Breast Flashcards
Margin for DCIS
2mm
What does radical mastectomy take?
Modified radical?
What and how much tissue/muscle, nodes?
Radical: total beast + pec major/minor muscles + lvl I/II/III nodes
Modified radical: total beast + fascia of pec major + lvl I/II nodes
What are the axillary node levels?
I: lateral to pec minor
II: under pec minor
III: medial to pec minor
Treatment for inflammatory breast CA
1) anthracyclin based neoadj chemo
2) modified radical mastectomy. SLN is contraindicated
3) chest wall radiation
Workup of palpable breast lesson for women <30 vs. >30?
<30: ultrasound first and then mammography if concerning features
> 30: mammography first then US + aspiration
Screening Breast MRI is only recommended for who? (4)
1) those with a BRCA mutation
2) a first-degree relative who is a BRCA carrier
3) a prior history of mantle irradiation
4) and a lifetime risk of breast cancer of at least 20 to 25% based on a careful family history
Evidence is not sufficient to recommend for or against annual breast MRI screening in women with a personal history of lobular carcinoma in situ or ductal carcinoma in situ
Margin forpatients with early-stage invasive breast cancer undergoing breast conservation therapy?
No ink on tumor. Because they’ll get radiation
ACOSOG Z0011 trial.
What the hell is it?
When do you do ALND?
randomized clinical trial comparing sentinel lymph node dissection (SLND) alone to SLND plus axillary lymph node dissection (ALND) in patients with cT1-2 N0 breast cancer found to have 1 or 2 positive sentinel lymph nodes.
Even though additional nodal disease was present in 27% of patients in the ALND arm of Z0011, there was no difference in rates of local recurrence, disease-free survival, or overall survival based on the performance of an ALND. The 5-year overall survival rates were 92.5% and 91.8% in the SLND-alone and ALND groups, respectively
Do ALND for
- inflammatory breast CA
- Pt undergoing mastectomy and if (+) SLN
- if the pt has palpable nodes then do ALND
- More than 2 (+) nodes
- extranodal extension
What to do with sentinel node when T2 cN1 undergoes neoadj chemo?
Do the SLN after the chemo.
Only clinical exam, no radiographic response needed
Surveillance schedule for BRCA(+) women if they don’t undergo prophylactic mastectomy
What % of cancers does mammography miss?
Annual mammography + MRI alternating every 6 months
Up to 15%
Breast cancer risk reduction by tamoxifen in BRCA1 vs BRCA2?
Reduction by 60% in BRCA2
no reduction in BRCA1
Lifetime risk of breast cancer in men with BRCA1?
Is prophylactic mastectomy recommended for men with BRCA1?
1.2%
Prophylactic mastectomy not recommended
Lifetime breast CA risk for nonBRCA men is ~0.1%
Screening guideline for pts with known LCIS?
When to do lumpectomy vs. Not for LCIS?
Radiation or not for LCIS after lumpectomy?
Yearly mammogram + yearly MRI in high risk pts
If LCIS is found incidentally on core needle biopsy then omit lumpectomy.
Suspicious mammogram + stereotactic biopsy -> LCIS -> lumpectomy
No radiation for LCIS because it’s a risk factor, not a cancer. DCIS you can radiate
Margin for phyllodes tumor?
Radiation? Survival benefit from radiation?
1cm
Only for tumors >2cm after breast conserving therapy OR tumor >10cm after mastectomy
Radiation improves local recurrence. No change in survival
Axillary Mass. Biopsy shows breast. Mammography is negative. Next step?
Treatment for patients diagnosed with occult breast cancer who have a negative preoperative breast MRI?
Breast MRI
Breast conservation (axillary lymphadenectomy alone) with whole breast radiation therapy is an option. significantly better overall survival compared with patients treated with modified radical mastectomy.
Tamoxifen vs. aromatase inhibitor in premenopausal vs postmenopausal? Raloxifene?
Side effects of tamoxifen?
How long do you treat hormonal therapy? Trastuzamab?
Tamoxifen for premenopausal
Aromatase inhibitor (anastrazole) for postmenopausal -> increased osteoporotic fractures, myalgias, arthralgia
Raloxifene: selective estrogen inhibitor. Postmenopausal. About 80% as effective as tomaxifen. Less side effects
Tamoxifen -> thromboembolic, uterine cancer
Hormonal therapy ~5 yrs. Trastuzamab: 1yr
What is the % risk of breast cancer in someone with ADH?
30% over 25 year period
1) Leading cause of cancer deaths in women?
2) What % of all women in the US will develop cancer in their lifetime? What % will develop breast CA?
3) White vs black women for breast CA incidence and mortality?
4) incidence of male breast CA?
1) #1: lung #2: breast
2) 38% of all women will get cancer. 12% will be breast
3) higher incidence in white female, higher mortality in black women. Higher triple negative in blacks
4) 1% of all breast CA males. 1 in 833 males get diagnosed with breast cancer in their lifetime ~0.1% risk
Breast CA risk factors:
- menarche when?
- menopause when?
- if no pregnancy, how much is the risk increased?
- first pregnancy at what age increases risk? Reduces?
- OCP’s?
Previous breast cancer increases your risk of another breast cancer by how much?
Hx of endometrial or ovarian cancer increases breast cancer risk by how much?
What % of women already diagnosed with breast CA have family history?
If you have a family history then how is your breast CA risk changed?
- Menarche before 12
- Delayed menopause after age 50. Think more estrogen -> more breast CA
- increased by 30%
- first preg after age 30 -> 2x risk. First preg before 18 -> reduces risk
- OCP’s may increase risk if prolonged use
Prev breast CA -> 5x higher risk
Endometrial/ovarian CA -> 2x higher risk
Only 20% has family history
If (+) FHx then 2-6x higher risk
For screening, mammography should start at what age?
Annual vs. biennial?
Start annually at 40
Biennial at age 50
Or 10 years earlier than the youngest first degree relative with breast cancer
Breast MRI finding. Type I vs. III enhancement?
Type I: slow and continued rise. 5% chance if malignancy
Type III: rapid initial rise followed by washout. 60-80% chance malignancy
Treatment for Paget’s disease of the breast
Mastectomy or lumpectomy + radiation
Removal of nipple
SLN
Who may not need RT after lumpectomy for invasive cancer?
Women >75, tumor <2cm, ER(+)
Molecular features of breast CA
- Luminal A
- Luminal B
- HER2
- Basal
- Luminal A: ER/PR(+), HER2(-), low KI67
- Luminal B: ER/PR(+), HER2(+), high Ki67
- HER2: ER/PR(-), HER2(+)
- Basal: triple (-)
Can you still do a lumpectomy with a (+) sentinel node?
Does mastectomy have a better cure rate compared to lumpectomy?
Yes. Can still do lumpectomy
Cure rate similar between mastectomy & lumpectomy. Therefore lumpectomy is a preferred treatment
First and best test for evaluating breast cancer in pregnancy?
can they get MRI?
can they get Radiation?
can they get Chemotherapy?
Do they have worse prognosis stage for stage?
Ultrasound
MRI Is contraindicated because gadolinium is teratogenic
Radiation is contraindicated
Pregnant pts can receive chemo
Same prognosis stage for stage
How many nodes to be considered adequate axillary dissection?
Minimum 10
Who gets radiation after MASTECTOMY?
- tumors > 5cm
- tumors invading chest wall or skin
- inflammatory breast CA
- Any extranodal invasion
- (+) surgical margin
BRCA 1 vs. 2
- male breast cancer?
- higher incidence of ovarian?
- which chromosomes?
- No other associated cancers
- autosomal dominant or recessive?
- male breast cancer? BRCA 2. BRCA 1 doesn’t have male breast CA
- higher incidence of ovarian? neither. BRCA 1: equal breast/ovarian. BRCA2: less ovarian
- which chromosomes? BRCA1: 17, BRCA2: 13
- No other associated cancers: BRCA 1
- autosomal doninant
TP53?
What syndrome?
What cancers?
Males vs females?
Li-Fraumeni
Breast, leukemia, brain, sarcomas
Male: up to 73% lifetime cancer risk
Female: 100% lifetime cancer risk (breast)
Cowden: PTEN (breast & thyroid)
BRCA2 men
What screening is recommended? Mammography?
Tamoxifen for chemoprevention?
Prostate cancer screening. Mammography only if dense breast or gynecomastia
Tamoxifen only for treatment, not for prevention
Breast reconstruction option for smokers?
Tissue expander. No flaps
Indication for neoadj chemo for breast CA
is HER2 (+) status alone an indication for neoadj chemo?
- any T3, T4 regardless of subtype
- any T1, T2 with high tumor to breast volume ratio
- any HER2(+) yes.
- triple negative cancers
- cancers that have (+) LNs on presentation.
- Arm or breast edema
- Inflammatory breast CA
- chest wall or skin inolvement, ulceration
Long thoracic
Serratus anterior
Winged scapula
Thoracodorsal nerve
Supplies the latissimus dorsi
extension and ADDuction of arm.
same as pec minor (medial pectoral nerve)
Cowden syndrome.
what gene?
what kind of tumors?
PTEN
breast, thyroid, uterine
Over what size do you excise fibroadenoma?
> 3cm
Do you get radiation for DCIS after excision?
Yes
Woman had modified radical. Now has weakness of arm flexion at shoulder. What nerve?
Lateral pectoral nerve
This motion is raising your arms while keeping them straight
Woman had MRM. Now has difficulty with arm extension, internal rotation. What nerve?
Thoracodorsal or medial pectoral nerve
What happens when you injury the axillary nerve during MRM?
You don’t encounter axillary nerve during MRM.
Deficit would be: weakness of arm ABDuction, flexion and extension of the arm at the shoulder
What’s basal type luminal A luminal B?
How do the types relate to adjuvant rx?
Luminal A: ER or PR (+), her2 (-). KI-67 < 14%
Luminal B: ER or PR (+), her2 (-). KI-67 > 14%
Basal: Triple negative
For > 1cm
Luminal A: endocrine therapy only
Luminal B: cytotoxic + endocrine rx
Basal: cytotoxic therapy
No fam hx, first mammogram is recommended at what age?
45
Difference between screening vs diagnostic mammogram?
Screening: no radiologist present at the time. Batch read at the end of the day. 2 views
Diagnostic: radiologist present at the time, able to do additional tests if needed
What is the most likely risk factor for development of arm edema after ALND?
weight gain. 3-5 fold increase
Lifetime risk of breast cancer if you have BRCA1?
65%
Cowden syndrome
What gene?
What cancers?
PTEN
breast, thyroid, multiple hamartomas, benign tumor of hair follicles
Should ppl with personal history of LCIS and or DCIS get yearly MRI’s
Insufficient MRI to support such practice
high risk LCIS can get MRI/mammo every year
Does having a single intraductal papilloma removed in the past without atypical ductal hyperplasia or DCIS raise your risk of future breast cancer?
It does not.
What nerve is involved in arm extension?
This is bringing your arm down and going as far back as you can while keeping your arms straight
Medial pectoral nerve AND thoracodorsal nerve (lat dorsi)
Histology shows large pale-staining cells between normal keratinocytes. What is this?
Treatment?
Pagets
Simple mastectomy
Histology: whorled stromal cells, epithelial lined clefts. What is this? Treatment?
Phyllodes tumor
WLE 1cm margin
Breast pain. B/l, non-cyclical. Over the counter meds and diclofenac doesn’t work after 2 weeks. What do you do?
Selective estrogen receptor modulator
Bronocriptine is 3rd/4th line therapy for mastodynia
Primrose doesn’t work. Vitamin cream doesn’t work.
Histology: small ovoid cells with little cytoplasm in an infiltrating single-file pattern
Infiltrating lobular carcinoma
Post-mastectomt lymphangio sarcoma:
- when is the usual onset? Is it a slow process or rapid process?
- T/F: tumor cells originate from dermal vascular adventitia
- ranges from 1-30 years, commonly after 10 yrs. Slow growing over 5-10 years
- false. From dermal vascular ENDOTHELIUM
Things you have to re-excise for (+) margin
Pleomorphic LCIS
DCIS and above
Don’t need to go back for ADH, ALH, regular LCIS.
DCIS needs 2mm margin
14 obese male with boobs. Puberty started 2 years ago. 3cm breast buds.
- do these buds develop into full breasts?
- what size limit should you be concerned?
- benign pubertal gynecomastia will not develop into full breasts.
- more than 4cm then maybe endocrinologic workup is needed
Significance of E-cadherin in breast?
Differentiating ALH and ADH
ALH: E-cadherin (-)
ADH: E-cadherin (+)
What the fuck is in the Gale model (7)
- Age
- Age at first period/menses
- Age at first child
- # of FIRST DEGREE relatives with breast cancer
- # of past breast biopsies
- # of biopsies with atypia
- Race/ethnicity
Gail model is for women who never had DCIS/LCIS
BRCA1 breast cancer is associated with what ER/PR/HER2 status?
BRCA1 breast cancers tend to be triple (-)
What is the risk of ovarian cancer for BRCA1 vs BRCA2?
BRCA1: 16-63%
BRCA2: 10-27%
What are the chances of an excised ADH having DCIS or cancer?
15-30%
T/F: Trauma, previous surgery, and infection make up >90% of etiology for fat necrosis
False. <50%. Most of the time you can’t find any etiology.
How do BRCA 1 breast cancers compare with BRCA 2 cancers in prognosis? hormone receptors?
How do the breast CA mortality compare with sporadic breast CA pts?
BRCA1 cancers tend to carry worse prognosis. Tend to be high grade, triple (-) tumors
Overall mortality actually similar between BRCA Breast can vs sporadic
Risk of contralateral breast cancer with DCIS?
<5%
How much increase in breast cancer risk with ADH, ALH, and LCIS?
ADH: 30% over 25 years. 4.5x average population risk
ALH: same as ADH. 4.5x
LCIS: 1% per year or 20-30% at 15 years. 7-12x average population
What is the lifetime risk if ovarian cancer with BRCA1?
45%
What is the lifetime risk of ovarian cancer with BRCA2?
20-30%
Breast pathology: large cells with pale cytoplasm and prominent nucleoli in the epidermis
Pagets disease
What is the treatment for lymphangiosarcoma?
WLE, which in most cases is upper extremity amputation
Chemo radiation doesn’t work
A) Breast pathology: abundant proliferation of both stromal and epithelial contents
B) spiculated mass with central sclerosis surrounded by entrapped normal ducts and lobules perioherally
C) lipid laden macrophages
D) increases central cellularity with lobules and intact myoepithelial contents
E) complex and branching fonds lined by epithelial cells that are cuboidal or columnar
A) fibroadenoma
B) radial scar
C) fat necrosis
D) sclerosing adenosis
E) intraductal papilloma
1st trimester T2N0 breast cancer ER/PR(+), HER2(-). Treatment?
simple mastectomy (because can’t get radiation. Postpartum radiation would be too late)
Sentinel lymph node because you’re doing a mastectomy
In what % breast biopsies done for benign lesions is LCIS found?
1-8%
Intraductal papilloma. Got a ductography. What to do next?
- Ductography shows a single duct responsible for the discharge -> excisional biopsy
- Ductography doesn’t isolate a single responsible duct -> subareolar ductal exploration with duct ligation and excision
Factors that should trigger genetic testing discussion
- triple negative breast CA
- diagnosis of cancer <60 age
- 1st degree relative with breast cancer at an early age
T/F: radiation therapy improves overall survival in breast conserving surgeries
True. Decreases local recurrence and actually improves survival
DCIS. do you have to do sentinel node or not?
No sentinel node. 2mm margin + adj radiation
27yo, asymptomatic F. 2 x 1.5cm simple cyst. what to do next?
what if the cyst is complex?
reassurance.
if the cyst is tense or symptomatic then can aspirate
if cyst is complex, then f/u U/S in 6 mo. (0.3% chance malignancy)
