Breast Disorders

Question 0

Breast cancer screening for non-high risk patients

Answer 0

• Self exams qM after 20
• CBE exams q2-3 years age 20-39, q1y after 40
• Mammogram q1y at 40

Question 1

M/c risk factor that increases risk of breast cancer?

Answer 1

one or more first-degree relatives who have had breast cancer

Question 2

Breast cancer screening for high risk patients

Answer 2

• SBE monthly at 20 y/o
• 25 y/o biannual CBE
• Mammogram 30 y/o q 1-2 years or 10 years before diagnosis of relative.
• Mammogram 40 y/o qY

Question 3

What is the mortality reduction for breast cancer screening?

Answer 3

mortality reduction of 30% or more in women over 50 years of age.

Question 4

How can mammographic abnormalities be classified?

Answer 4

1. Masses
2. Asymmetric densities

3. Microcalcifications

Question 5

BI-RADS

Answer 5

Breast Imaging Reporting and Database System

Question 6

BI-RADS O

Answer 6

Needs additional evaluation

Question 7

BI-RADS 1

Answer 7

Normal

Question 8

BI-RADS 2

Answer 8

Benign findings, recommend routine screening

Question 9

BI-RADs 3

Answer 9

Probably benign, recommend short initial (6-month) follow-up

Question 10

How should you manage a BI-RADS 4?

Answer 10

Suspicious, biopsy should be considered

Only 15%-35% of lesions recommended for biopsy prove malignant.

Question 11

BI-RADS 5

Answer 11

Highly suggestive of malignancy

Question 12

Mammogram shows pleomorphic microcalcifications, with no associated mass. These findings are suspicious for ductal carci­noma in situ (DClS). Breast examination is normal, with no palpable abnormalities. Next step?

Answer 12

magnification mammography ->

stereotactic-guided core needle biopsy or a localization and open sur­gical biopsy.

Question 13

When is core needle biopsy used vs open wire guided Excisional biopsy?

Answer 13

If the mammographic lesion is INDETERMINATE and even less suspicious, stereotactic core-needle biopsy is preferable because it produces a sample that allows a reliable histologic diagnosis, obviating the need for an open biopsy

Needle localization and open surgical biopsy may be preferable if a lesion is HIGHLY suspicious for malignancy on mammography

Question 14

Ductal carcinoma in situ (DCIS) is diagnosed. How do you proceed?

Answer 14

SINGLE SMALL LESION DCIS -> Breast conserving therapy (BCT) refers to Wide excision and local radiotherapy, document pathology-free margins in the speci­men.

DIFFUSE/MULTICENTRIC DCIS -> Simple mastectomy with or without reconstruction is the current gold standard.

Question 15

For a small lesion diagnosed as DCIS, wide excision is done. Why should you add radiotherapy?

Answer 15

Recurrence falls to 22% s/p wide excision at 10 years
Recurrence falls from 19% vs 9% on RT at 15 years (B17, B24 RCT)
Recurrence falls to 4% s/p simple mastectomy at 10 years

Question 16

Is nodal dissection necessary with diagnosis of DCIS?

Answer 16

Nodal dissection is not necessary, only consider sentinel node if DCIS is comedo variant.

Question 17

What is breast conserving therapy?

Answer 17

refers to wide excision of the tumor with negative surgical margins followed by radiation therapy (RT) to eradicate any residual disease.

Also referred to as Lumpectomy, partial mastectomy.

Question 18

What is adequate histologically negative margins in BCT?

Answer 18

negative margins = tumor-filled ducts separated by a measurable distance from the inked surface, suggestion is 10 mm but if RT, 2 mm is adequate.

Question 19

Is LCIS malignant?

Answer 19

LCIS is a malignant disease marker, with a 15%-20% chance of development of invasive cancer in either breast over a 20-year period.

Question 20

Can LCIS metastasize to the axilla?

Answer 20

there is almost no risk of axillary metastasis.

Question 21

Treatment for LCIS?

Answer 21

close observation, with examination and mammography every 6 months for at least the next several years. In higher-risk patients with a history of breast cancer, bilateral simple mastectomies and immediate reconstruction may be preferable.

Question 22

What is the risk of cancer for atypical ductal hyperplasia? Treatment for atypical ductal hyperplasia?

Answer 22

associated risk of cancer is four to five times higher. When core biopsy results demonstrate atypical ductal hyperplasia, needle localization and excision are appropri­ate. From 15% to 50% of cases prove malignant, depending on the volume of tissue ini­ tially sampled

Question 23

What conditions cause a slightly increased relative risk of carcinoma? Slightly increased risk (1.5-2X)

Answer 23

Hyperplasia of usual type, moderate or florid
Sclerosing adenosis, papilloma

Question 24

Which conditions cause a moderate increased risk for carcinoma?

Answer 24

Moderately increased risk (4-5 X )

Atypical ductal hyperplasia and atypical lobular hyperplasia

Question 25

Which type of histological lesion is associated with a high risk of progressing to carcinoma?

Answer 25

High risk (8-10X) [carcinoma in situ]
Lobular carcinoma in situ and ductal carcinoma in situ

Question 26

Which types of histological findings are associated with no increased risk for carcinoma?

Answer 26

No increased risk (no proliferative disease)

Apocrine change
Ductal ectasia - lactiferous duct becomes blocked or clogged
Mild epithelial hyperplasia of usual type

Question 27

Lumpy breast

Answer 27

Fibrocystic disease of the breast

Question 28

most common breast tumor in women under 25 years of age? Treatment?

Answer 28

fibroadenoma
Excision establishes diagnosis. Biopsy or FNA may also be used. Observation may be appropriate for small lesions, but many patients desire excision. Removal of larger lesions is necessary.

Question 29

20 year old woman with 14 cm mass in breast.

Answer 29

A phyllodes tumor (cystosarcomaphyllodes,giantcellfibroadenomas), a large, bulky mass of variable malignant potential with occasional ulceration of the overlying skin, is the sus­pected diagnosis. Factors that determine malignancy are (1) tumor behavior and (2) an in­ creased number of mitoses per high power field compared with benign phyllodes tumors (on histology).

Question 30

34 year old female with nipple discharge. What is the appropriate management?

Answer 30

Clear -> Fibrocystic disease
Bloody -> Intraductal papilloma

Mammography
Ductogram and surgically excise

Bloody discharge from a single duct requires surgical biopsy.
Bloody discharge, particularly in older women, does carry a small risk of carcinoma (4%-13% in most studies)

Question 31

How are breast tumors staged?

Answer 31

T1 = Tumor 2 cm or less in greatest dimension
T2= Tumor greater than 2cm but no more than 5 cm
T3 = Tumor greater than 5 cm in greatest dimension
T4= tumor of any size with direct extension into Chestwall or skin

Question 32

How are regional lymph node staging assigned?

Answer 32

No =No palpable axillary nodes
N1= Metastases to movable axillary nodes
N2 = Metastases to fixed, matted axillary nodes

Question 33

What is Ki-67?

Answer 33

a nuclear protein associated with mitosis, correlates with S–phase fraction and mitotic index Worse prognosis; tumors have a higher proliferative component

Question 34

What if the tumor contains Her-2-Neu oncogene?

Answer 34

erb-2, related to epidermal growth factor receptor)
Worse prognosis; increased expression of gene product is associated with shorter relapse time and shorter survival time in patients with positive nodes

Question 35

An ulcerated breast lesion with an underlying mass

Answer 35

inflammatory carcinoma - worse prognosis

Question 36

Adema of the skin overlying the mass

Answer 36

peau d’orange because it appears similar to the surface of an
orange. The associated tumor invasion oflocal dermal lymphatics worsens the prognosis

Question 37

Extensive edema of the breast

Answer 37

Inflammatory carcinoma

Question 38

Retraction of the skin overlying the mass

Answer 38

Suggests invasion of the structural support and lymphatics of the breast with tumor

Question 39

A 1.5-cm mass fixed to the deeper tissues

Answer 39

Fixation to the chest wall indicates invasion of structures outside the breast. This finding worsens the prognosis.

Question 40

A lymph node palpable in the supraclavicular area

Answer 40

node in this location represents stage IV disease with distant metastases. It is unre­sectable and incurable.

Question 41

hard, fixed lymph node in the ipsilateral axilla

Answer 41

suggests the presence of a matted group of nodes with metastases, which would give the patient a node-positive N2 status.

Question 42

soft lymph node in the ipsilateral axilla

Answer 42

inflammatory node from some other process or a metastasis.

Question 43

Small nodules on the skin of the breast

Answer 43

satellite nodules of carcinoma on the skin. Biopsy is warranted. A diagno­ sis of cancer worsens the prognosis.

Question 44

Arm edema

Answer 44

obstruction of the axillary lymphatics and worsens the prognosis.

Question 45

61-year-old woman with crusty lesions of right breast. What is your initial evaluation?

Answer 45

chronic eczematoid lesion of the nipple may be benign, but it is necessary to rule out the possibility of Paget’s disease of the breast. BIOPSY the mass!

95% of patients with Paget’ s disease have an un­ derlying carcinoma, either as infiltrating ductal carcinoma or DCIS Examination for a sub­ areolar mass and a mammogram are essential.

Question 46

A mass is found under the nipple and you suspect Paget’s disease. What is the next step in management?

Answer 46

Associated masses are present in approximately 50% of cases; these patients should undergo mastectomy and staging. If no mass is present, a biopsy of the nipple lesion is appropriate. The presence of Paget’s cells prompts a high sus­picion for cancer. If the lesion is confined to the nipple (<10% of cases), treatment for cure may involve excision of the nipple areolar complex or primary radiotherapy.

Question 47

A modified radical mastectomy

Answer 47

most commonly performed mastectomy.
The surgeon removes breast tissue, skin, and axillary lymph nodes, as in the radical mastectomy, but spares the pectoralis major muscle.

Question 48

When is RT indicated s/p mastectomy?

Answer 48

local radiation therapy following mastectomy is indicated for patients who have tu­mors greater than 5 cm in diameter, that involve the margin of resection, or that invade the pectoral fascia or muscle.

Question 49

Rx for stages 0 and I cancers with small < 1 cm) tumors (no positive nodes),

Answer 49

lumpec­tomy, axillary sampling, and radiation therapy is acceptable treatment, and no further therapy is necessary for ER Negative and hormonal therapy for ER Positive patient.

Question 50

Rx for stage I cancer with larger (1-2 cm) tumors (no positive nodes)

Answer 50

lumpec­tomy, axillary sampling (with either axillary dissection or sentinel node biopsy), and postoperative radiation therapy. Adjuvant therapy is beneficial in most patients. The choice of therapy is based on estrogen receptor status and menopausal status.

Question 51

Rx for stage II cancer (larger primary lesions or node-positive disease)

Answer 51

surgical treat­ment is the same as for stage I, with the additional option of modified radical mastec­tomy for larger primary lesions or for patients with smaller breasts in which a lumpec­tomy could result in a poor cosmetic result.

Adjuvant therapy is beneficial; it is based on estrogen receptor and menopausal status.

Question 52

Rx for stage III cancer (>5-cm lesions, fixed nodes, or inflammatory lesions),

Answer 52

neces­sary to consult an oncologist before surgery, because preoperative (neoadjuvant) chemotherapy is beneficial.

Question 53

Rx for stage IV cancer (distant metastases)

Answer 53

palliative radiation and chemotherapy is ap- propriate. Surgery is reserved only for local control of the primary tumor.

Question 54

What is the histology of inflammatory carcinoma?

Answer 54

cancer cells invading dermal lymphatics and vessels with a large inflammatory component.

Question 55

Rx for inflammatory carcinoma?

Answer 55

• Multimodality treatment
• staging workup, including a complete blood count (CBC), liver enzymes, alkaline phosphatase, calcium, total bilirubin, CT scan of the chest, a bone scan, and a CT scan of the liver
• If the cancer responds to chemotherapy, four to six more cycles are ap­ propriate. The treatment then involves modified radical mastectomy, adjuvant chemotherapy, hormonal therapy (for estrogen receptor-positive patients), and radia­ tion therapy to the chest and regional lymph node basins.

Question 56

Hx of breast cancer with decreased sensation and motor function in the right leg that is new in onset

Answer 56

extradural metastasis to the spine that may be im­ pinging on the spinal cord is a concern. Localized back pain is an earlier presenting symp­ tom. Diagnosis of cord compression necessitates an MRI scan. Steroids, cord decompres­ sion, and radiation therapy are then warranted.

Question 57

Hx of breast cancer presents with confusion and AMS and coma.

Answer 57

Acute hypercalcemia due to bony metastasis and parathormone-related peptide is one of the many possible diagnoses.

Question 58

6-year-old girl with a firm 1 em unilateral breast mass.

Answer 58

Breast bud

Question 59

Gynecomastia in a 50-year-old man?

Answer 59

diuretics, estrogens, isoniazid, marijuana, digoxin, and alcohol abuse. It is rarely confused with carcinoma, which usually forms a nontender, hard, well-circumscribed mass.