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Surgery > breast > Flashcards

breast Flashcards

1
Q

polythelia

A

accessory nipple; can occur anywhere along the milk line from axilla to inguinal region

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2
Q

polythelia

A

accessory nipple; can occur anywhere along the milk line from axilla to inguinal region

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3
Q

polymastia

A

accessory breast tissue; mostly occurs in the axilla

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4
Q

amastia

A

congenital absence of the breast

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5
Q

amazia

A

lack of breast tissue development with perseverance of the nipple

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6
Q

what does inc hormonal production by the ovary at puberty cause

A

ductal budding and initial formation of acini; proliferations of the terminal ducts lined w secretory cells for milk production

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7
Q

what effects do estrogen and progesterone have

A

full maturation of the ductal and lobular components of the breast

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8
Q

gynecomastia

A

enlarged breasts may be asym and tender secondary to a physiologic excess of plasma estradiol relative to plasma testosterone; age 20 male

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9
Q

what should be considered for a solid mass in a postmenopausal woman

A

cancer until proven otherwise

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10
Q

risk of hormone replacement therapy

A

inc risk of breast cancer; esp estrogen plus progestin

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11
Q

major risk factors for breast cancer

A

females, inc age, fhx, proliferative pathology with atypic on bx (atypical ductal or lobular hyperplasia)

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12
Q

what familial cancer syndromes are assoc w greater risk of breast cancer

A

Li-Fraumeni and Cowden’s

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13
Q

what genes are assoc with breast cancer

A

BRCA 1 long arm of chromosome 17 and BRCA 2 long arm of chromosome 13

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14
Q

guidelines on referral for genetic counseling

A

Individuals from a family with a known BRCA1 or BRCA2 mutation;Personal history of breast cancer with one of the following:

  • Diagnosed at or before age 45
  • Diagnosed at or before age 50 with one or more close family relatives diagnosed with breast cancer or ovarian cancer at or before 50a
  • Diagnosed at or before age 50 with two or more synchronous primary breast cancers
  • Diagnosed at any age and two or more close family relatives with breast or ovarian cancera
  • Two or more close family relatives with breast or ovarian cancera
  • Personal history of ovarian cancer
  • Close male relative with breast cancer
  • High-risk ethnic background (i.e., Ashkenazi Jewish)
  • Personal history of male breast cancer
  • Close family member with one or more of the above criteria
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15
Q

what two drugs showed a reduction in incidence of breast cancer for high risk pt

A

tamoxifen and raloxifene

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16
Q

what two surgeries lowers the risk of developing breast cancer

A

mastectomy and salpino-oophorectomy

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17
Q

what is the best palpating method that has the lowest incidence of missed abnormalities

A

vertical strip

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18
Q

spontaneous nipple discharge

A

discharge on clothing in the absence of breast stimulation; in contrast, elicited discharge is noted after the nipple or breast is squeezed, or after vigorous mammography; only spontaneous discharge requires evaluation.

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19
Q

what type of discharge is more likely a result from an underlying malignancy

A

unilateral bloody single duct spontaneous discharge especially if there is an assoc mass

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20
Q

mc cause of unilateral spontaneous bloody nipple discharge

A

benign papilloma

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21
Q

what is the foundation of breast cancer screening

A

annual mammogram

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22
Q

American Cancer Society Guidelines for Breast Cancer Screening

A

Yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health.

Women should know how their breasts normally feel and report any breast change promptly to their health care providers. BSE is an option for women starting in their twenties.

Women at high risk (>20% lifetime risk) should get an MRI and a mammogram every year. Women at moderately increased risk (15%–20% lifetime risk) should talk with their doctors about the benefits and limitations of adding MRI screening to their yearly mammogram. Yearly MRI screening is not recommended for women whose lifetime risk of breast cancer is

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23
Q

what are the two views of a mammography

A

craniocaudal (CC) and median lateral oblique (MLO)

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24
Q

Breast imaging reporting and data system classification score for need for additional studies or interval follow up

A 
0 (add imx eval)
1(negative)
2 (benign finding)
3 (probably benign, short interval f/u)
4 (suspicious abn, bx)
5 (highly sugg malig, approp action)
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25
Q

additional dx views

A

tissue compression and magnification

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26
Q

2 technological advances for imaging

A

computer assisted detection (CAD) software and digital mammography

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27
Q

what is a imaging adjunct to mammography

A

us- good at characterizing a mammography density or palpable mass as cystic or solid, and in guiding core needle bx

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28
Q

benign sonographic features of masses on us include

A

well demarcated borders, posterior enhancement, absence of internal echoes (characteristic of cysts)

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29
Q

what features are suspicious for malignancy on us

A

poorly demarcated borders, posterior shadowing, heterogeneous internal echoes, and a taller than wide orientation that invades across tissue planes

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30
Q

what does an mdi use to produce breast images w improved resolution of soft tissues

A

fat, water, and iv gadolinium contrast in magnetic fields

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31
Q

what imaging test is appropriate in women who carry deleterious BRCA1/2 mutation, or who by fhx and other risk factors

A

mri- if lesion is detected can do an mri directed bx

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32
Q

what is the definitive dx of breast lesions

A

microscopic examination of tissue by either cytology (individual cells obtained by fine needle aspiration) or histology (samples of tissue obtained by core needle or surgical bx)

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33
Q

which tissue sampling gives a rapid dx of suspected malignancy

A

cytology

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34
Q

what do histologic specimens provide

A

invasive vs in situ carcinoma, type of cancer, expression of estrogen/progesterone/HER2/neu

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35
Q

difference between bx of palpable lesion and one detected radiologically

A

palpable can be needle bx directly; radiologic must be under guidance

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36
Q

bx of mass lesions

A

us guidance

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37
Q

bx microcalcifications and subtle abnorm

A

stereotactic localization in mammography suite

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38
Q

triple test to say lesion is benign

A

concordance between clinical exam, radiographic appearance, and pathology

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39
Q

what is the needle bx results are discordant

A

excisional bx guided by localizing wire placed under radiological guidance is necessary

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40
Q

why shouldn’t an open excisional bx without a prior needle bx be done

A

possible positive margins, cosmetically unfavorable incision placement, need to go back to the operating room for lymph node staging

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41
Q

when should a pt be reeval if pe and imaging show typical areas of fibroglandular tissue without discrete mass

A

6-12weeks

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42
Q

what do all pt who have a discrete persistent mass require

A

tissue dx

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43
Q

dx test for age

A

us

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44
Q

dx test for age >30 w palpable breast mass

A

mammogram and us

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45
Q

palpable breast mass that is cystic on imaging and asymptomatic simple

A

re examine 2-3months

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46
Q

palpable breast mass that is cystic on imaging and symptomatic or complex

A

aspirate and if no residual mass then 2-6m f/u; if there is a residual mass then bx

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47
Q

palpable breast mass that is solid on imaging

A

fna or core bx: non dx (action depends on clinical correlation), benign, malignancy (definitive therapy)

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48
Q

what is a common experience a few days preceding menses

A

mild, cyclic b/l breast tenderness and swelling; rarely prompts medical consultation

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49
Q

in the absence of any physical or radiological abnormality what is the next step

A

reassurance and follow up exam in a few months

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50
Q

what is thought to be the underlying cause of mastalgia

A

hormonal stimulation of glandular breast tissue

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51
Q

what is recommended to be stopped in postmenopausal women w breast pain

A

HRT

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52
Q

therapeutic measures for breast pain/tenderness

A

compressive elastic style bra (sport or minimizer bra), dec caffeine consumption, non steroidal anti inflammatory analgesics, evening primrose oil capsules

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53
Q

what androgen analogue is effective in relieving breast pain and tenderness and when is it used

A

danazol and used only after failure of prev measures because of adverse effects such as deepening the voice and hirsutism

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54
Q

fibroadenoma

A

very common benign tumor of the breast usually occurring in young women

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55
Q

typical pe findings of fibroadenoma

A

1-3cm in size and palpated as a freely movable, discrete, firm round mass in the breast

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56
Q

histologically what are fibroadenomas composed of

A

fibrous stromal tissue and tissue clefts lined w normal epithelium

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57
Q

what establishes dx of fibroadenomas

A

fns or core bx

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58
Q

tx of fibroadenomas

A
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59
Q

tx rapid growing fibroadenomas during pregnancy

A

due to hormonal stimulation and tx is excision

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60
Q

tx giant fibroadenoma

A

core needle bx prior to excision to distinguish the relatively rare phyllodes tumor

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61
Q

phyllodes tumor

A

usually a benign tumor of the stromal elements requiring wide margins of resection to prevent local recurrence

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62
Q

mc cause of breast mass in women in 4/5th decade of life

A

cyst

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63
Q

how do cysts present

A

solitary or multiple, firm, mobile, slightly tender masses often with less defined borders

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64
Q

what fluctuates w menstrual cycle and cysts

A

size and degree of tenderness

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65
Q

imaging of cysts

A

mammography will detect nonpalpable cysts; us in simple cyst as well demarcated hypo echoic mass w posterior enhancement of transmission

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66
Q

does the us finding of a cyst require bx

A

no

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67
Q

tx cyst

A

aspiration on large symptomatic cyst; fluid may be straw colored or greenish and no cytologic analysis needed

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68
Q

us appearance of complex cyst and tx

A

shows internal echoes or an assoc solid component; mammography and core needle bx needed prior to excision

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69
Q

mc cause of nipple discharge

A

duct ectasia- nonneoplastic condition characterized by multiple dilated ducts in subareolar space

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70
Q

eval of nipple discharge

A

apply to occult blood test paper and further evaluation performed when blood is present

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71
Q

what nipple discharge is considered pathological

A

persistent, spontaneous discharge from a single duct and bloody discharge

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72
Q

intraductal papilloma

A

local proliferation of ductal epithelial cells that typically presents in women in their 4/5th decade of life

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73
Q

what is important to be done to evaluate for malignancy w nipple discharge

A

mammography

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74
Q

tx nipple discharge in the absence of clinical or radiological evidence of malignancy

A

duct excision through a circumareolar incision allows definitive histological dx and eliminates discharge

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75
Q

breast that is warm, edematous and erythematous represents ddx revolves around

A

infx process

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76
Q

what is mastitis mc assoc w

A

lactation

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77
Q

what may occur in nonlacting women who smoke

A

recurrent retroareolar abscess may occur w chronic inflammation and fistula formation between the skin and the duct

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78
Q

pe findings of breast w erythema

A

erythema spreading in lymphangitic pattern from areola toward the axilla, skin thickening w accentuation of the pores (peau d’orange), lymphadenopathy, overall breast enlargement and heaviness, mass that may be fluctuant

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79
Q

difference of pain w malignancy and abscess

A

malig has no pain while abscess is very tender

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80
Q

dx imaging with erythematic breast

A

mammography and us; mri is no mass is demonstrated

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81
Q

what will us show w erythema breast

A

drainable fluid collections

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82
Q

tx breast abscess

A

repeated aspiration combined w abx may allow resolution of the abscess without open drainage

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83
Q

tx of chronic retroareolar inflammation and mammary duct fistula

A

abx then excision of subareolar ducts including fistula tract

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84
Q

what is mastitis in lactating women usually caused by

A

staphylococci or streptococci

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85
Q

what abx used for abscess

A

dicloxacillin or clindamycin

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86
Q

earliest sign of breast cancer

A

abnormality on a mammogram

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87
Q

what happens as breast cancers grow

A

produce palpable mass that is often hard and irregular

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88
Q

signs of breast cancer

A

thickening, swelling, skin irritation, dimpling

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89
Q

nipple changes due to breast cancer

A

scaliness, dryness, ulceration, retraction, discharge

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90
Q

preinvasive form of ductal cancer

A

ductal cancer in situ (DCIS); intraductal carcinoma

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91
Q

typical appearance of DCIS on mammography

A

microcalcifications; rarely a mass on pe or mammography

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92
Q

histologic types od DCIS

A

solid, cribiform, micropapillary, comedo type

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93
Q

classification of DCIS

A

based on nuclear grades 1-3 with 1 being most favorable

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94
Q

what constitutes approx 80% of invasive breast cancers

A

infiltrating ductal carcinoma

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95
Q

higher incidence of mulicentricity in same breast and by its presence in contralateral breast; difficult to detect

A

infiltrating lobular carcinoma

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96
Q

higher incidence of mulicentricity in same breast and by its presence in contralateral breast; difficult to detect

A

infiltrating lobular carcinoma

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97
Q

polymastia

A

accessory breast tissue; mostly occurs in the axilla

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98
Q

amastia

A

congenital absence of the breast

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99
Q

amazia

A

lack of breast tissue development with perseverance of the nipple

How well did you know this?
1
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2
3
4
5
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100
Q

what does inc hormonal production by the ovary at puberty cause

A

ductal budding and initial formation of acini; proliferations of the terminal ducts lined w secretory cells for milk production

101
Q

what effects do estrogen and progesterone have

A

full maturation of the ductal and lobular components of the breast

102
Q

gynecomastia

A

enlarged breasts may be asym and tender secondary to a physiologic excess of plasma estradiol relative to plasma testosterone; age 20 male

103
Q

what should be considered for a solid mass in a postmenopausal woman

A

cancer until proven otherwise

104
Q

risk of hormone replacement therapy

A

inc risk of breast cancer; esp estrogen plus progestin

105
Q

major risk factors for breast cancer

A

females, inc age, fhx, proliferative pathology with atypic on bx (atypical ductal or lobular hyperplasia)

106
Q

what familial cancer syndromes are assoc w greater risk of breast cancer

A

Li-Fraumeni and Cowden’s

107
Q

what genes are assoc with breast cancer

A

BRCA 1 long arm of chromosome 17 and BRCA 2 long arm of chromosome 13

108
Q

guidelines on referral for genetic counseling

A

Individuals from a family with a known BRCA1 or BRCA2 mutation;Personal history of breast cancer with one of the following:

  • Diagnosed at or before age 45
  • Diagnosed at or before age 50 with one or more close family relatives diagnosed with breast cancer or ovarian cancer at or before 50a
  • Diagnosed at or before age 50 with two or more synchronous primary breast cancers
  • Diagnosed at any age and two or more close family relatives with breast or ovarian cancera
  • Two or more close family relatives with breast or ovarian cancera
  • Personal history of ovarian cancer
  • Close male relative with breast cancer
  • High-risk ethnic background (i.e., Ashkenazi Jewish)
  • Personal history of male breast cancer
  • Close family member with one or more of the above criteria
109
Q

what two drugs showed a reduction in incidence of breast cancer for high risk pt

A

tamoxifen and raloxifene

110
Q

what two surgeries lowers the risk of developing breast cancer

A

mastectomy and salpino-oophorectomy

111
Q

what is the best palpating method that has the lowest incidence of missed abnormalities

A

vertical strip

112
Q

spontaneous nipple discharge

A

discharge on clothing in the absence of breast stimulation; in contrast, elicited discharge is noted after the nipple or breast is squeezed, or after vigorous mammography; only spontaneous discharge requires evaluation.

113
Q

what type of discharge is more likely a result from an underlying malignancy

A

unilateral bloody single duct spontaneous discharge especially if there is an assoc mass

114
Q

mc cause of unilateral spontaneous bloody nipple discharge

A

benign papilloma

115
Q

what is the foundation of breast cancer screening

A

annual mammogram

116
Q

American Cancer Society Guidelines for Breast Cancer Screening

A

Yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health.

Women should know how their breasts normally feel and report any breast change promptly to their health care providers. BSE is an option for women starting in their twenties.

Women at high risk (>20% lifetime risk) should get an MRI and a mammogram every year. Women at moderately increased risk (15%–20% lifetime risk) should talk with their doctors about the benefits and limitations of adding MRI screening to their yearly mammogram. Yearly MRI screening is not recommended for women whose lifetime risk of breast cancer is

117
Q

what are the two views of a mammography

A

craniocaudal (CC) and median lateral oblique (MLO)

118
Q

Breast imaging reporting and data system classification score for need for additional studies or interval follow up

A 
0 (add imx eval)
1(negative)
2 (benign finding)
3 (probably benign, short interval f/u)
4 (suspicious abn, bx)
5 (highly sugg malig, approp action)
119
Q

additional dx views

A

tissue compression and magnification

120
Q

2 technological advances for imaging

A

computer assisted detection (CAD) software and digital mammography

121
Q

what is a imaging adjunct to mammography

A

us- good at characterizing a mammography density or palpable mass as cystic or solid, and in guiding core needle bx

122
Q

benign sonographic features of masses on us include

A

well demarcated borders, posterior enhancement, absence of internal echoes (characteristic of cysts)

123
Q

what features are suspicious for malignancy on us

A

poorly demarcated borders, posterior shadowing, heterogeneous internal echoes, and a taller than wide orientation that invades across tissue planes

124
Q

what does an mdi use to produce breast images w improved resolution of soft tissues

A

fat, water, and iv gadolinium contrast in magnetic fields

125
Q

what imaging test is appropriate in women who carry deleterious BRCA1/2 mutation, or who by fhx and other risk factors

A

mri- if lesion is detected can do an mri directed bx

126
Q

what is the definitive dx of breast lesions

A

microscopic examination of tissue by either cytology (individual cells obtained by fine needle aspiration) or histology (samples of tissue obtained by core needle or surgical bx)

127
Q

which tissue sampling gives a rapid dx of suspected malignancy

A

cytology

128
Q

what do histologic specimens provide

A

invasive vs in situ carcinoma, type of cancer, expression of estrogen/progesterone/HER2/neu

129
Q

difference between bx of palpable lesion and one detected radiologically

A

palpable can be needle bx directly; radiologic must be under guidance

130
Q

bx of mass lesions

A

us guidance

131
Q

bx microcalcifications and subtle abnorm

A

stereotactic localization in mammography suite

132
Q

triple test to say lesion is benign

A

concordance between clinical exam, radiographic appearance, and pathology

133
Q

what is the needle bx results are discordant

A

excisional bx guided by localizing wire placed under radiological guidance is necessary

134
Q

why shouldn’t an open excisional bx without a prior needle bx be done

A

possible positive margins, cosmetically unfavorable incision placement, need to go back to the operating room for lymph node staging

135
Q

when should a pt be reeval if pe and imaging show typical areas of fibroglandular tissue without discrete mass

A

6-12weeks

136
Q

what do all pt who have a discrete persistent mass require

A

tissue dx

137
Q

dx test for age

A

us

138
Q

dx test for age >30 w palpable breast mass

A

mammogram and us

139
Q

palpable breast mass that is cystic on imaging and asymptomatic simple

A

re examine 2-3months

140
Q

palpable breast mass that is cystic on imaging and symptomatic or complex

A

aspirate and if no residual mass then 2-6m f/u; if there is a residual mass then bx

141
Q

palpable breast mass that is solid on imaging

A

fna or core bx: non dx (action depends on clinical correlation), benign, malignancy (definitive therapy)

142
Q

what is a common experience a few days preceding menses

A

mild, cyclic b/l breast tenderness and swelling; rarely prompts medical consultation

143
Q

in the absence of any physical or radiological abnormality what is the next step

A

reassurance and follow up exam in a few months

144
Q

what is thought to be the underlying cause of mastalgia

A

hormonal stimulation of glandular breast tissue

145
Q

what is recommended to be stopped in postmenopausal women w breast pain

A

HRT

146
Q

therapeutic measures for breast pain/tenderness

A

compressive elastic style bra (sport or minimizer bra), dec caffeine consumption, non steroidal anti inflammatory analgesics, evening primrose oil capsules

147
Q

what androgen analogue is effective in relieving breast pain and tenderness and when is it used

A

danazol and used only after failure of prev measures because of adverse effects such as deepening the voice and hirsutism

148
Q

fibroadenoma

A

very common benign tumor of the breast usually occurring in young women

149
Q

typical pe findings of fibroadenoma

A

1-3cm in size and palpated as a freely movable, discrete, firm round mass in the breast

150
Q

histologically what are fibroadenomas composed of

A

fibrous stromal tissue and tissue clefts lined w normal epithelium

151
Q

what establishes dx of fibroadenomas

A

fns or core bx

152
Q

tx of fibroadenomas

A
153
Q

tx rapid growing fibroadenomas during pregnancy

A

due to hormonal stimulation and tx is excision

154
Q

tx giant fibroadenoma

A

core needle bx prior to excision to distinguish the relatively rare phyllodes tumor

155
Q

phyllodes tumor

A

usually a benign tumor of the stromal elements requiring wide margins of resection to prevent local recurrence

156
Q

mc cause of breast mass in women in 4/5th decade of life

A

cyst

157
Q

how do cysts present

A

solitary or multiple, firm, mobile, slightly tender masses often with less defined borders

158
Q

what fluctuates w menstrual cycle and cysts

A

size and degree of tenderness

159
Q

imaging of cysts

A

mammography will detect nonpalpable cysts; us in simple cyst as well demarcated hypo echoic mass w posterior enhancement of transmission

160
Q

does the us finding of a cyst require bx

A

no

161
Q

tx cyst

A

aspiration on large symptomatic cyst; fluid may be straw colored or greenish and no cytologic analysis needed

162
Q

us appearance of complex cyst and tx

A

shows internal echoes or an assoc solid component; mammography and core needle bx needed prior to excision

163
Q

mc cause of nipple discharge

A

duct ectasia- nonneoplastic condition characterized by multiple dilated ducts in subareolar space

164
Q

eval of nipple discharge

A

apply to occult blood test paper and further evaluation performed when blood is present

165
Q

what nipple discharge is considered pathological

A

persistent, spontaneous discharge from a single duct and bloody discharge

166
Q

intraductal papilloma

A

local proliferation of ductal epithelial cells that typically presents in women in their 4/5th decade of life

167
Q

what is important to be done to evaluate for malignancy w nipple discharge

A

mammography

168
Q

tx nipple discharge in the absence of clinical or radiological evidence of malignancy

A

duct excision through a circumareolar incision allows definitive histological dx and eliminates discharge

169
Q

breast that is warm, edematous and erythematous represents ddx revolves around

A

infx process

170
Q

what is mastitis mc assoc w

A

lactation

171
Q

what may occur in nonlacting women who smoke

A

recurrent retroareolar abscess may occur w chronic inflammation and fistula formation between the skin and the duct

172
Q

pe findings of breast w erythema

A

erythema spreading in lymphangitic pattern from areola toward the axilla, skin thickening w accentuation of the pores (peau d’orange), lymphadenopathy, overall breast enlargement and heaviness, mass that may be fluctuant

173
Q

difference of pain w malignancy and abscess

A

malig has no pain while abscess is very tender

174
Q

dx imaging with erythematic breast

A

mammography and us; mri is no mass is demonstrated

175
Q

what will us show w erythema breast

A

drainable fluid collections

176
Q

tx breast abscess

A

repeated aspiration combined w abx may allow resolution of the abscess without open drainage

177
Q

tx of chronic retroareolar inflammation and mammary duct fistula

A

abx then excision of subareolar ducts including fistula tract

178
Q

what is mastitis in lactating women usually caused by

A

staphylococci or streptococci

179
Q

what abx used for abscess

A

dicloxacillin or clindamycin

180
Q

earliest sign of breast cancer

A

abnormality on a mammogram

181
Q

what happens as breast cancers grow

A

produce palpable mass that is often hard and irregular

182
Q

signs of breast cancer

A

thickening, swelling, skin irritation, dimpling

183
Q

nipple changes due to breast cancer

A

scaliness, dryness, ulceration, retraction, discharge

184
Q

preinvasive form of ductal cancer

A

ductal cancer in situ (DCIS); intraductal carcinoma

185
Q

typical appearance of DCIS on mammography

A

microcalcifications; rarely a mass on pe or mammography

186
Q

histologic types od DCIS

A

solid, cribiform, micropapillary, comedo type

187
Q

classification of DCIS

A

based on nuclear grades 1-3 with 1 being most favorable

188
Q

what constitutes approx 80% of invasive breast cancers

A

infiltrating ductal carcinoma

189
Q

firm irregular mass on pe

A

infiltrating ductal carcinoma

190
Q

higher incidence of mulicentricity in same breast and by its presence in contralateral breast; difficult to detect

A

infiltrating lobular carcinoma

191
Q

forms small tubules, randomly arranged, each lined by a single uniform row of cells; tends to occur in slightly younger patients

A

tubular carcinoma

form of ductal carcinoma

192
Q

extensive tumor invasion by small lymphocytes; tends to be rapidly growing and large and assoc w DCIS; less commonly metastasizes to regional lymph nodes

A

medullary carcinoma

193
Q

clumps and strands of epithelial cells in pools of mucoid material; grows slowly and occurs more often in older women

A

colloid or mucinous carcinoma

194
Q

what type of carcinoma is hard to differentiate histologically from intraductal papilloma (benign lesion)

A

true papillary carcinoma

195
Q

presents with skin edema (peau d’orange) and erythema; skin edema is secondary to dermal lymphatics congested w malignant cells

A

inflammatory carcinoma

poor prognosis

196
Q

what malignancies rarely occur in the breast

A

sarcomas, lymphomas, leukemia

197
Q

cutaneous nipple abnormality, which may be moist and exudative, dry and scaly, erosive or just thickened area; +/- itching, burning, or sticking pain in the nipple; over times spreads from the duct orifice

A

Paget’s ds of the nipple

(dermis is infiltrated by Paget’s cells, which are of ductal origin, large and pale, with large nuclei, prominent nucleoli, and abundant cytoplasm

198
Q

mc areas of breast cancer metastasis

A

bone, lung, liver, brain

199
Q

TNM staging system for breast cancer

A

Primary tumor (T): tis (carcinoma in situ), t1 (5cm), t4 (any size with extension to chest wall or skin)

Lymph Nodes (N): no( no nodes), n1 (1-3 axillary nodes), n2 (4-9 axillary nodes), n3 (>10 axillary)

M0= no distant metastasis

M1= distant metastasis

200
Q

stage 0 of breast cancer using tnm scale

A

tis, no, mo

201
Q

stage 1 of breast cancer using tnm scale

A

t1, no, mo

202
Q

stage 2a of breast cancer using tnm scale

A

(to, n1, mo), (t1,n1,mo), (t2,no,mo)

203
Q

stage 2b of breast cancer using tnm scale

A

(t2,n1,mo) (t3,no,mo)

204
Q

stage 3a of breast cancer using tnm scale

A

t0-3 with n2 (one t3 can be w n1) with mo

205
Q

stage 3b of breast cancer using tnm scale

A

t4 with n0-2, mo

206
Q

stage 3c of breast cancer using tnm scale

A

any t, n3,mo

207
Q

stage 4 of breast cancer using tnm scale

A

any t, any n, m1

208
Q

what tests are needed before surgery when the pt’s risk for metazoic ds is low (

A

chest radiograph and cbc

more adv need chest and abd ct plus bone scans

209
Q

what is the single most important factor in determining ds free and overall survival

A

axillary lymph node status; then tumor size and estrogen receptor status

210
Q

what does f/u for breast cancer pts include

A

b/l mammogram 6m after completion of radiation therapy following lumpectomy and yearly thereafter

211
Q

what should be performed annually after mastectomy

A

contralateral breast mammogram

212
Q

pe f/u breast cancer

A

every 3-6m for 3 yrs then annually

213
Q

local tx of breast cancer

A

surgery and radiation

214
Q

systemic tx of breast cancer

A

iv and oral medicines

215
Q

what size tumor is lumpectomy feasible

A
216
Q

lumpectomy, wide excision, segmental, and partial mastectomy

A

excision of malignancy w circumferential margin of microscopically normal tissue

217
Q

simple or total mastectomy

A

removes entire breast w pectoralis major fascia

218
Q

modified radical mastectomy

A

simple mastectomy w axillary dissection

219
Q

indications for mastectomy

A

dermal lymphatic involvement, diffuse or multiple tumors, unwillingnes or inability to undergo radiation therapy, cosmetically unacceptable

220
Q

what should be discussed with all pt undergoing mastectomy

A

breast reconstruction using prosthetic implants or autologous tissue

221
Q

what has become the standard of care for early breast cancer

A

sentinel node bx

222
Q

what allows surgeon to id the first lymph node that receives drainage from the breast

A

radioactive colloid and or blue dye in quadrant of tumor

223
Q

what are absolute contraindications to radiation therapy

A

pregnancy and previous radiation to same field

224
Q

relative contraindications to radiation therapy

A

prev radiation to same general area, underlying pulmonary ds or cardiomyopathy, significant vasculitis, inability to lie flat

225
Q

when should omitting radiation be considered

A

at least 70yo, single cancer

226
Q

whole breast external beam radiation

A

take few min and given 5d/wk for a period of at least 4-6wks, usually w a boost to the tumor bed

227
Q

partial breast irradiation

A

local area of the lumpectomy is radiated more intensively w external beams, radioactive material in a balloon, or radioactive seeds

228
Q

selective estrogen receptor modulators (SERMs)

A

-tamoxifen; act as estrogen receptor antagonists in breast tissue and as estrogen agonists in bone

229
Q

what are SERMs used to tx

A

estrogen receptor positive (ER+) tumors, dec incidence of contralateral breast cancer and dec recurrence

230
Q

aromatase inhibitors (AIs)

A

letrozole, anastrozole, exemestane; dec circulating estrogen levels in postmenopausal women

231
Q

indications for chemotherapy

A

node positive ds or tumors >1cm in greatest diameter

232
Q

most commonly used chemo regimen

A

anthracycline, a taxane (paclitaxel and docetaxel), and possibly an alkylating agent

233
Q

cytotoxic chemo

A

chemical agents that kill cells; never given as a single agent

234
Q

what improves survival in pts w HER 2 positive tumors

A

trastuzumab

235
Q

tx of operable breast cancer in men

A

mastectomy

236
Q

what is the tx for recurrence of local tumor after lumpectomy

A

mastectomy

237
Q

tx for recurrence of tumor after mastectomy

A

excision and radiation

238
Q

what are brain metastases tx w

A

radiation

239
Q

tx bony metastases

A

radiation and surgical fixation; bisphosphonates give bone strength

240
Q

common side effects of tamoxifen

A

fatigue, night sweats, hot flashes, fluid retention, vaginitis, thrombocytopenia

241
Q

side effects AIs

A

osteoporosis, fractures, muscle and join pains, hot flashes

242
Q

se chemo

A

n,v, bone marrow suppression, stomatitis, alopecia

243
Q

se trastuzumab

A

usually mild but may include significant cardiac or pulmonary toxicity as well as fever, nausea, vomiting, diarrhea, weakness, headache, anemia, neutropenia, tumor pain, cough, dyspnea, and infusion reactions. Combining trastuzumab with chemotherapy increases cardiac risk.

244
Q

A 35-year-old woman comes to clinic because of right breast pain for the past 3 months. The pain Is cyclical in nature. Her mother and two maternal aunts were all diagnosed with breast cancer In their 30s. There are no abnormal findings on exam and a recent diagnostic mammogram and ultrasound are normal. Which of the following would be the most appropriate option for management?

A

high risk screening and genetic counseling

245
Q

A 35-year-old woman comes to clinic because of a 2-month history of thickening In the upper outer quadrant of her left breast. The patient’s mother had breast cancer at age 48. Physical examination shows a slight retraction of the skin in the upper outer quadrant when the patient is upright. The breast tissue In that quadrant is rather firm, with the Impression of a poorly demarcated thickening. A mammogram also shows dense tissue with no distinct mass or suspicious microcalcifications. What Is the next step In the evaluation?

A

Ultrasound Is an adjunct to mammography that is useful to characterize palpable masses; ultrasound of the palpable area may give the most useful information at this time. The radiographic finding Is discordant with suspicious clinical presentation; further diagnostic workup is required. Excislonal biopsy without prior attempted needle biopsy can lead to suboptimal management of a breast cancer. Stereotactic biopsy can only be performed on a lesion demonstrated by mammography. A breast abscess Is exquisitely tender and demonstrable by ultrasonography. Section: Evaluation of the patient with breast mass.

246
Q

A 51 -year-old woman comes to clinic because of a mass In the left breast for 2 weeks. She has no previous history of breast problems. Her last menstrual period was 1 week ago, menarche was at age 12 and she had her first child at age 30. She has no history of any major medical Illness. Her paternal aunt had breast cancer at age 75. On physical examination, she has a 1 -cm mass in the upper outer quadrant of the left breast. The mass is firm and freely movable with Indistinct borders. There is minimal tenderness and skin dimpling over the mass. There is no nipple discharge and no axillary lymphadenopathy. The mammogram and breast ultrasound are normal. A biopsy shows cancer. Which of the following Is the most likely histologic type of cancer causing these findings?

A

Infiltrating lobular often presents as described In this patient. Inflammatory breast cancer will have red edematous skin. Infiltrating ductal carcinoma will be hard with irregular borders and will usually be seen on mammogram and ultrasound. Lobular carcinoma in situ does not usually present as a mass. It is usually found incidentally when excising other breast pathology. Paget’s disease Involves the nipple.

247
Q

A 45-year-old woman is seen in clinic because of skin nodules on the upper portion of the breast and over the clavicle. One year ago, she underwent lumpectomy and sentinel node biopsy for Stage HA invasive ductal carcinoma, ER+, PR-, and HER-2/neu-. She then received a full course of whole-breast radiation with a boost to the tumor bed. After four cycles of cytotoxic chemotherapy, she was started on tamoxifen by her oncologist. Physical exam shows several clusters of firm nodules In the skin over the clavicle and along the upper portion of the left breast. Biopsy of one of these nodules shows metastatic breast cancer. What is the best treatment now?

A

Cytotoxic chemotherapy should be started as soon as possible. An aromatase inhibitor Is not Indicated. The patient has already failed hormonal treatment, as her cancer has advanced while she was taking tamoxifen. This is not a single skin nodule but rather several clusters extending beyond the breast. Mastectomy is a local treatment and may be considered, including excision of the entire area of Involved skin and possible skin graft, if she responds to systemic treatment (cytotoxic chemotherapy). The breast has already been radiated once and should not be radiated again. Trastuzumab is only effective in HER2/neu-positlve breast cancers; it is a monoclonal antibody that binds selectively to the Her-2 protein, a regulator of cell growth. This patient is HER-2/neu negative.

248
Q

A 52-year-old woman comes to clinic because of a bloody nipple discharge. She has noticed spontaneous bloody nipple discharge from her left breast every 2 to 3 days for the last month. She has no pain and takes no medications. Menarche was at age 12. She has four children and was 22 years old when her first child was born. There Is no family history of breast cancer. There are no palpable breast masses, but a small amount of bloody discharge can be expressed from the upper Inner quadrant of the left nipple. A mammogram done earlier today was read as normal. What Is the most Important next step in her evaluation?

A

-duct excision

MRI Is not useful in the evaluation of nipple discharge. Ductography will not avoid the need for duct excision. Cytology has been shown to be unhelpful In the workup and diagnosis of nipple discharge. A significant percentage of patients with nipple discharge have no mammographic abnormalities.

Surgery (21 decks)

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