Breast - MK

Question 1

What are the three BRCA associated cancers to focus on during family history?

Answer 1

Ovarian
Colon
Prostate

Question 2

What is triple concordance?

What do you do with a palpable lesion not visible on mammography?

Answer 2

Need agreement of physical exam, radiology and path.

Biopsy a palpable lesion even if mammography is negative.

Question 3

What are margins for DCIS?

Answer 3

2mm

Question 4

Who do you offer breast radiation after excision of DCIS?
What is benefit?
Who is possible exclusion

Answer 4

Almost all patients.
%50 reduction in ipsilateral recurrence.
possibly exclude elderly low grade.

Question 5

Who do you offer tamoxifen after excision of DCIS? 
What is benefit? 
What are (3) complications to potentially exclude patients?

Answer 5

Any ER+ DCIS, especially high grade.
50% reduction in both breasts.
DVT/PE, endometrial cancer, cataracts

Question 6

When would you offer a SLNB for DCIS?

Answer 6

When doing a mastectomy for extensive disease

(cannot go back to inject blue dye)

Question 7

Breast Cancer Staging
I
IIA
IIB
IIIA
IIIB
Stage IV

Answer 7

Stage I primary <2 cm, no nodes
Stage II A <2cm with axillary nodes
2-5 cm with no nodes
Stage II B primary from 2-5 cm with nodes or
>5 cm tumor no nodes
Stage III A 5 cm with nodes,
bulky but not fixed axillary adenopathy; Stage III B disease beyond MRM: chest wall invasion, peau d’orange, ulceration and inflammatory breast cancer; supraclavicular adenopathy
Stage IV metastatic disease

Question 8

Additional tests for “metastatic screening” in Stage I&II Breast Cancer patients?

Answer 8

CXR and LFTs

Question 9

Criteria for Breast Conserving Therapy

Answer 9

Stage I or II breast cancer
Lesion <5cm or good tumor to breast ratio
Multicentic (multiple quadrants) disease
No contraindications to radiation

Question 10

Absolute Contraindications to Radiation Therapy (Breast) - 5

Answer 10

• Clinical diagnosis of inflammatory breast cancer
• Multicentric disease with two or more primary tumors in separate quadrants of the breast such that they cannot be encompassed in a single excision
• Diffuse malignant microcalcifications on mammography
• Prior therapeutic radiation therapy that included a portion of the affected breast; two most common scenarios are prior mantle radiation to the chest wall for Hodgkin lymphoma and prior whole breast radiotherapy for breast cancer
• Pregnancy: breast cancer diagnosed during the first trimester should be treated with mastectomy. Breast cancer diagnosed during the second or third trimester can be managed with BCS followed by adjuvant chemotherapy, or with neoadjuvant chemotherapy followed by postpartum surgery and radiotherapy. For breast cancer diagnosed late in the third trimester, it may be possible to perform BCS in the third trimester, deferring breast irradiation until after delivery

Question 11

What breast cancer patients to do complete node dissection on if they got neoadjuvant chemotherapy?

Answer 11

Board answer is to complete node dissection on all those patients found to have macrometastases (>2 mm) even if only one node positive. (There are currently clinical trials for this question in 2020)

Question 12

Stage I&II Breast cancer, who gets chemotherapy?

Answer 12

would consider for any primary tumor >0.5cm or nodal disease.
Limited data for women >70.

Question 13

Who are candidates for Oncotype testing?

Answer 13

Stage I&II node negative ER+ patients.

(helps decide whether to add chemo)

Question 14

Two most common adjuvant chemo regimens for stage I&II Her-2 negative Breast cancer?

Answer 14

24 weeks of
Adriamycin Cytoxan (AC) (cardiotoxic)
Cytoxan Methotrexate 5-FU (CMF)

Question 15

Additional chemo for Stage II breast cancer?

Answer 15

additional 4 cycles of a taxane, Taxotere in most cases

Question 16

Most common adjuvant chemo regimens for stage I&II Her-2 positive Breast cancer?

Answer 16

Herceptin, Cisplatin Taxane (TCH) is given as adjuvant therapy

Question 17

Stage I&II Breast cancer: Who gets post-op chest wall and lymphatic (axilla, supraclav and internal mammary) radiation?

Answer 17

Primary >4 cm
>3 Lymph nodes

Question 18

What two additional staging/metastatic work up procedures for suspected Stage III Breast cancer?

Answer 18

PET/CT
Axillary ultrasound with biopsy of nodes, do SLNB prior to Neoadjuvant chemo if US is negative.

Question 19

Neoadjuvant chemo for Stage III Her-2 negative breast cancer?

Answer 19

Dose dense AC (doxorubicin/cyclophosphamide) followed by paclitaxel every 2 weeks

Question 20

Neoadjuvant chemo for Stage III Her-2 positive breast cancer?

Answer 20

AC (doxorubicin/cyclophosphamide) followed by paclitaxel plus transtuzumab/pertuzumab

Question 21

When to do BCT after neoadjuvant therapy for stage III breast cancer?

Answer 21

same as Stage I or II breast cancer, just post chemo
Lesion <5cm or good tumor to breast ratio
Multicentic (multiple quadrants) disease
No contraindications to radiation

Question 22

When do you do ALND for stage III breast cancer?

Answer 22

Patients should receive full axillary dissection if nodes were clinically positive on presentation, turn positive during treatment or the ultrasound-guided or sentinel node biopsy was positive prior to chemo. No role for sentinel node biopsy after neoadjuvant chemotherapy

Question 23

Stage III Breast cancer: Who gets post-op chest wall and lymphatic (axilla, supraclav and internal mammary) radiation?

Answer 23

Everybody without direct contraindication

Question 24

Stage III breast cancer: Who gets postoperative hormonal therapy?

Answer 24

Everybody who is ER+
tamoxifen or aromatase inhibitor

Question 25

Treatment for Inflammatory Breast Cancer?

Answer 25

Same as Stage III: Chemo, MRM, radiation

Question 26

Who can you offer immediate breast reconstruction?

Answer 26

those patients who appear to have a complete response after neoadjuvant chemo, but not to those with obvious persistent tumor as their local recurrence rates exceed 50%.

Question 27

Pregnancy and breast cancer: When can you give chemo?

Answer 27

AC chemotherapy can be given during pregnancy after the late first trimester
Cant give taxane or Herceptin

Question 28

Pregnancy and breast cancer: When can you give radiation?

Answer 28

not considered safe during any trimester, but usually will need to undergo up to 24 weeks of chemotherapy before they are ready for radiation

Question 29

Pregnancy and breast cancer: When can you give tamoxifen?

Answer 29

not until after delivery

Question 30

Pregnancy and breast cancer: Contraindicated tests?

Answer 30

CT (relative if not to pelvis)
Bone scan (absolute)
SLNB lymphazurin blue dye

Question 31

Pregnancy and breast cancer: Safe tests?

Answer 31

Mammography
CXR
MRI - no contrast

Question 32

Stage IV Breast Cancer: Treatment for ER+ disease

Answer 32

tamoxifen or AI

Question 33

Stage IV Breast Cancer: Treatment for Symptomatic bony mets

Answer 33

Radiation
Denosumab with calcium and Vit D

Question 34

Stage IV Breast Cancer: Treatment triple negative

Answer 34

CAF - Adriamycin, cytoxan, 5-FU

Question 35

Stage IV Breast Cancer: Treatment for Her-2+ disease

Answer 35

pertuzumab/trastuzumab with paclitaxel

Question 36

Paget’s Disease: how to make diagnosis?

Answer 36

Always involves the nipple
punch biopsy the skin

Question 37

Paget’s disease with no additional identifiable mass: What do you do?

Answer 37

consider MRI to find an occult primary.
Central lumpectomy including NAC with WBRT
Total mastectomy with possible immediate reconstruction

Question 38

Axillary lymph node without breast primary: What do you do?

Answer 38

1. Remove node first to let path direct work-up.
2. If breast then mammo, consider MRI. Would offer MRM if no primary found.
3. Serum Ca-125 for Ovarian (chemo will prolong life)
4. GI work-up is a wast of time (Stage IV diesease)

Question 39

Treatment for Local Recurrence:
depends on skin v parenchyma and previous therapy

Answer 39

Always stage systemically first. 
Parenchymal recurrence (prior radiation)- simple mastectomy 
Skin recurrence (prior radiation) - rare/controversial, MRM and have Rad/Onc to review if they can give more RT 
Skin recurrence (MRM without radiation) - local excision and chest wall radiation.

Question 40

How do you manage bloody nipple discharge?

Answer 40

If there is a mammogram finding or a mass, they switch to a cancer biopsy/operation algorithm

Negative mammogram/PE for mass/negative
responsible quadrant
→ total subareolar ductal system resection
(b) Negative mammogram/PE for mass/positive
responsible quadrant
→ subareolar wedge resection ductal system for
that quadrant

Question 41

How do you do a breast duct exploration?

Answer 41

Circumareolar incision (some make incision at nipple/
areola border)
Elevate areola
Dissect ducts leading to areola
Identify abnormal duct by dilatation, stent, dye or mass
(if can identify single duct otherwise subareolar
wedge resection of the ductal system draining that
quadrant)
Tie off distal duct or will still drain out of nipple postop
(your seroma!)

Question 42

What is baseline lifetime risk of breast cancer after DCIS excision?

Answer 42

~33%

Question 43

What do you do for LCIS on core needle biopsy?

Answer 43

Need to do a needle guided surgical biopsy for adequate sampling.

Question 44

What is risk reduction therapy after BCT?

Answer 44

5 years
tamoxifen if premenopausal
tamoxifen or Aromatase inhibitor if postmenopausal

Question 45

What is therapy for inflammatory breast cancer?

Answer 45

doxorubicin/cyclophosphamide with paclitaxel (AC+T)
with transtuzumab/pertuzumab for HER2-positivity

Question 46

What is the difference between inflammatory breast cancer and Paget’s disease?

Answer 46

Inflammatory - invasion of dermal lymphatics
Paget’s - invasion along ducts (involves the nipple)

Question 47

What do you do after inflammatory breast cancer responds to chemo?

Answer 47

Total mastectomy, ALND with RT to chest wall and nodal basins

delay reconstruction

Question 48

What do you do for inflammatory breast cancer if no response to chemo?

Answer 48

Try another chemo formulation or radiation.

Do not take to OR since you will never clear the dermal disease.

Question 49

Case 1. 45-year-old female had a routine mammography which contained microcalcifications

Diagnostic mammography >> 10 clustered and irregularly branching microcalcifications in an area approximately 1cm located in the upper outer quadrant of the left breast. These were not seen in a mammogram 2 years ago.

Stereotactic — Will you do it? How is it done? Needle localization and excision?

Answer 49

Stereotactic: For mammographic abnormalities not well visualized on US, stereotactic CNB is performed. The patient is upright or prone during the procedure, depending on the machine, and the biopsy needle is positioned under x-ray guidance. Breast compression during the procedure is required.

While the majority of mammographic lesions can be biopsied using the stereotactic technique, some lesions (eg, lesions close to the nipple or chest wall, very faint calcifications) are not amenable to this approach. Mammographic lesions not amenable to stereotactic biopsy may undergo a localization procedure for surgical excision

Clip can be placed at same time as the stereotactic biopsy.

Alternatively, needle localization and excisional biopsy.

Side note: CNB - A small skin incision is made through which the core biopsy needle (typically 9 to 14 gauge [approximately 2.1 mm outer diameter]) is introduced. The shortest path to the lesion is typically chosen. Patient safety (eg, staying parallel to the chest wall to avoid pneumothorax) is another important factor in the approach. CNB is typically performed under local anesthesia.

Question 50

Case 1. 45-year-old female had a routine mammography which contained microcalcifications

Initial questions

Answer 50

Gail Model (estimated breast ca risk in next 5 years and over lifetime)

Age at first period

Age at the time of the birth of a first child (or has not given birth)

FH of breast CA (mother, sister, daughter)

Number of past breast biopsies

Number of breast biopsies showing atypical hyperplasia

Race/ethnicity

_____

History of OCPs,

PMH/PSH

Medications

____

PE: Focused exam and will focus on bilateral axilla and breasts, both seated and supine

Question 51

What stages are considered early-stage breast cancer?

Answer 51

Patients with clinical stage I, IIA, or a subset of stage IIB disease (T2N1) are classified as having early-stage breast cancer.

Question 52

What stages are classified as having locally advanced breast cancer?

What percent of patients will present with distant metastases (stage IV) at diagnosis?

Answer 52

Patients with a T3 tumor without nodal involvement (T3N0, a subset of patients with clinical stage IIB disease) and those who present with stage IIIA to IIIC disease are classified as having locally advanced breast cancer.

Approximately 5 percent of patients will present with distant metastases (stage IV) at diagnosis

Question 53

Early-stage breast cancer - surgical approach to the primary tumor.
Dependent upon?
Options and outcomes?

Answer 53

The surgical approach to the primary tumor depends on the size of the tumor, whether or not multifocal disease is present, and the size of the breast.

The options include:

1. breast-conserving therapy + RT
2. mastectomy +/- RT

Both approaches result in equivalent cancer-specific outcomes.

Question 54

For patients presenting with clinically suspicious axillary nodes - preoperative work-up?

Answer 54

For patients presenting with clinically suspicious axillary nodes, a preoperative work-up including ultrasound plus lymph node biopsy can help to determine the best surgical approach

LN biopsy >> positive >> proceeds directly to surgery, an axillary node dissection should be performed

LN biopsy >> negative >> sentinel lymph node biopsy (SLNB) at the time of surgery should be performed

Question 55

Patients who present with a clinically negative axilla do not require a preoperative work-up. These patients should undergo an SLNB at the time of definitive breast surgery.

SLNB results and next step?

Answer 55

Patients who have <3 pathologically involved sentinel nodes by SLNB might not require an axillary node dissection.

Whether or not patients with ≥3 pathologically involved sentinel nodes involved should undergo an axillary node dissection is best determined on an individualized basis, taking into account all other tumor risk factors and the patient’s performance status and comorbidities

Question 56

SLNB results and management of axilla based on Z-0011 criteria?

Answer 56

Based upon pathologic results obtained by SLNB, we recommend no further axillary surgery for patients who meet all of the following criteria (“Z-0011-eligible” criteria):

●Clinically negative nodes based on an adequate clinical node evaluation, including imaging when necessary, such as in obese patients.

●A T1 or T2 (≤5 cm) primary breast cancer

●Fewer than three metastatic sentinel lymph nodes on SLNB

●Patients undergoing breast-conserving surgery followed by whole-breast irradiation

A completion ALND is required for patients who have:

●Three or more metastatic sentinel lymph nodes on SLNB.

●One or two metastatic sentinel lymph nodes on SLNB but who do not desire whole-breast irradiation

Question 57

Breast - Physical examination

Basics?

If nipple discharge?

Answer 57

Vissual inspection for asymmetry and skin lesions such as rash, retraction, or erythema

Palpation should systematically cover all areas of both breasts including the axillary tail and should include examination of the axillary and supraclavicular nodal basins

If nipple discharge is present, it should be characterized in terms of color and location as well as whether it arises from a single duct or multiple ducts and whether a trigger point can be identified

Question 58

Palpable Breast Mass

Premenopausal women

Postmenopausal women

Answer 58

Premenopausal >> most palpable breast masses are found to be cysts, fibrocystic change, or fibroadenomas, with a minority representing cancer. Ruling out cancer is an essential part of the evaluation of a breast mass.

Postmenopausal >> a new breast mass should be assumed to be cancer until proven otherwise.

Note: in most cases, a cyst (well circumscribed, fluid filled on ultrasound) or fibroadenoma (smoothly marginated firm rubbery mass in a premenopausal woman) can be distinguished from a cancer (ill-defined or spiculated solid density)

Question 59

Nipple discharge that is spontaneous, persistent, unilateral, and involving a single duct requires further diagnostic evaluation and occasionally surgical intervention. It may be sanguineous or serous. Evaluation begins with physical examination as well as mammogram and ultrasound. If a specific, targetable suspicious lesion such as abnormal microcalcifications or a solid mass is found, the lesion can be targeted for core needle biopsy. If no suspicious lesion is found, an excisional biopsy of the offending duct is necessary to make a specific diagnosis and rule out a cancer. A ductogram (galactogram) is sometimes useful in preoperative planning to identify ductal filling defects. The fluid-producing duct is cannulated and contrast material is injected, followed by a mammogram to identify the location of filling defects within the duct. Cytology and hemoccult testing are seldom of significant value in the evaluation of patients with nipple discharge.

Question 60

High Risk Breast Lesions - FEA (Flat epithelial atypia)

Diagnosis

Management after core needle biopsy[1]

Upgrade rate with excision

Management of margins after excision

Relative risk for invasive cancer

Risk reduction with active surveillance and chemoprevention

Answer 60

Question 61

High Risk Breast Lesions - LCIS

Diagnosis

Management after core needle biopsy[1]

Upgrade rate with excision

Management of margins after excision

Relative risk for invasive cancer

Risk reduction with active surveillance and chemoprevention

Answer 61

Question 62

High Risk Breast Lesions - ALH

Diagnosis

Management after core needle biopsy[1]

Upgrade rate with excision

Management of margins after excision

Relative risk for invasive cancer

Risk reduction with active surveillance and chemoprevention

Answer 62

Question 63

High Risk Breast Lesions - ADH

Diagnosis

Management after core needle biopsy[1]

Upgrade rate with excision

Management of margins after excision

Relative risk for invasive cancer

Risk reduction with active surveillance and chemoprevention

Answer 63

Question 64

BI-RADS

Categories and Management

Answer 64

Question 66

Non-Lactational Nipple Discharge

Important Characteristics to Identify?

Physiologic vs Pathologic?

Additional questions unrelated to discharge

Answer 66

Appearance of the discharge (bloody versus nonbloody)

Frequency of the discharge

Spontaneous or provoked by manipulation of the breast

Unilateral or bilateral

Uniductal or multiductal

______________________

Physiologic nipple discharge is usually non-bloody, bilateral, multiductal, and occurs with breast manipulation

If up to date with mammography, no breast imaging necessary. Evaluation (galactorrhea workup) should include a pregnancy test, prolactin levels, renal and thyroid function tests, and appropriate follow-up with an endocrinologist prn

Pathologic (w/increased CA risk) >> spontaneous, bloody, unilateral, uniductal, associated with a breast mass, and/or occurs in a woman over 40 years of age

______________________

Hot flashes, vaginal dryness >> may indicate hypogonadism and hyperprolactinemia

Trauma >> including recent mammography, manipulation; bloody discharge + anticoagulation should prompt consideration for traumatic discharge

Question 67

Non-Lactational Nipple Discharge

Possibly the most important question in terms of workup?

Answer 67

Is there a palpable mass on exam?

Question 68

Pathologic Nipple Discharge

Imaging Recommendations Based on Demographic

Answer 68

• Women ≥40 years of age should undergo both diagnostic mammography and focused breast ultrasonography. Patients who have had a recent mammogram (<6 months) or are pregnant may undergo breast ultrasonography alone.
• Women between 30 and 39 years of age should undergo diagnostic mammography first, followed by breast ultrasonography if necessary.
• Women <30 years of age should undergo breast ultrasonography first; mammography is only performed if the initial ultrasound shows a suspicious finding or if the patient is genetically predisposed to hereditary breast cancer.
• MEN with pathologic nipple discharge should undergo both diagnostic mammography and breast ultrasonography to assist in diagnosis and guidance for biopsy if necessary

Question 69

Pathologic Nipple Discharge

Negative mammogram and ultrasound…now what?

Answer 69

At institutions where it is available, galactography or ductoscopy may also be performed to evaluate pathologic nipple discharge in patients who have negative mammogram and ultrasound

Question 70

Galactography

Answer 70

Galactography is a delicate, technically challenging study that can only be performed if the nipple discharge is reproducible on physical examination. During a galactography examination, the discharging nipple orifice is cannulated and injected with a small amount of contrast material, which allows a subsequent mammogram to visualize a filling defect. The intraductal lesion will appear as an intraductal filling defect, a complete ductal obstruction, or a wall irregularity

Galactography can cause mastitis if too much contrast material is injected or if too much pressure is used during injection, resulting in perforation of the duct and extravasation of contrast material.

Magnetic resonance (MR) galactography is a different technique than standard breast MRI. It utilizes heavy T2 weighting, which accentuates the visibility of fluid-containing structures. No directly instilled or intravenous contrast material is necessary. MR galactography provides a three-dimensional image and can show the precise shape and location of the abnormal duct and lesion in the breast.

Question 71

Ductoscopy

Answer 71

Ductoscopy — Practiced more widely in Asia than in North America, mammary ductoscopy is another minimally invasive method for evaluation and treatment of nipple discharge. As with galactography, ductoscopy also requires a reproducible discharge and the ability to cannulate and dilate the discharging duct.

When a solitary intraductal lesion is identified, it is either surgically excised or biopsied, both through a separate skin incision. Surgical excision is guided by transillumination from the ductoscope; when biopsy is planned, the tip of the ductoscope is identified with ultrasound so that percutaneous biopsy of lesions located near the scope tip can be carried out.

Question 72

Pathologic Nipple Discharge in Pregnancy

Answer 72

Bloody nipple discharge can be seen in up to 20 percent of women during the second or third trimester of pregnancy and lactation. The cause is usually hypervascularity of developing breast tissue, which is benign and requires no treatment

However, the evaluation of breast complaints in pregnancy and lactation can be complicated by the changing breast examination. Surgical evaluation is warranted for those with persistent bloody nipple discharge

Persistent pathologic nipple discharge during pregnancy >> breast ultrasonography. If the result is negative, they can be followed, and further workup performed after delivery if their symptoms persist. If a suspicious lesion is identified on ultrasound, then an ultrasound-guided core needle biopsy can be performed, and they should be treated according to the result of the biopsy.

Some women have bloody nipple discharge during the first days of lactation. This is more common with the first pregnancy, and it is thought to be caused by the increased vascularization of the lobules and ducts with the onset of milk production. There is no contraindication to infants consuming milk that contains a little blood. If bloody nipple discharge persists for more than one week, other causes of bloody milk should also be considered and the patient should be formally evaluated for pathologic nipple discharge

Question 73

Pathologic Nipple Discharge

CNB Findings - Benign lesions withOUT high-risk features?

Next Step?

Answer 73

Generally speaking, benign breast lesions withOUT high-risk features, such as usual ductal hyperplasia and fibroadenoma, do not require surgical excision.

It is controversial whether surgical excision is necessary for all intraductal papilloma diagnosed by core needle biopsy (for the purpose of the exam, go for excision)

Make sure to council the female regarding possible difficulty with future lactation after all duct-related biopsies and procedures

Question 74

Pathologic Nipple Discharge

CNB Findings - Benign lesions with high-risk features (4)?

Next Step?

Answer 74

Biopsy findings of intraductal papillomas, atypical ductal hyperplasia, atypical lobular hyperplasia, and radial scar are benign but high-risk lesions

The primary concerns are the known rates of carcinoma associated with these specific lesions found on core needle biopsy and the risk of sampling error that may occur with needle biopsy. Because there does not appear to be a group in which surgical excision can be omitted, we suggest that all benign lesions with high-risk features be surgically excised to rule out concomitant malignancy as well as to alleviate the nipple discharge

Question 75

Nipple Discharge - Single Duct Excision

Answer 75

When a discharging duct can be identified with the assistance of a lacrimal duct probe, methylene blue injection, or another method, a single duct can be excised without injuring the other ductal elements.

Dissection is then carried out to completely remove the duct without injuring the other nipple ductal elements. If the location of the lesion is not known, care should be taken to remove 2 to 3 cm of breast parenchyma deep to the nipple itself, thereby maximizing the chances of excising the target lesion

Orient the specimen to allow for directed excision of surgical margins if cancer is the final diagnosis. Additionally, a specimen radiograph should be obtained if localization was performed to ensure removal of the area of concern

Question 76

Complete subareolar duct excision

Answer 76

Also called complete terminal duct excision, is performed for intractable discharge from multiple ducts that is causing significant distress to the patient; copious amounts of nipple discharge may be anxiety provoking and socially embarrassing.

Periareolar incision along the lateral areola, > Dissection is carried toward the nipple duct elements with a combination of electrocautery and blunt dissection >> ductal elements are freed from their attachments to the nipple with sharp dissection, taking care not to injure the nipple itself >> some surgeons advocate closure of the orifice stumps from the underside of the nipple with 4-0 Prolene sutures to avoid potential formation of fistulas

Question 77

Counciling patients who believe mastectomy is more aggressive therefore better than BCS

-Four primary points-

Answer 77

BCT and mastectomy have equivalent survival outcomes.

Mastectomy does not eliminate the possibility of local recurrence or new primary cancer.

Adjuvant radiotherapy may still be indicated after mastectomy if there are clinical features of increased risk of chest wall recurrence.

Decisions about chemotherapy are made independent of surgical approaches (ie, BCS versus mastectomy).

Question 78

Location of Incision for Lumpectomy

Answer 78

In general…

Tumor in the upper part of the breast, incisions should be curvilinear or transverse and follow the natural skin creases (Langer’s lines).

Tumor in the lower part of the breast, the choice of a curvilinear or radial incision is dependent upon the contour of the breast, the distance from the skin to the tumor, and the amount of breast tissue to be resected.

In select patients, incisions may be placed along the lateral contour of the breast, within the inframammary fold, or circumareolar, to improve the cosmetic outcome and hide the scar, even though these recommendations may deviate from the above principles. Factors such as the size of the tumor and likelihood of subsequent mastectomy and the extent of tunneling necessary should be considered when planning the incision

Question 79

Techniques to reduce positive margins in BCS

Answer 79

Positive margins are associated with a twofold increase in local recurrence rate [50], reoperation is frequently necessary after initial BCS to obtain negative margins. In the United States, BCS has an aggregate reoperation rate of 21.6 percent even with contemporary imaging methods

Tools that can be used to reduce reoperation rate and improve cosmetic outcomes of BCS include specimen orientation and radiography, intraoperative margin assessment, and post-excision cavity shaving

Note: Data suggest that circumferential, but not selective, cavity shaving reduces the rate of positive margins

Question 80

Pt with bulky tumor that wishes to undergo BCT

Answer 80

Neoadjuvant approach to chemotherapy can also increase the volume of patients who are eligible for breast-conserving surgery (BCS) without increasing local recurrence rate

A metal clip must be placed in the tumor bed to guide BCS, or else a mastectomy is performed, for patients about to undergo neoadjuvant chemotherapy just in case there is a complete response.

Question 81

When should a fibroadenoma be excised?

Answer 81

A fibroadenoma should be excised if it is large (>3 cm at diagnosis), symptomatic, if it increases in size, or if it significantly contributes to patient anxiety. If the pathology of the core biopsy does not clearly confirm the clinical impression of fibroadenoma the lesion may need to be excised to rule out more serious findings.

Question 82

A core biopsy reported as cellular fibroepithelial lesion

Answer 82

Most benign phyllodes tumors present similarly to a fibroadenoma but can grow more rapidly and become locally aggressive. Ultrasound alone cannot distinguish a fibroadenoma from a phyllodes tumor so core needle biopsy is required.

A core biopsy reported as cellular fibroepithelial lesion could represent either a fibroadenoma or a phyllodes tumor and should be excised for diagnosis and local control**. All benign phyllodes tumors should be excised to a **clear margin to reduce the chance of local recurrence.

Question 83

Breast Cysts - Features concerning for pathologic cyst

Answer 83

By ultrasound, cysts that are well circumscribed, thin-walled, and without septations or an associated solid component are referred to as simple cysts and are unlikely to be associated with a cancer.
Ultrasound- or palpation-guided aspiration is appropriate for simple cysts that are large or symptomatic. Routine aspiration of small, asymptomatic simple cysts is not needed.

Cyst fluid that is bloody should be sent for cytopathology; nonbloody cyst fluid is usually discarded.

Cysts that by ultrasound have septations, debris, or an associated solid component are known as complex cysts and should be biopsied. Ultrasound-guided core needle biopsy should be performed with a clip left in place to mark the location in the event that excisional biopsy is subsequently required.

Question 84

Diabetic Mastopathy

Answer 84

This uncommon, dense, fibrous lesion usually occurs between ages 30 and 50 in patients with a long history of type 1 diabetes, particularly those with microvascular complications, although it has been described in type 2 diabetics as well.

Patients present with a dense, hard mass; both the physical examination and radiologic studies may appear suspicious for carcinoma. In the correct clinical setting, a core needle biopsy may be diagnostic, with excisional biopsy occasionally needed for confirmation. No active intervention is required beyond confirmation of the diagnosis.

Question 85

Nonlactational mastitis can be divided into periductal mastitis and idiopathic granulomatous mastitis (IGM)

Answer 85

Periductal mastitis is more common in women who are smokers, have large breasts, are overweight, or have had previous surgery or radiation to the breast. As with lactational mastitis, Staphylococcus and Streptococcus are the most common pathogens and treatment should involve symptom relief, antibiotics, ultrasound to rule out an abscess.

IGM is a rare benign inflammatory breast disease of unclear etiology. Patients may present with a painful mass sometimes in association with fistulas, abscesses, and inflammatory changes. Its presentation is sometimes similar to inflammatory breast cancer and appropriate diagnostic workup with biopsy may be required.

The diagnosis of IGM is established via core needle biopsy of a solid mass visualized on ultrasound. The biopsy should be sent for Gram stain, bacterial culture, acid-fast bacilli stain and culture, fungal stain and culture, and histopathology. The microbiology laboratory should be alerted to clinical concern for Corynebacterium.

Biopsy findings typically demonstrate non-necrotizing granulomatous lesions centered on the breast lobule.

IGM usually behaves as an inflammatory mastitis that generally resolves within 9 to 24 months, although recurrences are common. There are reports of medical management with steroids, methotrexate (+ folatE), or antibiotics, and yet it is unclear whether the underlying course of the disease can be improved with medical management. Management should be pursued for treatment of any associated infection.

Question 86

Fat Necrosis

Answer 86

Fat necrosis in the breast can result from injury to the soft tissues. Typical radiologic characteristics include a rounded density with or without calcifications. Fat necrosis sometimes cannot be distinguished from cancer radiographically and core needle biopsy can be necessary. A large area of fat necrosis can form a focal hard mass that can cause anxiety, and some patients prefer to have it excised.

radiologists can usually determine that a lesion represents fat necrosis based on mammographic and ultrasound findings such as oil cysts (collections of liquefied fat)

Question 87

Proliferative lesions without atypia include…?

Answer 87

Usual ductal hyperplasia, intraductal papillomas, sclerosing adenosis, radial scars, adenomas, fibroadenomas, and pseudoangiomatous stromal hyperplasia.

Question 88

Sclerosing adenosis

Answer 88

Sclerosing adenosis is a lobular lesion with increased fibrous tissue and interspersed glandular cells. It can present as a mass or suspicious finding on mammogram. The risk of subsequent breast cancer in those with sclerosing adenosis is about twofold that in the general population. Currently, no treatment, chemoprevention, or enhanced screening is recommended for sclerosing adenosis in the absence of atypia.

Question 89

Some proliferative lesions without atypia usually recommended for excisional biopsy include:

Answer 89

complex sclerosing lesion, radial scar, and intraductal papilloma

Question 90

Women with increased risk of breast cancer can be encouraged to make lifestyle modifications that include…?

Answer 90

Women with increased risk of breast cancer can be encouraged to make lifestyle modifications that include dietary fat and alcohol reduction, attention to maintaining a normal body weight, smoking cessation, and exercise. Drugs such as tamoxifen and raloxifene are approved for use in chemoprevention in high-risk women.

Question 91

Male Breast Pathology - Gynecomastia

Answer 91

Gynecomastia usually presents with a firm, sometimes painful thickening of the subareolar tissues and may be bilateral or unilateral, even if caused by systemic factors. Gynecomastia has been associated with estrogen excess or testosterone deficiency. It may be associated with cirrhosis of the liver, primary hypogonadism, testicular tumors, obesity, and numerous drugs including: steroids, estrogens, flutamide, ketoconazole, digoxin, spironolactone, phenothiazines, and marijuana use

If evaluation is consistent with benign gynecomastia and the medical history implicates a specific drug, discontinuation of that drug (if medically acceptable) with reevaluation in 3 to 6 months may be reasonable. Gynecomastia can also sometimes regress spontaneously. A persistent mass, particularly if painful, may be most appropriately managed by excisional biopsy for definitive diagnosis and symptom relief

Question 92

With use of average breast density as a reference point, the risk among women with heterogeneously dense breasts is ____ as great as the average, and with extremely dense breasts, ____ times as great.

Answer 92

With use of average breast density as a reference point, the risk among women with heterogeneously dense breasts is 1.2 times as great as the average, and with extremely dense breasts, 2.1 times as great.

This is equivalent to the elevated risk of breast cancer associated with having a first-degree relative with unilateral, postmenopausal breast cancer.

Question 93

3D breast tomosynthesis

Answer 93

Several manufactures now offer the capability to reconstruct synthesized 2D (s2D) mammograms from digital breast tomosynthesis datasets as a replacement for digital mammography. In this way, patients only receive radiation from the tomosynthesis component with elimination of the digital mammographic component, decreasing the overall radiation exposure by up to 45%.

s2D imaging has been associated with decreased recall rates and maintained cancer detection rates

Question 94

Who gets a screening breast MRI?

Answer 94

In 2007, the ACS recommended annual screening MRI as a supplement to screening mammography for women with high risk for breast cancer, based either on a known BRCA mutation, a first-degree relative of a known BRCA mutation carrier, or a predicted lifetime risk of 20%–25% or greater according to risk modeling. On the basis of expert consensus opinion, the National Comprehensive Cancer Network (NCCN) also recommended annual MRI screening for those individuals who received radiation to the chest between the ages of 10 and 30 years; those with Li-Fraumeni, Cowden’s, or Bannayan-Riley-Ruvalcaba syndromes, and their first-degree relatives

Question 95

Chemotherapy for ER/PR+, Her2+

Answer 95

TCHP

Taxane (Docetaxel)

Carboplatin

(Herceptin) Trastuzumab

Pertuzumab

Question 96

Patient with clinically positive axilla who receives neoadjuvant chemotherapy. Management of the axilla after radiation if it becomes clinically negative.

Answer 96

Downstaging to a clinically negative axilla permits SLNB. It is therefore prudent to place a clip/marker next to previously abnormal node BEFORE therapy. If SLNB is performed, it should be done with dual tracers (radiotracer and dye), 3 nodes sampled and one of the nodes should be the clipped node. In this case, sending nodes for intraop pathology, touch prep, frozen specimen is helpful because a positive node means ALND. This is NOT Z-011 criteria (only applies to a clnically node negative patient and in those who do not receive mastectomy)

Question 97

DCIS - Management of Axilla

Exceptions??

Answer 97

By definition, this is NOT an invasive disease therefore no risk of spread to nodes.

******There are exceptions******

1. DCIS with planned mastectomy (injecting radiolabeled tracer into the breast parenchyma near the area of DCIS or, alternatively, in a periareolar location). After a total mastectomy, the lymphatic drainage pattern will be permanently altered, making it impossible to accurately perform SLNB at a later date if invasive cancer is found unexpectedly in the mastectomy specimen
2. DCIS with suspicious features — Some also recommend SLNB to patients undergoing breast-conserving surgery for DCIS clinically suspected of harboring invasive cancer, including DCIS larger than 5 cm and DCIS with a palpable mass

Question 98

Contraindications to stereotactic biopsy (7+)

Answer 98

Patient unable to lie prone or cooperate

Patient’s excess weight (typically > 300 lb)

Lesion location near nipple, too superficial to skin, too posterior to chest wall, or too close to implant

Lesion mammographically occult

Patient has severe kyphosis or movement disorders

Lack of breast tissue thickness for adequate compression

Pregnancy

NOTE: Core needle biopsy may still be performed safely in patients receiving anticoagulant therapy or aspirin, but the patient should be informed of increased risk of bleeding and hematoma formation

Question 99

Indications for Surgical Excision After Stereotactic Core Biopsy

Answer 99

Imaging findings and pathologic findings do not correlate (discordance)

Atypical ductal hyperplasia

Atypical lobular hyperplasia

Radial scar, complex sclerosing lesion

Papillary lesions

Cellular fibroepithelial lesions and Phyllodes tumors

Lobular carcinoma in situ

Mucocele-like lesions

Question 100

For most patients with concordant radiologic-pathologic findings after biopsy, a follow-up mammogram is suggested at approximately ___ months.

Answer 100

For most patients with concordant radiologic-pathologic findings after biopsy, a follow-up mammogram is suggested at approximately 6 months.

Question 101

Luminal A breast cancers

Luminal B breast cancers

Answer 101

Luminal A breast cancers express high levels of ER and demonstrate the best response rate to endocrine therapy. They represent the most common subtype (40%) and have the best prognosis compared with other breast cancer subtypes.

Luminal B breast cancers are less common (20%) and, although they still have a good overall prognosis, they demonstrate more aggressiveness and a worse prognosis compared with luminal A tumors. Luminal B tumors display a higher grade, lower levels of ER positivity, and higher expression of the proliferation cluster (Ki-67) compared with luminal A tumors. In concordance with the lower ER expression, their response to endocrine therapy is lower than luminal A tumors; however, their response to traditional chemotherapy is superior to luminal A tumors. When compared with basal-like and HER2-enriched tumors, luminal B tumors have a superior prognosis.

Question 102

ER and PR Positive Tumors - In General

Answer 102

About 65% of ER-positive tumors are also progesterone receptor (PR) positive. The level of expression of ER is used to predict response to endocrine therapy. Approximately 70% of ER/PR-positive breast cancers respond to endocrine therapy. A small percentage of breast cancers are ER negative/PR positive, and some of these tumors have shown a response with endocrine therapy, suggesting downstream endocrine pathway activation.

Question 103

Briefly, describe the National Surgical Adjuvant Breast and Bowel Project (NSABP B-14)

Answer 103

a randomized, double-blind, placebo-controlled trial in 2800 patients with primary operable, ER-positive, and lymph node–negative breast cancer to determine the effectiveness of adjuvant tamoxifen therapy.

Disease-free survival was prolonged significantly through 10 years of follow-up in women treated with tamoxifen (69%) versus placebo (57%). There was also a 37% relative reduction in the cumulative incidence of a second primary breast cancer in the contralateral breast at 10 years of follow-up, 3.8% for tamoxifen-treated patients versus 6.1% for those on placebo (P = .007).

Question 104

Aromitase Inhibitors - General, mechanism, etc

Answer 104

AIs are the endocrine therapy of choice for postmenopausal patients with ER-positive tumors. The AIs currently approved in the clinical setting include exemestane, anastrozole, and letrozole. AIs block the conversion of adrenally synthesized androgens to estrogen, the final step in steroid conversion to the active form of the hormone. AIs do not alter the estrogen production from the ovary and are therefore contraindicated as single-agent endocrine therapy in premenopausal women, but AIs can be administered to premenopausal women with ovarian function suppression (OFS) therapy

Question 105

For women at an increased risk for developing breast cancer, we suggest endocrine therapy rather than observation

Answer 105

Our criteria include age 35 years or older with a life expectancy of at least 10 years and one of the following:

• A history of thoracic radiation administered prior to 30 years of age.
• A history of lobular carcinoma in situ.
• A ≥1.7 percent five-year risk for breast cancer.
• Atypical hyperplasia

Question 106

Hormonal Therapy for postmenopausal women with baseline osteopenia/osteoporosis

Answer 106

For postmenopausal women with baseline osteopenia/osteoporosis, we suggest a SERM rather than an AI alone (Grade 2C). However, some women who would prefer to avoid the risks of a SERM (eg, thromboembolic disease and endometrial cancer) may reasonably opt for an AI instead, with appropriate treatment for their loss of bone density

Question 107

For patients with hormone receptor-positive, human epidermal growth factor receptor 2 (HER2)-negative, node-positive breast cancer at high riskof recurrence and a Ki-67 score ≥20 percent, consider adding…?

Answer 107

For patients with hormone receptor-positive, human epidermal growth factor receptor 2 (HER2)-negative, node-positive breast cancer at high riskof recurrence and a Ki-67 score ≥20 percent, we suggest the addition of adjuvant abemaciclib (Verzenio, a CDK 4/6 inhibitor) to endocrine therapy (Grade 2C), but note that it is also acceptable not to administer this additional treatment, given the toxicity (notably, diarrhea) and only short-term supporting data. High risk in this instance is defined as either ≥4 involved axillary lymph nodes, or 1 to 3 involved lymph nodes and either tumor grade 3 or tumor size ≥5.0 cm

Question 108

Timing to initiate endocrine therapy

For women with hormone receptor-positive breast cancer who are not recommended to receive other adjuvant therapy (eg, chemotherapy and/or radiotherapy)

For patients receiving adjuvant chemotherapy

For women receiving adjuvant radiation therapy (RT) for breast cancer

Answer 108

For women with hormone receptor-positive breast cancer who are not recommended to receive other adjuvant therapy (eg, chemotherapy and/or radiotherapy), endocrine therapy is usually initiated four to six weeks after surgery.

For patients receiving adjuvant chemotherapy, the initiation of endocrine therapy is commonly begun after chemotherapy has completed (ie, sequentially) rather than during chemotherapy (ie, concurrently), in order to minimize toxicities and possible antagonism. Consider starting 4-6 weeks after chemo.

For women receiving adjuvant radiation therapy (RT) for breast cancer, some experts at UpToDate initiate endocrine therapy concurrently with RT, while other experts initiate endocrine therapy sequentially, following the completion of RT. Multiple studies show that the timing of endocrine therapy in relation to RT does not impact survival; older studies suggest that concurrent treatment increases the risks of treatment complications (including pulmonary and/or breast fibrosis)

Question 109

Oncotype Dx (Genomic Health)

Answer 109

Oncotype Dx (Genomic Health) is a multigene assay to predict recurrence of ER-positive breast cancers. Using reverse transcriptase-polymerase chain reaction assay of 21 genes in formalin-fixed, paraffin-embedded tumor tissue

An individualized risk estimate or recurrence score (RS) of 0 to 100 is provided for each tumor sample: low risk, less than 18; intermediate risk, 18 to 30; and high risk, 31 or greater. A low RS indicates that hormone therapy alone is adequate treatment. A high RS shows a high-risk patient who would benefit from chemotherapy followed by hormonal therapy. Studies have shown that associations of RS with survival are independent from standard clinicopathologic factors.

Question 110

HER2 testing - who, why and how?

Answer 110

HER2 overexpression is an independent poor prognostic indicator. HER2 should be tested on all invasive breast cancers because of its significant implications for prognosis and treatment. HER2 status can be determined through IHC testing or fluorescence in-situ hybridization (FISH). In the United States, 80% to 90% of testing is done with IHC with confirmatory FISH testing for equivocal results

Question 111

TNBC - Quick Hits

Answer 111

TNBC accounts for about 10% to 20% of all breast cancers and is biologically the most aggressive. TNBC frequently affects younger patients (<40 years) and is more prevalent in African-American women than in other demographic groups. These tumors tend to be larger, palpable, higher grade, and more often seen as interval cancers occurring between mammogram screenings; therefore, TNBC is associated with a higher relapse rate and a poorer survival rate than non-TNBC. Distant metastases typically occur at visceral sites rather than bone and often present within the first 3 years after diagnosis.

Question 112

Adjuvant radiation therapy is recommended following lumpectomy but is sometimes omitted in women ….

Following mastectomy, radiation is indicated for women ….

Answer 112

Adjuvant radiation therapy is recommended following lumpectomy but is sometimes omitted in women: older than 70 with hormone sensitive tumors ≤2 cm in size

Following mastectomy, radiation is indicated for women with: tumors larger than 5 cm, positive margins, or evidence of axillary lymph node involvement

Question 113

A thorough family history should be obtained from the patient to determine eligibility for genetic testing.

Answer 113

any woman diagnosed with breast cancer before age of 50 (or with triple negative breast cancer before age of 60), women diagnosed with breast cancer at any age who have a strong family history of breast and/or ovarian cancer, women diagnosed with breast cancer who are of Ashkenazi Jewish descent, and any male diagnosed with breast cancer should be referred for genetic counseling and testing

Question 114

Nipple-sparing mastectomy - preserves the entire skin envelope of the breast including the nipple and areola. The preferred options for incision placement are…?

Eligibility for nipple-sparing mastectomy?

Importance of the subareolar margin?

Answer 114

The preferred options for incision placement are typically in the inframammary fold or along the inferolateral border of the breast. An inferolateral incision allows for access to the axillary lymph nodes to perform a sentinel lymph node biopsy or an axillary lymph node dissection

Eligibility for nipple-sparing mastectomy depends on the proximity of the cancer to the nipple, as well as risk factors for poor blood supply to the nipple such as large breast size, significant breast ptosis, current smoking status, and longstanding diabetes. Additional risks inherent to nipple-sparing mastectomy include a positive subareolar margin and nipple necrosis, both of which could necessitate removal of the nipple areolar complex at a later date. The subareolar margin is the ductal tissue removed from directly underneath the nipple and sent to pathology for examination separately from the main mastectomy specimen. If there is evidence of malignancy in the subareolar margin, then the nipple should be resected to ensure no disease is left behind.

Question 115

Clinically positive axilla in a patient selected to undergo neoadjuvant therapy.

Pre-treatment objectives?

Surgical considerations post-treatment?

Answer 115

For patients who present with clinically positive axillary lymph nodes at diagnosis, an axillary US followed by an US-guided FNA or core needle biopsy is indicated for tissue diagnosis. A sonographically visible clip should be placed into the lymph node at the time of biopsy. If pathology confirms evidence of lymph node involvement, then the axilla should be reassessed following neoadjuvant therapy

The surgical technique used during the sentinel lymph node biopsy procedure is also critical to minimize the false-negative rate to an acceptable level. As demonstrated by the ACOSOG Z1071 and SENTINA trials, the use of dual tracer (isosulfan blue dye and technetium sulfur colloid radiotracer), attempting to remove at least 3 sentinel lymph nodes, and successfully retrieving the previously biopsied clipped lymph node all contribute to a lower false negative rate

The term “targeted axillary dissection” has been coined to refer to retrieval of the clipped lymph node in addition to the sentinel lymph nodes

Question 116

Typically technetium sulfur colloid for SLNB in breast cancer does not use lymphscintigraphy. What are a couple exceptions to this?

Answer 116

Patients who have had extensive breast (likely including extensive cosmetic surgery such as reduction mammoplasty or breast augmentation) or axillary surgery may have disruption or alteration to the normal pattern of lymphatic drainage, which may increase the false negative rate of SLNB. Thus, in these patients, we perform preoperative lymphoscintigraphy prior to SLNB.

In women who were previously treated with breast-conserving therapy and have in-breast recurrence or a new ipsilateral breast cancer, we perform a lymphoscintigraphy to identify the sentinel node(s) before attempting a repeat SLNB.

Question 117

Breast CA staging (8th ed AJCC) and relationship to Oncotype Dx

Answer 117

If Oncotype Dx has been performed on a T1 or T2 N0, ER+, any PR status, HER2-negative tumor, and the score is less than 11, then the tumor is classified as Stage IA regardless of tumor size.

If the Oncotype Dx score is 11 or greater, then the pathologic staging is based on TNM grade, ER, PR, and HER2 criteria.

Oncotype Dx Score 0-100

Recurrence risk

Predicts response to endocrine therapy and chemotherapy

Question 118

RFA for Breast CA

Answer 118

To perform RFA, a needle is inserted percutaneously within the tumor, usually with ultrasound guidance, but CT or MRI guidance may be used. A generator creates a high-frequency alternating current; in response, ions attempt to follow the changing direction, causing agitation and frictional heating. This results in destruction of the tumor tissue through thermal coagulation and protein denaturation

RFA appears to be limited to tumors with a maximum size of 2 cm. RFA treatment is not suitable for infiltrating lobular breast tumors, tumors with an extensive in situ component, and in patients treated with neoadjuvant systemic therapy. Complications from RFA are rare and generally mild, including skin or muscle burns and ecchymosis.