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Surgery Clerkship > Breast > Flashcards

Breast Flashcards

1
Q

What’s in the differential for a benign palpable breast mass?

A 
Fibrocystic change
Fibroadenoma
Intraductal papilloma
Fat necrosis
Abscess
Galactocele
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2
Q

What’s in the differential for a malignant palpable breast mass?

A 
DCIS
Invasive ductal carcinoma
Invasive lobular carcinoma
Mucinous carcinoma
Inflammatory carcinoma
Phylloides tumor
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3
Q

What features on PE suggest breast cancer?

A
  • Asymmetry, skin changes, nipple discharge (or crusting)
  • Single dominant lesion that is hard, immobile and with irregular borders
  • Look at lymph nodes: enlarged, firm, immobile and/or matted suggest mets
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4
Q

What are the most important risk factors for breast cancer?

A
  • Female gender
  • Increasing age
  • Family history of premenopausal breast cancer
  • All have increased lifetime exposure to estrogen
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5
Q

What are the 3 types of nipple discharge?

A

Lactation
Physiologic discharge
Pathologic discharge

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6
Q

What does physiologic discharge look like, and what usually causes it?

A

Clear, bilateral and multi ductal

- Post lactation, fluctuating hormone levels or nipple stimulation

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7
Q

What can cause pathologic nipple discharge?

A 
Prolactinoma
Hypothyroidism
Cushing's
Medications
Papilloma: tumor of lining of breast duct
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8
Q

In what circumstances is nipple discharge likely to be cancer?

A
  • Bloody, spontaneous, unilateral, uniductal discharge
  • Associated with breast mass
  • In women > 40
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9
Q

What are the fibrocystic changes and their associated increased risk of cancer?

A

Apocrine metaplasia: none
Ductal hyperplasia / Sclerosing adenosine: doubles risk of cancer
Atypical hyperplasia: highest risk

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10
Q

What is pathophys of “peau d’orange”? When is it seen?

A

Lymph drainage is compromised by tumor –> edema in inter follicular dermis –> dimples that look like orange peels
Seen in inflammatory breast cancer

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11
Q

What is pathophys of nipple retraction?

A

Breast tumor infiltrates suspensory ligaments (Cooper’s ligaments) and retracts the skin often around the nipples

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12
Q

What is the triple test for new breast mass?

A

PE
Imaging
Tissue sample

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13
Q

How does age of patient affect workup of a new palpable breast mass?

A

< 30: Ultrasound

> 30: mammogram plus ultrasound

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14
Q

How do we work-up a mass in a patient <30, after US, if it is a:
simple cyst
Painful/enlarging cyst
Solid mass?

A

Simple cyst: observe
Painful/enlarging cyst: aspirated and sent to cytology if bloody
Solid: do a core needle biopsy

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15
Q

Once a mass is identified in a woman > 30, what is the next step?

A

Core needle biopsy to exclude cancer

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16
Q

What metastatic workup is recommended after diagnosis of breast cancer?

A

None

  • CXR
  • LFTs
  • alk phos, Ca to examine liver and bone function
  • Otherwise, follow symptoms and only do bone scan, CT abdomen/chest/brain if suspicion for mets is high
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17
Q

How do we stage breast cancer?

A

Tumor
Nodes
Metastases

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18
Q

What surgical options are available for stage I and II breast cancer?

A
  1. Breast conserving therapy: lumpectomy + sentinel lymph node biopsy. Then radiation
  2. Simple mastectomy
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19
Q

What are the contraindications to breast conserving therapy?

A
  • Primary tumors in 2+ quadrants
  • Diffuse malignant appearing micro calcifications throughout breast
  • Previous history of chest wall radiation
  • Positive surgical margins despite repeat excision
  • Early pregnancy (cannot give radiation)
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20
Q

Can nipple and breast skin be spared during simple mastectomy?

A

Yes

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21
Q

What is management for clinically advanced stage III breast cancer?

A
  • Large tumor: simple mastectomy
  • Lymph nodes enlarged: axillary lymph node dissection (ALND)
  • Both: modified radical mastectomy: mastectomy + ALND
  • Any skin invasion: chemo before surgery to shrink margins
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22
Q

What is considered stage III breast cancer?

A
  • Tumors > 5c
  • Tumors that invaded skin
  • Presence of large matted clinically positive axillary lymph nodes
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23
Q

What is premise behind SLNB?

A

Hypothetical first node from which lymphatics of breast drain… if first ones are free of cancer, likely the rest are not, either.

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24
Q

How many sentinel nodes at a time usually?

A

2-4

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25
Q

What to do if during SLNB, no sentinel lymph node lights up?

A

Proceed to ALND: remove level I and II lymph nodes

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26
Q

When to perform axillary lymph node dissection?

A
  • If >2 positive sentinel lymph nodes, or in patients who underwent mastectomy (because they don’t get radiation)
  • Otherwise, can do radiation to axilla
27
Q

What is the purpose of ALND?

A

Used for staging: not been shown to affect survival

28
Q

What is the premise behind hormonal therapy?

A
  • Decrease steroid hormone levels or antagonizing receptors that promote growth of cancer cells
  • Usually adjuvant to prevent recurrence
29
Q

What study must be done before trastuzumab?

A

Echocardiogram or MUGA to determine EF

30
Q

Why are aromatase inhibitors only effective in post menopausal women?

A

E.g. anastrozole: Inhibit aromatase enzyme in fat tissue that make small amounts of estrogen in postmenopausal women: only work in people whose ovaries stopped producing estrogen

31
Q

What are key hormonal therapies and mechanisms of action in breast cancer?

A

Tamoxifen/raloxifene/fulvestrant: blocks ER
Anastrozole: aromatase inhibitor
Trastuzumab: monoclonal Ab blocking HER-2 receptors

32
Q

what are the key chemotherapeutics used for breast cancer and their mechanisms of action?

A

Doxorubicin: inhibit DNA/RNA synthesis by inhibiting topoisomerase II
Cyclophosphamide: promotes DNA damage: alkylates guanine bases
Methotrexate/5-FU: interfere with DNA synthesis
Paclitaxel: inhibits mitotic phase in cell cycle

33
Q

Does everyone with breast cancer require chemo?

A

Most, except:

  • Carcinoma in situ
  • < 1cm with favorable tumor markers and negative SLNB
34
Q

In breast cancer patients who do not get chemo, what test do they get and why?

A

Oncotype DX: look at molecular level cancer characteristics to predict chemo benefit and recurrence

35
Q

What are options for breast reconstruction?

A

Immediate: autologous tissue flap with temporary tissue expander
Delayed: if patient requires post-op radiation

36
Q

What nerves can be damaged during dissection of lymph nodes in breast cancer?

A

1 Long thoracic: winged scapula (serratus anterior)
2 Thoracodorsal: weak latissimus dorsi
3 Medial pectoral: weak internal rotation of humerus (pec minor and major)
4 Lateral pectoral: weak flexion, adduction and internal rotation of humerus (pec major)

37
Q

What is the worst complication of lymph node dissection?

A

Lymphedema (more likely with ALND vs. SLNB)

38
Q

What is the concern with lymphedema from ALND?

A
  • Increased risk of infection

- Lymphangiosarcoma: poor prognosis even after limb amputation

39
Q

What to do with a breast mass during pregnancy?

A
  • Do not ignore!
  • Patient can get chemo in second trimester
  • In 3rd trimster, wait until after birth
  • Never get radiation or hormones during pregnancy
40
Q

What types of breast cancer do men typically get, and when?

A

65-70 years of age

Invasive ductal carcinoma

41
Q

Should stage 4 breast cancer patient have a mastectomy?

A

Several studies that suggest mastectomy in select patients provides some survival benefit

42
Q

What is most common cause of palpable breast mass?

A

Fibrocystic change

43
Q

What’s the differential for abnormal mammogram without palpable breast mass?

A 
Benign:
Skin calcification
Vascular calcification
Eggshell calcification
Suspicious:
Amorphous calcification
Coarse heterogeneous
High probability malignancy:
- Fine pleomorphic (BI-RADS 5)
- Fine linear/linear branching
44
Q

What are recommendations for breast cancer screening?

A

Age 40-44: Optional
45-54: annual screening mammography
55+: Annual or every 2 years

45
Q

What are the risks of mammography?

A
  • Radiation
  • Detection of cancers that would not lead to symptoms
  • Not always accurate
46
Q

Why is mammography not useful in women < 30?

A

Denser breast tissue: make it harder to detect abnormal calcifications or masses

47
Q

What is one quick feature to help differentiate between benign and malignant conditions on mammography?

A

Macrocalcifications: usually benign
Microcalcifications: more often breast cancer

48
Q

What is presentation of DCIS vs. LCIS?

A

DCIS: incidental micro calcification: mammo
LCIS: incidental finding on histopath

49
Q

What is location of DCIS vs. LCIS?

A

DCIS: Ducts
LCIS: lobules

50
Q

What is pattern of DCIS vs. LCIS?

A

DCIS: Comedy with prominent necrosis in the center of the involved spaces
LCIS: solid

51
Q

Is there axillary metastasis in DCIS vs. LCIS?

A

DCIS: 1-13%
LCIS: usually absent

52
Q

What is the incidence of concurrent invasive carcinoma and risk of subsequent invasive carcinoma in DCIS vs. LCIS?

A

DCIS: Higher
LCIS: lower

53
Q

What is treatment of DCIS?

A

Excision to negative margin, consider SLNB in select group

54
Q

What is treatment of LCIS?

A
  • If found on excisional biopsy: observation or tamoxifen
  • If on core needle biopsy: rule out adjacent cancer
  • High risk: offer prophylactic bilateral mastectomy
55
Q

What does LCIS signify?

A

Marker for development of future invasive breast cancer, but not a precursor lesion!

56
Q

How are mammograms used in staging breast lesions?

A

BIRADS: summarize reporting of mamographic findings to determine relative likelihood of benign or malignant diagnosis.

0: more imaging needed
1: Negative
2: Benign most likely (2% risk)
3: Probably benign: more follow-up
4: Suspicious abnormalities: biopsy (15-30% risk)
5: Highly suspicious: biopsy
6: Already proven to be malignant

57
Q

What if stereotactic biopsy indicates DCIS?

A

BCS to avoid progression to invasive ductal cancer

58
Q

What if stereotactic biopsy indicates LCIS?

A

Excisional biopsy to rule out any adjacent cancer. If path finds only LCIS: no further surgery.

59
Q

What if stereotactic biopsy shows invasive ductal carcinoma?

A

Standard treatment:

  1. BCS with SLND + radiation
  2. Mastectomy with SLNB
60
Q

Do DCIS cancers require SLNB?

A
  • Usually no, but considered in some high risk patients with extensive microcacifications or palpable mass
  • Also recommended if patient chooses mastectomy
61
Q

Does mammography actually reduce mortality from breast cancer?

A

Recent study: no

62
Q

Who could be considered a candidate for prophylactic bilateral mastectomy?

A

Patients with LCIS

Patients with family history of breast cancer

63
Q

What is ACS guideline for clinical breast exams?

A

Every 3 years: Age 20-39

Annually after 40

64
Q

What BIRADS scores get stereotactic biopsy?

A

4 or 5

Surgery Clerkship (16 decks)

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