1
Q
What are the levels of the axilla?
A
level one is most superficial (lateral to pec minor)
2
Q
What nerves are at risk during an axillary node dissection and the resulting deficit.
A
- long thoracic to the serrates anterior resulting in winged scapula
- thoracodorsaol to the latissimus doors resulting in weekend arm adduction
- intercostobrachial resulting in sensory deficit to the medial arm
3
Q
What do the medial and lateral pec nerves inner?
A
- medial innervates both
- the lateral innervates only the major
4
Q
What are the boundaries of an axillary node dissection?
A
- superior: axillary nerve
- medial: chest wall, serratus anterior
- lateral: skin
- anterior: pectoralis
- posterior: latissimus dorsi
5
Q
Describe the presentation and management of fibrocytic disease of the breast.
A
- can present with pain, nipple discharge, or lumps that vary throughout the menstrual cycle
- most can be expectantly managed
- symptomatic cysts can be aspirated (if bloody or recurrent send for cytology and do an excisional biopsy)
6
Q
What is Mondor’s disease? How does it present and how is it treated?
A
- a superficial thrombophlebitis of the breast involving the lateral thoracic vein
- presents with a tender, palpable subcutaneous cord
- is benign and treated with NSAIDs
7
Q
Blood aspirate from a cyst should be managed in what way?
A
- send fluid for cytology
- do an excisional biopsy
8
Q
What is the diagnostic breast imaging of choice based on age?
A
- ultrasound if under 35
- mammogram if over 35
9
Q
How are fibroadenomas managed?
A
- surveillance for most
- excisional biopsy if enlarging
- excisional biopsy if > 6cm given difficulty differentiated from a phyllodes
- excisional biopsy if complex (with sclerosis adenosis, papillary apocrine hyperplasia, cystic degeneration, or epithelial calcifications)
10
Q
What is a tubular adenoma of the breast?
A
a benign variant of fibroadenoma
11
Q
Describe the pathology, malignant potential, and management of a phyllodes tumor.
A
- 10% become malignant
- tumor will stain for actin and vimentin
- treat with wide local excision to negative margins
- doesn’t spread via LN so not SLNB
12
Q
What should the workup for nipple discharge include?
A
- ductal fluid for cytology
- contrast ductogram/ductoscopy
- duct excision
13
Q
How do you perform a duct excision of the breast?
A
- make a peri-areolar incision
- identify the dilated duct
- cannulate it with a lacrimal duct probe
- excision the tissue around the probe
- close the incision
14
Q
What is the appropriate management of an intraductal papilloma of the breast?
A
subareolar resection of the involved duct and papilloma
15
Q
How do you manage a breast abscess during pregnancy?
A
- antibiotics (reflex or bactrim)
- continued breast feeding
- aspiration
16
Q
What is the risk of a breast I&D during breast feeding if an abscess is found?
A
milk fistula
17
Q
A patient presents with recurrent, unresolving mastitis. What must you do beyond treating the infection?
A
skin biopsy to rule out inflammatory breast cancer
18
Q
A patient undergoes breast biopsy, which reveals sclerosing adenosine. What is the management?
A
if no atypia and imaging findings are concordant, can observe as this is not a precursor lesion
19
Q
What other names are there for radial scar? What is the management?
A
- sclerosing papillary proliferations, benign sclersoing ductal proliferations
- managed with excisional biopsy given difficulty differentiated it from invasive breast carcinoma on core biopsy alone
20
Q
What is sclerosing papillary proliferations of the breast?
A
another name for radial scar, perform excisional biopsy
21
Q
What is benign sclerosing ductal proliferations of the breast?
A
another name for radial scar, perform excisional biopsy
22
Q
Describe the clinical significance, workup, and management of atypical lobular hyperplasia.
A
- not pre-malignant but a marker of increased risk of invasive cancer
- diagnosed with core needle biopsy
- treated with excisional biops
- patients need chemoprophylaxis with tamoxifen or anastrazole as well as high-risk annual surveillance with MRI
23
Q
Describe the clinical significance, workup, and management of atypical ductal hyperplasia.
A
- not pre-malignant but a marker of increased risk of invasive cancer
- diagnosed with core needle biopsy
- treated with excisional biopsy
24
Q
How does the management of atypical ductal hyperplasia differ for that of atypical lobular hyperplasia?
A
lobular hyperplasia carries a greater lifetime risk of cancer so patients require high risk screening and chemoprophylaxis for cancer
25
A patient undergoes excision of LCIS and the margin is positive, what is the next step?
nothing, does not require re-excision unless path is pleomorphic LCIS
26
What is unique about pleomorphic LCIS?
it is treated like DCIS, so need to re-excise to a 2mm margin
27
How is LCIS managed?
- it is a significant risk factor for developing breast cancer in either breast
- treated with excisional biopsy (some evidence to support not doing this)
- would recommend chemoprophylaxis
- can consider high-risk screening with breast MRI
28
What is the most aggressive subtype of DCIS? How does this change management?
- it is DCIS with comedo necrosis
- treatment is simple mastectomy with SLNB with no role for breast conservation
29
How is DCIS managed?
- eligible for BCT but requires 2mm margins and adjuvant radiation (no SLNB)
- also need adjuvant hormonal therapy with tamoxifen versus anastrozole
- need simple mastectomy with SLNB if large, multi-quadrant, with comedo necrosis, or in those with other contraindications to BCT
30
When is anastrozole used rather than tamoxifen in breast cancer patients
anastrozole is preferred for post-menopausal women
31
How should those with BRCA mutations be screened for breast cancer?
start at age 25 with annual mammogram, breast MRI, pelvic exam, and CA-125
32
What are the current ACOG breast cancer screening guidelines?
- every 1-2 years from age 40-75 for average risk women
- 10 years before youngest familial case
33
What findings on mammography raise concern for cancer?
- irregular borders
- speculated margins
- distortion of breast architecture
- small or thin linear branching calcification
34
Describe the BIRADS system as well as the appropriate management of each finding.
0 = incomplete (further imaging)
1 = negative (routine follow up)
2 = benign (routine follow up)
3 = probably benign (6-month follow up)
4 = suspicious (biopsy)
5 = highly suggestive of malignancy (biopsy)
6 = biopsy-confirmed malignancy
35
Describe the TNM staging of breast cancer.
T1: 0-2cm
T2: 2-5cm
T3: >5cm
T4: chest wall or skin involvement
N1: 1-3 nodes
N2: 4-9 nodes
N3: 10+ nodes or supraclavicular nodes
36
How is inflammatory breast cancer treated?
- neoadjuvant chemotherapy
- modified radical mastectomy with ax node dissection
- adjuvant chamoradiation
37
Describe the histology of Paget's disease of the breast.
cells with clear cytoplasm and enlarged nucleoli
38
Describe the significance, presentation, histology, workup, and management of Paget's disease of the breast.
- marker of underlying malignancy
- presents with eczematous changes of the breast with scaling and ulceration of the nipple
- get bilateral mammogram and US
- manage with mastectomy and SLNB
39
For men with BRCA2 mutations, what additional screening do they need?
prostate screening
40
For men with breast cancer, what is the appropriate surgery?
modified radical mastectomy
41
How does pregnancy affect the management of breast cancer?
- can't get blue dye or radiation (diagnostic or therapeutic)
- can't get contrasted MRI
- 1st trimester: treat with mastectomy and SLNB
- late 2nd or 3rd trimester: treat with BCT including post-op chemotherapy and postpartum radiation
42
What are the contraindications to breast-conserving therapy for breast cancer?
- early pregnancy
- multicentric disease
- positive margins after re-excision
- previous radiation
- active connective tissue disease
- tumors >5cm
43
Which patients should get adjuvant chemotherapy for breast cancer?
- tumors > 1cm (unless HR+ and N0)
- those with positive nodes
- those with triple negative disease
- those with high oncotype DX recurrence score
44
What adjuvant therapy should a 3cm IDC get that is HR+ and N0?
these patients can get adjuvant hormonal therapy alone
45
What is the Most common chemotherapy regimen for breast cancer?
TAC (docetaxel, doxorubicin, cyclophosphamide)
46
Which patients with breast cancer get neoadjuvant chemotherapy?
- T4 disease (including inflammatory)
- N2/N3 disease
- if patient wants BCT but tumor is too large
- Her2/neu+ tumors > 1cm
47
What are the indications for chemoradiation after mastectomy for breast cancer? What are the indications for additional nodal irradiation?
- N2/N3 disease
- fixed nodes
- internal mammary nodal involvement
- T3/T4 disease
- positive margins
- N2/N3 disease also get supraclavicular/infraclavicular/axillary radiation
- tumors in the central area of the breast get internal mammary node radiation
48
Which patients should get hormonal therapy for breast cancer?
anyone with ER or PR positive disease
49
Which hormone receptor positivity conveys a better prognosis?
PR is better than ER although both is better
50
Women with PR+ tumors get what kind of hormonal therapy?
they also get tamoxifen or anastrozole
51
What treatment is added for women with Her2/neu+ breast cancer?
1 year of adjuvant traztuzumab
52
What does the ACOSOG Z0011 trial suggest about breast cancer treatment?
do not need completion axillary lymphadenectomy for patients > 18 with T1/T2 tumors that have 1-2 positive lymph nodes who are planned to get BCT with whole breast radiation
53
How should you troubleshoot if patient's sentinel node mapping doesn't map?
- confirm dosage and administration
- check the probe being used
- look for extra-mammary hot spots (internal mammary)
- inject blue dye in the OR
- inject 10-40mL of normal saline at the site of radio colloid injection
- perform gentle massage of the injection site
- perform complete dissection
54
What nodes are taken during axillary lymph node dissection for breast cancer?
- levels 1 and 2
- level 3 if clinically positive
55
What surveillance and adjuvant therapy does DCIS need?
- get first mammogram 6-12 months after completion of radiation and continue with annual screening
- consider endocrine therapy for all patients (reduces occurrence but not survival)
- clinical exam every 6 months for 2 years, then annually
56
How should you treat occult primary breast cancer (T0N+)?
options are modified radical mastectomy versus ALND with whole breast radiation
57
What are the most common flaps for breast reconstruction?
- TRAM (transverse rectus abdominus myocutaneous flap off the superior epigastric)
- DIEP (deep inferior epigastric perforator)
58
What is the preferred reconstructive option for women with breast cancer that have undergone irradiation?
autologous grafts are preferred
59
When is immediate breast reconstruction for cancer contraindicated?
in those with inflammatory breast cnacer
60
What are contraindications to nipple sparing mastectomy?
- tumors that extend to the nipple
- microcalcifications encroaching on the subareolar region
- nipple retraction
- inflammatory breast cancer
- Paget's disease
61
What is the cumulative risk of breast and ovarian cancer with BRCA1 and BRCA2?
- BRCA1: 65% for breast, 40% for ovarian
- BRCA2: 45% for breast, 10% for ovarian
62
What are the risks and benefits of tamoxifen relative to anastrozole?
- tamoxifen has higher rates of VTE and uterine cancer
- tamoxifen has decreases osteoporosis
63
A patient previously had an axillary dissection, which has been complicated by chronic lymphedema. They present with a dark purple lesion on the upper arm. What is the diagnosis?
lymphangiosarcoma
64
What is the problem with screening MRI for breast cancer?
high false positive rate
65
Where is the incision for most nipple-sparing mastectomies?
inframammary fold
66
What are some unique steps in a nipple-sparing mastectomy compared to a simple mastectomy?
- remember to mark the areolar margin on the specimen
- send the areolar margin for frozen
- confirm perfusion of flap (ICG)
67
What are the boundaries of breast tissue and mastectomy?
- anterior: breast capsule/subcutaneous tissue
- posterior: pectoralis muscle (fascia with specimen)
- lateral: latissimus dorsi
- medial: sternal border
- superior: clavicle
- inferior: inframammary crease
68
Which nodes should be removed during a SLNB?
- clinically positive
- radio labeled with counts > 10% of highest
69
How long is hormonal therapy given for breast cancer?
5-10 years
70
What would be considered suspicious-appearing calcifications on mammography?
- clustered, branching linear, or pleomorphic
- increased number/prominence during interval
71
For which population is screening breast MRI recommended?
those with a lifetime cancer risk > 20%
72
What should the margin be for a patient with DCIS and IDC in the same lesion?
for these patients, no tumor on ink is adequate
73
What type of incision should you use during breast conservation surgery?
- peri-areolar
- above the nipple: transverse or curvilinear
- below the nipple: radial (because scar contracture can displace the nipple)
74
Describe a simple mastectomy incision.
an elliptical incision in horizontal or oblique orientation
75
What is the risk of IDC after a core needle biopsy with DCIS?
10-20%
76
How should you counsel women with BRCA mutations who are considering breast conservation surgery versus mastectomy?
mastectomy offers risk reduction for breast cancer but does not alter survival
77
What gross margin should you attempt to get during an excisional biopsy or DCIS/IDC resection?
1cm gross margin
78
After the specimen is out in a breast cancer, what do you need to remember to do?
- mark the specimen
- take radiographs to confirm the disease is in the specimen
- mark the cavity with clips to guide radiation
79
When should you remove a mastectomy drain?
when it puts out 30-40cc per day
80
At what rate is atypical ductal hyperplasia upgraded to DCIS or IDC?
5-30%
81
How should you counsel standard risk patients about breast conservation versus mastectomy for IDC?
no difference in recurrence or survival
82
Where are methylene blue and radio colloid injected for lymph node mapping in breast cancer?
- peri-tumoral
- peri-areolar
- prefer the subdermal plane
83
What is the risk of lymphedema after SLNB versus ALND?
- SLNB: 5-10%
- ALND: 20-30%
84
What are the indications for genetic testing in those with breast cancer?
- age < 50
- triple negative cancer
- lobular breast cancer with a personal or family history of gastric cancer
- relative with breast cancer, ovarian cancer, male breast cancer, or pancreatic cancer
- family with BRCA mutation
85
In someone with a new diagnosis of breast cancer, how should the axilla be evaluated?
- physical exam
- and ultrasound
86
Which patients with breast cancer get a metastatic workup?
those with stage III or greater (T4, T3N1, any T with N2)
87
How should you deal with pectoralis involvement in those with breast cancer?
en bloc resection to normal muscle
88
On what timeline is adjuvant therapy given after breast cancer surgery?
start 4-6 weeks post-op
89
Describe an axillary LN dissection.
- curvilinear incision in the axilla
- follow the latissimus doors medially along its anterior surface until it turns tendinous at which time the axillary vein crosses
- clear the anterior surface of the vein from lateral to medial
- then begin dissecting inferior from the vein
- thoracodorsal will be the first deep lateral branch
- long thoracic is identified against the chest wall
- the fat between the two nerves is encircled and swept inferiorly, continuing the dissection in an inferior direction
90
How should you manage a patient with continued inflammatory changes of the skin after initiating neoadjuvant therapy?
do not operate unless patients have resolution given the poor prognosis for those that fail to achieve local control, would try a new systemic agent
91
When should evaluation and treatment of benign breast findings be performed?
after pregnancy
92
Is termination of pregnancy ever indicated for those with breast cancer?
- almost never as it does not improve outcomes
- the exception is those with locally advanced or metastatic Her2/neu+ cancers who would benefit from early initiation of traztuzumab, which is contraindicated during pregnancy
93
A pregnant patient presents with stage III breast cancer, how would you complete the metastatic evaluation?
- usually would get CT C/A/P or PET but in this case want to limit radiation
- instead, get a CXR and a liver US
- consider non-contrast MRI of the axial skeleton and brain if there is concern for bone pain or CNS symptoms
94
Can patients breastfeed while getting adjuvant therapy for breast cancer?
no, they should not breastfeed
95
Should males with breast cancer undergo surveillance? AT what interval?
- yes they should
- including mammography if they maintain contralateral breast tissue or underwent BCT
- there are no guidelines for this though
96
How should women with dense breast tissue (C/D) be screened?
annual mammography and US (not MRI)
97
What endocrine therapy is offered to men with breast cancer? What is an alternative?
- first line is tamoxifen
- second line is leuprolide (GnRH analogue) with an aromatase inhibitor
98
What is granulomatous mastitis?
- chronic, benign inflammatory condition with recurrent fluid collections/non-caseating granulomas
- treated with steroids and immunosuppression rather than antibiotics and drainage
99
What is the Oncotype DX Breast Recurrence Score?
- a gene assay that reports risk of recurrence for those with ER+ and Her2/neu- cancer
- directs the need for adjuvant therapy in those with low-stage tumors
- less than 18 is low risk
100
What breast cancer treatments are contraindicated during pregnancy?
- tamoxifen
- trastuzumab
- radiation
- docataxel
101
How does neoadjuvant therapy for breast cancer alter the management of the axilla?
- often see a complete pathologic response, so can start with SLNB and targeted dissection rather than ALND
- that said, not candidates for Z11 and any positive nodes necessitates ALND
102
A surgical duct excision can remove lesions where?
within 3cm of the areola
103
How should you handle BRCA mutations of uncertain significance?
shouldn't affect your decision making
104
What is the PALB2 gene?
a partner and co-localizer of the BRCA2-interacting protein, mutations convey increased breast cancer risk
105
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