Sabiston Ch 34

Question 1

What is the name of the fibrous bands in the breast?

Answer 1

Suspensory ligaments of Cooper

Question 2

Define the axillary lymph nodes by level (anatomically):.

Answer 2

I - Lateral to the lateral border of Pectoralis Minor
II - Posterior to the Pectoralis Minor Muscle
III - Medial to the Pectoralis Minor Muscle, also include subclavicular nodes

Question 3

What percentage of lymphatic drainage goes to the axilla?

Answer 3

75% (remainder Internal Mammary)

Question 4

What nerve innervates the serratus anterior?

Answer 4

Long Thoracic

Question 5

Injury to what nerve causes a winged scapula?

Answer 5

Long Thoracic

Question 6

What nerve innervates the latissimus dorsi?

Answer 6

Thoracodorsal

Question 7

What nerve innervates the pectoralis major muscle?

Answer 7

Medial Pectoral

Question 8

What nerves supply sensation to the undersurface of the upper part of the arm and skin of the chest wall along the posterior margin of the axilla?

Answer 8

Brachial Cutaneous Nerves

Question 9

What are the 3 principle tissue types of the breast?

Answer 9

1) Glandular epithelium
2) Fibrous stroma and supporting structures
3) Adipose tissue

Question 10

What layer is maintained in DCIS (to differentiate from invasive breast cancer)?

Answer 10

Basement membrane layer of breast ducts

Question 11

What are lymph nodes called in the space between the pec major and minor?

Answer 11

Rotter’s nodes (or Interpectoral group)

Question 12

How does the breast composition change with age?

Answer 12

Pre-Puberty: Dense fibrous stroma

Post-Menopausal: Largely adipose tissue

Question 13

Name features of nipple discharge concerning for malignancy.

Answer 13

Bloody or serous
Spontaneous
Unilateral (especially if coming from a single duct)

Question 14

What is the treatment of galactocele?

Answer 14

Needle aspiration

Surgery only if cannot be aspirated or becomes infected

Question 15

What are hallmarks of inflammatory breast carcinoma?

Answer 15

Peau d’orange (edema of the skin), and tenderness, warmth, and swelling of breast

Question 16

Describe Paget’s disease.

Answer 16

Changes within dermis of the nipple
Commonly associated with underlying breast cancer
Nipple first, then extends to areola.

Question 17

Name two scenarios when FNA biopsy is indicated in breast work-up.

Answer 17

1) Evaluating second suspicious lesion in ipsilateral breast in presence of known malignancy (to confirm multifocality)
2) Evaluate suspicious lymph node

Question 18

What is the method of choice to sample breast lesions?

Answer 18

Core needle biopsy (under Ultrasound, stereotactic, or MRI guidance) with biopsy clip left behind

Question 19

When ADH is found on breast core biopsy, what percentage of cases will have DCIS or IDC

Answer 19

20%

Question 20

What is the treatment for cellular fibroadenoma on core needle biopsy?

Answer 20

Excisional biopsy to rule out Phyllodes tumor

Question 21

What are the USPSTF and ACS recommendations for screening mammography?

Answer 21

USPSTF: Biennial screening mammography for women 50 - 74 years old
ACS: Annual screening mammography for women > 40 years old

Question 22

ACS Indications for Breast MRI Screening

Answer 22

HIGH LIFETIME RISK of Breast Cancer (MRI screening indicated starting at age 30)

1) Known BRCA1 or BRCA2 gene mutation
2) 1st degree relative w/ BRCA1 or BRCA2
3) Lifetime risk of breast cancer >20-25%
4) Radiation therapy to chest b/w age 10-30
5) Li-Fraumeni or Cowden syndrome (or 1st degree relative with either)

MODERATELY INCREASED LIFETIME RISK of Breast Cancer (MRI screening up for discussion)

1) Lifetime risk of breast cancer 15-20%
2) Personal h/o Breast cancer, DCIS, LCIS, ADH, or atypical lobular hyperplasia
3) Extremely dense or unevenly dense breast tissue on mammograms

Question 23

Describe BIRADS system

Answer 23

BI-RADS 0 - Incomplete assessment
BI-RADS 1 - Negative (nothing to comment on)
BI-RADS 2 - Benign, rec annual screening
BI-RADS 3 - Probably Benign, short-interval f/u
BI-RADS 4 - Suspicious Abnormality, consider biopsy
BI-RADS 5 - Highly suggestive of Malignancy, take action
BI-RADS 6 - Proven malignancy

Question 24

Treatment options for LCIS.

Answer 24

1) Close observation
2) Chemoprevention w/ tamoxifen or raloxifene
3) Bilateral Mastectomy

Question 25

Which BRCA genetic mutation is associated with male breast cancer?

Answer 25

BRCA2

Question 26

Name typical histopathological features of BRCA-1 associated breast cancers.

Answer 26

High Grade Hormone receptor negative Aneuploid Increased S-phase fraction

Question 27

Name two selective estrogen receptor modulators (SERM).

Answer 27

Tamoxifen (TMX, Nolvadex, Genox, Tamifen, etc) | Raloxifene (Evista)

Question 28

Name aromatase inhibitors.

Answer 28

``` Anastrozole (Arimidex) Letrozole (Femara) Exemestane (Aromasin) Vorozole (Rivizor) Formestane (Lentaron) Fadrozole (Afema) ```

Question 29

What is the most common breast tumor in women younger than 30 years old?

Answer 29

Fibroadenoma

Question 30

What is the most common bacteria causing breast infections?

Answer 30

Staph aureus

Question 31

Name 2 risk factors for breast infections in non-lactating women.

Answer 31

Smoking and diabetes

Question 32

What is the initial treatment of a breast abscess?

Answer 32

Needle aspiration and antibiotics (I&D reserved for abscesses that do not resolved with aspiration and antibiotics)

Question 33

What are the two most common types of breast cancer?

Answer 33

1) Invasive Ductal Carcinoma (50-70%) 2) Invasive Lobular Carcinoma (10%) then Mixed Ductal/Lobular

Question 34

Name 2 subtypes of invasive ductal carcinoma. Which one carries a better/worse prognosis?

Answer 34

Mucinous - usually low grade | Medullary - usually high grade, usually triple negative

Question 35

What is the defining feature of Metaplastic Carcinoma?

Answer 35

Most are node negative, but have a high potential for metastatic spread.

Question 36

What humanized monoclonal antibody is an effective treatment for Her-2 positive breast cancer?

Answer 36

Trastuzumab (Herceptin)

Question 37

What is an Oncotype DX assay?

Answer 37

A 21-gene test run on tumor material from breast surgical specimens, which provides a recurrence score for ER+ breast cancer to determine if adjuvant chemotherapy is recommended

Question 38

What is MammaPrint?

Answer 38

Multigene assay for determining breast cancer prognosis used on ER+ or ER- tumors.

Question 39

Adjuvant tamoxifen reduces the risk for a second breast cancer in the unaffected breast by what percent?

Answer 39

47% (Early Breast Cancer Trialists' Collaborative Group EBCTCG)

Question 40

What is a Phyllodes Tumor?

Answer 40

Breast tumor with biphasic proliferation of stroma and mammary epithelium. Usually benign. Show on mammogram as round density with smooth borders. Differ from fibroadenomas by larger size, faster growth, and occurrence in older patients. Malignant if --> increasing cellularity, an invasive margin, and sarcomatous appearance.

Question 41

What margin is desired on a Phyllodes tumor?

Answer 41

1cm to prevent local recurrence

Question 42

How do malignant Phyllodes tumors spread?

Answer 42

Hematogenously - most often lung, bone, abdominal viscera, and mediastinum

Question 43

Name a secondary malignancy of the breast. What populations are at risk?

Answer 43

Angiosarcoma Prior breast irradiation increases risk in breast Lymphedema increases risk in upper extremity (can also arise de novo)

Question 44

Describe the staging for Breast Cancers.

Answer 44

Stage 0 - in situ cancer Stage I - <2cm AND micromets only in LN Stage II - more positive LNs allowed if smaller tumor Stage III - T4 (invasion into chest wall or skin changes) Stage IV - distant mets

Question 45

Most common sites of metastasis of breast cancer?

Answer 45

Liver Lung Bone

Question 46

Contraindications to Radiation?

Answer 46

- Pregnancy - Systemic scleroderma - Lupus - Prior radiation - Severe pulmonary or cardiac disease (if left sided) - Inability to be positioned for radiation (supine, arm abducted) - p53 mutation

Question 47

Requirements for breast conserving therapy.

Answer 47

Can be excised with clear margins and acceptable cosmesis

Question 48

What is the required margin on for invasive breast carcinoma?

Answer 48

no ink on tumor

Question 49

Name two indications for more strongly considering oncoplastic reconstruction in lumpectomy?

Answer 49

>20-30% of total breast volume to be excised AND tumors lying directly under nipple-areolar complex or inferior to NAC

Question 50

What is the occurrence of lymphedema in SLNB vs ALND?

Answer 50

SLNB - 5% | ALND - 15-20%

Question 51

What did the Z0011 trial change? What population is it applicable to?

Answer 51

ALND was not justified in all patients with early-stage breast cancer with 1-2 positive sentinel nodes. - T1 or T2 - clinically node-negative breast cancer - Lumpectomy + Radiation - No neoadjuvant

Question 52

What special subset of patient undergoing lumpectomy do NOT need adjuvant radiation?

Answer 52

- Age > 70 years - ER-positive - Stage I - Undergoing adjuvant hormonal therapy

Question 53

Name features of breast cancer that make it a suitable candidate for partial breast irradiation (according to American Society for Radiation Oncology).

Answer 53

- ER positive Invasive ductal carcinoma - Age >60 years - Tumor < 2cm (T1) with >2mm margins - Unicentric - Negative LNs - No neoadjuvant chemotherapy

Question 54

What is the principle cause of death from breast cancer?

Answer 54

Metastatic Disease

Question 55

What breast cancer biomarker statuses are associated with WORSE prognosis?

Answer 55

ER- PR- Her2+

Question 56

What are the main side effects for breast cancer chemotherapy?

Answer 56

Anthracyclines - Cardiomyopathy | Taxanes - Peripheral Neuropathy

Question 57

What is Trastuzumab?

Answer 57

Brand Name: Herceptin | Humanized monoclonal antibody developed to target the extracellular domain of the Her-2 receptor.

Question 58

What are common side effects of Tamoxifen?

Answer 58

Hot flashes or vasomotor symptoms | Rare: VTE, uterine cancer

Question 59

What is the duration of Tamoxifen therapy?

Answer 59

Treat for 5 years. If patient is still pre-menopausal, offer an additional 5 years.

Question 60

In what patient group are Aromatase Inhibitors contraindicated?

Answer 60

Pre-menopausal or Peri-menopausal women

Question 61

What is the pathogenesis of Inflammatory Breast Cancer?

Answer 61

Tumor involvement of dermal lympathic channels within the breast and overlying skin causing erythema, edema, and warmth of breast.

Question 62

What breast cancer population s/p lumpectomy may NOT require radiation?

Answer 62

``` >70 years old ER+ <2cm Negative LNs Receiving hormonal therapy (CALGB trial, equivalent breast cancer-specific survival) ```

Question 63

What is the treatment of Paget disease?

Answer 63

Mastectomy w/ axillary staging OR wide local excision of the nipple-areolar complex w/ axillary staging and radiation

Question 64

How does Paget disease appear clinically?

Answer 64

Scaling skin and erythema of the nipple-areolar complex. Associated with pruritus. May progress to crusting/ulceration.