Breast Benign and Malignant

Question 1

What are the boundaries of the breast tissue on the body?

Answer 1

• from infraclavicular space to inframammary fold

- from sternum to latissimus dorsi and axilla

Question 2

What are you looking for on the breast physical exam?

Answer 2

• overall shape, symmetry
• lump: note location, size, mobility, shape
• nipple discharge
• skin: dimpling, retraction, erythema, nipple crusting, peau d’orange
• lymph nodes

Question 3

Screening Mammography Recommendations

Answer 3

• yearly age 50-75
• screening during 40s and after 75 at discretion of pt and provider
• high risk: start screening 10 years earlier than age at which youngest relative was diagnosed

Question 4

Diagnostic Mammogram

Answer 4

• done if screening mammo is abnormal
• clinical exam finding: mass, pain, discharge
• BIRADS score 1-4 based on level of suspicion

Question 5

Ultrasound

Answer 5

• adjunct to diagnostic mammo

- primary diagnostic tool in pts

Question 6

MRI

Answer 6

• high risk pts: previous CA, dense breasts, significant family hx
• higher false positive rate than mammogram

Question 7

What are causes of benign histology from the breast?

Answer 7

• fibrofatty tissue
• fibrocystic change: fibrosis, cysts, hyperplasia, metaplasia
• fibroadenoma
• simple cysts
• phyllodes tumor

Question 8

Atypical Ductal Hyperplasia

Answer 8

• precursor to invasive carcinoma 4-5x increased risk

- requires excision w/ clear margin

Question 9

What is fibrocystic change?

Answer 9

-normal change that occurs in the breast in response to hormones

Question 10

What are symptoms of fibrocystic change?

Answer 10

• lumpy breasts
• tenderness, esp at menstruation
• may have significant non-cyclic pain

Question 11

Treatment of Fibrocystic Change

Answer 11

• reassurance
• NSAIDs for pain
• change or stop OCPs
• vit B complex
• fish oil

Question 12

What is a fibroadenoma?

Answer 12

• most common solid mass in women of reproductive years
• benign w/ no increased CA risk
• may be multiple and recurrent
• firm, round, well-circumscribed, mobile mass

Question 13

How is a fibroadenoma diagnosed and treated?

Answer 13

• Dx: classic US and/or needle biopsy

- Tx: does not require excision, but most pts prefer

Question 14

Nipple Discharge

Answer 14

• usually a benign process
• may be clear, milky, greenish, bloody
• bilateral milky may be galactorrhea (check for pg or high prolactin levels)
• clear or greenish is normal
• bloody usually due to intraductal papilloma (benign growth)

Question 15

Causes of Mastitis/Abscess

Answer 15

• pregnancy, lactation
• injury
• nipple piercing

Question 16

Sxs of Mastitis

Answer 16

• pain

- swollen, erythematous breast

Question 17

Tx of Mastitis

Answer 17

• antibiotics
• mammogram to R/O abscess
• percutaneous aspiration of abscess
• if no abscess identified and abx don’t clear infx, refer to surgeon for biopsy to R/O inflammatory breast CA

Question 18

What group is at risk of recurrent retroareolar infections?

Answer 18

-smokers

Question 19

Breast Cancer

Answer 19

• most common CA in women
• 2nd leading cause of CA death
• incidence increasing, mortality decreasing

Question 20

Risk Factors for Breast CA

Answer 20

• early menarche or late menopause
• first birth after 30 or nulliparity
• family hx
• atypical hyperplasia or LCIS
• known carrier of BRCA 1 or 2
• personal hx of ovarian, colon, uterine CA
• hormone replacement therapy

Question 21

LCIS

Answer 21

• not cancer, but a risk factor for cancer
• incidental finding
• tx: close observation, bilateral prophylactic mastectomy

Question 22

DCIS

Answer 22

• usually presents as abnormal appearing microcalcifications
• proliferation of malignant cells in ducts
• tx: lumpectomy/radiation, mastectomy; NO lymph node dissection or chemo

Question 23

Invasive Ductal/Lobular Carcinoma

Answer 23

• 80% of breast CA is ductal
• lobular carcinoma more diffuse and difficult to detect on mammogram
• lymphatic spread
• Tx: axillary node biopsy for staging, lumpectomy/radiation or mastectomy, chemo/hormone therapy

Question 24

Inflammatory Breast CA

Answer 24

• stage IIIb, poor prognosis
• signs: swollen non-tender breast, erythema, peau d’orange, may not have dominant mass
• Tx: preoperative chemo, mastectomy and axillary node dissection, radiation, hormone therapy

Question 25

Paget's Dz

Answer 25

- eczematous changes of the nipple - associated w/ underlying invasive cancer - diagnosed with nipple biopsy - tx with mastectomy

Question 26

1. Incisional Biopsy | 2. Excisional Biopsy

Answer 26

1. removing a piece of suspicious mass for diagnosis only | 2. completely excising mass for diagnosis; clear margins may be adequate CA surgery

Question 27

Lumpectomy

Answer 27

- excision of mass and normal surrounding tissue - reserved for tx of cancers, not benign lesions - requires post-op radiation to reduce risk of recurrence

Question 28

Mastectomy

Answer 28

- excision of breast tissue, pectoralis fascia, and overlying skin - option of immediate reconstruction - modified radical mastectomy includes axillary lymph nodes (usually for inflammatory)

Question 29

Sentinel Lymph Node Biopsy

Answer 29

- remove only lymph nodes with highest likelihood of metastasis - radioactive dye injected - lymph nodes identified via discoloration - reduces post-op pain and risk of upper extremity lymphedema

Question 30

Poor Prognostic Factors

Answer 30

- positive lymph nodes - size >2 cm - high grade - estrogen receptor negative (does not respond to hormones) - her-2 positive

Question 31

Chemotherapy

Answer 31

- usually recommended if tumors >2 cm, positive lymph nodes or high risk genomic test - adriamycin/cyclophosphamid 4 cycles - taxol added if + lymph nodes or poor prognosis

Question 32

Herceptin

Answer 32

- adjuvant therapy in tumors with Her2 gene overexpression | - Her2 controls cell growth and death --> herceptin binds to the Her2 receptors to make them ineffectvie

Question 33

Tamoxifen

Answer 33

- competitive inhibitor of estrogen receptors | - survival advantage and decreased recurrence rates

Question 34

Side Effects of Tamoxifen

Answer 34

- risk of uterine cancer - thrombotic events - hot flashes - weight gain

Question 35

Aromatase Inhibitors (Arimidex)

Answer 35

- inhibits production of estrogen | - only for post-menopausal women

Question 36

Indications for Radiation Therapy

Answer 36

- most pts with lumpectomy - mastectomy of tumor >5 cm - chest wall involvement - postive axillary lymph nodes

Question 37

Therapy at Stage 0 DCIS

Answer 37

+/- hormone therapy

Question 38

Therapy at Stage 1

Answer 38

- premenopause: tamoxifen +/- chemo | - postmenopause: arimidex

Question 39

Therapy at Stage 2

Answer 39

-chemo and hormone therapy

Question 40

Therapy at Stage 3

Answer 40

-chemo, hormone therapy, radiation to chest wall and lymph nodes

Question 41

Therapy at Stage 4

Answer 41

-hormone therapy, radiation to metastatic dz

Question 42

Factors Associated w/ Increased Risk of Genetic Cancer

Answer 42

- bilateral cancer in paired organs (breast, lung, kidney) - multiple primary CA - multifocal CA - early age of onset - CA in 2 or more relatives - Ashkenazi Jewish ancestry

Question 43

What are 4 genetic breast cancer syndromes?

Answer 43

- BRCA1 - BRCA2 - Cowden (breast, gastrointestinal, thyroid) - Li Fraumeni (breast, brain, adrenal CA, sarcoma, leukemia)