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General Surgery Oral Boards Review > Breast > Flashcards

Breast Flashcards

1
Q

What are the three BRCA associated cancers to focus on during family history?

A

Ovarian
Colon
Prostate

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2
Q

What is triple concordance?

What do you do with a palpable lesion not visible on mammography?

A

Need agreement of physical exam, radiology and path.

Biopsy a palpable lesion even if mammography is negative.

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3
Q

What are margins for DCIS?

A

2mm

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4
Q

Who do you offer breast radiation after excision of DCIS?
What is benefit?
Who is possible exclusion

A

Almost all patients.
%50 reduction in ipsilateral recurrence.
possibly exclude elderly low grade.

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5
Q 
Who do you offer tamoxifen after excision of DCIS?
What is benefit?
What are (3) complications to potentially exclude patients?
A

Any ER+ DCIS, especially high grade.
50% reduction in both breasts.
DVT/PE, endometrial cancer, cataracts

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6
Q

When would you offer a SLNB for DCIS?

A

When doing a mastectomy for extensive disease

cannot go back to inject blue dye

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7
Q 
Breast Cancer Staging
I
IIA  
IIB
IIIA  
IIIB
Stage IV
A 
Stage I      primary <2 cm, no nodes
Stage II A  <2cm with axillary nodes 
                   2-5 cm with no nodes
Stage II B   primary from 2-5 cm with nodes or 
                    >5 cm tumor no nodes
Stage III A  5 cm with nodes, 
                   bulky but not fixed axillary adenopathy; Stage III B  disease beyond MRM: chest wall invasion, peau d’orange, ulceration and inflammatory breast cancer; supraclavicular adenopathy 
Stage IV  metastatic disease
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8
Q

Additional tests for “metastatic screening” in Stage I&II Breast Cancer patients?

A

CXR and LFTs

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9
Q

Criteria for Breast Conserving Therapy

A

Stage I or II breast cancer
Lesion <5cm or good tumor to breast ratio
Multicentic (multiple quadrants) disease
No contraindications to radiation

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10
Q

Contraindications to Radiation Therapy (Breast)

A

Collagen Vascular disease
Pregnancy
Prior radiation

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11
Q

What breast cancer patients to do complete node dissection on if they got neoadjuvant chemotherapy?

A

Board answer is to complete node dissection on all those patients found to have macrometastases (>2 mm) even if only one node positive. (There are currently clinical trials for this question in 2020)

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12
Q

Stage I&II Breast cancer, who gets chemotherapy?

A

would consider for any primary tumor >0.5cm or nodal disease.
Limited data for women >70.

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13
Q

Who are candidates for Oncotype testing?

A

Stage I&II node negative ER+ patients.

helps decide whether to add chemo

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14
Q

Two most common adjuvant chemo regimens for stage I&II Her-2 negative Breast cancer?

A

24 weeks of
Adriamycin Cytoxan (AC) (cardiotoxic)
Cytoxan Methotrexate 5-FU (CMF)

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15
Q

Additional chemo for Stage II breast cancer?

A

additional 4 cycles of a taxane, Taxotere in most cases

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16
Q

Most common adjuvant chemo regimens for stage I&II Her-2 positive Breast cancer?

A

Herceptin, Cisplatin Taxane (TCH) is given as adjuvant therapy

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17
Q

Stage I&II Breast cancer: Who gets post-op chest wall and lymphatic (axilla, supraclav and internal mammary) radiation?

A

Primary >4 cm

>3 Lymph nodes

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18
Q

What two additional staging/metastatic work up procedures for suspected Stage III Breast cancer?

A

PET/CT

Axillary ultrasound with biopsy of nodes, do SLNB prior to Neoadjuvant chemo if US is negative.

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19
Q

Neoadjuvant chemo for Stage III Her-2 negative breast cancer?

A

Dose dense AC (doxorubicin/cyclophosphamide) followed by paclitaxel every 2 weeks

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20
Q

Neoadjuvant chemo for Stage III Her-2 positive breast cancer?

A

AC (doxorubicin/cyclophosphamide) followed by paclitaxel plus transtuzumab/pertuzumab

21
Q

When to do BCT after neoadjuvant therapy for stage III breast cancer?

A

same as Stage I or II breast cancer, just post chemo
Lesion <5cm or good tumor to breast ratio
Multicentic (multiple quadrants) disease
No contraindications to radiation

22
Q

When do you do ALND for stage III breast cancer?

A

Patients should receive full axillary dissection if nodes were clinically positive on presentation, turn positive during treatment or the ultrasound-guided or sentinel node biopsy was positive prior to chemo. No role for sentinel node biopsy after neoadjuvant chemotherapy

23
Q

Stage III Breast cancer: Who gets post-op chest wall and lymphatic (axilla, supraclav and internal mammary) radiation?

A

Everybody without direct contraindication

24
Q

Stage III breast cancer: Who gets postoperative hormonal therapy?

A

Everybody who is ER+

tamoxifen or aromatase inhibitor

25
Q

Treatment for Inflammatory Breast Cancer?

A

Same as Stage III: Chemo, MRM, radiation

26
Q

Who can you offer immediate breast reconstruction?

A

those patients who appear to have a complete response after neoadjuvant chemo, but not to those with obvious persistent tumor as their local recurrence rates exceed 50%.

27
Q

Pregnancy and breast cancer: When can you give chemo?

A

AC chemotherapy can be given during pregnancy after the late first trimester
Cant give taxane or Herceptin

28
Q

Pregnancy and breast cancer: When can you give radiation?

A

not considered safe during any trimester, but usually will need to undergo up to 24 weeks of chemotherapy before they are ready for radiation

29
Q

Pregnancy and breast cancer: When can you give tamoxifen?

A

not until after delivery

30
Q

Pregnancy and breast cancer: Contraindicated tests?

A

CT (relative if not to pelvis)
Bone scan (absolute)
SLNB lymphazurin blue dye

31
Q

Pregnancy and breast cancer: Safe tests?

A

Mammography
CXR
MRI - no contrast

32
Q

Stage IV Breast Cancer: Treatment for ER+ disease

A

tamoxifen or AI

33
Q

Stage IV Breast Cancer: Treatment for Symptomatic bony mets

A

Radiation

Denosumab with calcium and Vit D

34
Q

Stage IV Breast Cancer: Treatment triple negative

A

CAF - Adriamycin, cytoxan, 5-FU

35
Q

Stage IV Breast Cancer: Treatment for Her-2+ disease

A

pertuzumab/trastuzumab with paclitaxel

36
Q

Paget’s Disease: how to make diagnosis?

A

Always involves the nipple

punch biopsy the skin

37
Q

Paget’s disease with no additional identifiable mass: What do you do?

A

consider MRI to find an occult primary.
Central lumpectomy including NAC with WBRT
Total mastectomy with possible immediate reconstruction

38
Q

Axillary lymph node without breast primary: What do you do?

A
  1. Remove node first to let path direct work-up.
  2. If breast then mammo, consider MRI. Would offer MRM if no primary found.
  3. Serum Ca-125 for Ovarian (chemo will prolong life)
  4. GI work-up is a wast of time (Stage IV diesease)
39
Q

Treatment for Local Recurrence:

depends on skin v parenchyma and previous therapy

A 
Always stage systemically first.
Parenchymal recurrence (prior radiation)- simple mastectomy
Skin recurrence (prior radiation) - rare/controversial, MRM and have Rad/Onc to review if they can give more RT
Skin recurrence (MRM without radiation) - local excision and chest wall radiation.
40
Q

How do you manage bloody nipple discharge?

A

If there is a mammogram finding or a mass, they switch to a cancer biopsy/operation algorithm

Negative mammogram/PE for mass/negative
responsible quadrant
→ total subareolar ductal system resection
(b) Negative mammogram/PE for mass/positive
responsible quadrant
→ subareolar wedge resection ductal system for
that quadrant

41
Q

How do you do a breast duct exploration?

A

Circumareolar incision (some make incision at nipple/
areola border)
Elevate areola
Dissect ducts leading to areola
Identify abnormal duct by dilatation, stent, dye or mass
(if can identify single duct otherwise subareolar
wedge resection of the ductal system draining that
quadrant)
Tie off distal duct or will still drain out of nipple postop
(your seroma!)

42
Q

What is baseline lifetime risk of breast cancer after DCIS excision?

A

~33%

43
Q

What do you do for LCIS on core needle biopsy?

A

Need to do a needle guided surgical biopsy for adequate sampling.

44
Q

What is risk reduction therapy after BCT?

A

5 years
tamoxifen if premenopausal
tamoxifen or Aromatase inhibitor if postmenopausal

45
Q

What is therapy for inflammatory breast cancer?

A

doxorubicin/cyclophosphamide with paclitaxel (AC+T)

with transtuzumab/pertuzumab for HER2-positivity

46
Q

What is the difference between inflammatory breast cancer and Paget’s disease?

A

Inflammatory - invasion of dermal lymphatics

Paget’s - invasion along ducts (involves the nipple)

47
Q

What do you do after inflammatory breast cancer responds to chemo?

A

Total mastectomy, ALND with RT to chest wall and nodal basins

delay reconstruction

48
Q

What do you do for inflammatory breast cancer if no response to chemo?

A

Try another chemo formulation or radiation.

Do not take to OR since you will never clear the dermal disease.

General Surgery Oral Boards Review (14 decks)

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