Breast

Question 0

What correlates best with odds for breast cancer?

Answer 0

Age

Question 1

A “Must do” in all breast disease?

Answer 1

Rule out cancer

Question 2

Mammography – typically started when? Unless?

Do not do if? (Why?)

Answer 2

Age 40 (but earlier if family history)

Do not do before age 20 (breast is too dense) or during lactation (only see milk)

Question 3

Breast masses seen in young women? Description? Diagnosed with? Treatment?

Answer 3

Fibroadenomas

Firm, rubbery mass that moves easily with palpation

FNA or sonogram

Optional removal

Question 4

Breast masses seen in a very young adolescents? Treatment?

Answer 4

Giant juvenile fibroadenomas

Removal needed to avoid deformity or distortion of breast

Question 5

Breast masses seen in late 20s? Natural history? Cancerous? Diagnosis? Treatment

Answer 5

Cystosarcoma phyllodes

Grow over many years, become very large, replace/distort breast (but do not invade or become fixed)

Potential to become malignant sarcomas

Core or incisional biopsy (FNA not sufficient)

Mandatory removal

Question 6

Breast disease seen in reproductive ages? Related to? Diagnosis?

Answer 6

Mammillary dysplasia (fibrocystic disease, cystic prostatitis)

Cystic disease related to menstrual cycle

1. Mammogram if no dominant/persistent mass
2. If dominant mass, aspiration
3. If aspirate bloody fluid, send for cytology
4. If mass persists after aspiration, formal biopsy

Question 7

Reproductive age woman with bloody nipple discharge – likely diagnosis? Testing options? Treatment?

Answer 7

Intraductal papilloma

1. Mammography to identify other possible causes (will not show papilloma)
2. Galactogram for diagnosis and to guide resection

Resect

Question 8

Breast disease seen only in lactating women)? Treatment?

Similarly appearing mass in non-lactating woman?

Answer 8

Breast abscess

1. Biopsy abscess wall to rule out cancer
2. Aspiration
3. If aspiration fails, Incision and drainage

Cancer

Question 9

Strong indicators of breast cancer?

Answer 9

1. Ill defined, fixed mass
2. Retraction of overlying skin or nipple
3. Orange peel skin
4. Eczematous lesion of areola
5. Palpable axillary nodes

Question 10

Diagnosis and Treatment of breast cancer during pregnancy?

Answer 10

No difference in diagnosis

Treatment is the same except:

1. No radiotherapy during pregnancy
2. No chemotherapy during first trimester

Question 11

Radiologic appearance of breast cancer in mammograms?

Answer 11

Irregular area of increased density with fine microcalcifications

Question 12

Treatment of resectable breast cancer?

Answer 12

1. Lumpectomy with axillary sampling + post op radiation (Only if tumor is small, breast is large, and tumor is away from nipple/areola)
2. Modified radical mastectomy with axillary sampling

Axillary sampling is done by identification and removal of sentinel nodes

Question 13

Standard form of breast cancer? Treatment?

Variants with a better prognosis? Treatment?

Variant with worse prognosis? Treatment?

Variant with the highest incidence of bilaterality?

Answer 13

Infiltrating ductal carcinoma

lobular, medullary, mucinous carcinomas. Treated the same as standard infiltrating ductal carcinoma.

Inflammatory carcinoma. Needs preop chemo.

Lobular – risk not high enough to warrant bilateral mastectomy

Question 14

Breast cancer that does not need axillary sampling? (Why?)

Treatment?

Answer 14

Ductal carcinoma in situ (cannot metastasize)

1. Total simple mastectomy (high risk of recurrence if a local excision, possibility of missing an invasive focus in multicentric disease)
2. Can add sentinel node biopsy
3. If lesion is confined to one quarter of the breast, can do lumpectomy followed by radiation

Question 15

What defines an inoperable breast cancer? Treatment?

Answer 15

Local extent (not metastasis)

Chemotherapy +/- radiation

Question 16

Adjuvant systemic therapy following breast cancer surgery?

Answer 16

1. Chemotherapy
2. Add hormonal therapy if tumor is receptor positive (tamoxifen if premenopausal or anastrozole if postmenopausal)
3. Hormone therapy alone if old, frail woman with non-aggressive tumors

Question 17

Symptoms in breast cancer patients that suggests metastasis? Test? Treatment for brain metastases? Most likely location of metastases on spine?

Answer 17

Persistent headache or back pain with areas of localized tenderness

MRI

Radiation or resection

Vertebral pedicles

Question 18

Postmenopausal breast lump – differential?

Answer 18

1. Malignancy unless proven otherwise
2. Fibrocystic change if taking hormone replacement therapy
3. Far necrosis