Breast

Question 1

Risk factors for breast cancer

Answer 1

Female gender, increasing age, and a family history of premenopausal breast cancer. Family history of breast cancer in males or premenopausal women, bilateral breast cancer, a history of ovarian cancer, and multiple relatives with cancer. BRCA1 or BRCA2 gene mutations. Diethylstilbestrol (DES) exposure, early menarche, nulliparity or childbirth after age 30, and/or late menopause.

Question 2

Three categories of nipple discharge

Answer 2

Normal milk production (lactation), physiologic nipple discharge, or pathologic nipple discharge.

Question 3

Characteristics of nipple discharge that suggest cancer

Answer 3

Bloody, spontaneous, unilateral, uniductal, associated with a breast mass, or occurs in women over 40.

Question 4

What is Peau d’Orange?

Answer 4

Lymph drainage in the breast is compromised by a tumor, resulting in edema expanding the interfollicular dermis, producing characteristic dimples which resemble the texture and appearance of orange peels. When deeper subcutaneous layers are involved, it can also cause pitting.

Question 5

What is the pathophysiology of nipple retraction?

Answer 5

When a breast tumor infiltrates Cooper’s ligaments, the suspensory ligaments of the breast, it can retract the skin, often at or around the nipples.

Question 6

What is the triple test for a new breast mass?

Answer 6

Careful examination, imaging, and tissue sampling.

Question 7

What is a triple negative breast cancer?

Answer 7

Breast cancer that is negative for estrogen (ER), progesterone (PR), and human epidermal growth factor 2 (HER-2) receptors. Prognosis is worse, requires more aggressive therapy.

Question 8

What is the premise behind sentinel lymph node biopsy (SLNB)?

Answer 8

A sentinel lymph node is the hypothetical first node or group of nodes from which the lymphatics of the breast drain. The premise behind SLNB is that if the sentinel node(s) is(are) free of metastasis, then other lymph nodes in the axilla will also be disease free, and therefore, there is no need to remove the remaining lymph nodes in the axilla.

Question 9

What are the boundaries in the axilla for breast dissection?

Answer 9

Axillary vein (superior), floor of axilla (posterior), latissimus dorsi muscle (lateral), pectoralis minor muscle (medial).

Question 10

Five hormonal therapies for breast cancer

Answer 10

Tamoxifen, Raloxifene, Fulvestrant, Anastrozole, Trastuzumab

Question 11

Four chemotherapy regimens for breast cancer

Answer 11

Anthracyclines, Alkylating agent, Antimetabolites, Taxanes

Question 12

Nerves at risk for damage during dissection of lymph nodes for breast cancer

Answer 12

Long thoracic, thoracodorsal, medial pectoral, lateral pectoral

Question 13

Most common cause of palpable breast mass

Answer 13

Fibrocystic disease

Question 14

Incidence of breast cancer in women in U.S.

Answer 14

1 in 8 women will develop breast cancer in U.S.

Question 15

The most common malignant neoplasm of the breast

Answer 15

Invasive ductal carcinoma

Question 16

The most common breast neoplasm in premenopausal women

Answer 16

Fibroadenoma

Question 17

Imaging to be ordered for new breast mass based on age

Answer 17

<30 ultrasound, >30 ultrasound + mammogram

Question 18

Management for early stage breast cancer

Answer 18

Lumpectomy with SLND and radiation OR simple mastectomy with SLND

Question 19

Why is mammography not useful in women <30 years old?

Answer 19

Younger women tend to have denser breast tissue due to a decreased level of fat. Dense breasts make it difficult to detect abnormal calcifications or masses.

Question 20

What is the Gail risk model?

Answer 20

AKA Breast Cancer Risk Assessment Tool (BCRAT); a mathematical model used to calculate the risk of developing breast cancer. The model considers factors such as age, age at menarche, reproductive history, family history in first-degree relatives, and prior biopsies.

Question 21

What impact does lesion size on mammography have on the likelihood of being benign or malignant?

Answer 21

Larger calcifications (macrocalcifications) are almost always benign, while smaller calcifications (microcalcifications) are
more frequently seen in patients with breast cancer.

Question 22

DCIS

Answer 22

Ductal Carcinoma in situ: characterized by malignant epithelial cells within the mammary ductal system, without invasion into the surrounding stroma (does not metastasize). Very high incidence of recurrence.

Question 23

LCIS

Answer 23

Lobular Carcinoma in situ: characterized by malignant epithelial cells that arise from the lobules and terminal ducts of the breast. Unlike DCIS, it is not a premalignant lesion, but rather is a marker for the development of future ipsilateral as well as contralateral invasive breast cancer (ductal or lobular).

Question 24

What is the BI-RADS assessment?

Answer 24

American College of Radiology’s Breast Imaging Reporting and Data System (BI-RADS), standardizes the reporting of mammographic findings and indicates the relative likelihood of a normal, benign, or malignant diagnosis.

Question 25

What are the first steps in management of DCIS?

Answer 25

Lumpectomy, then margins of tissue are inked for remaining cancer cells. If positive, re-excision or mastectomy are recommended.

Question 26

What are the first steps in management of LCIS?

Answer 26

Excisional biopsy (a smaller tissue size is excised than lumpectomy). The goal is not clear margins (like for DCIS), but instead to check for nearby cancer. If negative, LCIS still indicates increased risk of breast cancer in EITHER breast.

Question 27

Fibroadenomas: who is at risk, what does it look like, and what do you do?

Answer 27

Young women (teens, early 20’s). Firm rubbery mass that moves easily with palpation. FNA is diagnostic, removal is optional.

Question 28

Giant Juvenile Fibroadenomas: who is at risk, what does it look like, and what do you do?

Answer 28

Very young adolescents. Grows very fast. Removal is needed to avoid deformity of the breast.

Question 29

Cystosarcoma phylloides: who is at risk, what does it look like, and what do you do?

Answer 29

Late 20’s. They grow over many years, becoming very large, replacing and distorting the entire breast: yet not invading or becoming fixed. Most are benign, but they have potential to become outright malignant sarcomas. Core or incisional biopsy is needed (FNA is not sufficient), and removal is mandatory.

Question 30

Intraductal papilloma; who is at risk, what does it look like, and what do you do?

Answer 30

20’s to 40’s. Bloody nipple discharge. Galactogram may be diagnostic and guide resection.

Question 31

Breast abscess is only seen in what kind of women

Answer 31

Lactating women

Question 32

Most common form of breast cancer

Answer 32

Invasive ductal carcinoma

Question 33

Adjuvant systemic hormonal therapy for premenopausal vs. postmenopausal women

Answer 33

Premenopausal get tamoxifen. Postmenopausal get anastrozole

Question 34

Favorite location for breast cancer metastasis to the spine

Answer 34

Vertebral pedicles