Breast Disorders Flashcards
Breast cancer screening for non-high risk patients
- Self exams qM after 20
- CBE exams q2-3 years age 20-39, q1y after 40
- Mammogram q1y at 40
M/c risk factor that increases risk of breast cancer?
one or more first-degree relatives who have had breast cancer
Breast cancer screening for high risk patients
- 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
What is the mortality reduction for breast cancer screening?
mortality reduction of 30% or more in women over 50 years of age.
How can mammographic abnormalities be classified?
- Masses
- Asymmetric densities
3. Microcalcifications
BI-RADS
Breast Imaging Reporting and Database System
BI-RADS O
Needs additional evaluation
BI-RADS 1
Normal
BI-RADS 2
Benign findings, recommend routine screening
BI-RADs 3
Probably benign, recommend short initial (6-month) follow-up
How should you manage a BI-RADS 4?
Suspicious, biopsy should be considered
Only 15%-35% of lesions recommended for biopsy prove malignant.
BI-RADS 5
Highly suggestive of malignancy
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?
magnification mammography ->
stereotactic-guided core needle biopsy or a localization and open surgical biopsy.
When is core needle biopsy used vs open wire guided Excisional biopsy?
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
Ductal carcinoma in situ (DCIS) is diagnosed. How do you proceed?
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.
For a small lesion diagnosed as DCIS, wide excision is done. Why should you add radiotherapy?
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
Is nodal dissection necessary with diagnosis of DCIS?
Nodal dissection is not necessary, only consider sentinel node if DCIS is comedo variant.
What is breast conserving therapy?
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.
What is adequate histologically negative margins in BCT?
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.
Is LCIS malignant?
LCIS is a malignant disease marker, with a 15%-20% chance of development of invasive cancer in either breast over a 20-year period.
Can LCIS metastasize to the axilla?
there is almost no risk of axillary metastasis.
Treatment for LCIS?
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.
What is the risk of cancer for atypical ductal hyperplasia? Treatment for atypical ductal hyperplasia?
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
What conditions cause a slightly increased relative risk of carcinoma? Slightly increased risk (1.5-2X)
Hyperplasia of usual type, moderate or florid
Sclerosing adenosis, papilloma
Which conditions cause a moderate increased risk for carcinoma?
Moderately increased risk (4-5 X )
Atypical ductal hyperplasia and atypical lobular hyperplasia
Which type of histological lesion is associated with a high risk of progressing to carcinoma?
High risk (8-10X) [carcinoma in situ]
Lobular carcinoma in situ and ductal carcinoma in situ
Which types of histological findings are associated with no increased risk for carcinoma?
No increased risk (no proliferative disease)
Apocrine change
Ductal ectasia - lactiferous duct becomes blocked or clogged
Mild epithelial hyperplasia of usual type
Lumpy breast
Fibrocystic disease of the breast
most common breast tumor in women under 25 years of age? Treatment?
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.
20 year old woman with 14 cm mass in breast.
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).
34 year old female with nipple discharge. What is the appropriate management?
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)
How are breast tumors staged?
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
How are regional lymph node staging assigned?
No =No palpable axillary nodes
N1= Metastases to movable axillary nodes
N2 = Metastases to fixed, matted axillary nodes
What is Ki-67?
a nuclear protein associated with mitosis, correlates with S–phase fraction and mitotic index Worse prognosis; tumors have a higher proliferative component
What if the tumor contains Her-2-Neu oncogene?
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
An ulcerated breast lesion with an underlying mass
inflammatory carcinoma - worse prognosis
Adema of the skin overlying the mass
peau d’orange because it appears similar to the surface of an
orange. The associated tumor invasion oflocal dermal lymphatics worsens the prognosis
Extensive edema of the breast
Inflammatory carcinoma
Retraction of the skin overlying the mass
Suggests invasion of the structural support and lymphatics of the breast with tumor
A 1.5-cm mass fixed to the deeper tissues
Fixation to the chest wall indicates invasion of structures outside the breast. This finding worsens the prognosis.
A lymph node palpable in the supraclavicular area
node in this location represents stage IV disease with distant metastases. It is unresectable and incurable.
hard, fixed lymph node in the ipsilateral axilla
suggests the presence of a matted group of nodes with metastases, which would give the patient a node-positive N2 status.
soft lymph node in the ipsilateral axilla
inflammatory node from some other process or a metastasis.
Small nodules on the skin of the breast
satellite nodules of carcinoma on the skin. Biopsy is warranted. A diagno sis of cancer worsens the prognosis.
Arm edema
obstruction of the axillary lymphatics and worsens the prognosis.
61-year-old woman with crusty lesions of right breast. What is your initial evaluation?
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.
A mass is found under the nipple and you suspect Paget’s disease. What is the next step in management?
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.
A modified radical mastectomy
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.
When is RT indicated s/p mastectomy?
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.
Rx for stages 0 and I cancers with small < 1 cm) tumors (no positive nodes),
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.
Rx for stage I cancer with larger (1-2 cm) tumors (no positive nodes)
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.
Rx for stage II cancer (larger primary lesions or node-positive disease)
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.
Rx for stage III cancer (>5-cm lesions, fixed nodes, or inflammatory lesions),
necessary to consult an oncologist before surgery, because preoperative (neoadjuvant) chemotherapy is beneficial.
Rx for stage IV cancer (distant metastases)
palliative radiation and chemotherapy is ap- propriate. Surgery is reserved only for local control of the primary tumor.
What is the histology of inflammatory carcinoma?
cancer cells invading dermal lymphatics and vessels with a large inflammatory component.
Rx for inflammatory carcinoma?
- 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.
Hx of breast cancer with decreased sensation and motor function in the right leg that is new in onset
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.
Hx of breast cancer presents with confusion and AMS and coma.
Acute hypercalcemia due to bony metastasis and parathormone-related peptide is one of the many possible diagnoses.
6-year-old girl with a firm 1 em unilateral breast mass.
Breast bud
Gynecomastia in a 50-year-old man?
diuretics, estrogens, isoniazid, marijuana, digoxin, and alcohol abuse. It is rarely confused with carcinoma, which usually forms a nontender, hard, well-circumscribed mass.
