Breast

Question 1

Indications for resection of fibroadenoma (5)

Answer 1

Size >2cm
Increasing size
Pain associated with lesion
Increased cellularity of lesion
Anxiety caused by presence of mass

Question 2

Treatments for mastalgia (1 Rx, 3 OTC, 2 diet modifications)

Answer 2

Rx: NSAIDs
OTC: Vitamin E, fish oil, evening primrose oil
Diet: Low fat, low caffeine

Question 3

Treatment for nipple discharge that can be induced from several ducts with manipulation of the breast

Answer 3

Reassurance

Question 4

Treatment for nipple discharge that is spontaneous, unilateral, recurrent and involving a single duct

Answer 4

Dx mammography and ultrasound, possible biopsy and surgical excision. Suspicious nipple discharge is bloody or clear.

Question 5

Most common causes of nipple discharge (3)

Answer 5

Papillomas, duct ectasia and fibrocystic breast disease (all benign)

Question 6

When is there a high suspicion for inflammatory breast cancer in a patient presenting with “mastitis”?

Answer 6

Patient is postmenopausal and non-lactating, with no precipitating factors or systemic signs of infection

Question 7

What is the treatment for patients with needle biopsy results of atypical ductal hyperplasia?

Answer 7

Excisional biopsy, coexisting malignancy present in 15-20% of cases

Question 8

What is the treatment for patients with needle biopsy results of atypical lobular hyperplasia?

Answer 8

Excisional biopsy, coexisting malignancy present in 10-15% of cases

Question 9

What is the treatment for patients with needle biopsy results of sclerosing adenosis with radial scarring?

Answer 9

Excisional biopsy, coexisting malignancy present in 10-15% of cases

Question 10

What is the immediate treatment for patients with needle biopsy results of LCIS?

Answer 10

Excisional biopsy to decrease sampling error

Question 11

If excisional biopsy demonstrates only LCIS, what should be offered?

Answer 11

High-risk screening and antiestrogen therapy

High risk screening: annual mammogram, annual MRI, breast exam every 6mo

Question 12

Who are high risk patients? (6)

Answer 12

BRCA mutation
Family history
History of chest wall radiation
Past breast cancer
LCIS
Atypia

Question 13

BIRADS 0

Answer 13

Incomplete, need for additional imaging

Question 14

BIRADS 1

Answer 14

Negative, resume routine screening

Question 15

BIRADS 2

Answer 15

Benign, resume routine screening

Question 16

BIRADS 3

Answer 16

Probably benign, risk of malignancy <2%, 6mo follow up recommended

Question 17

BIRADS 4

Answer 17

Suspicious abnormality, intermediate risk of malignancy, biopsy recommended

Question 18

BIRADS 5

Answer 18

Highly suggestive of malignancy (>95% chance)

Question 19

BIRADS 6

Answer 19

Known biopsy-proven malignancy

Question 20

Treatment of BIRADS 5 lesion after benign needle biopsy

Answer 20

Excisional biopsy, risk is too high of false-negative

Question 21

Treatment of clinically suspicious palpable lesion, occult on mammogram and ultrasound, with benign needle biopsy

Answer 21

Excisional biopsy

Question 22

ACS criteria for annual breast MRI (5)

Answer 22

First-degree relative of BRCA carrier, untested
Lifetime risk >20% (models dependent on family history)
Radiation to chest between ages of 10-30y
Li-Fraumeni syndrome and first-degree relatives
Cowden and Bannayan-Riley-Ruvacaba syndromes and first-degree relatives

Question 23

Per ACS, can consider annual breast MRI (5)

Answer 23

Lifetime risk 15-20% (family history models)
LCIS or atypical lobular hyperplasia
Atypical ductal hyperplasia
Heterogeneously or extremely dense breast on mammography
Personal history of breast cancer or DCIS

Question 24

Incidence of breast cancer caused by genetic abnormalities

Answer 24

5-10%

Question 25

What is the treatment for patients with needle biopsy results of flat epithelial hyperplasia?

Answer 25

Excisional biopsy to rule out sampling error

Question 26

Indications for stereotactic biopsy (8)

Answer 26

Lesions that are highly-suggestive of malignancy (BIRADS 5) Lesions that are suspicious for malignancy (BIRADS 4) Lesions that are BIRADS 3 when there are other clinical reasons to suspect malignancy or when short-term follow up is not feasible Multiple suspicious lesions Mammographic lesions that correspond to suspicious lesions on MRI A nonpalpable suspicious solid mass on mammography that is not seen on ultrasound Suspicious microcalcifications that are new or at site of prior lumpectomy Suspicious architectural distortion

Question 27

What is the presumptive diagnosis and treatment of a fibroepithelial lesion on core biopsy?

Answer 27

Phylloides tumor, wide local excision

Question 28

What breast cancer patient should have an Oncotype sent?

Answer 28

ER(+), node-negative cancers Can consider in ER(+), node-positive, HER2(-) cancers as well

Question 29

Contraindications to breast-conserving therapy (5)

Answer 29

``` Multicentric disease Locally-advanced cancer Inflammatory breast cancer Unfavorable breast-tumor ratio Any contraindication to radiation therapy ```

Question 30

What are the patient criteria required to qualify for “Z11”? (5)

Answer 30

Tumor size <5cm (T1 or T2) Fewer than 3 positive SLN No evidence of extracapsular tumor extension in SLN Planned whole breast RT Planned standard of care adjuvant therapy

Question 31

If a patient qualifies for Z11, what does that mean?

Answer 31

She may avoid completion sentinel lymph node dissection even in the presence of a positive sentinel lymph node. As a reminder, Z11 means: Tumor size <5cm (T1 or T2) Fewer than 3 positive SLN No evidence of extracapsular tumor extension in SLN Planned whole breast RT Planned standard of care adjuvant therapy

Question 32

Why do SLNB for DCIS?

Answer 32

15-20% chance of upstaging when excisional biopsy complete

Question 33

What is the benefit of tamoxifen in high-risk patients?

Answer 33

Reduces cancer risk by 50% Does increase risk of endometrial cancer and DVT.

Question 34

What patients are not eligible for a SLNB?

Answer 34

Patients with inflammatory breast cancer (tumor emboli cause lymphatics) T4 lesions Biopsy-proven positive nodes