperplasia (ADH)

Answer 46

4-fold increased lifetime risk of breast cancer.

chemoprevention is recommended to decrease the risk of breast cancer for women found to have ADH or ALH.

The risk of breast cancer is associated with the number of foci of atypia; breast cancer risk increases with multifocal atypia.

Question 47

atypical lobular hyperplasia (ALH)

Answer 47

4-fold increased lifetime risk of breast cancer

chemoprevention is recommended to decrease the risk of breast cancer for women found to have ADH or ALH

Question 48

Flat epithelial atypia (FEA)

Answer 48

recommended for surgical excisional biopsy to rule out malignancy

not an indication for chemoprevention.

Question 49

papillomas with atypia

Answer 49

recommended for surgical excisional biopsy to rule out malignancy

have the highest risk of concurrent malignancy identified on excision, with reported rates greater than 20%.

Question 50

Sclerosing adenosi

Answer 50

benign finding that does not require surgical excision unless the radiologic and pathologic findings are discordant.

Question 51

Intraductal papilloma

Answer 51

is the most common cause of pathologic nipple discharge

should be surgically excised to rule out concomitant malignancy.

Question 52

B-IRADS

Answer 52

0 insuf imaging - reimage
1 benign normal f/u
2 beign nomral f/u
3 probably benign close f/u
4 suspicious - bx
5 highly suspicious take action
6 known cancer

Question 53

MRI to evaluate breast is indicated when

Answer 53

patients with nodal disease and occult primary cancers,

multifocal or multicentric tumors,

difficult primaries, such as invasive lobular carcinoma (NOT LCIS)

o assess response to neoadjuvant chemotherapy in selected patients.

in addition to mammography for patients at very high risk for breast cancer, especially those with gene mutations such as BRCA1 and 2, but it is not indicated to take the place of screening mammography.

further delineate the extent of a primary tumor and to identify unsuspected, occult cancers in the contralateral breast.

Presentation with clinically involved axillary nodes without any identifiable primary

Question 54

Breast abscesses smaller than what size can be treated successfully with

Answer 54

5cm

ultrasound localization with repeated aspirations as required, leading to improved cosmesis at the drainage site.

ultrasound can facilitate complete drainage of abscesses, including loculations.

A thick abscess rind associated with septa may indicate the need for surgical drainage in patients with larger abscesses.

Question 55

idiopathic granulomatous mastitis

Answer 55

is a rare condition characterized histologically by noncaseating granulomas centered on lobules.

can be associated with fistulas and abscesses.

treated with a variety of therapies, including steroids, which may treat an underlying autoimmune cause.

Aggressive surgical management is rarely required.

Regardless of treatment, idiopathic granulomatous mastitis often “burns out” spontaneously in 6–12 months.

biopsy, and close observation are critical to rule out inflammatory breast cancer.

Question 56

periductal mastitis,

Answer 56

can be associated with fistulas and abscesses.

associated with smoking, occurs in younger women, and is often associated with recent pregnancy.

associated with
oral contraceptives previously,
white,

classic treatment
surgical drainage and antibiotics.

biopsy, and close observation are critical to rule out inflammatory breast cancer.

Question 57

Ductal carcinoma in situ (DCIS) is most commonly detected as

Answer 57

suspicious microcalcifications on routine screening mammography in an asymptomatic woman.

Question 58

newly diagnosed DCIS for breast conservation treatment what is post op treatment

Answer 58

radiation
and
tamoxifen

Question 59

do you excise isolated lobular carcinoma in situ (LCIS) when found on core needle biopsy (CNB)

Answer 59

not for incidental finding on margin

depends on multiple factors, 
imaging indication,
imaging findings, 
extent of LCIS on CNB, 
the presence of concurrent atypical ductal hyperplasia on CNB.

Question 60

A proposed treatment algorithm allows for close follow-up of patients with calcifications on routine mammography and isolated LCIS on CNB that meet the following criteria:

Answer 60

(1) normal-risk patient undergoing routine screening mammography found to have calcifications,
(2) fewer than 4 foci of LCIS on CNB,
and
(3) no other high-risk lesion present.

Question 61

adjuvant for LCIS

Answer 61

Tamoxifen and raloxifene are equally effective in reducing this risk.

Question 62

Immunohistochemical staining for LCIS vs DCIS

Answer 62

E-cadherin can be used to differentiate ductal versus lobular carcinoma in situ, because membranous staining is seen in most DCIS, and negative staining is seen in lobular neoplasia.
Patients with a history of LCIS have a 4- to 10-fold increased risk of subsequent invasive disease.

Question 63

The 2 most common agents used to identify sentinel nodes are

Answer 63

isosulfan blue and technetium-labeled sulfur colloid.

used independently or in combination.

Question 64

Isosulfan blue
when should be injected
should pregenent pt receive

Answer 64

iinjected into the breast 5–10 minutes before making the axillary incision.

category “C” (possible teratogen) by the US Food and Drug Administration and, therefore, should not be used for sentinel node biopsy in pregnant patients.

Question 65

Technetium-labeled sulfur colloid
when should be injected
should pregenent pt receive

Answer 65

injected on the day before surgery or as little as 20 minutes before surgery, depending on nuclear medicine facilities available at the institution.

The potential radiation dose to the fetus appears to be minimal, and the authors believe the procedure should be safe.

Question 66

Lobular carcinoma in situ (LCIS

Answer 66

marker for increased risk of breast cancer.

8-fold increased risk of lifetime development of breast cancer,

risk is for both breasts, regardless of which side the LCIS was identified.

Question 67

classic LCIS should it be excised

Answer 67

LCIS is often an incidental finding. Excisional biopsy to rule out a coexistent malignancy is recommended. Negative margins are not required at the time of surgical excision of classic LCIS

Sentinel node biopsy for nodal staging is not required at the time of surgical excision of LCIS and is reserved for cases with invasive disease.

Adjuvant radiation is not required for classic or pleomorphic LCIS.

Both classic and pleomorphic LCIS are associated with invasive lobular carcinoma, although invasive ductal carcinomas also occur in these patients.

Question 68

Pleomorphic LCIS should it be excised

Answer 68

shows a more aggressive nature based on a higher proliferative index and immunohistochemical markers.

Excisional biopsy to rule out a coexistent malignancy is recommended.

Negative margins ARE required at the time of surgical excision of pleomorphic LCIS, which behaves more like ductal carcinoma in situ.

Sentinel node biopsy for nodal staging is not required at the time of surgical excision of LCIS and is reserved for cases with invasive disease.

Adjuvant radiation is not required for classic or pleomorphic LCIS.

Both classic and pleomorphic LCIS are associated with invasive lobular carcinoma, although invasive ductal carcinomas also occur in these patients.

Question 69

Seborrheic keratoses

Answer 69

the most common benign skin tumor in older people.

most common on the face, neck, and back, and like melanoma, are usually related to sun exposure.

can spontaneously regress, although this event is rare and usually associated with pregnancy, inflammatory skin conditions, and malignancy.

almost never occur before the age of 30 and are essentially never found on the mucosa, palms, or soles.

They can be clinically distinguished from melanoma by their raised, stuck-on appearance and their “greasy” or “waxy” texture. often oval and slightly raised.

they are most often treated with ablative techniques such as cryotherapy, laser, and electrodessication.

have an apparent familial predisposition with a postulated autosomal dominant inheritance with incomplete penetrance.

Question 70

Lymph node involvement is rare in adult soft tissue sarcoma, but it is somewhat more frequent in certain subtypes, including

Answer 70

high-grade rhabdomyosarcoma,
synovial cell sarcoma,
epithelioid sarcoma.

Sentinel lymph node biopsy may be indicated in these subtypes