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NMS Casebook > Breast Disorders > Flashcards

Breast Disorders Flashcards

1
Q

Mammographic abnormalities to follow

A
  1. masses
  2. Asymmetric densities
  3. Microcalcifications
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2
Q

If abnoramlities are found on screening mammogram

A

Additional imaging is necessary with spot magnification

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3
Q

Causes of asymmetric densities

A
  1. Operative procedures
  2. Previous radiation tx
  3. Previous infxn
  4. normal variation
  5. Local processes
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4
Q

radiographic imaging wihout palpable abnormalities

A
  1. Perform ADDITIONAL magnification mammography
  2. Stereotactic guided core needle biopsy
  3. Localization and open surgical biopsy
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5
Q

FNA vs. core needle biopsy

A

Core needle is diagnostic while FNA is nondiagnositc

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6
Q

Lesion that his highly suspicious for malignancy on mammogram

A

Open surgical biopsy should be performed which may in fact be sufficient therapy via complete excision of the lesion

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7
Q

DCIS

A
  1. Incidental microcalcification on mammography
  2. +/- breast mass
  3. Req’s surgery
  4. +/- infiltrative component at excision
  5. If left not completely resected then there is a 30% chance of development of invasive CA at 10yrs
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8
Q

DCIS histologic patterns

A
  1. comedo (30% malignant potential)
  2. Micropapillary
  3. Cribiform
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9
Q

Tx of DCIS

A
  1. Diffuse/multicentric DCIS = simple mastectomy +/- reconstruction
  2. Smaller lesions = wide excision with path-free margins and radiotherapy
  3. Nodal sampling may be reqd in the comedo variant ONLY since there may be spread to axillary nodes
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10
Q

LobularCIS findings

A
  1. Rarely p/w mass
  2. If adjacent to benign mass then surveillance is necessary. If no mass then close observation w/mammography q6mo is necessary
  3. Core bx may show calcification in which case needle localization and excision is necessary
  4. No risk for axillary mets
  5. 15-20% chance of developing invasive CA in the breast
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11
Q

Sclerosing adenosis

A
  1. Clusetered microcalcifications
  2. Simialr to invasive tubular CA
  3. Follow up on sclerosing adenosis
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12
Q

Atypical ductal hyperplasia

A
  1. Atypical hyperplasia in ducts/lobules
  2. 4-5x higher CA risk
  3. Reqs needle localization and excision
  4. Tx = complete excision and close observation
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13
Q

Workup for breast carcinoma

A
  1. Mammogram
  2. US of mass if it feels cystic or hx of cysts
  3. Aspiration indicated if mass is painful or enlarging
  4. Biopsy if the mass feels solid
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14
Q

35-60yo women with palpable breast mass

A

cancerous until proven otherwise

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15
Q

28yo women with palpable breast mass

A

Higher incidence of benign lesions and higher risk of radiation from mammography. 98% of solid lesions in this age group are solif fibroadenomas. if lumps appear physiologic then observation for 1-2 menstrual cycles is appropriate in low risk pts.

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16
Q

Fibrocystic change

A
  1. Uncommon before adolescence or after menopause
  2. Lumpy breasts (usually B/L)
  3. Premenstrual tenderness
  4. Estrogen responsive and responsive to decreased progresterone
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17
Q

Tx of fibrocystic change

A
  1. Eliminate caffeine from diet
  2. Supplement Vit E
  3. Cyst aspiration
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18
Q

Firm, rubbery, nontender, freely movable breast mass w/o involvement of opposite breast/LN’s

A

Fibroadenoma = most common in AA’s. Dx based on biopsy or FNA

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19
Q

Large, bulky, breast mass of variable malignant potential and occasional ulceration of overlying skin

A

Phyllodes tumor. Malignancy depends on: tumor behavior and number of mitoses per HPF

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20
Q

Bloody nipple discharge. Hx of multiple pregnancies.

A

NONmilky nipple discharge in a NONlactating women warrants investigation

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21
Q

Workup for nipple discharge

A
  1. Uni/Bilateral
  2. Contains blood
  3. Involves single/multiple ducts
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22
Q

Most common cause of bloody nipple discharge. Workup

A

Intraductal papilloma. Requires surgical biopsy. Small risk for carcinoma and thus patients should undergo mammography to r/o other breast abnormalities and close exam to ID a single duct that is the source of bloody discharge

23
Q

Staging infiltrating ductal carcinoma

A
  1. Determine extent of dz (regional LN’s, distant mets

2. Mammography to r/o other lesions and lesions in other breast

24
Q

Prognosis for infiltrating ductal carcinoma

A

Worse prognosis when axillary LNs contain mets, large primary tumor, distant mets

25
Q

Workup for pt with infiltrating ductal carcinoma

A
  1. CXR to r/o lung/bone mets
  2. Bone scan in case of bone pain
  3. Skull CT in case of neuro s/s
  4. LFT’s to r/o liver mets (alk phos, bilirubin)
26
Q

Ulcerated breast lesion w/underlying mass, Extensive breast edema (also seen w/cellulitis/abscess of breast). Cancer cells invading dermal lymphatics and vessels.

A

Inflammatory carcinoma (worse prognosis than infiltrating ductal CA)

27
Q

Skin edema overlying a mass

A

peau d’orange. Worse if tumor invasion involves local dermal lymphatics

28
Q

Retraction of skin overlying the mass/retraction of nipple

A

tumor involvement of breast support structures/lymphatics

29
Q

Previous fluid aspiration from cystic mass with rapid recurrence of cystic fluid

A

Must excise to r/o CA

30
Q

1.5cm mass fixed to deeper tissues

A

Fixation to chest wall = invasion of structures outside of the breast

31
Q

Palpable Supraclavicular LN

A

= stage IV disease d/t LN mets

32
Q

Hard fixed LN in the ipsilateral axilla

A

Matted group of nodes with metastasis which give the patient node-positive N2 status

33
Q

Soft LN in ipsilateral axilla

A

May be some other inflammatory etiology of the LN

34
Q

Small nodules on skin of breast

A

Satellite nodules of CA on the skin

35
Q

Arm edema

A

Obstruction of axillary LNs

36
Q

Paget’s disease of the breast

A
  1. 95% have underlying CA (infiltrating ductal CA or DCIS)
  2. Evaluate any mass w/biopsy
  3. Chronic eczematoid lesion of nipple
  4. Benign
  5. Paget’s cells
37
Q

Anatomical structure of the breast

A
  1. 15-20 radially arranged lobes, each with 20-40 lobules
  2. Duct converges on the nipple and provides drainage for each lobe
  3. Internal mammary artery and lateral thoracic arteries provide arterial supply
38
Q

Breast CA techniques

A
  1. Modified radical mastectomy
  2. Auchincloss modification = spares the pec minor
  3. Patey modification = transection of pec minor and dissection of level III nodes
  4. Radiation therapy is indicated for tumors >5cm or involving the pectoral fascia/muscle or involve the resection margin or involvement of supraclavicular nodes
  5. Radical mastectomy = removal of breast, skin, pec maj/minor, and axillary LN’s (useful for tumors that extend into pec muscle)
  6. Simple mastectomy = breast, nipple-areolar complex, and skin
  7. SubQ mastectomy = breast tissue only
  8. Lumpectomy/semental mastectomy = (good for solitary tumor <5cm) removes primary lesion w/clear margins, axillary node sampling, local radiotherapy to the breast
39
Q

LN sampling techniques

A
  1. Lymph node removal at levels I and II

2. Sentinel node technique

40
Q

Patients who should have mastectomy over lumpectomy w/radiation

A
  1. Small breast + large tumor
  2. Younger pts d/t higher risk of local recurrence
  3. Pts w/large breasts d/t increased complications of radiation tx
  4. Pts with connective tissue dz or prior radiation ot the chest/breast
41
Q

Contraindications to mastectomy

A
  1. Primary lesions involving the chest wall
  2. Extensive local/regional disease
  3. Stage III/IV CA
42
Q

Stage 0 or small 1 CA tx

A

lumpectomy, axillary sampling, radiation tx. No need for adjuvent therapy

43
Q

Larger Stage I cancer

A

Lumpectomy, axillary sampling, post-op radiation tx, adjuvent tx (depends on ER and menopausal status)

44
Q

Stage II CA

A

Same as stage I + modified radiacl mastectomy for larger primary lesions or pts w/small breasts in which lumpectomy would yield poor cosmetic results + adjuvant tx (depends on ER and menopausal status)

45
Q

Adjuvant tx options based on age

A

Premenopausal pts tolerate CTX better

Postmenopausal pts tolerate hormonal tx better

46
Q

small 0.5cm nodule in the suture line 5yrs post-op for stage II BCA

A

Local recurrence until proven otherwise. Must perform surgical vs. core-needle bx. Local excision indicated if bx shows CA and pt has had previous mastectomy but mastectomy should be performed if previous surgery was a lumpectomy.

47
Q

Unilateral painful breast. Currently breastfeeding. Low grade fever. Very firm, red, tender, indurated breast mass. Tx?

A

Mastitis secondary to skin breaks in the nipple allowing bacteria to enter. Must eval for s/s of infection, abscess formation. Tx = warm compress + ABx to tx staph/strep infections. Pt may continue breastfeeding or use pump to allow milk let-down

48
Q

Mastitis + area of fluctuance in the tender inflamed area

A

Abscess formation requiring open surgical drainage (Needle drainage is INADEQUATE!)

49
Q

If pt is treated for suspected mastitis w/ABx and does not improve what should you suspect?

A

Suspect inflammatory carcinoma of the breast.

50
Q

Tx of BCA in pregnancy

A

ER/PR status are NOT reliable in pregnancy. Stage I/II may be treated with mastectomy/lumpectomy + rads (may delay rads till postpartum if BCA detected in 3rd tri) with only 1% spontaneous abortion. Certain CTX regimens are safe in 2nd/3rd tri. Stage III/IV require immediate rads + CTX and thus may necessitate abortion

51
Q

Workup for MALE with 1cm hard nodule beneath the right nipple. Non-painful but fixed to surrounding tissue). Tx?

A
  1. B/L mammogram to r/o gynecomastia vs. CA

Tx = mastectomy + post-op rads

52
Q

Natural hx of males w/BCA

A
  1. males present at later stage with fixation, nipple retraction, and ulceration.
53
Q

Medications a/w gynecomastia in older men

A
  1. Diuretics
  2. Estrogens
  3. Isoniazid
  4. Marijuana
  5. Digoxin
  6. EtOH abuse

NMS Casebook (8 decks)

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