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Repro Week 1 > ICL 10.3: Breast Disorders Pathology > Flashcards

ICL 10.3: Breast Disorders Pathology Flashcards

1
Q

what is amasita?

A

absence of breast

unilateral amastia is more common than bilateral – usually associated with congenital absence of shoulder girdle, chest or arm

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2
Q

what is accessory breast tissue?

A

accessory breast tissue is located along a line from the axilla to the groun

accessory nipples are more common than accessory nipple and areola components or accessory breast

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3
Q

what are the 2 kinds of breast abscess?

A
  1. parenchymal breast abscess

2. subareolar breast abscess

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4
Q

what is a parenchymal breast abscess?

A

usually in younger women

more common during lactation

staph Aureus is commonest bacteria

presents with very tender mass with or without erythema

initially treated with aspiration or incision and drainage and antibiotic.

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5
Q

what is a subareolar breast abscess?

A

milk duct gets clogged and there’s enlargement of the duct and rupture which leads to inflammation and bacterial infiltration resulting gin abscess

staph Aureus, strep, enterococci are common organisms

the treatment requires excision of all the involved subareolar ducts and antibiotics.

has high incidence of recurrent subareolar abscess.

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6
Q

what are the benign breast lesions?

A
  1. fibroadenoma
  2. ductal and lobular hyperplasia
  3. ductal metaplasia
  4. atypical ductal and tubular hyperplasia
  5. sclerosis adenosis
  6. papilloma of the ducts
  7. gross cystic and microcytic breast disease
  8. fibrocystic breast disease
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7
Q

what is fibrocystic breast disease?

A

a benign disease comprised of a number of different pathologic entities including: ductal ectasia, apocrine metaplasia, fibrosis, cyst formation, ductal or lobular hyperplasia, atypical ductal or lobular hyperplasia (atypical proliferative disease, sclerosing adenosis and papillomatosis

sclerosing adenosis, atypical proliferative disease such as atypical ductal hyperplasia, or atypical lobular hyperplasia has increased risk (relative risk 3-4 times) of subsequent development of cancer

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8
Q

what are the neoplastic diseases of the breast?

A
  1. ductal carcinoma in situ
  2. lobular carcinoma in situ
  3. invasive ductal carcinoma
  4. invasive lobular carcinoma
  5. malignant phylloides tumor
  6. sarcoma
  7. lymphoma
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9
Q

what is the incidence of breast cancer?

A

projected incidence is 1 in 9 women

approximately 240,000 new cases/year

the incidence of breast cancer in average woman without any risk factor is 6%.

chance of women developing breast cancer in ten year period from age 40 to age 50 is about 1.3%

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10
Q

what are the risk factors for breast cancer?

A

LOW RISK
1. early menarche/late menopause

  1. HRT
  2. multiparity
  3. post-menopausal
  4. obesity
  5. alcohol

INTERMEDIATE
1. one 1st degree relative with breast cancer

  1. CHEK-2 mutation
  2. 1st childbirth over 35 years old
  3. dense breast

HIGH
1. BRCA1 or 2 mutation

  1. CDH-1 mutation
  2. p53 suppression
  3. LCIS
  4. ADH/ALH
  5. early age radiation exposure
  6. CDH 1 mutation in female patients
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11
Q

what genetic mutations are the most common causes of breast cancer?

A

92% is actually sporadic breast cancer….

all the rest are only 1%…

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12
Q

what is familial breast cancer?

A

at least two 1st degree relatives involved

one of them is below age 50

one of them is bilateral or multi-centric

maternal history more important

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13
Q

which gene mutations are involved in familial breast cancer?

A
  1. BRCA-1 mutation
  2. BRCA-2 mutation
  3. Li Fraumeni Syndrome
  4. CHEK-2 mutation
  5. MMR gene mutation (HNPCC)
  6. CDH-1 mutation
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14
Q

which chromosomes are BRCA 1 and 2 on?

A

BRCA1 is on chromosome 17

BRCA2 is on chromosome 13

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15
Q

what is the risk of breast cancer in BRCA1, 2 and CDH1?

A

BRCA 1 = 50-60%

BRCA2 = 50-65%

CDH-1 = 40%

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16
Q

which gene mutation is most associated with male breast cancer?

A

BRCA2

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17
Q

which cancers are associated with BRCA 2 mutations?

A

2% pancreas

increased prostate

6% male breast cancer

10-25% ovary primary peritoneal

35% in 5 years for contralateral breast cancer

55-80% female breast cancer

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18
Q

what are the prognostic markers associated with sporadic breast cancer?

A

70% ER (+)

60% PR (+)

15-20% HER2/NEU (+)

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19
Q

what are the prognostic markers associated with BRCA1 breast cancer?

A

20-30% ER (+)

30% PR (+)

0-3% HER2/NEU (+)

so they’re more likely to be triple negative breast cancers….

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20
Q

what are the prognostic markers associated with BRCA2 breast cancer?

A

70% ER (+)

60% PR (+)

15-20% HER2/NEU (+)

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21
Q

how do you manage a BRCA mutated patient?

A
  1. bilateral prophylactic mastectomy offers best but not absolute protection against breast cancer (90% reduction of risk of cancer)
  2. bilateral prophylactic oophorectomy after childbearing decreases breast cancer by 50% and ovarian cancer by 70%
  3. bilateral mastectomy and bilateral oophrectomy reduces the risk of breast cancer by 95%

bilateral oophorectomy is really important because they have higher risk of mortality

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22
Q

how do you manage patients with BRCA mutations that don’t want prophylactic mastectomy?

A
  1. self-breast exam every 6 months
  2. physician conducted exam every 6 months
  3. both yearly mammograms and MRI to start at age 5 years before youngest affected member or by age 35
  4. pelvic ultrasound yearly from age 30
  5. value of CA-125 is unproven
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23
Q

how do you treat breast cancer in a gene mutated patient who has cancer?

A
  1. bilateral total mastectomy with SLN biopsy (AND if necessary) on side of breast cancer is the standard treatment
  2. partial mastectomy and rad has high incidence of IBTR after 8 yrs. period of time
  3. prophylactic bilateral salpingo-oophorectmy should be strongly recommended
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24
Q

how do you screen for breast cancer?

A

mammography is the only acceptable population-based screening study

MRI is indicated for surveillance of high risk group but not general population

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25
Q

how accurate is mammography for screening breast cancer?

A

mammography is the proven main modality in screening for breast cancer

the false negative rate of mammography is between 5-15%….yikes

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26
Q

what causes false negative mammograms?

A
  1. obscuration of the mass by overlying breast tissue
  2. poor image quality
  3. errors of perception
  4. breast cancer indistinguishable from normal breast tissue
  5. failure to image the region of interest
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27
Q

what is the BI-RADS classification system?

A

Breast Imaging Reporting and Data System

it standardized reporting of mammography findings, facilitates communication of findings, recommendations and medical audits

first published by The American College of Radiology in 1992, and is revised periodically

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28
Q

what are the categories of the BI-RADS?

A

0
- incomplete imaging - additional imaging needed

1
- negative imaging - routine screening recommended

2
- benign findings - routine screening recommended

3
- probably benign - 6 M. F/U recommended

4
- suspicious - biopsy should be considered

5
- highly suggestive - appropriate action suggested

6

  • known biopsy with proven cancer
  • appropriate action suggested
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29
Q

on mamograms, what are the characteristics of benign vs. suspicious calicifications?

A

benign = coarse, rough, large

suspicious = faint, fine, small, branching –> often a marker of ductal carcinoma in situ

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30
Q

what is the role of US in breast cancer?

A

ultrasound is a helpful modality for lesion characterization; cystic versus solid and in evaluating benign or malignant features of solid lesions

something benign like a fibroadenoma would be hypo echoic but there’s no shadow, it’s actually bright around it and there are large lobules with a relatively smooth border

something malignant like an infiltrating ductal carcinoma would also be hypo echoic but there will be a dark shadow near it, lots of smaller lobules and an irregular border

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31
Q

what is PET imagining used for with breast cancer?

A

essential in staging of breast cancer and also in restaging and evaluating response to therapy

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32
Q

what is the use of PET/CT for breast cancer?

A

allows for accurate localization of and the spread of cancer

total body technique so you can evaluate for distant metasatisis

sensitivity is high when lesions are greater than 1 cm but can be low when there’s inflammation

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33
Q

when are breast MRI used?

A
  1. evaluation of implant integrity

2. evaluation of breast tissue –> diagnostic or screening

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34
Q

what are the clinical uses of MRI when evaluating breast tissue?

A
  1. assess extent of known carcinoma
  2. search for additional occult carcinoma
  3. monitor pre surgical chemotherapy
  4. evaluate axillary mets with occult breast primary
  5. palpable lump not evident on US/Mamms
  6. evaluate indeterminate imaging findings
  7. spectroscopy is helpful in confirming malignancy
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35
Q

when do you use MRI to screen for breast cancer?

A
  1. personal history of breast cancer treated by lumpectomy or mastectomy

MRI is really useful if there’s a strong family history or genetic predisposition; this is the only 2 things that insurance would even cover

  1. dense breast with high risk of breast cancer
  2. history of ADH or LCIS in biopsy
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36
Q

what are the enhancement patterns seen on breast MRI and what do they mea?

A

I: contrast continues to accumulate in tumor

II: contrast levels plateaus in the tumor

III: contrast levels decrease in the tumor –> this is the most concerning; the other 2 types are usually benign

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37
Q

what are the limitations of screening the breast using MRI?

A
  1. cost
  2. high sensitivity but limited specificiity
  3. limited detection of DCIS
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38
Q

how do you manage clear nipple discharge?

A

do not do cytology; it will show degenerating cells

if clinical exam and imaging studies are negative – follow the patient.

water clear serous discharge from a single duct has higher incidence of cancer and needs ductogram and duct excision for histologic examination.

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39
Q

how do you manage milky nipple discharge?

A

rule out pregnancy and drugs

obtain prolactin level if no history of pregnancy or drugs.

obtain MRI or CT Sella Turcica if prolactin is high.

10% prolactinoma associated with MEN-1.

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40
Q

how do you manage bloody nipple discharge?

A

Intraductal papilloma – 95% (all age groups)

%5 change it’s malignancy

needs physical exam and imaging

if no cancer is found, needs selective duct excision

41
Q

what is the common presentation of a patient with breast cancer?

A

most cases are detected by screening mammography (>/= 70%).

  1. palpable breast or axillary mass (20%)
  2. bloody nipple discharge
  3. clinical feature of metastatic disease
  4. commonest cause of enlarged axillary node in absence of a breast mass is benign adenopathy
42
Q

how do you work up a palpable breast mass?

A
  1. ultrasound of the mass. If the mass is solid then do core needle biopsy. If the mass is cystic then do fine needle aspiration
  2. mammogram

ALWAYS BIOPSY A PALPABLE SOLID BREAST MASS

43
Q

how do you work up a cystic breast mass?

A
  1. if you get bloody fluid on aspiration then send fluid for cytology and biopsy the lesion
  2. if you get clear fluid on aspiration and if mass disappears completely – follow patient.= –> but if mass persists after FNA or reappears then do a biopsy
44
Q

what are the types of biopsy for breast tissue?

A
  1. fine needle aspiration – doesn’t differentiate in situ cancer from invasive cancer.
  2. core needle biopsy: over all best diagnostic biopsy procedure
  3. stereotactic biopsy (Image guided Bx)
  4. excisional or incisional biopsy (NOT good)
45
Q

what are the types of benign epithelial lesions?

A
  1. nonproliferation breast disease

fibrocystic changes and lactational adenoma; no increased risk fo carcinoma

  1. proliferative breast disease without atypia

epithelial hyperplasia, sclerosis adenosis, papilloma, complex sclerosis lesion; increased cancer risk of 1.5-2x

  1. proliferative breast disease with atypia

atypical ductal hyperplasia and atypical lobular hyperplasia; increased cancer risk of 4-5x

46
Q

how are cysts formed?

A

dilation and unfolding of lobules

grossly large cyst dn their contents may appear blue in color = blue dome cysts

47
Q

what causes fibrosis?

A

due to ruptured cysts leading to scarring

48
Q

what is apocrine metaplasia?

A

characterized by large polygonal cells having an abundant, granular, eosinophilic cytoplasm with small, round nuclei

resembles normal apocrine epithelium of sweat glands

49
Q

what is adenosis?

A

increased number of acini per lobule

50
Q

what is the progression of breast cancer?

A

normal –> proliferative without atypia –> proliferative with atypia –> carcinoma in situ (DCIS, LCIS) –> invasive cancer (ductal, lobular)

51
Q

what is Paget’s disease of the nipple?

A

malignant cells aka Paget cells extends from DCIS within the ductal system via the lactiferous insures into nipple skin without crossing the BM

involves skin of the nipple and areola and resembles eczematoid skin rash –> pruritus may be mistaken for eczema….

presents with unilateral erythematous nipple with clay crust

always invasive ductal carcinoma with or without palpable mass

involved skin has pagetoid cells

treated with either modified radical mastectomy or central mastectomy, SLN bx and radiation

palpable mass in 50-60% and almost all of these women have underlying invasive carcinoma – most women without a palpable mass only have DCIS

52
Q

what is lobular carcinoma in situ?

A

clonal proliferation of cells within ducts and lobules that grow in a discohesive fashion, usually due to an acquired loss of the tumor suppressive adhesion protein E-cadherin

incidental finding

bBilateral in 20% to 40% of cases, compared with 10% to 20% of cases of DCIS.

uniform population of cells with oval or round nuclei and small nucleoli involving ducts and lobules

not associated with calcifications or stromal reactions

almost always expresses ER and PR

53
Q

what does invasive ductal carcinoma look like?

A

grossly, the tumors often are retracted, firm, white, with chalky yellow streaks or gritty calcifications

may have a “stellate” or “crab-like” appearance

less commonly, tumors present as deceptively well-circumscribed masses having scant stromal reaction, or may be almost imperceptible, having scattered neoplastic glands or single tumor cells infiltrating otherwise unremarkable fibrofatty tissue

54
Q

what do invasive ductal carcinomas look like histologically?

A

the tumor cells are arranged as glands or sheets and infiltrate a fibrotic stroma +/- DCIS component

55
Q

what is inflammatory carcinoma?

A

invasive carcinoma involving superficial dermal lymphatic spaces

poor prognosis (T3 disease)

erythema and induration of the skin, so called “inflammatory changes”.

peau d’orange-dimpling of
involved skin due to retraction
caused by lymphatic involvement
and obstruction

56
Q

what are the most common types of invasive carcinoma of the breast?

A

Ductal, No Specific Type (NST: 70-80%)

lobular 10%

tubular 6%

mucinous (colloid) 2%

medullary 2%

papillary 1%

metaplastic <1%

57
Q

what is a phyllodes tumor?

A

arise from intralobular stroma but mostly benign –> does not spread to axillary lymph node

most present in the sixth decade, 10 to 20 years later than the peak age for fibroadenomas

associated with clonal acquired chromosomal changes, with gains in chromosome 1q being the most frequent

the larger lesions often have bulbous protrusions (phyllodesis Greek for “leaflike”) due to the presence of nodules of proliferating stroma covered by epithelium. In some tumors these protrusions extend into a cystic space

phyllodes tumors are distinguished from fibroadenomas on the basis of higher cellularity, higher mitotic rate, nuclear pleomorphism, stromal overgrowth, and infiltrative borders

58
Q

what are the 3 types of malignant breast pathology?

A
  1. ductal cancer in situ
  2. lobular cancer in situ
  3. invasive ductal cancer
59
Q

what is lobular cancer in situ?

A

younger pre-menopausal population

presents as an incidental lesion

35% incidence of subsequent development of invasive breast cancer (50% in ipsilateral breast and 50% in contralateral breast) in 15 to 20 years – you dont know where the subsequent invasive carcinoma, you can’t do targeted therapy so you just observe….

incidence of invasive cancer increases with increasing multifocal sites

almost all subsequent invasive cancer are invasive ductal cancer

subsequent invasive cancer has excellent prognosis even when presents as a palpable mass - 90% 10 year survival.

60
Q

how do you manage lobular carcinoma in situ?

A

observation only or antiestrogen therapy

margin positive LCIS patient does not need re-excision

core biopsy showing LCIS does need re-excision (needle localized excisional Bx).

mastectomy is indicated only for mutation positive patient

management of Pleomorphic lobular Ca in situ is lumpectomy. Radiation is used in selected cased

61
Q

what is ductal carcinoma in situ?

A

mostly peri- or post-menopausal women

presents as an index lesion

following complete excision (except in some select patients), 30% chance of subsequent development of invasive Breast Cancer in 7 to 10 years ):

most of these invasive Breast Cancer will be in ipsilateral breast and most will originate (70%) in same quadrant of same breast.

subsequent invasive cancer are all ductal type with 60% 10 year survival

incidence of axillary node metastasis is 1%

62
Q

how do you among ductal carcinoma in situ?

A

non-palatable, less than 1cm lesion with low-grade tumor (papillary or cribiform pattern) may be managed with lumpectomy only

all other DCIS require either lumpectomy and radiation or total mastectomy

adequate margin following lumpectomy for DCIS is at least 2mm

63
Q

how does anti estrogen therapy help treat ductal carcinoma in situ?

A

anti estrogen therapy reduces the risk of recurrence but does not improve survival

64
Q

how do you stage breast cancer?

A

Based on :

Size of the primary tumor (T stage)

Metastasis in regional lymph nodes (N stage)

Metastasis in distant site or organs (M stage)

LN metastasis 0.2mm or less in size is considered as negative for metastasis

65
Q

what are the prognostic factors for breast cancer?

A
  1. size
  2. presence of Axillary Nodal metastases Best prognostic marker.
  3. number of Axillary nodal metastases.
  4. molecular Prog. markers (ER, PR, Her-2/NEU, Ki 67)
  5. menopausal status
  6. histology
  7. age of patients: Young patients have higher incidence of in breast recurrence with partial mastectomy and radiation
  8. nvasive Ca with extensive DCIS has higher incidence of in breast recurrence
66
Q

how do you manage invasive breast cancer?

A

all invasive breast carcinomas are managed exactly the same way irrespective of histology except PURE invasive tubular carcinoma

the incidence of lymph node metastasis in pure invasive tubular carcinoma is exceedingly low and does not need axillary lymph node biopsy or axillary node dissection

67
Q

what are the 2 issues to consider when trying to decide on management of early invasive breast cancer?

A
  1. partial mastectomy (lumpectomy) vs. Total mastectomy

2. selected Lymph node biopsy (SLN Bx) and SLN based AxND or routine axillary node dissection

68
Q

what are the advantages of lumpectomy over mastectomy?

A

lumpectomy preserves the breast (when done along with radiation after lumpectomy) without any higher incidence of recurrence or metastasis for invasive breast cancer in well selected patient population compared to total mastectomy.

69
Q

what is the criteria that would indicate a lumpectomy?

A
  1. must have microscopically negative margin
  2. must not have extensive loss of volume of breast
  3. patient must not have contraindication for radiation to breast after lumpectomy
70
Q

what is the selection criteria that would indicate a lumpectomy?

A
  1. location of lesion –> do the lumpectomy
  2. multicentricity; can be done unless triple negative
  3. size of breast and size of lesion –> small breast with big lesion it’s better to just do mastectomy
  4. morphology –> starburst pattern is bad
  5. age of patients –> younger patients have higher recurrence after lumpectomy
  6. tumor free margin
  7. associated in situ carcinoma
71
Q

what are the contraindications for lumpectomy?

A
  1. early pregnancy before 22 weeks
  2. h/o prior breast radiation
  3. diffuse microcalcification
  4. multi-centric tumor involving different quadrants
  5. persistent positive margin
  6. scleroderma, active lupus
72
Q

what are the types of mastectomy?

A
  1. radical mastectomy
  2. modified radical mastectomy
  3. total mastectomy with sacrifice of nipple and areola
  4. total mastectomy with preservation of nipple and areola
73
Q

what is a radical mastectomy?

A

remove pec major, minor and lymph nodes

not done anymore

74
Q

how do you manage axillary nodes in a patient with?

A

selective axillary node dissection based on sentinel Lymph node Biopsy – leave axilla alone unless there’s a high volume tumor

prophylactic axillary node dissection isn’t really done any more for breast carcinoma because a lot of patients get lymphedema

75
Q

what is the sentinel lymph node?

A

first draining Lymph node(s) from any given area of the body is the Sentinel LN

the presence or absence of metastatic tumor cells in Sentinel LN indicates the lymph node metastasis status for the tumor.

76
Q

when would you biopsy the sentinel lymph node?

A

axillary node dissection after SLN biopsy is indicated if:

more than 2 positive nodes or any number of positive LN if external beam radiation is not used for axilla

77
Q

what are the contraindications for sentinel lymph node biopsy?

A
  1. pregnant patients
  2. presence of metastatic lymph nodes
  3. previous axillary procedure
  4. reduction/augmentation mammoplasty
  5. locally advanced lesions or after adjuvant chen-radiation therapy

previous breast biopsy and multricentric lesions are not contraindication for SLN biopsy

78
Q

what is the sequence of treatment for early breast cancer?

A
  1. lumpectomy
  2. chemotherapy (when indicated) with 4 cycles of Adriamycin and Cytoxan at 28 day intervals and herceptin when indicated (Her-2 neu amplified tumor) for one year.
  3. 4500 rads radiation to whole breast with additional 1000 rads radiation to area of lumpectomy after completion of systemic chemotherapy.
  4. anti estrogen therapy (with Tamoxifen or aromatase inhibitor (only in post menopausal patients), for estrogen receptor positive tumors for 5 years after radiation therapy is completed
79
Q

when do you give adjuvant therapy for breast carcinoma?

A

you would give it to high risk patients for subsequent recurrence or metastasis receives additional local, regional or systemic therapy to reduce the risk of recurrence:

  1. adjuvant radiation therapy:

all patients with invasive breast cancer after lumpectomy

selected patients after total mastectomy if primary tumor is larger than 5 cm or patient has 4 or more positive LNs.

  1. adjuvant systemic therapy:

adjuvant Hormone therapy for ER positive patients or adjuvant chemotherapy for high risk tumor or high recurrence scor based on tumor genetic study (mammaprint or oncotype) or if Her 2 neu is amplified

80
Q

when do you give neoadjuvant systemic therapy?

A

give before lumpectomy or mastectomy if:

  1. ER Neg PR Neg Her-2 neu Neg (Triple negative tumors)
  2. tumors which are borderline for lumpectomy obtaining a negative margin.
  3. as initial treatment of locally advanced or inflammatory cancer
81
Q

what are the characteristics of neoadjuvant chemo?

A
  1. increase in local recurrence without higher mortality from breast cancer.
  2. pathologic response rate is less than clinical response rate and complete pathologic response occurs in about 15% of patients.
  3. all patients with complete response should still undergo lumpectomy
  4. increases breast conservation
  5. does not increase survival
82
Q

what is the molecular assessment for adjuvant therapy?

A
  1. ER+/PR+/HER2/NEU -
    premenopausal: tamoxifen +/- chemo, consider oophorectomy

postmenopausal: aromatase inhibitors +/- chemo

  1. ER+/PR+/HER2/NEU +
    premenopausal: chemo, herceptin, tamoxifen, consider oophrectomy

postmenopausal: chemo + herceptin + aromatase inhibitors
3. ER-/PR-/HER2/NEU -

chemo for both

  1. ER-/PR-/HER2/NEU +

chemo + herceptin for both

83
Q

what adjuvant hormone therapy do you give for breast cancer?

A

tamoxifen for pre-menopausal patients

aromatase inhibitors for post-menopausal patients

adjuvant hormone therapy is given for 5 years

longer than 5 yrs. therapy reduces risk of local recurrence by 2 to 3%

bilateral Oophorectomy has best result as adjuvant hormone therapy and for ER positive metastatic disease

84
Q

what is locally advanced breast cancer?

A
  1. breast cancer with skin or muscle involvement –> nodule or ulceration of the skin; not just attachment to the skin
  2. breast cancer larger than 5 cm and matter lymph nodes in axilla or internal mammary chain
85
Q

what is inflammatory breast cancer?

A

edema and redness involving 1/3 or more of the skin of the breast which has biopsy-proven carcinoma

involvement of skin or dermal lymphatics by cancer cells are not necessary for diagnosis of inflammatory breast ca.

86
Q

how do you treat locally advanced inflammatory breast cancer?

A
  1. incisional biopsy and ER/PR/Her-2/Neu assay.
  2. metastatic work-up with CT scan and or PET scan.
  3. initial treatment is ALWAYS Induction chemotherapy preferably with Adriamycin

herceptin is added if the tumor is positive for HER-2/neu over expression.

  1. radiation to breast
  2. mastectomy only for residual disease
  3. following radiation/mastectomy complete 6 more cycles of adriamycin –> this is followed by taxol 4 cycles if there is persistent distant metastases
  4. herceptin for 1 yr. when tumor is positive for HER-2/NEU.
    Antiestrogen for all receptor (+) tumor.
87
Q

how do you treat a pure tubular carcinoma?

A

all invasive carcinomas are treated exactly the same way based on size, axillary nodal status and status of distant metastasis except pure tubular carcinoma

it’s treated by total mastectomy or lumpectomy and radiation without axillary node biopsy or dissection.

88
Q

how do you treat phyllodes tumors?

A

treated with excision

mastectomy is done only if lumpectomy is technically not possible

treatment for local recurrence is re-excision

axillary node dissection is not indicated because it doesn’t spread to axillary lymph nodes

89
Q

what male breast cancer is most common?

A

almost all male breast cancers are invasive ductal type

most are 70 ears old and present with unilateral mass or nipple mass

BRCA2 associated

high incidence of estrogen receptor (90-95%) = very hormone responsive

90
Q

how do you screen for breast cancer in males?

A

screening mammography is not done for early detection of male breast cancer

if there is a palpable mass, it should be biopsied.

if there is no palpable mass, routine screening mammography has no role in detection of male breast cancer

91
Q

what do you do if you find a solid breast mass in a pregnant woman?

A

ALL palpable solid breast mass in pregnant patients, just like in any adult patient must be biopsied promptly without delay

it is unnecessary to terminate pregnancy for early stage breast cancer (Stages I & II)

modified radical mastectomy is the treatment of choice prior to 22 wks. Breast preservation with radiation may be considered beyond 22 weeks of pregnancy if patient is candidate for adjuvant chemotherapy

if patient is not a candidate for adjuvant chemotherapy, then modified radical mastectomy is treatment of choice up to 32 weeks

pregnant patient cannot receive radiation until the baby is delivered

do not give systemic adjuvant chemotherapy during first trimester

never give Methotrexate during pregnancy

antifolate activity results in neural tube development deficit.

92
Q

The initial treatment for Inflammatory Breast cancer is:

  1. Chemotherapy
  2. Radiation Therapy
  3. Total Mastectomy
  4. Adequate Lumpectomy
  5. Immunotherapy.
A
  1. Chemotherapy?
93
Q

Which one of the following breast cancers has a worse prognosis with adequate treatment?

  1. ER + / PR + / HER-2 NEU negative
  2. ER + / PR - / HER-2 NEU positive
  3. ER - / PR - / HER-2 NEU negative
  4. ER - / PR + / HER-2 NEU negative
A
  1. ER - / PR - / HER-2 NEU negative?
94
Q

The best management option for lobular carcinoma in situ (lobular neoplasia) in a patient without any family history is:

  1. Lumpectomy with radiation
  2. Radiation only
  3. Observation
  4. Total mastectomy and sentinel lymph node biopsy
  5. Modified radical mastectomy
A
  1. Observation?
95
Q

All of the following are risk factors for breast cancer except:

  1. Estrogen
  2. BRCA mutation
  3. CDH-1 mutation in female patients
  4. Trauma
  5. Radiation at a young age
A
  1. Trauma?
96
Q

Which of the following is not associated with increased risk of breast cancer?

  1. Lobular carcinoma in situ
  2. Sclerosing adenosis
  3. History of ductal cancer in situ
  4. Personal history of breast cancer
  5. History of ductal hyperplasia
A

?

97
Q

Which one of the following breast cancers has the lowest incidence of lymph node metastasis?

  1. Inflammatory breast cancer
  2. Invasive lobular carcinoma
  3. Invasive ductal carcinoma
  4. Male breast cancer
  5. Pure tubular breast cancer
A

?

98
Q

A 32 year old pregnant female (8th week of gestation) noted a 1.5 cm mass in the upper outer quadrant of the left breast. The best management option is:

  1. Ultrasound every 3 months and biopsy if there is a change in size.
  2. MRI of the breast and biopsy if it looks suspicious
  3. Mammogram of the breast and biopsy if it looks suspicious
    1. Biopsy of the mass.
A

?

99
Q

Phyllodes tumors are:

  1. Always benign
  2. Malignancy is confirmed if there is recurrence
  3. Lymph node metastasis is common
  4. Needs excision with about 1 cm normal tissue margin.
A

?

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