BREAST Flashcards
1
Q
RF breast cancer in men
A
- BRCA2
- changes in estrogen:adrogen ratio (Klinefelter, testicular abn, cirrhosis, obesity)
- alcoholism
- NOT hx of gynecomastia
2
Q
Staging breast CA
A
1 = small tumor, no nodes 2 = larger tumor or minor node involvement (T3N0, T2N1) 3A/3B = local invasion + no nodes (T4N0) OR larger tumor + some nodes (T3N2) 3C = clavicular node involvement 4 = distant mets
3
Q
MC vein involved in Mondor disease
A
lateral thoracic vein
4
Q
If involvement of supra/infraclavicular nodes, what stage?
A
3C (bc N3)
5
Q
Criteria of inflammatory breast cancer
A
- rapid onset breast erythema, edema, or peau d’orange or warm breast w/wo palp mass
- duration of hx <6mo
- erythema over >1/3 breast
- histology confirms invasive carcinoma
6
Q
MC benign breast mass
A
fibroadenoma
7
Q
Phyllodes tumor pathology stains positive for…?
A
vimentin + actin
8
Q
DCIS w/ high risk local recurrence (hence, rec mastectomy instead of BCT)
A
- large size
- comedo histology
- pos tumor margins
- extensive multicentricity
- young age
9
Q
Mgmt Stewart-Treves syndrome
A
WLE 3-6cm margins, but overall poor prognosis (tumors <5cm have better prognosis)
10
Q
Risk of malignancy associated with radial scar
A
1.5-2x RR of malignancy (similar to other proliferative lesions wo atypia)
11
Q
Mgmt BIRADS-4B mammogram after benign, concordant core biopsy
A
observation
12
Q
Chemotherapy regimens for breast CA
A
13
Q
MC organism causing mastitis
A
staph aureus
14
Q
Do you do SLNBx for phyllodes tumor?
A
NO - spreads hematogenously
15
Q
Risks tamoxifen therapy
A
thromboembolism (DVT, PE) and endometrial CA
16
Q
Dx imaging of choice for Mondor disease
A
US
17
Q
Risk of lymphadenopathy in pts s/p SLBx
A
7% 6-mo after surgery
18
Q
s/p BCT for DCIS several years ago, now presenting with lump at incision site… concern for? Dx?
A
recurrence - will occur earliest at lumpectomy site (early recurrence due to untreated disease)
Dx: scar biopsy (not mammo bc limited by post-surgical changes)
19
Q
Absolute C/I to BCT (5)
A
- 2+ primary tumors in separate quads of breast (multicentric)
- persistent pos. margins after surgery
- pregnancy (bc cannot have radiation)
- hx radiation to breast and re-treatment wound > acceptable radiation dose
- diffuse malignant-appearing microcalcifications
21
Q
Radiation recommended in post-mastectomy Stage II only if…?
A
- extracapsular invasion
- lymphovascular invasion
- <40yo
- close surgical margins
- nodal positivity ratio >20%
- pts who have undergone less than standard level I or II ax. dissection
22
Q
SLNBx false-negative rates decrease if use both…?
A
radiolabeled tracer + blue dye
23
Q
Relative C/I to BCT (3)
A
- hx scleroderma or active SLE
- large tumor in small breast (may consider neoadjuvant chemo)
- large or pendulous breasts
24
Q
Paget’s disease of breast association with breast cancer?
A
Up to 92% females with Paget’s have underlying breast cancer - need partial vs. total mastectomy
25
Q
Next step: if atypia hyperplasia on excisional biopsy and pos. margins
A
nothing. no need for neg margins. +/- tamoxifen
26
Is neoadjuvant chemoRx indicated for triple-neg breast CA?
no - no survival advantage over standard adjuvant; only indicated to downstage primary tumor for cosmesis after breast conservation
27
B/l breast pain + green nipple discharge in young pt... think?
fibrocystic change
28
T-stage breast CA
```
T1 = 0-2cm
T2 = 2-5cm
T3 = >5
T4 = invastion chest wall or skin (not including pec major)
```
29
Annual risk of contralateral breast CA for women w/ ER+ first breast cancer
0.3-0.5% per year (3-5% in 10 years)
30
Ataxia telangiectasia: tumor gene? associated with what CA?
(ATM): cerebellar and neuromotor deterioration, lymphoma, leukemia
32
Mgmt bilateral gynecomastia
- stop implicated Rx if possible (spironolactone, CCB, PPI, H2-blockers, antiandrogens [prostate CA tx])
- tamoxifen
33
What sxs should pt stop breastfeeding if have mastitis?
purulent nipple discharge = epidemic puerperal mastitis (due to MRSA)
35
Tx non-cyclical mastalgia
weight loss + sports bra
36
Steward Treves Angiosarcoma
lymphangiosarcoma: chronic lymphedema following ax dissection -> dark purple lesion on arm
38
Are intraductal papillomas associated with increased risk breast CA?
NO
39
Mondor's disase
thrombophlebitis of breast
40
Chemotherapy choice during pregnancy (breast)?
TAC during 2nd/3rd trimester.
Tamoxifen (and other selective estrogen-R modulators) should be deferred until after pregnancy - birth defects (craniofacial malformation, ambiguous genitalia)
41
Phyllodes tumor classified as benign, borderline, or malignant based on...?
- pleomorphism
- stromal overgrowth
- mitotic count
- character of tumor border (circumscribed vs. infiltrative)
42
What is pathognomonic on histology for inflam breast cancer? (although its abscence does not exclude dx)
tumor emboli in dermal lymphatic channels
43
Veins typically effected by Mondor disease
- lateral thoracic vein
- thoracoepigastric vein
- superficial epigastric vein
44
Stewart-Treves syndrome tumor cells originate from...?
dermal vascular endothelium
45
Systemic therapy for triple-neg breast cancer
cytotoxic chemoRx
47
Mgmt inflam breast cancer
- neoadjuvant (anthracycline + taxanes over 4-6mo before surgery)
- modified radical mastectomy
- post-op radiation
48
Common sites breast CA mets
brain, bone, lung, liver (isolated deposits <0.2mm not considered mets)
49
When do surgical I&D for breast abscess?
- multiloculated
- when there is overlying skin necrosis
- if recur after multiple aspirations
52
What is removed with simple mastectomy?
- nipple-areola complex
- breast parenchyma
- necessary skin
53
Gail model for assessment of invasive breast CA risk includes...
- age
- age at menarche
- age at first live birth
- first degree relative with breast CA
- previous breast bx
- race
54
Patho periductal fistula
obstruction of milk duct -> collection becomes infected -> acute subareolar abscess, which drains to border or areola -> fistula helas, but bc recurrent abscess -> chronic fistula
55
If T4 breast cancer, no nodes... what stage?
3B (locally advanced)
56
MC papillary lesion of the breast
intraductal papilloma
57
Bilateral prophylactic salpingo-oophorectomy reduces risk of ? in BRCA1/2 mutations
- reduces risk breast CA (by 50%)
- reduces risk of ovarian cancer (by 96%)
- improves overall survival
58
Pathology of clear cytoplasm, large nuclei, and Her2+ ... what is it?
paget's disease of breast
58
Absolute C/I SLNBx
- inflam breast CA
| - presence of mets ax lymphadenopathy
59
Cowden: tumor gene? associated with what CA?
(PTEN): mucocutaneous lesions, thyroid CA, endometrial CA, colon CA, brain CA
60
Tx cyclical mastalgia
tamoxifen, danazol, COP, bromocriptine
61
Do we do SLNBx for inflam breast CA?
NO - lymphatic involvement of tumor cells and unreliable SLN - need to do ax LN dissection.
61
Typical demographics for pt w/ Mondor disease
- female (3:1 F>M)
- 30-60yo
- no correlation to race/family hx
62
Blood supply for transverse rectus abdominis muscle (TRAM) flap?
superior epigastric artery and vein
63
Next step: atypia hyperplasia on CNB
excisional biopsy
64
Mgmt BIRADS-5 mammogram after benign core biopsy
excision - bc deemed "benign-discordant)
65
Rx that can cause glactorrhea
- OCP
- phenothiazines
- TCA
- metoclopramide
66
Pathology of Paget's disease
large cells w/ pale cytoplasm + prominent nucleoli involving epidermis of nipple
67
Who needs Level 1 and 2 axillary dissection?
- clinically pos nodes confirmed by FNA or CNB
- palpable nodes
- sentinel nodes (need 3) not identified during SLNBx
69
Typical demographic of pts w/ triple-neg breast CA
- young females (<40yo)
- AA, Hispanics
- BRCA1
70
Indications for MRI
- annual MRI screening start 30-yo if have lifetime risk >20%
- untested and 1st degree w/ BRCA
- has known BRCA
- radiation to chest ages 10-30yo
- Li-Fraumeni, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome in pt or 1st degree
71
% CA risks for BRCAI
higher ovarian CA risk compared to BRCA2 (breast:ovarian CA risk = 65% vs. 40%)
72
Malignant phyllodes tumors MC mets to where?
lungs (heme mets)
73
Patho of sclerosing adenosis
typically found in pts with fibrocystic changes - increased number of small terminal ductules associated with stromal tissue proliferation
74
Why bone common location for breast mets?
Batson venous plexus (valveless veins that connect deep pelvic veins + thoracic veins - drains bladder, breast, prostate)
74
Benefit of endocrine therapy on risk of developing contralateral breast CA
decrease risk of contralateral development
74
Method of excision for fibroadenoma, if indicated
enucleation - possible bc well-encapsulated
75
Li-Fraumeni: tumor marker? associated with what CA?
(p53): sarcoma, brain tumors, leukemia, adrenocortical malignancy
76
Most common etiology of Mondor disease?
idiopathic (although hx trauma, surgery/biopsy, or underlying connective tissue or breast CA may contribute)
78
DCIS histology types (from best to worst)
1. papillary (well-diff, nonpleomorphic)
2. cribiform (cellular polarity, atypia)
3. comedo (architectural distortion, cellular necrosis, Ca deposition)
79
Muier-Torre: tumor gene? associated with what CA?
(MLH1, MLH2): multiple skin tumors, benign and malignant tumors of GI/GU tracts
80
Dx Paget's disease of breast
full-thickness biopsy - bc dermal based lesion
81
Bilateral prophylactic mastectomy reduces risk of ? in BRCA1/2 mutations
reduces risk of breast CA (by >90%)
| does NOT affect overall survival
82
What is granulomatous mastitis? Demographic?
idiopathic inflam condition of breast; often presents with abscess and fistulas at multiple locations of breast; nonwhite women of childbearing age
83
Mgmt phyllodes tumor; do you need ax-node dissection?
WLE w/ 1-2cm margins; if too large may need mastectomy; NO ax-node dissection bc tumor spreads heme (rare LN mets)
84
Radiological abnormality of LCIS
none - often found incidentally on core needle biopsy for something else
85
% CA risks for BRCAII
breast: ovarian CA risk = 45% vs. 10%
| - note that increased panc and prostate CA in men
85
Mgmt milk fistula s/p needle biopsy during breast feeding
stop breast feeding
85
Dx granulomatous mastitis
CNB w/ granulomas; tissue should be sent for acid-fast bacilli and fungal stains to r/o underlying disease
87
Who gets chemotherapy (breast)?
- tumors >1cm (or >0.5cm in men)
- positive nodes
- triple negative nodes
- high oncotype dx recurrence score
88
If N2 breast cancer, at least what stage?
3A
89
Mgmt granulomatous mastitis
oral steroids; excision only if refractory (often recurs)
90
Pathology of numerous dermal tumor emboli in papillary and reticular dermis of skin... what is it?
inflammatory breast CA
91
N-stage breast CA
```
N1 = 1-3 nodes
N2 = 4-9
N3 = 10+ OR supra/infraclavicular nodes
```
91
Use of preoperative MRI prior to BCT?
none - does not demonstrate lower rates +margins; actually increases use of mastectomy
91
Dx LCIS increases risk by ? per year for breast CA
1-2% per year equally on both breasts (10-20% in 10yrs) - 8-10x higher risk than general population
93
Next step: cellular fibroadenoma on CNB
excision biopsy (bc cannot distinguish from phyllodes tumor - both have fibroepithelial component)
93
Annual risk of breast CA in pts with atypical ductal hypreplasia
0.5-1% per year (5-10% in 10 years) - 4x increase risk than general population
93
What is removed with modified radical mastectomy?
- nipple-areola complex
- breast parenchyma
- skin
- level I-II axillary LN (pec major spared)
94
Mgmt periductal fistula
excision of entire fistula tract
94
Axillary radiation associated with ? risk lymphedema
increased, ~20%
95
Adjuvant radiation therapy after mastectomy for...?
All T3-T4 or N2-N3 disease
96
#1 and #2 factor most predictive of poor prognosis in pts with breast cancer
```
#1 - LN status
#2 - HER2 status (associated with poor differentiation, high proliferative rates, decreased expression of steroid-hormone-R, and increased likelihood of having LN mets)
```
97
Margins for Phyllodes tumor
1cm
98
Phyllodes tumor is characterized based on...
- cellular atypical
- mitotic activity
- stromal overgrowth
99
C/I nipple-sparing mastectomy
- >2cm tumors
- centrally located lesions with small tumor-to-nipple distance
- lymphovascular invasion
100
Mgmt close surgical margin (<1mm) at fibroglandular boundary of breast (skin or chest wall) after lumpectomy for DCIS
Higher boost dose radiation to lumpectomy site can be considered - surgical re-excision not indicated
101
Peutz-Jeghers syndrome associated with...
- intestinal hamartomas
- hyperpigmented lesions of oral mucosa
- extracolonic cancers: breast, cervical, thyroid, lung (screening starting @25yo)
102
Dx for lymphedema
lymphoscintigraphy - radiolabeled macromolecular tracer injected intradermal within interdigit space of affected limb
