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ABSITE Review: Fiser, Decker, SCORE, UpToDate, TrueLearn > Chapter 24 - Breast+ > Flashcards

Chapter 24 - Breast+ Flashcards

1
Q

Estrogen leads to what part of breast development?

A

Duct (double layer of columnar cells)

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2
Q

Progesterone leads to what part of breast development?

A

Lobular (glandular) development

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3
Q

Prolactin has what effect on breast development?

A

Synergizes estrogen and progesterone

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4
Q

Estrogen causes what cyclic change in the breast?

A

Increased breast swelling, growth of glandular tissue

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5
Q

Progesterone causes what cyclic change in the breast?

A

Increased maturation of glandular tissue; withdrawal causes menses.

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6
Q

What cyclic change is caused by LH, FSH surge?

A

Causes ovum release

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7
Q

Long thoracic nerve innervates what? Injury results in what?

A

Serratus anterior; winged scapula

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8
Q

Thoracodorsal nerve innervates what? Injury causes what?

A

Latissimus dorsi; weak arm pull-ups and adduction

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9
Q

What artery goes to the serratus anterior?

A

Lateral thoracic artery (same name as nerve)

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10
Q

What artery goes to latissimus dorsi?

A

Thoracodorsal artery (same name as nerve)

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11
Q

Medial pectoral nerve innervates what?

A

Pectoralis major and minor

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12
Q

Lateral pectoral nerve innervates what?

A

Pectoralis major only

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13
Q

Intercostobrachial nerve comes from where? Innervates what?

A

From lateral cutaneous branch of the 2nd intercostal nerve; sensation to medial arm and axilla. Most commonly injured nerve.

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14
Q

Branches of what arteries supply the breast?

A

Internal thoracic artery, intercostal arteries, thoracoacromial artery, lateral thoracic artery

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15
Q

Batson’s plexus allows what to happen in breast cancer?

A

Valveless vein plexus that allows direct hematogenous mets to spine

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16
Q

What disease does primary axillary adenopathy most likely indicate?

A

1 lymphoma

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17
Q

Positive supraclavicular nodes indicate what nodal stage disease?

A

pN3c

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18
Q

Most common bacteria in breast abscess?

A

S. aureus, group B strep; associated with breastfeeding.

May need to cover Pseudomonas in neutropenic pts.

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19
Q

Treatment for abscesses?

A
  • I&D; ice, heat
  • drain milk - pump or breastfeed
  • if MRSA suspected - PO Bactrim or clindamycin
  • if no MRSA risk - dicloxacillin or cephalexin okay
  • if unstable or systemic illness - IV Vancomycin
    • leukocytosis, fever, tachycardia
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20
Q

Most common bacteria in infectious mastitis?

A

S. aureus; in nonlactating women can be due to chronic inflammatory diseases (actinomyces, TB, syphilis)

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21
Q

Workup for infectious mastitis?

A

Need to rule out necrotic cancer. If suspected, can do incisional biopsy including skin.

If purulent nipple discharge, gram stain and culture +/- I&D or needle aspiration.

Repeat episodes warrant duct excision.

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22
Q

What is periductal mastitis?

A

Inflammation of the subareolar ducts.

Mammary duct ectasia or plasma cell mastitis; dilated mammary ducts, inspissated secretions, marked periductal inflammation

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23
Q

Symptoms of periductal mastitis?

A

Noncyclical mastodynia, nipple retraction, creamy discharge from nipple; can have sterile subareolar abscess; pts with difficulty breastfeeding.

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24
Q

Treatment for periductal mastitis?

A

Reassure if discharge is creamy, non bloody and not associated with nipple retraction; otherwise r/o cancer.

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25
Q

What is a galactocele?

A

Breast cysts filled with milk usually 2/2 obstruction; occurs with breastfeeding.

Imaging shows fat-fluid level or indeterminate mass.

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26
Q

Treatment for galactocele? What is a possible complication?

A
  • Can aspirate - milky substance
  • Excision unnecessary - no malignant risk
  • Milk fistula:
    • usually following biopsy of galactocele
    • ​psx: milk drainage from biopsy site
    • tx: resolve w/ cessation of breastfeeding
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27
Q

What is galactorrhea caused by?

A

High prolactin (pituitary prolactinoma), OCPs, TCAs, phenothiazines, metoclopramide, alpha-methyl dopa, reserpine… either prolactinoma or meds.

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28
Q

What is gynecomastia? Caused by?

A
  • cimetidine, spironolactone, marijuana, idiopathic
  • cirrhosis, malnutrition
  • testicular tumors
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29
Q

What is the cause of neonatal breast enlargement?

A

Due to circulating maternal estrogens; will regress

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30
Q

Most common location for accessory breast tissue?

A

Axilla

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31
Q

What is the most common breast abnormality?

A

Accessory nipples

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32
Q

What is Poland’s syndrome?

A

Hypoplasia of chest wall, amastia, hypoplastic shoulder, no pectoralis muscle.

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33
Q

Workup for mastodynia?

A

Pain in breast; rarely represents breast CA. Workup is minimal unless concerning signs on H&P.

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34
Q

Treatment for mastodynia?

A
  • OCPs, tylenol, NSAIDs
  • Can try caffeine avoidance, primrose oil
  • Bromocriptine no longer used
  • Danazol - effective, but androgenic sfx
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35
Q

What is cyclic mastodynia most commonly caused by?

A

Fibrocystic disease

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36
Q

What is continuous mastodynia caused by?

A

Most commonly acute or subacute infection

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37
Q

What is Mondor’s disease?

A

Superficial vein thrombophlebitis of breast; cordlike, can be painful.

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38
Q

What is Mondor’s associated with? Treatment?

A

Trauma and strenuous exercise; NSAIDs. Abx usually not necessary unless severe or systemic. Surgery last line.

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39
Q

Symptoms of fibrocystic disease?

A

Breast pain, nipple discharge (uncommon, yellow to brown), masses, lumpy breast tissue that varies with hormonal cycle.

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40
Q

How can sclerosing adenosis present?

A

Cluster of calcifications on mammogram without mass or pain

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41
Q

How is sclerosing adenosis differentiated from breast CA pathologically?

A

By regularity of nuclei and absence of mitoses

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42
Q

Most common cause of bloody discharge from nipple?

A

Intraductal papilloma

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43
Q

Malignancy risk with intraductal papilloma?

A

NOT premalignant

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44
Q

Treatment of intraductal papilloma?

A

Resection (subareolar resection curative)

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45
Q

What is the most common breast lesion in adolescents and young women?

A

Fibroadenoma

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46
Q

Characteristics of fibroadenoma?

A
  • Young females
  • Painless, slow growing, well-circumscribed, firm and rubbery
  • Usually single lesion
  • Change size in pregnancy (hormone affected)
  • Grows to several cm in size then stops
  • imaging: solid w/ lobulated margins on
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47
Q

Pathology of fibroadenoma? Mammography findings?

A

Prominent fibrous tissue compressing epithelial cells; popcorn lesions (large, coarse calcifications)

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48
Q

Work up of nipple discharge?

A
  • H&P: nonbloody and multiductal vs persistent, uniductal, unilateral, spontaneous
  • If suspicious: ultrasound and bilateral mammogram
  • Pathological nipple discharge requires excision of the duct.
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49
Q

What is green discharge due to? What is the treatment?

A

Fibrocystic disease; if cyclical and nonspontaneous, reassure patient

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50
Q

What is bloody discharge due to? Treatment?

A

Most commonly intraductal papilloma, occasionally ductal CA; excision of that ductal area

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51
Q

What is serous discharge due to? Treatment?

A
  • Usually d/t papilloma, but worrisome for cancer.
  • If unitaleral and spontaneous, will require full workup and excisional biopsy of that ductal area.
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52
Q

What is spontaneous discharge due to? Treatment?

A

Worrisome for cancer no matter what color or consistency; ductal excision

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53
Q

What is nonspontaneous discharge due to? Treatment

A

Pressure, tight garments, exercise; not as worrisome

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54
Q

Characteristics of diffuse papillomatosis? Risk of cancer?

A

Multiple ducts of both breasts, larger when solitary, serous discharge; increased risk of cancer (40%)

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55
Q

Mammogram findings of diffuse papillomatosis?

A

Swiss cheese appearance

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56
Q

Definition of ductal carcinoma in situ?

A

Malignant cells of ductal epithelium without invasion of the basement membrane

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57
Q

% risk of cancer with DCIS?

A

50-60% get cancer if not resected; 5-10% will get cancer in contralateral breast.

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58
Q

Mammogram findings with DCIS?

A

Usually not palpable; cluster of calcifications on mammography

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59
Q

Margins needed with excision of DCIS?

A

2-3mm

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60
Q

Patterns of DCIS?

A

Solid, cribriform, papillary, comedo

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61
Q

What is the most aggressive subtype of DCIS?

A

Comedo pattern; with necrotic areas; high risk for multicentricity, microinvasion, recurrence

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62
Q

What characteristics increase the recurrence risk following excision of DCIS?

A

Comedo type, lesions >2.5cm

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63
Q

Treatment for DCIS?

A
  • Lumpectomy and XRT, +/-tamoxifen
  • Simple mastectomy for high grade, if large tumor not amenable to lumpectomy, or not able to get good margins
  • NO ALND
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64
Q

Cancer risk with lobular carcinoma in situ?

A

40% get cancer (either breast)

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65
Q

Is LCIS premalignant?

A

NO, considered a marker for the development of breast CA; do NOT need negative margins

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66
Q

What type of breast CA do patients with LCIS develop?

A

More likely to develop ductal CA (70%)

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67
Q

% risk of having synchronous breast CA at the time of diagnosis of LCIS?

A

5%

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68
Q

Treatment for LCIS?

A
  • If dx by CNB - surgical excision
  • If dx surgical excision - done
    • pleomorphic requires excision to (-) margins
  • otherwise: (-) margins, radiation, nodes not needed
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69
Q

Lifetime risk of breast cancer?

A

1 in 8 women (12%); 4-5% in women with no risk factors

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70
Q

What % will screening decrease mortality of breast cancer by?

A

25%

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71
Q

Median survival of untreated breast cancer?

A

2-3y

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72
Q

Clinical features of breast CA?

A

Distortion of normal breast architecture, skin/nipple distortion or retraction, hard, tethered, indistinct borders

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73
Q

Workup for symptomatic breast mass in pt <30y?

A

US: if solid - needle bx; excisional biopsy if needle bx is nondiagnostic

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74
Q

Workup of symptomatic breast mass in patient 30-50y?

A

Bilateral dx mammograms and needle bx; excisional biopsy if needle bx nondiagnostic (discordant findings).

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75
Q

Workup of symptomatic breast mass in pt >50y?

A

Bilateral mammograms and excisional or core needle biopsy.

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76
Q

Workup for a breast cyst?

A
  • US and FNA…
  • bloody: cyst excisional biopsy
  • clear + recurs: rpt US FNA
    • if recur x3: US, mammo, MRI
    • if suspicious: excisional bx
  • complex: FNA, CNBx, or cyst excisional bx
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77
Q

What is the sensitivity/specificity of mammography?

A

90%; sensitivity increases with age as the dense parenchymal tissue is replaced with fat

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78
Q

Size of tumor that is able to be detected by mammography?

A

>5mm

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79
Q

General screening guidelines for patients at average risk for breast cancer?

A
  • USPSTF: After 50, every 2 yrs; 40-50 if wanted
  • ACS/ACR/NCCN: yearly 40-54; every other year thereafter
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80
Q

What are the node levels of the breast?

A
  • I: lateral to pec minor
  • II: beneath pec minor
  • III: medial to pec minor
  • Rotter’s nodes - between the pec major and minor
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81
Q

What level node needs to be sampled in breast cancer patients undergoing axillary lymph node dissection?

A

Level I and II

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82
Q

What is the most important prognostic factor in breast cancer?

A

Nodal status; also tumor size, grade, progesterone/estrogen receptor status

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83
Q

5-year survival if 0 positive nodes?

A

75%

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84
Q

% of nonpalpable nodes that are positive at surgery?

A

30%

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85
Q

5 year survival if 1-3 nodes are positive (N1)?

A

60%

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86
Q

5 year survival if 4-10 nodes are positive (N2)?

A

40%

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87
Q

What is the most common location of distant mets in breast cancer?

88
Q

What characteristics of tumor have increased multicentricity?

A

Central and subareolar tumors

89
Q

T staging for breast cancer?

A
  • T1: <2 cm
  • T2: 2-5 cm
  • T3: >5 cm
  • T4: skin or chest wall involvement, peau du’orange, inflammatory cancer
90
Q

N staging for breast cancer?

A
  • N1: 1-3 nodes
  • N2: 4-9 nodes
  • N3: 10 or more
91
Q

Factors that will greatly increase breast cancer risk?

A
  • BRCA gene
  • >2 primary relatives w/ BL/premenopausal br ca
  • DCIS and LCIS
  • fibrocystic disease with atypical hyperplasia
92
Q

Factors that will moderately increase risk of breast cancer?

A
  • FH of breast cancer
  • early menarche
  • late menopause
  • nulliparity
  • radiation
  • previous breast CA
  • environmental risk factor (high-fat diet, obesity)
93
Q

How much does a 1st degree relative with bilateral, premenopausal breast cancer increase breast cancer risk?

94
Q

Other cancers associated with BRCA I?

A
  • ovarian (50%)
  • endometrial CA
  • consider TAH, bilateral oophorectomies
95
Q

Other cancer associated with BRCA II?

A

Male breast cancer

96
Q

Requisites for prophylactic mastectomy?

A
  • FH + BRCA gene
  • LCIS, plus one of the following: anxiety, poor access to follow up exams, difficult lesion to follow, patient preference
97
Q

Receptor positive tumors lead to what prognosis?

A

Better response to hormones, chemo, surgery, and better overall prognosis

98
Q

Which receptor-positive tumors have best prognosis?

A
  • Progesterone > estrogen
  • Both positive with best prognosis
99
Q

What % of breast cancers are negative for both receptors?

100
Q

What type of cancer do males usually have?

101
Q

Male breast cancer is associated with what?

A

Steroid use, previous XRT, FH, Klinefelter’s syndrome, prolonged hyperestrogenic state

102
Q

Treatment of male breast cancer?

A

If not much breast tissue, do mastectomy with SLNB.

If adequate breast tissue, do lumpectomy w/ XRT.

103
Q

What % of breast CAs are ductal?

104
Q

What are the subtypes of ductal CA?

A

Medullary, tubular, mucinous, scirrhotic

105
Q

Characteristics of medullary breast CA?

A

Smooth borders, high lymphocytes, ductal type cancer with bizarre cells; majority E+/P+, more favorable prognosis.

106
Q

Characteristics of tubular CA?

A

Small tubule formations, nodes + in 10%, more favorable prognosis.

107
Q

Characteristics of mucinous CA?

A

Colloid, produces an abundance of mucin, more favorable prognosis

108
Q

Characteristics of scirrhotic CA?

A

Worse prognosis

109
Q

Treatment for invasive ductal CA?

A
  • local therapy: lumpx + SLNB w/ rad vs mastx +/- rad
  • systemic therapy pending pathology
110
Q

What % of breast cancers are lobular?

111
Q

Characteristics of lobular CA?

A

Does not form calcifications, infiltrative, inc. bilateral, multifocal and multicentric

112
Q

Lobular cancer with signet ring cells have what prognosis?

113
Q

Treatment for lobular CA?

A

MRM or lumpectomy with ALND (or SLNB); postop XRT

114
Q

Treatment for inflammatory cancer?

A

treat like locally advanced breast cancer

  • dx: peau d’orange <6mo in >1/3 of breast w/ bx showing invasive cancer
  • stage w/ CT CAP, bone scan
  • neoadjuvant chemo
  • modified radical mastectomy
  • adjuvant radiation
115
Q

Stage of inflammatory cancer?

A

Considered T4

116
Q

Median survival of inflammatory cancer?

A

Very aggressive; 36mo

117
Q

What causes the peau d’orange lymphedema of inflammatory cancer?

A

Dermal lymphatic invasion; erythematous and warm

this is characteristic on biopsy, though not required for diagnosis

118
Q

Preoperative studies needed before breast surgery?

A
  • bilateral diagnostic mammograms
  • +/- CXR
  • +/- CBC, LFTs
  • if LFTs elevated - abdominal CT
  • if headaches - head CT
  • if bone pain or inc ALP - bone scan
119
Q

Simple mastectomy indications?

A
  • extensive DCIS, LCIS (consider adding SLNB d/t risk of upstaging)
  • candidates for BCT, but would rather have mastectomy
  • candidates for BCT, but cannot get radiation
  • consider skin-sparing mastectomy in these patients (oncologically safe)
    • not possible for inflammatory breast cancer
  • if patients require axillary node dissection (matted nodes or bx proven cancer in nodes) - do MRM
120
Q

Margins necessary when doing a simple mastectomy?

A

try for 1cm

121
Q

Contraindications for SLNB?

A
  • no need: DCIS/LCIS (unless doing mastectomy)
  • contraindicated:
    • pts with clinically positive nodes (stage III)
    • T4 disease
    • inflammatory breast cancer
    • neoadjuvant chemo
    • prior axillary surgery
  • can be done: previous excisional biopsy
122
Q

Complications of lymphazurin blue?

A

Type I hypersensitivity reactions

123
Q

What next if no SLN found during SLND?

A

Formal ALND

124
Q

The sentinel node is found in what % of the time?

125
Q

Modified radical mastectomy includes what?

A
  • all breast tissue
  • pectoralis fascia
  • nipple areolar complex
  • axillary node dissection (level I and II)
126
Q

Radical mastectomy includes what?

A
  • MRM and overlyting skin
  • pectoralis major and minor
  • level I, II, III lymph nodes
127
Q

Complications of axillary lymph node dissection?

A

Infection, lymphedema, lymphangiosarcoma, axillary vein thrombosis, lympatic fibrosis, intercostal brachiocutaneous nerve injury

128
Q

Signs of axillary vein thrombosis?

A

Sudden, early, postop swelling

129
Q

Most commonly injured nerve after ​mastecomy?

A

Intercostal brachiocutaneous nerve; hypersthesia of inner arm and lateral chest wall

130
Q

Radiotherapy dose for breast cancer?

A

5000 rad for lumpectomy and XRT

131
Q

Complications of XRT?

A

Edema, erythema, rib fractures, pneumonitis, ulceration, sarcoma, contralateral breast CA

132
Q

Contraindications of XRT?

A

Scleroderma, previous XRT, SLE, active RA

133
Q

What is the chance of recurrence following lumpectomy with XRT?

A

10%; usually within first 2 years, average is 3-4 yrs

134
Q

Treatment with local recurrence?

A
  • risk higher if never received RT; usually occurs 3-4 yrs s/p tx
  • suspect if any change/new mass 2-3 yrs s/p tx
  • dx: CT CAP, bone scan, needle bx
  • Salvage mastectomy​
    • if no previous RT - add adj RT
    • if skin involved/inflammatory - neoadj chemo
    • if clinically neg axilla and no previous ALND - SLNB
135
Q

Which patients get chemo?

A
  • Large/T3/5cm, Stage III/Positive nodes
  • neoadj preferred if found pre-op
  • add postop if upstaged
136
Q

By what percent does tamoxifen decrease short-term risk of breast cancer by?

137
Q

What is the risk of blood clots on tamoxifen?

138
Q

What is the risk of endometrial cancer in patients that are on tamoxifen?

139
Q

What are the symptoms of a metastatic flare? What is the treatment?

A

Pain, swelling, erythema in metastatic areas; XRT

140
Q

What is occult breast cancer?

A

Breast-cancer that presents as axillary metastases with unknown primary

141
Q

What percent of occult breast-cancer are found to have breast cancer at mastectomy?

142
Q

What are benign conditions that mimic breast cancer?

A

Radial scar, fibromatosis, granular cell tumors, fat necrosis

143
Q

Which malignant tumors have a benign appearance; smooth rounded masses?

A

Mucinous cancer, medullary cancer, cystosarcoma phyllodes

144
Q

How does Paget’s disease present? What is the treatment?

A

Presents with scaly skin lesion on nipple; biopsy shows Paget’s cells. Need modified radical mastectomy if cancer present, otherwise simple mastectomy

145
Q

What percent of cystosarcoma phyllodes are malignant? How is the diagnosis made?

A

10%; based on mitoses per high-power field, resemble giant fibroadenoma, has stromal and epithelial elements

146
Q

What is the treatment for cystosarcoma phyllodes?

A

Wide local excision with negative margins, no ALND

147
Q

What is Stuart-Treves syndrome?

A

Lymphangiosarcoma from chronic lymphedema following axillary dissection, presents with dark purple nodule on the arm 5 to 10 years after surgery

148
Q

What is the prognosis for a mass that presents during pregnancy?

A

Worse prognosis because it tends to present late

149
Q

Treatment for breast cancer that presents during pregnancy?

A

First trimester: MRM; second trimester: MRM; third trimester: MRM or if late can perform lumpectomy with ALND and postpartum XRT; no chemo or radiation while pregnant, no breast-feeding after delivery

150
Q

Surgical evaluation is indicated if there is what associated with nipple discharge?

A
  • breast mass
  • spontaneous
  • uniductal
  • bloody
151
Q

In patients with nipple discharge, if physical examination is otherwise normal, imaging is negative, and the discharge is multiductal and nonbloody, what does the patient need?

A

laboratory tests, medical evaluation, and galactorrhea workup.

152
Q

What to do with BI-RADS 1 or 2?

A

continue annual mammography

153
Q

What to do with BI-RADS 3?

A

short-term follow-up - ipsilateral mammogram at 6 months, bilateral mammograms at 12 and 24 months

154
Q

What to do with BI-RADS 0?

A

Additional imagin

155
Q

What is the use of an ultrasound in a breast exam?

A

to distinguish between solid and cystic, especially in the younger population

156
Q

When is surgical biopsy appropriate for breast cancer workup?

A

If percutaneous biopsy is not feasible d/t anatomic considerations. If image-guided biopsy reveals discordant pathology from imaging.

157
Q

When is MRI appropriate in the setting of breast cancer?

A

Used for imaging after the diagnosis of breast cancer and for women who have increased risk in breast cancer. There is minimal evidence to support its use for screening in the general population.

158
Q

Next step for 31yr patient with breast mass?

A

mammogram and ultrasound

159
Q

Next step for 29yr patient with breast mass?

A

ultrasound, +/- mammogram pending findings

160
Q

How to manage cystic breast masses?

A
  • common in premenopausal women
  • US is diagnostic, add mammo if >30
  • FNA biopsy/aspiration - do not send clear fluid d/t high likelihood of false positive
  • If mass doesn’t completely disappear, get biopsy of solid component
161
Q

How do you manage mastalgia?

A

This is often non-cancerous and of unknown etiology. Treat conservatively and reassure. Consider NSAIDs. Consider danazol, tamoxifen. Surgery is not recommended.

162
Q

How do you manage lumpy or cobblestone breasts with ridges of tissue appreciated on palpation that evolves with the menstrual cycle?

A

Likely fibrocystic change (not “disease”). This is a normal variant that often occurs in women 30-50, improves with OCPs, and resolves with menopause. Treat symptoms. Unlikely breast cancer if no dominant mass can be found (workup like breast mass if one is found).

163
Q

What is physiological nipple discharge?

A

milky and bilateral

164
Q

Nipple discharge that is nonbloody, but dark green or brown is associated with what?

A

Ductal ectasia - a result of keratin plugs w/ associated inflammation and secretion causing dilation that can be seen on US.

165
Q

Workup for pathological nipple discharge?

A
  • US and BL mammography
  • tissue diagnosis of masses found
  • surgical excision of duct
166
Q

In a patient with nipple discharge and concern for endocrine disorder, what labs should be ordered?

A

TSH, prolactin

167
Q

In a patient with nipple discharge, concern for endocrine disorder, and elevated prolactin, what test should be ordered?

A

MRI to look for prolactinoma

168
Q

How do you differentiate a fibroadenoma from a phyllodes tumor?

A
  • Clinical findings are the same
  • The clues will be rapid growth and size
  • Imaging (mammo) will not always differentiate
  • CNB may not differentiate
  • surgical excision will definitively tell
169
Q

If CNB or FNA shows atypia, atypical ductal/lobular hyperplasia, LCIS, radial scar, what should be done?

A

formal surgical excision

170
Q

A young patient with a firm irregular breast mass presents and eventually receives a CNB showing saponification, chronic inflammation, lymphocytes, histiocytes. She has a hx of mammoplasty. What is the dx?

A

fat necrosis

171
Q

A patient who just gave birth presents with a tender nodule in a breast. Imaging shows well-circumscribed mixed denisty lesion. US shows partially cystic mass. What is the dx and treatment?

A

galactocele,

172
Q

A patient presents with a tender and palpable cord in her breast. What is the dx and treatment?

A

Mondor disease. Treat conservatively with NSAIDs. May require abx and even excision if infected or not responding to treatment.

173
Q

What is the most common organism identified in mastitis?

174
Q

In a patient with breast pain who gives a history of “cracked nipple” or an abrasion in the breast, what is the first thought for diagnosis?

A

Mastitis. Will usually also have erythema, swelling, and tenderness of the breast.

175
Q

Should a breastfeeding patient with mastitis continue breastfeeding?

A

Yes. Antibiotics chosen should take into account the safety of the infant.

176
Q

Do atypia and radial scar increase risk of breast cancer?

A

Yes. 4 fold. That’s why excisional biopsy is recommended.

177
Q

Is LCIS associated with an increased risk of breast cancer?

A

Yes. Increased lifetime risk of 20-25%. However it is not pre-malignant, so you don’t need negative margins. But because of the increased chance of associated cancer within the rest of the lesion, an excisional biopsy must follow.

178
Q

What happens to prolactin levels in most medication induced gynecomastia (men)? How do you treat?

A

Often elevated. Changing medication will usually cause regression. Aromatise inhibitors or tamoxifen can treat medically if surgery is to be avoided in men.

179
Q

A male presents with a solitary hard mass in his breast. There is palpable adenopathy and skin changes. What do you do?

A

Aggressive workup. Mammography and CNB are necessary.

180
Q

In a patient with nipple excoriation and a presumed dx of dermatitis of the breast, what do you do if there is no recovery after 2 weeks after topical steroids and removal of known offending agents?

A

Punch biospy. Need to rule out Paget disease.

181
Q

When is a lumpectomy considered adequate for invasive breast cancer?

A

no ink on tumor

182
Q

S/p lumpectomy, what do you do if there is ink on the tumor?

A

re-excision first, then mastectomy if positive again

(exception for need for re-excision is if positive margin was at chest wall where fascia had been taken OR at positive margin at the skin)

183
Q

What are the relative indications for mastectomy in patients with invasive ductal cancer?

A
  • multiple failed BCT attempts (no absolute number of attempts)
  • multicentric cancer in separate quadrants (separate by 5 cm)
  • extensive cancer (DCIS included)
  • lung cancer (consider neoadj therapy)
  • previous radiation to ipsilateral breast
  • patient preference (inherited susceptibility)
184
Q

When is immediate reconstruction reasonable?

A

early-stage, but remember that radiation can cause painful contracture

locally advanced cancer should (eg T4) should not undergo immediate reconstruction

185
Q

When is nipple-sparing mastectomy a reasonable choice for breast cancer?

A

the nipple and areola are normally resected with mastectomy

small tumors located in the periphery of the breast or breast cancer risk-reducing surgeries are situations where nipple-sparing surgery is reasonable

186
Q

During the physical exam for breast mass, there is a palpable mass in the axilla, but you are unsure if it is a lymph node. What do you do?

A

US-guided biopsy - FNA or core needle

187
Q

When must axillary lymph node dissection be used when sentinel nodes are positive?

A

If there are greater than 2 positive nodes.

188
Q

When should radiation be used in breast cancer?

A
  • postop lumpectomy
  • postop mastectomy if >5 cm tumor, margins positive, or lymph nodes positive (4 or more)
189
Q

What is the benefit of post-lumpectomy radiation?

A

decreases local recurrence and improves survival

190
Q

What do you do for breast cancer recurrence after BCT (not positive margin, but a remote recurrence)?

A

mastectomy - the recurrence may be multi-focal, radiation a second time is too damaging to tissues

191
Q

Adjuvant systemic therapy consists of what two types of meds?

A

endocrine (aromatase inhibitor), SERM (tamoxifen)

192
Q

When is neoadjuvant therapy used for breast cancer?

A

locally advanced breast cancer

  • larger tumors (>5cm, T3)
  • stage III breast cancer
  • clinically positive nodes
  • inflammatory breast cancer
193
Q

Who should antiestrogen therapy be given to?

A

Patients with hormone-receptor-positive breast cancer. 10 years.

194
Q

Who should aromatase inhibitors (anastrozole) be given to?

A

post-menopausal breast cancer patients who are hormone-receptor-positive

195
Q

What should you do for an otherwise healthy patient who is diagnosed with a small triple-negative breast cancer?

A

adjuvant chemotherapy

196
Q

What do you add for patients with HER-2/neu positive breast cancer?

A

standard chemo plus trastuzumab for 1 year - reduces the risk of distant metastatic disease

197
Q

What is the management in breast cancer spread to the supraclavicular nodes?

A

N3c - advanced disease

requires multidisciplinary/multimodal approach - surgery, chemotherapy, hormone therapy, and RT

198
Q

What is the role for surgery in distant metastasis (liver, lung)?

199
Q

What is the management for recurrent breast cancer in the axilla?

A
  • evaluate for metastasis: CT CAP, bone scan
  • ALND if previous SLNB
  • resect if no mets
  • supraclavicular nodes can be approached with curative intent - neoadjuvant systemic therapy, then local therapy (surgery vs RT vs combo)
200
Q

How do you manage axillary node disease shown to be adenocarcinoma after biopsy?

A
  • almost always breast cancer
  • mammography -> if negative, MRI -> if negative, assume breast cancer
  • ALND w/ stage and biomarker appropriate systemic therapy
    • if large/bulky nodes, give neoadj (stage III)
  • whole breast radiation
  • mastectomy is NOT necessary
  • whole body imaging is NOT necessary
201
Q

How is breast cancer in pregnancy managed?

A
  • try for the same treatment as non-pregnant
  • no chemo in first trimester
  • no radiation until after delivery (no BCT in 1st/2nd trimester)
  • SLNB done w/ radioactive sulfur colloid (no methylene blue, counter-intuitively)
  • BCT can be done 3rd trimester, otherwise, chemo considered until ok for BCT
202
Q

Which breast cancer pts require adjuvant radiation?

A
  • All BCT pts (even DCIS, LCIS does not)
  • neoadj pts (locally advanced: T3 or stage III)
  • positive margins after mastectomy
  • NOT needed: post-mastectomy with negative margins and, no high risk features, and negative nodes
203
Q

Which breast patients require stereotactic core needle biopsy?

A

can’t palpate the lesion

204
Q

Can breast cancer patients with locally advanced disease get SLNB?

A
  • only those with T3
  • clinically positive nodes, skin/chest wall involvement, inflammatory breast cancer are NOT candidates for SLNB
205
Q

What is the significance of ER positivity in breast cancer management?

A

Endocrine therapy - depends on menopausal status

  • Premenopausal - tamoxifen
  • Postmenopausal - anastrozole (aromatase inh)
206
Q

Guidelines for patients at high-risk for breast cancer.

A
  • genetics-based risk, 20% lifetime risk - annual mammogram at 30 yrs
  • hx of chest radiation before 30 - annual mammogram at 25 yrs
  • if both above are true - annual MRI starting 25-30 yrs
  • personal hx of breast cancer + dense breasts - annual MRI surveillance
  • hx ADH, atypical lobular hyperplasia, LCIS - consider MRI
  • all women should be evaluated at 30 for increased risk
207
Q

What has the innovation of tomosynthesis in mammography done to recall, cancer detection, and DCIS detection?

A

decreased recall rates (false-positive - additional imaging/biopsy w/ final benign dx)

increase in invasive cancer detection

no increase in detection of DCIS

208
Q

What does breast cancer do to mammogram sensitivity and risk of breast cancer?

A

decreases sensitivity

independent increased risk of breast cancer

supplemental screening like whole breast US can be used

209
Q

During initial screening mammogram, if an abnormality is detected requiring additional imaging, what is the BI-RADS assessment?

A

0 - requires additional imaging

210
Q

What is the most sensitive test to detect breast cancer?

A

Breast MRI. Unaffected by breast density. No radiation.

Uses: eval of extent after positive diagnosis, f/u after neoadj chemo, w/u of unknown primary w/ axillary metastasis, equivocal conventional imaging

211
Q

When planning an excisional biopsy, how do you plan the incision?

A

Along the lines of minimal skin tension (concentrically around the nipple), in areas that can be hidden.

212
Q

If image-guided biopsy reveals discordant pathology from imaging, what is the next step?

A

Surgical biopsy

213
Q

Which patients should be considered for annual MRI screening for breast cancer?

A
  • BRCA and first-degree relatives
  • 20% lifetime risk
  • radiation to the chest b/w 10-20 yrs
  • Li-Fraumeni (p53) and first-degree relatives
  • Cowden syndrome (PTEN) and first-degree relatives
  • if MRI screening is done, MRI biopsy should be available
214
Q

Which patients should be considered for chemoprevention?

What are options?

A
  • Gail score 1.67
  • ADH
  • LCIS
  • tamoxifen for most
  • raloxifene for postmenopausal (tx osteoporosis)
215
Q

What are the side effects of tamoxifen?

A

hot flashes, DVT, increased risk of endometrial cancer

216
Q

What procedure can reduce the risk of breast cancer by 90% in patients who are high-risk 2/2 genetic predisposition?

A

bilateral prophylactic mastectomy, should offer immediate recon

oophorectomy can confer a 50% breast cancer risk reduction

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