Surgical Disease of the Breast

Question 1

What are the types of breast cancer?

Answer 1

• -Ductal carcinoma in situ (noninvasive)
• -Invasive/infiltrating ductal carcinoma (most common type of breast cancer)
• -Invasive/infiltrating lobular carcinoma
• -Inflammatory breast cancer
• -Paget disease of nipple
• -Some other super rare kinds

Question 2

What are some ways to classify breast cancer?

Answer 2

1. By grade:
   grade 1 = well-differentiated
   grade 2 = moderately differentiated
   grade 3 = poorly differentiated
2. By receptors: estrogen receptor pos/neg; progesterone receptor pos/neg
3. By HER2 levels: normal or elevated
4. By genes, e.g. BRCA1 (helps with assessing likelihood of recurrence)

Question 3

How is breast cancer staged?

Answer 3

TNM system for breast cancer:
--T: tumor size
--N: whether it's spread to axillary/regional lymph nodes
--M: whether there is distant metastasis
"Tis" is carcinoma in situ
T1 = tumor < 20mm
etc. (it's really detailed)

Question 4

What are the signs and symptoms of malignant breast disease?

Answer 4

Abnormal mammogram
Breast mass (hard, immobile, single dominant lesion with irregular borders)
More advanced cancer: axillary adenopathy, skin findings e.g. erythema, thickening, dimpling

Question 5

What is the workup for malignant breast disease?

Answer 5

Biopsy
Receptor testing (ER, PR)
HER2 testing
Staging

Question 6

What are the surgical options for malignant breast disease:

Answer 6

1. Mastectomy

2. Breast conserving treatment (surgery + radiation)

Question 7

What are the factors that make a patient ineligible for breast conserving treatment (surgery + radiation) and therefore they will need mastectomy?

Answer 7

Patients will need mastectomy in the following cases:

1. Multiple tumors
2. Diffuse malignant microcalcifications
3. Prior breast radiation
4. Persistently positive resection margins
5. Large tumor relative to breast size
6. Pregnancy

Question 8

What is the evaluation for a breast lump?

UpToDate

Answer 8

HPI/PE - assess the following:
change in breast appearance
skin changes
new nipple inversion
breast pain
cervical/clavicular/axillary lymph nodes
breast exam including tail

Imaging - get an ultrasound or a mammogram:
If young woman with clinically benign mass and no family history of breast cancer, get ultrasound
Otherwise, get mammogram

(UpToDate)

Question 9

What is the workup for a breast mass?

Surgical Recall

Answer 9

1. Clinical breast exam
2. Mammogram or breast ultrasound
3. Fine needle aspiration, core biopsy, or
   open biopsy
   (Surgical Recall)

Question 10

How do you proceed if the

mass appears to be a cyst?

Answer 10

Aspirate it with a needle