Breast, Skin & Soft Tissue

Question 1

Breast mass work up - don’t forget to ask

Answer 1

Family history of breast (female & male), ovarian, cervical cancer

Gail model: age, race, hx of breast dz, age of menarche, parity, FMHx, number bx

DONT FORGET to ask about Hx radiation & smoking!!!

Question 2

Breast BIRADS

Answer 2

BI-RADS 0 - Incomplete → requires more imaging
Includes benign findings on initial screening mammogram that are no longer present

BI-RADS 1 - Negative → routine f/u

BI-RADS 2 - Benign finding → routine f/u

BI-RADS 3 - Probably benign finding (0-2%) → f/u mammogram in 3-6 months

BI-RADS 4 - Suspicious abnormality → Need CNBx

BI-RADS 5 - Highly suggestive of cancer (≥95%) → Need CNBx

Question 3

DCIS management

Answer 3

BCT with lumpectomy, XRT, 5 years of tamoxifen (AI if post-menopause)

High grade or large tumors (>2.5 cm) → simple mastectomy w SLNBx, no radiation

Question 4

LCIS management

Answer 4

Excise area of suspicion

Pleomorphic LCIS → Only LCIS that needs negative margins

Recommend Tamoxifen for 5 years vs bilateral prophylactic subcutaneous mastectomy

Question 5

Who should get neoadjuvant chemotherapy in breast cancer

Answer 5

Any locally advanced tumor (N2/N3, T4, inflammatory) or if tumor is too large for BCT & pt wants BCT

Question 6

Contraindications for SLNBx in breast CA

Answer 6

Clinically palpable nodes (need ALND which takes levels I & II)

Pregnancy (with blue dye only)

Multicentric disease

Prior axillary surgery

Locally advanced disease or inflammatory (higher false-negative rate following neoadjuvant chemotherapy)

Question 7

Breast CA patients with positive nodes get adjuvant chemotherapy EXCEPT

Answer 7

+ER & (low risk) postmenopausal→ Aromatase inhibitor only

or low oncotype dx….

Question 8

Breast CA patients with tumors > 1cm & negative nodes should get adjuvant chemotherapy EXCEPT

Answer 8

+ER
Postmenopausal→ AI only
Premenopausal→ tamoxifen only

Question 9

Indications for XRT after MASTECTOMY & chemo

Answer 9

≥N2 (advanced nodal disease)
≥T3 (>5 cm) or T4 (inflammatory or Skin/chest wall involvement)
Positive margins of resection

Question 10

Chemotherapy for breast cancer

Answer 10

TAC (Taxanes (docetaxel & paclitaxel), adriamycin, cyclophosphamide) for 6-12 weeks

Question 11

Breast cancer in pregnancy - work up, management, what is safe & what is not safe

Answer 11

Mammogram & U/S, NOT MRI; staging w CXR & liver U/S

SAFE IN PREGNANCY
Adriamycin, Cytoxan
Colloid/Tc-99

NOT SAFE IN PREGNANCY
MRI, PET
Radiation
Lymphazurin & methylene blue
Transtuzumab
Tamoxifen/AI

Question 12

Diagnosis & management of
1. Paget’s
2. Phyllodes
3. Stewart-Treves (lymphangiosarcoma from chronic lymphedema following ALND)
4. Cutaneous angiosarcoma from prior radiation
5. Male breast cancer

Answer 12

Paget’s disease (Patients have DCIS or ductal CA in breast)
Dx: full thickness incisional breast biopsy including the skin (first step)
Tx: need MRM if cancer or multicentric DCIS; otherwise simple mastectomy (including NAC!) with SLNBx if DCIS is present

Phyllodes tumor → The only way to distinguish a fibroadenoma from phyllodes tumor is excision for histologic confirmation
Tx: WLE with negative margins (1 cm); no ALND

Stewart–Treves syndrome (patients present with dark purple nodule or lesion on arm 5–10 years after surgery)
Tx: WLE with 3-6 cm margins

Radiation associated sarcoma or cutaneous angiosarcoma
Tx: Neoadjuvant chemotherapy w taxane & total mastectomy

Male breast cancer tx
Tx: MRM & Tamoxifen, consider neoadjuvant chemotherapy if advanced

Question 13

SLNBx

Answer 13

1. NM injects radiotracer and performs lymphoscintigraphy prior to surgery
2. Inject methelyne blue into dermis of lesion & perform massage for 10 minutes
3. Perform lymph node dissection
4. The hot and blue nodes are identified as SLN, and given a gamma count
   –All nodes with gamma counts greater than 10% of the SLN should be removed
   –All blue nodes should be removed
   –All firm nodes should be removed

Question 14

MRM procedure

Answer 14

Simple mastectomy
1. Transverse elliptical incision to remove nipple & areola used to exciss breast skin & permit tension free closure
2. Create mastectomy flaps at least 0.5 cm thick
3. Dissect & remove breast with fascia of pectoralis major to borders (sternum medially, slavicle superiorly, LD laterally, rectus sheath inferiorly)

ALND
1. Open clavipectoral fascia
2. Identify axillary vein, thoracodorsal bundle, & long thoracic nerve & preserve
3. Dissect axillary tissue within boundaries of axillary vein superiorly, serratus medially, LD/subscapularis posteriorly, pec major/minor anteriorly

Question 15

Melanoma stains for what? Who needs staging and with what?

Answer 15

Stains for S-100 & HMB 45

If clinically positive nodes, need CT/PET, brain MRI, LDH

Question 16

Who needs a SLNBx in melanoma?

Answer 16

SLNB indicated for >1 mm thick, ≤1mm thick w ulcer, or ≥ 1 mitosis per mm2

Question 17

What margins are needed in Melanoma?

Answer 17

Melanoma in situ or thin lentigo maligna → JUST NEED 0.5 cm MARGINS

≤1.0 mm → 1.0 cm margins

1.1-2.0 mm → 1.0-2.0 cm margins

> 2.0 mm → 2.0 cm margins

Question 18

Management of positive SLNBx in melanoma

Answer 18

MSLT-2 trial → CLND vs observation w U/S (ie q3 months).

With CLND, there is no difference in melanoma-specific survival, but improved 5-year disease-free survival at the cost of higher likelihood of lymphedema (24% vs 6%)

Question 19

Adjuvant therapies for melanoma

Answer 19

Nivolumab & Pembrolizumab (PD1 inhibitors) improve recurrence free survival by 10%

Question 20

Superficial & deep inguinal lymph node dissection

Answer 20

Send Cloquet’s lymph node (bridging node between superficial & deep lymph node basin; if positive, need to do deep inguinal dissection)

SUPERFICIAL
1. Longitudinal incision in femoral triangle, expose femoral vessels, divide & ligate GSV & reflect LNs off femoral vessels. Detach specimen at inguinal ligament & take fatty issue 5 cm above ligament.
2. Detach sarorius proximally, mobilize medially to cover vessels, secure to EO aponeurosis/inguinal ligament
3. Place drain & close

DEEP
1. Second transverse incision above inguinal ligament
2. Detach the inguinal ligament from the
anterior superior iliac spine and reflect medially
3. Dissect the nodal tissue along the external and common femoral vessels and obtura- tor nerve, preserving the nerve, vessels, and ureter.
4. Reconstruct inguinal ligament
5. Place drain, close in layers

Question 21

Basal cell carcinoma dx & management

Answer 21

MC malignancy in USA
Pearly, rolled borders

Diagnosis/Staging
Pathology → Peripheral palisading of nuclei & stromal retraction
Morpheaform type is most aggressive, has collagenase

Treatment
0.5 cm margins
Regional adenectomy for clinically positive nodes

Question 22

SCC dx & management; indications for SLNBx if immunosuppressed

Answer 22

0.5-1.0 cm margins
2 cm margins for Marjolin’s ulcers & genitalia

Risk factors that warrant consideration for SNL in immunosuppressed
1. Tumor diameter >2 cm for the trunk and extremities, >1 cm for the face, scalp, hands, and feet
2. Poorly differentiated tumors
3. Presence of angiolymphatic invasion and perineural invasion
4. Tumor depth greater than 6 mm or invasion beyond the subcutaneous fat

Question 23

Merkel cell cancer diagnosis & staging

Answer 23

Dx with IHC (+NSE, +Cytokeratin, +neurofilament protein)

CK-20, similar to lung small cell cancer (which, unlike MCC, expresses TTF-1)

Most common site of metastasis is LN, skin, lung, CNS, liver

Need whole body PET CT

Question 24

Merkel cell cancer management

Answer 24

WLE w 2-3 cm margins & SLNBx vs formal LN dissection

If ≥2 cm or +LN, need adjuvant radiation