Breast

Question 1

Main nerves encountered during axillary dissection?

Answer 1

Long thoracic nerve (serratus anterior), thoracodorsal nerve (latissimus dorsi), intercostal brachial nerve (lateral cutaneous branch of 2nd intercostal nerve, sensation to medial arm/axilla)

Question 2

Cord-like breast mass: dx/tx?

Answer 2

Mondor’s disease, superficial vein thrombophlebitis, tx w/ NSAIDs - rule out malignancy w/ MMG/US

Question 3

Tx options for DCIS, margins, lymph nodes, cancer risk

Answer 3

lumpectomy w/ XRT, consider SLNBx in high grade DCIS or w/ large/palpable masses (unable to do SLNBx after most lumpectomies and all mastectomies given disruption of lymphatics) 50% get ipsilateral cancer if not resected, 5% cancer contralateral

Question 4

Tx options for LCIS, margins, lymph nodes, cancer risk

Answer 4

marker for development of breast ca (not a premalig lesion), ex biopsy or tamoxifen, bilateral mastectomy; more likely to have ductal Ca, 40% get breast ca in either breast

Question 5

explain the BIRADS classification and recommendation

Answer 5

BIRADS 1 negative - routine screening, 2 benign finding - routine screening, 3 probably benign finding - short term follow up, 4 suspicious abnormality i.e. indeterminate calcification or architecture - CNBx, 5 highly suggestive of Ca - CNBx

Question 6

Breast cancer screening guidelines

Answer 6

MMG every 2-3 years after age 40, yearly after age 50; high risk screening MMG 10 years before youngest age of first breast ca 1st degree relative

Question 7

explain levels of axillary lymph nodes

Answer 7

level 1 = lateral to pec minor, 2 = under pec minor 3 = medial to pec minor

Question 8

What are Rotter’s nodes?

Answer 8

nodes between pec major and pec minor muscles

Question 9

What is the most important prognostic staging factor in breast ca?

Answer 9

Node status

Question 10

Explain TNM staging in breast cancer

Answer 10

T1 <2 cm, T2 >2 cm <5 cm, T3 >5 cm, T4 = extension to chest wall, skin edema, ulceration, satellite nodules, inflammatory; N1 = 1-3 axillary/IM nodes, N2 = 4-9 axillary nodes or clinically apparent IM nodes without axillary mets, N3 = 10+ axillary nodes, infraclavicular nodes, or IM nodes in presence of axillary nodes

Question 11

Ca associations and lifetime risks in BRCA1? BRCA2? hormone receptor status in BRCA1?

Answer 11

BRCA1 - female breast Ca 60%, Ovarian Ca 40%, male breast Ca 1%; BRCA2 = female breast ca 40-55%, ovarian Ca 10%, male breast Ca 10% (100x increase) – BRCA are tumor suppressor genes – BRCA1 breast ca tend to be hormone receptor negative / triple negative

Question 12

Tx of male breast cancer w/ clinically node negative dz?

Answer 12

Simple mastectomy + SLNBx

Question 13

Indications for XRT after mastectomy

Answer 13

positive nodes (>4), skin/chest wall involvement, positive margins, large tumor (T3 >5 cm), extracapsular nodal invasion, inflammatory Ca, fixed axillary nodes (N2) or internal mammary nodes (N3)

Question 14

scaly nipple lesion

Answer 14

Paget’s disease, underlying DCIS/ductal Ca, bx w/ punch/full thickness biopsy, mastectomy+RT or BCT+RT are acceptable, need to include nipple areolar complex – mastectomy often required given extent of underlying cancer

Question 15

dark purple nodules on arm 10 years after axillary dissection – dx, tx?

Answer 15

Stewart-Treves syndrome -> lymphangiosarcoma from chronic lymphedema; dx via open biopsy, tumor is highly aggressive w/ early mets to lung, tx consists of early wide surgical debridement (may require amputation), survival <2 years

Question 16

stromal/epithelial frond like pattern breast mass - dx, tx, spread?

Answer 16

Phyllodes tumor, no nodal metastasis -> hematogenous spread, 10% malignant based on mitoses per HPF, WLE w/ 1 cm margins, no ALND

Question 17

Borders of an axillary lymph node dissection

Answer 17

Axillary vein (superior), serratus anterior (medial), latissimus dorsi (lateral)

Question 18

hypoplasia of chest wall, amastia, hypoplastic shoulder, no pec muscle

Answer 18

Poland syndrome - men > women, R > L

Question 19

Gynecomastia: demographics, Ca risk, tx

Answer 19

infancy, puberty, and age >50; not considered risk factor for breast Ca, mammography useful to differentiate from malignancy, can tx w/ tamoxifen (surgery rarely)

Question 20

Features of pathologic nipple discharge

Answer 20

Serous or bloody, unilateral, uni-duct, spontaneous

Question 21

Tamoxifen decreases breast cancer risk in high risk patients by ….? What about prophylactic mastectomy

Answer 21

50% risk reduction in subsequent breast Ca (NSABP-P01 trial), 90% risk reduction in prophylactic mastectomy

Question 22

major side effects of tamoxifen?

Answer 22

increased risk of endometrial adenocarcinoma, increased risk of VTE; cataract formation

Question 23

Ultrasound features of a benign breast mass?

Answer 23

Homogenous, bilateral edge shadowing, wider than tall

Question 24

Ultrasound features of a malignant breast mass?

Answer 24

Heterogenous, taller than wide (means the lesion is infiltrative of the natural elements of the breast)

Question 25

Atypical ductal hyperplasia: risk of breast cancer, management?

Answer 25

5x higher relative risk of breast cancer, similar to DCIS, surgical excision is recommended, margins are not needed, tamoxifen is recommended after excisional biopsy confirms absence of cancer (50% reduction in subsequent cancer); no axillary staging is needed

Question 26

features of invasive lobular cancers

Answer 26

15% of invasive breast cancers, typically hormone positive, indiscrete on MMG/US, hard to appreciate nodal mets on frozen section

Question 27

Success rate of SLNBx? Safety of radioactive technetium in pregnancy?

Answer 27

>95%. false negative rate is around 10%. Radioactive technetium low dose, safe in pregnancy

Question 28

Summarize main points of NSABP B17

Answer 28

NSABP B17 established that XRT significantly reduces local recurrence when administered after lumpectomy,

Question 29

Summarize main points of ACOSOG Z0011

Answer 29

ACOSOG Z0011 demonstrated that pt w/ early invasive breast Ca T1/T2 undergoing BCT do not need completion ALND if the SLNBx is positive in <3 nodes

Question 30

Summarize main points of AMAROS trial

Answer 30

women w/ early breast Ca and no clinically palpable nodes could undergo radiotherapy in place of axillary dissection if LN were determined to be positive

Question 31

Contraindications to nipple-sparing mastectomy?

Answer 31

Extensive intraductal cancer, associated nipple discharge, Paget disease, cancer within 2 cm of nipple

Question 32

Pathologic difference between phyllodes and fibroadenoma?

Answer 32

stromal hypercellularity

Question 33

mammogram showing stellate lesion with transulcent central portion

Answer 33

radial scar (<1 cm) and complex sclerosing lesions (>1 cm) - characteristic central area of fat which differentiates it from carcinomas, need excisional biopsy of entire lesion

Question 34

Risk factors for breast ca (RR >4, RR 2-4, RR <2)

Answer 34

RR>4 - BRCA2, multiple family members w/ bilateral or premenopausal breast ca, DCIS/LCIS/ADH, RR 2-4 - prior breast ca, rads exposure, 1st deg relative w/ breast ca, age >35 1st birth; RR <2 - early menarche, late menopause, nulliparity, proliferative benign dz, obesity, EtOH use, hormonal replacement therapy

Question 35

Features of tubular breast carcinoma?

Answer 35

Ductal, 2%, well differentiated, most favorable prognosis

Question 36

Features of papillary breast carcinoma?

Answer 36

Ductal, <1%, occurs in post menopausal, favorable prognosis (vs micropapillary carcinoma which are aggressive)

Question 37

Features of medullary breast carcinoma?

Answer 37

Ductal, associated with BRCA1, poorly differentiated w/ aggressive features but generally have favorable prognosis

Question 38

Features of mucinous breast carcinomas?

Answer 38

Ductal, 5% of invasive breast ca, characterized by mucin component, well differentiated, w/ low rate of mets

Question 39

Management of early stage triple negative breast cancer?

Answer 39

Lumpectomy/XRT/SLNBx or mastectomy/SLNBx -- followed by chemotherapy

Question 40

Indications for axillary lymph node dissection in breast cancer

Answer 40

clinically node-positive axilla, occult breast cancer presenting as axillary node metastasis, SLN positive patients who fall outside the Z0011 selection criteria (i.e. >2 SLN positive), inflammatory, clinical stage T4, or high-risk T3 breast cancer, sentinel or axillary nodes which remain positive after neoadjuvant chemotherapy, axillary recurrence

Question 41

Management of inflammatory breast cancer

Answer 41

neoadjuvant chemotherapy followed by either surgery or XRT depending on resectability

Question 42

route of bone metastasis from breast cancer?

Answer 42

Batson plexus

Question 43

breast lymphoma: most common type, tx, most common mets

Answer 43

most are B cell (diffuse large B cell), if lesion localized/low grade can consider primary excision, intermediate/high grade need CHOP+radiation, tend to mets to central nervous system

Question 44

most significant side effect / complication associated with trastuzumab?

Answer 44

herceptin; cardiac toxicity - assoc. w/ cardiac failure manifesting as decreased LVEF, need serial assessment of LVEF