Breast Flashcards
List of benign breast masses
Fibroadenoma Cyst Fat necrosis Fibrocystic changes Phylloides tumor
Elements of breast mass history
timing
meds history (hormones)
Risk factors (age of menstruation, pregnancies, previous biopsies)
Family history
Bi-RAds
1: Negative for mass 2. Benign 3. Probably benign (6 mo follow up) 4: Suspicious (tissue dx) 5: Highly suspicious (tissue dx) 6. Known malignancy.
How to deal with palpable lymph nodes on initial examination
FNA
Diagnostic mammogram views
Cradiocaudal mediolateral oblique
Immunohistochemistry equivicol for Her2 then request…
FISH testing.
Requirements for SLNB in patient with clinically positive nodes prior to neoadjuvant chemotherapy. (ACOSOG 1071)
- Dual tracer
- 2, and ideally, 3 SLN
- Removal of clipped, clinically positive node. (If residual disease identified in SLN, then completion ALND)
SLNB removal criteria
Highest radioactivity - get number palpable blue > 10% of max SLN.
Post op considerations regarding cancer treatment
- Multidisciplinary approach 2. Hormones 3. Radiation 4. Chemotherapy (typically prior to radiation) 5. Mammogram 6 months after completion of therapy 6. Annual visit, exam, and mammogram
Breast mass algorithm
Findings on CNB that confer increased risk of breast cancer
- Atypical ductal hyperplasia
- Lobular neoplasia
- Papillomas with or without atypia
Margin required for DCIS
2 mm
Contraindications for radiation therapy
- Collagen vascular dissease
- Previous radiation
- Pregnancy
Extent of dissection in mastectomy
- clavicle superiorly
- sternum medially
- Latissimus laterally
- inframammary fold inferiorly.
Length of adjuvant hormonal therapy to achieve risk reduction
5 years
consideration for SLNB in DCIS
lesions > 4 cm
comedonecrosis
Mastectomy
Benefits of adjuvant radation in DCIS partial mastectomy
Decreased local recurrance. No survival benefit.
Size of needle for core needle biopsy
14 or 16 gauge (must place clip if doing it yourself)
Breast cancer risk for LCIS
1% per year (need tamoxifen or raloxifene for 5 years)
Side effects of estrogen receptor antagonists
tamoxifen (night sweats, hot flashes, increased uterine cancer risk in post menopausal women)
Treatment for DCIS
- Biopsy with determiniation of receptor status
- discussion at MD conference
- Lumpectomy with whole breast radiation
- Risk reduciton with tamoxifen
- H&P Q6 mo for 5 years, then annually with annual mammogram
Work up when diagnosis of breast cancer made
- Receptor status
- MD conference meeting
- consider genetic counseling
- pregnancy test
- Focused H&P looking for abdominal symptoms or neurological symptoms, and LN exam, followed by possible labs, CXR, head MRI
When should neoajuvant chemotherapy be considered
T2 (greater than 2 cm) or N1 lesions
What to do if nodes found on SLNB
ZII trial?
Consider staging work up if not obtained before.
Only real case where post op radiation is NOT indicated
Mastectomy with no positive nodes, tumor < 5 cm, and margin > 1 mm
Favorable histologic subtypes
- Pure tubular
- Pure mucinous
- Pure cribiform
- encapsulated or solid papillary
Important if also node negative, then don’t need adjuvant chemotherapy. All others get adjuvant chemo considered.
2 scenarios that may not need adjuvant chemotherapy
Favorable histologic subtypes with node negative disease
Standard subtypes with node negative disease ER/PR positive HER2 negative, < 0.5 cm
Above > 0.5 cm, consdier 21-gene assay
Work up prior to neoajuvant chemotherapy
Standard H&P, diagnostic mammogram, U/s of breast, biopsy, receptor status, MD conference, consider genetics
should also consider axillary U/S with FNA of suspicious nodes followed by possibly
labs, chest/a/p CT, bone scan
General treatment strategies for recurrence of breast cancer
Try to resect and stage axilla if possible
If axilla already dissected, resect recurrence
If havn’t recieved RT, gets resection and RT
If recurrent supraclavicular or internal mammary - RT
Z11 requirements
- T1 or T2 tumor
- 1 or 2 positve Sentinel lymph nodes
- Breast conserving surgery
- WBRT planned
- No pre-op chemo
What if can’t identify sentinel lymph node?
Must do axillary LN disseciton
What prompts concern for phyllodes tumr
U/S characteristics of fibroadenoma but > 3cm
Treatment of phyllodes tumor
Excision with 1 cm margins. (small % are malignant) no need for axillary staging.
Physical exam findings raising concern for Paget’s disease
areolar ezcema, bleeding, ulceration, itching
Work up for Paget’s disease
Clinical history and exam
diagnostic mammogram and u/s
Core needle biopsy of mass and full thickness skin biopsy of NAC
Treatment for Paget’s disease
Atleast central lumpectomy including NAC with WBRT
if cancer, may need SLNB
Work up for inflammatory breast cancer
- H&P with axillary exam
- Bilateral diagnostic mammogram and ultrasound
- CbC, CMP
- CT chest/abdomen/pelvis
- bone scan
- Biopsy with recetor status
- Disccussion at MD board
- Genetic counseling
Treatment for inflammatory breast cancer
- Neoadjuvant chemotherapy (anthracycline plus taxane) +/- trastuzumab/pertuzumab if HER2 positive
- Modified radical mastectomy
- Post op radiation, completion of HeR2 chemo, and endocrine therapy for receptor positive.
Cumulative risk of cancer with ADH
30% in 25 years (4.5X normal risk)
% DCIS upstaged on pathology
10-20%
% ADH diagnosed with concurrent cancer
up to 40%
Lifetime risk of breast cancer in BRCA1 or 2
40-90%
Risk of ovarian cancer in BRCA 1 and 2
BRCA 1 up to 60%
BRCA2 up to 30%
Treatment for Stewart Treves syndrome
amputation, chemotherapy for metastatic disease.
Margin needed if specimen has both invasive ductal carcinoma and DCIS
just no tumor on ink (do not need 2 mm margin if both in specimen)
Pale staining cells between keratinocytes
Paget’s disease
Well circumscrobed mass which may have calcifications
fibroadenoma
Eggshell calcifications
fat necrosis
Clustered microcalcifications on mammogram
DCIS
Other name for complex sclerosing lesion
radial scar
better prognosis Luminal A or B
Luminal A
Sometimes mammogram of inflammatory breast cancer can appear as mastitis, this is necessary if course of Abx has failed
skin biopsy
most common etiology of fat necrosis
most are idiopathic
