Breast Disorders

Question 1

How many women are affected by breast cancer during their lifetime?

Answer 1

1 in 8

Question 2

Most common factor that increases risk for breast cancer?

Answer 2

1st degree relative.

Question 3

BRCA 1 cancer associations

Answer 3

Breast and ovarian

Question 4

Breast cancer screening in average risk women

Answer 4

Regular self-breast exams at age 20. Clinical breast exams every 1-3 years from 20-40. Yearly mammograms starting at age 40.

Question 5

Breast cancer screening for high risk patients

Answer 5

Monthly self exams at age 20, clinical breast exams 2x/year from age 25, initial mammogram at age 30, mammograms every 1-2 years until 40, yearly mammograms after 40. Start yearly mammograms 10 years before age of 1st degree relative dx’d with breast cancer.

Question 6

A patient presents to the clinic with a small 1x1cm breast mass that is not concerning on mammogram. What is your next step?

Answer 6

Biopsy, always biopsy clinically suspicous masses regardless of what the mammogram says.

Question 7

What tool is used to interpret mammograms?

Answer 7

BI-RADS (Breast Imaging Reporting and Database System): 0 = Needs additional evaluation (compare old mammos, u/s, etc), 1 = Normal, 2 = Benign findings, routine screening, 3 = Probably benign findings (<2% are malignant), f/u in 6 months, 4 = suspicious, consider core needle biopsy (15-35% of core needle biopsies are malignant), 5 = highly suggestive of malignancy

Question 8

When would you use stereotactic-guided core needle biopsy over needle localization and open surgical biopsy?

Answer 8

Stereotactic if the lesion is indeterminate, small and less suspicious. Needle localization and open surgical biopsy if lesion is highly suspicous for malignancy on mammography.

Question 9

Tx for a patient dx’d with DCIS after core needle biopsy?

Answer 9

Surgical excision. 10-20% of DCIS dx will have additional infiltrative components at excision.

Question 10

What are the types of DCIS and which types have higher malignant potential?

Answer 10

Comedo, papillary, micropapillary, cribriform and mixed. 30% comedo type have invasive carcinoma and 4% have axillary LN mets, this is why you do sentinel LN w/comedo type.

Question 11

Tx for diffuse or multicentric DCIS

Answer 11

Simple mastectomy +/- reconstruction. No need for ax dissection or sentinel node of confined to ducts.

Question 12

What is the difference between atypical ductal hyperplasia and ductal carcinoma in situ?

Answer 12

ADH has secondary bridging and hypertophy of the epithelial and inner layers. DCIS has marked proliferation of carcinoma limited by the basal lamina

Question 13

Management of a patient who just had LCIS come back on biopsy that was next to a benign breast mass

Answer 13

LCIS is usually an incidental finding on biopsy and not seen on mammography. If found adjacent to benign breast mass, surveillance is okay. If found on core biopsy of calcified mass, excision is appropriate due to 15-20% risk of development into invasive cancer over 20 years, note however that there is almost 0 risk of axillary LN spread. F/u involves mammography every 6 months for the next several years and consideration of bilateral simple mastectomy if high risk.

Question 14

A patient presents with clustered microcalcifications on mammography. Biopsy shows cells similar to invasive tubular carcinoma, but it’s not. What could it be and how do you tx it?

Answer 14

Sclerosing adenitis. Tx w/routine follow-up despite slight increased risk for cancer

Question 15

Tx for a patient with ADH on core needle biopsy

Answer 15

Needle localization and excision. 15-50% of cases prove to be malignant.

Question 16

Why do you not usually use FNA for suspicious breast masses?

Answer 16

It cannot distinguish invasive from in situ carcinoma

Question 17

A 28 year old woman presents with a solid, rubbery and mobile 2cm mass in the outer upper quadrant of her breast that is not fluid filled on u/s. What is your next step?

Answer 17

Surgical excision of fibroadenoma. This can be done without core biopsy due to 98% of solid lesions in this age group (<30) being fibroadenoma.

Question 18

When is observation of a breast mass okay?

Answer 18

Low risk woman, age < 30 with likely physiologic cystic changes of the breast can be observed for 1-2 menstrual cycles.

Question 19

Lesions included with fibrocystic changes of the breast

Answer 19

Cysts, fibrosis, sclerosing adenosis, apocrine change and hyperplasia.

Question 20

Tx of painful fibrocystic changes

Answer 20

Cyst aspiration, elimination of caffeine, vitamin E and f/u in 3 months. If dx is unclear always do a biopsy because fibrocystic change carries a low risk of cancer.

Question 21

Most common breast tumor in women < 25

Answer 21

Fibroadenoma

Question 22

Tx of phyllodes tumor

Answer 22

Wide local excistion due to variable malignant potential and larger size when compared to fibroadenoma

Question 23

Dx for clear discharge from multiple ducts

Answer 23

Fibrocystic change in young people and subareolar duct ectasia in older women

Question 24

Most common cause of unilateral bloody nipple discharge? How do you work this up? How do you treat it?

Answer 24

Intraductal papilloma. Pt should also have mammogram to check for other abnormalities and ductogram to locate papilloma. Work up with cannulation of the duct in surgery and excision of the duct and ductal system due to small risk of carcinoma.

Question 25

How is breast cancer staged?

Answer 25

Stage 1 = 93% 5 year survival

Stage 2 = 72% 5 year survival

Stage 3 = 41% 5 year survival

Stage 4 = 18% 5 year survival

Question 26

Work up for metastatic breast cancer

Answer 26

CXR, LFT, bone scan and CT head/abdomen

Question 27

Least favorable histologic types of breast cancer

Answer 27

Infiltrating ductal carcinoma (most common), infiltrating lobular carcinoma (multicentric + bilateral), medullary carcinoma (better than invasive ductal, worse than invasive lobular) and inflammatory carcinoma.

Question 28

Poor prognostic indicators for breast cancer

Answer 28

> 4 + LNs, size > 5cm, + axillary LNs, aneuploidy, high Ki-67 (s-phase fraction) and ER-/Pr-/Her2-Neu +

Question 29

What is the prognosis for a woman presenting with enlarged supraclavicular LNs due to breast cancer?

Answer 29

This is stage IV disease, 5 year survival is 18%

Question 30

A woman presents with a crusty nipple lesion and an underlying mass. What is the most likely cause of her condiiton and how do you treat it?

Answer 30

She has Paget’s disease of the nipple, which is associated with underlying DCIS or ductal carcinoma 95% of the time. She needs a mammogram, mastectomy and staging due to the underlying mass. If no mass were present and carcinoma were confined to the nipple she could undergo excision of the NAC or radiotherapy.

Question 31

Best marker of outcome for breast cancer

Answer 31

Histologic status of level I and II axillary nodes and the # of nodes involved (10+ nodes = 14% 5 year survival)

Question 32

What is the basic anatomy of the breast?

Answer 32

15-20 lobes w/ 20-40 lobules in each lobe. Ducts drain each lobe and converge at the nipple. 60% of blood supply is from the internal mammary and 30% from the lateral thoeracic arteries. Venous drainage from the axillary and internal mammary veins. Lymphatic drainage is to the axillary and parasternal LNs.

Question 33

Contraindications to breast conserving therapy that would make you tell a patient they’d better get a mastectomy instead

Answer 33

Connective tissue disease (they tolerate radiation poorly), large tumor in small breast (BCT possible w/neoadjuvant chemorads and tumor shrinkage), multicentric disease, diffuse calcifications on mammography, prior radiation therapy, persistently positive margins after resection and pregnancy.

Question 34

Modified radical mastectomy

Answer 34

Surgeon removes breast tissue, skin and axillary nodes but spares the pec major +/- pec minor

Question 35

What patient get radiation therapy after modified radical mastectomy?

Answer 35

Tumor > 5cm, + margins or invasion of pectoral fascia/muscle. Also if sentinel node biopsy shows + internal mammary or supraclavicular LNs

Question 36

Radical mastectomy

Answer 36

Removal of breast tissue, skin pec major, pec minor and axillary LNs. Still used for tumors that extend into the pectoralis.

Question 37

Simple mastectomy

Answer 37

Removal of breast tissue, NAC and skin. Typically for LCIS or DCIS.

Question 38

BCT

Answer 38

Lumpectom/segmental mestectomy w/0.5-1cm margins + axillary node sampling + local radiotherapy to breast and nodes (if needed) = modified radical mastectomy if tumor is localized and < 5cm.

Question 39

Levels of axillary LNs

Answer 39

All in relation to pec minor

Question 40

A 60 year old woman presents with 1.5cm breast mass, no palpable axillary nodes and negative metastatic disease. How do you treat this woman?

Answer 40

She needs axillary LN sampling for final staging. If she is stage I or II, modified radical mastectomy is equal to breast conserving therapy. Many patient benefit from adjuvant chemo and hormonal therapy depending on receptor status. If she undergoes modified radical mastectomy can be followed by immediate breast reconstruction for best cosmetic results, but this is contraindicated if she is beyond stage IIa.

Question 41

What patients respond better to chemo for breast cancer and what patients respond better to hormonal therapy?

Answer 41

Chemo - premenopausal. Hormonal - post-menopausal

Question 42

F/u for stage I and II breast cancer

Answer 42

F/u visits biannually. Annual CXR and LFTs. If pt had BCT, mammography of affected breast every 6 months for 2 years followed by yearly mammograms.

Question 43

A 63 year old woman presents with a 6cm breast mass diagnosed as infiltrating ductal carcinoma of the breast with clinically positive and matted ipsilateral axillary LNs. How do you treat this patient?

Answer 43

For staging you need to get the histologic nodal status, MRI to assess extent of tumor and check for distant metastasis. If stage III (< 5cm, fixed nodes or inflammatory), neoadjuvant chemotherapy + radiation, then surgery, then adjuvant chemotherapy. If stage IV (distant mets), paliative chemorads and no surgery unless primary tumor is painful or infected.

Question 44

Tx of inflammatory breast cancer

Answer 44

1st assess for distant mets with CBC, LFTs, CT chest/liver and bone scan. Start with neoadjuvant chemo, modified radical mastectomy, then adjuvant chemo/hormonal therapy + chest and nodal radiation therapy.

Question 45

A patient presents 5 years after BCT with a 0.5cm nodule in the suture line. What do you do?

Answer 45

Biopsy surgically or with a core-needle to r/o cancer. If cancerous, patient must undergo staging again (CT chest/abdomen, bone scan, CBC, LFTs) followed by modified radical mastectomy due to local recurrence.

Question 46

A patient who had BCT 5 years ago presents to the ED with confusion and no focal findings. What tests do you do?

Answer 46

You’d probably do CT head, but simple BMP will likely show hypercalcemia due to bony mets or PTHrP.

Question 47

Tx of mastitis

Answer 47

Warm compress and abx w/continued breast feeding

Question 48

Tx of breast abscess

Answer 48

Needle drainage is often inadequate and requires surgical drainage.

Question 49

How do biopsy for inflammatory breast carcinoma

Answer 49

Always include a skin segment

Question 50

Tx for breast cancer found in a pregnant patient

Answer 50

Lumpectomy in 3rd trimester w/delayed RT or modified radical mastectomy for stage I and II disease. 1% risk of abortion. Hormone receptor status is typically unreliable. For stage III and IV disease abortion may be necessary to allow for rapid chemoradiation therapy.

Question 51

How might you manage a breast mass in a 95 year old vs. a 35 year old woman?

Answer 51

You need to discuss the option of doing less with the family of the 95 year old: observation only, needle biopsy w/dx and observation, needle biopsy w/dx and lumpectomy or simple mastectomy or complete stagin and traditional tx similar to a younger patient are typical options

Question 52

Work up of a man with a 1cm hard fixed nodule beneath his right nipple that is not painful

Answer 52

Bilateral mammogram to differentiate gynecomastia from cancer. If cancer, pt undergoes mastectomy w/post-op RT. If gynecomastia in younger adolescent, it usually regresses on its own. If gynecomastia in an older man excision is appropriate if patient desires.

Question 53

Management of a 6 year old girl with a firm 1cm unilateral breast mass

Answer 53

Excision or biopsy are contraindicated because this is likely a breast bud