Breast

Question 1

Mastectomy define
Muscles underlying
Lymph nodes levels

Answer 1

Removal of the entire breast

Pectoralis major then the pectoralis minor

Level 1 (low) -lateral to pectoralis minor
Level 2 middle - deep to pectoralis minor 
Level 3 (High) - medial to pectoralis minor

Question 2

Complications when removing the lymph nodes to the axilla during mastectomy

Answer 2

Long thoracic nerve supplying the serratus anterior - winging of scapular

Thoracodorsal never supplying lattisimus dorsi

Intercostobrachial nerve supplies sensation to the upper aspect of the arm

Question 3

Benign vs malignant breast condition ( name them)

Answer 3

Benign: 
Fibrocystic change
Cyst
Fibroadenoma
Duct ectasia 

Malignant
Paget disease
Phylloidea tumor
Carcinoma

Question 4

Marker vs precursor for breast ca…

Answer 4

LCIS is a marker

DCIS is a precursor

Question 5

Why is cardiac Hx is important in a px with suspected breast ca

Answer 5

Because many side effects of chemotherapy and immunotherapy is cardiotoxic

Question 6

Peau d’orange , what is it

Answer 6

Invasion of turmoil to the lymphatics to the skin is locally advance breast ca

Question 7

Radiological investigations for breast ca

Answer 7

Uss

Mammogram (if >40 years)

Question 8

Uss in breast lump shows / tells you as a dr what ?

Answer 8

Whether the lump is solid or cystic

Question 9

Which 2 views is a mammogram done

Answer 9

Mediolateral oblique ( the muscle pectoralis major is seen)

Craniocaudal

Question 10

BIRADS (breast imaging reporting and data systems)

Answer 10

0- investigations inadequate 
1- normal
2- benign 
3- suspicious, prob benign 
4- suspicious, prob malignant 
5- highly suspicious for malignancy 
6- known biopsy with proven malignancy

Question 11

On mammogram findings for suggestive of breast ca

Answer 11

Stellate lesions with micro calcification

Question 12

Screening for breast ca includes

Answer 12

A monthly breast self exam
An annual clinical breast examination by your dr
An annual breast mammogram every year from the age of 40

Question 13

Percent of persons with normal mammogram with an abnormal clinical exam

Answer 13

10%

Question 14

Regarding breast lump , multifocality vs multicentricity

Answer 14

Multifocality: the presence of two or more foci of cancer within the same quadrant of the same breast

Multicentricity: the presence of two or more foci if cancer indifferent quadrants if the same breast

Question 15

Fine needle aspiration procedure

FNAC tells what about a lesion

Answer 15

Attach needle to syringe.
Enter lump using needle, move the needle up and down to get certain amount of cells in the needle
Spray needle content on slide

Determines whether the lesion is benign or malignant

Question 16

Core biopsy determines what about a lesion

Answer 16

Invasive
Pathological type ( ductile vs lobular)
Grade
IHC (ER, PR, Her2)

Question 17

Classifications of invasive ductal carcinoma

Answer 17

Tubular
Cribriform
Papillary 
Mutinous
Medullary

Tubular, cribriform and mucinous are well differentiate and have a better prognosis

Question 18

What is stereotactic breast biopsy which uses mammogram

And it’s advantages

Answer 18

A specific type of breast imaging that uses low dose X-ray - to help locate a breast lump or abnormally and remove a tissue sample for examination under a microscope

Less invasive than surgical biopsy
Leaves little to no scarring
An excellent way to evaluate calcium deposits if tiny masses that are not visible under ultrasound

Question 19

Fibroadenoma, clinical features and Mx

Answer 19

Clinical features : young female , size varies with hormonal change , well defined , bosselated, firm and mobile

Mx : if patient desires - lumpectomy
:If surgery not contemplated- triple assessment to R/O malignancy (USS, FNAC)
:if large - lumpectomy to ensure not phylloidea tumor

Question 20

Simple breast cyst , clinical features and Mx

Answer 20

Clinical features : perimenopausal, cyclical mastalgia;sometimes painful, well define, smooth surface, tender mass

Mx: confirm on USS
: If asymptomatic- reassure
:if symptomatic-Aspirate- if fluid straw colored and lump disappears then reassure
-if anything else but straw colored (eg bloody) or lump persists then cytology and excise lump

Question 21

Breast discharges : bloody, green, clear, milk, pus - what’s your differentials for each …

Answer 21

Bloody: intraductal papilloma (most common) , then carcinoma

Green, cheesy: duct ectasia

Clear: fibrocystic change

Milk: galactocele, prolactinema

Pus: breast abscess

Question 22

Intraductal papilloma Mx

Answer 22

MMG/USS the underlying mass

- Microdochectomy (excision if a lactiferous duct)

Question 23

Breast abscess presentation and Mx

Answer 23

Tender , red , fluctuate mass in postpartum

• aspirate, antibiotics (S.Aureus)
• if this fails then I&D

Question 24

Mastalgia clinical features and Mx

Answer 24

Cyclical vs non cyclical?
Cyclical usually due to fibrocystic change - presents with pain,mass and discharge

Conservative Mx

• discontinue caffeine and fatty foods
• support bras

Vitamin E
Evening primrose oil
Danazol
Bromocriptine

Question 25

Breast cancer , once dx is made in FNAC, core biopsy, open biopsy then staging the patient ... what is the clinical stage for breast cancer

Answer 25

``` T(tumor size) T1 <2 cm T2 2-5 cm T3 >5cm T4 fixed ``` ``` N(lymph nodes ) N0 no palpable nodes N1 mobile axillary N2 fixed axillary N3 internal mammary or supraclavicular nodes ``` M (Metastasis) Liver, lung, bone,brain

Question 26

Investigations for stages breast cancer

Answer 26

LFT CXR US or CT scan of liver, bone scan for advanced disease CT Brain only if symptomatic

Question 27

Preop staging - operable breast cancer, stage and what’s your Mx - locally advance , stage and Mx Metastatic, stage and Mx

Answer 27

Operable breast cancer : T1-3, N0-1 -surgery first then adjuvant treatment Locally advance : T4, N2-3 -Adjuvant treatment first (neoadjuvant) then surgery Metastatic: M1 -palliative therapy

Question 28

What are the 2 Options of breast surgery

Answer 28

Breast ablation (mastectomy) Breast conservation surgery

Question 29

Breast conservation surgery

Answer 29

Tumor removed with 1 cm margin Must be accompanied by adjuvant radiotherapy to the remaining breast

Question 30

Criteria to help choose between breast conservation and mastectomy

Answer 30

Patient Choice Multifocality Tumors size Tumor location Pregnancy -2nd trimester ( if u are pregnant you cannot have RT therefore no breast conservation) Connective tissue disorder - others who can’t have RT are those with scleroderma or SLE Lack of access to RT

Question 31

Surgery to axillary .. why remove axillary nodes?

Answer 31

It is the only means if staging the axilla Best prognostic factor Determines need for adjuvant therapy ``` Regional control (improves QoL) -metastasis in axillary LNs Lymphedema Invasion of brachial plexus Invasion of axillary a/v ```

Question 32

What is Axillary clearance and it’s complications

Answer 32

The removal of all axillary lymph nodes ``` Complications: Brachial plexus injury Long thoracic nerve Thoracodorsal Intercostobrachial ``` Lymphedema can progress to an angiosarcoma known as steward treves syndrome

Question 33

Breast reconstruction options

Answer 33

Implants Latissimus dorsi flap Transverse rectus abdominis myocutaneous flap (TRAM)

Question 34

Sentinel lymph node biopsy procedure

Answer 34

General anesthesia is used to put patient to sleep Inject around the tumor with methylene blue or radioactive dye Make a small incision in the axilla and find the lymph node that drains it first Take the node out Send it to the frozen section for testing

Question 35

Who gets chemotherapy? Side effect and base types (3) | St Gallen’s criteria

Answer 35

Any patient with potential for metastasis will benefit from chemotherapy Side effect - cardio toxicity Bases- cyclophosphamide, adriamycin ( usually) , 5FU Criteria (any 1 of the 7 present given they should get ) ``` 1 Age <35 2 Tumor size >2cm 3 Grade (High) 4 LN +ve 5 Lymphovascular Invasion 6 HR -ve 7 Her 2u +ve ```

Question 36

Who gets hormonotherapy? Postmenopausal vs premenopausal

Answer 36

For HR +ve patients only Post men - aromatase inhibitors ( drug of choice), tamoxifen Pre men- tamoxifen( drug of choice ) , GnRH, Ovarectomy

Question 37

Aromatase and tamoxifen side effects in post menopausal women

Answer 37

Aromatase inhibitors(superior) : osteoporosis, pathological fractures - always do DEXA (bone density) scan , commence on biphosphonates Tamoxifen: endometrial cancer, DVT, PE, infertility

Question 38

Hormonotherapy side effects in pre menopausal women

Answer 38

Tamoxifen (superior) : but not if patient desires a family GnRH : expensive - if patient desires a family Ovarectomy: patient in 40s, Ovarectomy converts to postmenopausal, start AI

Question 39

Immunotherapy for breast cancer , targets, used if ____ +ve, side effect

Answer 39

Targets the HER 2u receptors (human epidermal growth factor ) Used if Her 2u +ve Side effect : Cardiotoxicity

Question 40

Paget disease vs eczema of the breast - presentation

Answer 40

Paget- erosion starts in the nipple and progresses to the areola Eczema - erosions begins in the areola and progresses to the nipple ..

Question 41

Paget disease , what is it and tx

Answer 41

Erosion, erythema of nipple, it is in situ carcinoma of nipple Tx - wide local excision ( ie breast conservation) of the nipple-areola complex followed by adjuvant RT

Question 42

Phylloidea Tumor,- typed of tumor, also known as, mistaken for , derived from and Tx

Answer 42

Giant fibroadenomas my be mistaken for a phyllodes tumor It is also known as cystosarcoma It is sarcoma Derives from mesenchyma Tx: mastectomy if big ; WLE if small

Question 43

Indications for further investigations using an MRI in breast investigations

Answer 43

- Multicentricity in a dense breast - if patient has implants - screening tool if patient has a mutation in Barca

Question 44

So sacromas spread to the lymph nodes

Answer 44

No

Question 45

Presenting complaints when taking a breast history

Answer 45

Mass - how detected , change in size , associated pain Discharge- bloody, spontaneous, single duct Mastalgia - cyclical vs non cyclical Skin changes - scaling, erythema of nipple then areola ( paget disease) or - scaling , erythema of areola then nipple (eczema)

Question 46

Risk factors for breast cancer

Answer 46

Controllable - weight - exercise - diet - smoking - never breast fed - HRT - late child bearing - Nulliparious Uncontrollable - age - family hx - early Menarche - late Menopause - Radiation heredity - Genetics

Question 47

What do want to know in medical and surgical history for breast cancer

Answer 47

Medical - cardiac Surgical - hysterectomy ( because certain form of the endocrine therapy can cause endometrial carcinoma) - ovarectomy ( renders the patient automatically postmenopausal , this is important as the endocrine treatment of postmenopausal is different to that of premenopausal breast cancer)