breast

Question 1

who should be screened with mammography

Answer 1

free for all women over 40

for screening to be useful and effective, you need to be obtaining a diagnosis that will allow for a likelihood of survival of at least 10 years (since expected mortality is age 85, stop screening at 75)

Question 2

what views are used in screening mammography

Answer 2

2 views

medial/lateral/oblique to include axial tail and cranial-caudal

Question 3

are screening and diagnostic mammography the same thing?

Answer 3

no

screening is two views

diagnostic is done after an abnormality is detected (i.e palpable lump or abnormal screening mammogram)–> has several views including lateral and magnification/cone views

Question 4

describe the elements of a breast history

Answer 4

1. lump–> duration, tenderness, change with menses
2. nipple discharge–> color, spontaneous, unilateral or bilateral
3. nipple inversion or scaling
4. breast dimpling, ulceration, erythema, edema
5. symptoms of distant mets disease
6. gyne history–> age of menarche, menopaus; parity; age at first pregancy; breast feeding; use of OCPs or hormone replacement therapy
7. PMHx–> previous history of breast disease, recent breast trauma, prior radiation, family history

Question 5

what elements make up a complete breast exam

Answer 5

both breasts

both axillae and supraclavicular fossae

lungs and liver and vertebral percussion tenderness (if indicated

Question 6

what is the most common cancer for women

Answer 6

breast

Question 7

DDx of a breast mass

Answer 7

Vascular–> hematoma, AVM

Inflammatory–> mastitis, abscess

Neoplasm–> benign (fibroadenoma) or malignant (breast or non breast) primary or secondary

Degenerative/deficiency/drugs

Idiopathic, intox

Congenital–> breast bud

Autoimmune/allergic–> non infectious mastitis

Traumatic–> fat necrosis

Endocrine–> fibrocystic change, cysts, gynecomastia

Question 8

screening for ages 50-74 with no family history

Answer 8

every 2 years

Question 9

screening for ages 50-74 with family history

Answer 9

annually

Question 10

screening for ages 40-49 with no family history

Answer 10

discuss with MD

Question 11

how much does screening reduce mortality from breast cancer

Answer 11

30% reduction

Question 12

screening for ages 40-49 with family history

Answer 12

offered every 2 years

Question 13

screening for ages above 74

Answer 13

discuss with MD

Question 14

how does the accuracy of mammograms change with age

Answer 14

more accurate as you get older because breast less dense

30% less accurate under age 40

Question 15

screening for ages below 40

Answer 15

not recommended unless high risk requires referral

Question 16

major risk factors for breast cancer

Answer 16

1. being female
2. family history of breast cancer in 1st degree relative especially if premenopausal or bilateral or ovarian cancer in 1st degree relative (most women who are dx have no family history)
3. known BRCA1/2 mutation carrier
4. personal history of lobular carcinoma in situ (LCIS)
5. atypical hyperplasia
6. previous chest wall irradiation to developing breast
7. mammographic density greater than 75% of the breast volume

Question 17

what is the most common abnormality found on mammography

Answer 17

micro calcifications (not palpable)

worry about calcifications that are irregular and clumped together (more than 10 in one area)

Question 18

moderate risk factors for breast cancer

Answer 18

older age

personal history of breast cancer

north american/european descent

hyperplasia without atypia

some mammographic density

Question 19

lesser risk factors for breast cancer

Answer 19

family history of post menopausal breast cancer

nulliparity

later age at menopause or early age at menarche

post menopausal obesity

alcohol consumption and diet

Question 20

what factor might make you consider a breast lump to be malignant

Answer 20

taller than wide in breast tissue

Question 21

how do breast cysts present

Answer 21

likely due to estrogen stimulation, common between ages 40-60/premenopausal

may be multiple or solitary, fluctuate in size and degree of tenderness and the menstrual cycle

are mobile, may be ill defined, usually round, not always fluctuant

may recur after aspiration so reassess in 6 weeks

Question 22

how do you investigate a breast mass

Answer 22

1. imaging (U/S, mammogram)
2. clinically guided FNA, aspiration (can be done as family doc without local) for immediate diagnosis and treatment
3. core biopsy gets architecture to tell you if a cancer is invasive or not

Question 23

how do you do an FNA in clinic

Answer 23

22 gauge needle, 10 cc syringe, alcohol swab and bandaid, urine specimen container

only gathers cells but can say whether benign or malignant

fluid enters if its at least partially a cyst–> examine the fluid and re-examine the breast

• -green tinged or straw colored fluid/clear cloudy is normal
• -re-examine the breast to be sure the mass is gone
• -if the fluid is normal and the mass is gone, discard the sample
• -old blood or persistence of the mass, send fluid for cytology and arrange breast imaging

Question 24

describe what fibrocystic breast changes are in the breast

Answer 24

common manifestation of normal breast physiological changes related to the menstrual hormone cycle that occurs in almost all women–> usually lumpiness (no discrete lump) with pain and fluctuates with cycle

microscopic cysts embedded in dense fibrous tissue of the breast gives a “lumpy” or nodular quality without a discrete mass –> imaging is normal

Question 25

management of breast fibrocystic changes

Answer 25

reassurance--> no increased risk of malignancy manage pain and diet--> reduce salt, caffeine intake, dietary fat intake severe mastalgia responds to hormonal manipulation (sometimes over OCPs, danazole, tamoxifen)

Question 26

if 50% of your relatives have breast cancer, what is your lifetime risk?

Answer 26

50% send this women for BRCA mutation testing

Question 27

if your mother has breast cancer, what is your lifetime risk?

Answer 27

30%

Question 28

BRCA positive women have what risk for breast cancer

Answer 28

85% or greater risk curable with mastectomies

Question 29

what is lobular carcinoma in situ and how is it detected

Answer 29

detected by doing biopsy for other reasons i.e fibroadenoma LCIS implies a greater personal risk (1% a year) of developing breast cancer in either breast not a mass--> it is an insidious pathological finding

Question 30

is a tissue confirmation necessary if radiology says a breast lump is consistent with a fibroadenoma?

Answer 30

not always if very young or very typical physical exam and imaging yes if older patient, solid and cystic components, atypical features on physical and imaging (irregular margins, lobulation etc)

Question 31

what kind of tissue diagnosis is needed for a fibroadenoma

Answer 31

FNA biopsy showing benign cells is enough if not worried if concerned you can get a core biopsy

Question 32

what is the natural history of a breast fibroadenoma

Answer 32

if less than 3cm in diameter--> 1/3 get smaller, 1/3 remain stable, 1/3 enlarge may enlarge during pregnancy risk of malignancy in adenoma is less than the chance of cancer in the rest of the breast remove if enlarging, symptomatic or at patient request generally follow with U/S imaging for growth

Question 33

what is the "triple test" for breast lump

Answer 33

clinical assessment imaging cytology if all three are benign, lesion is probably benign (98%) and can be followed if any aspect of the triple test is inconclusive or suspicious, needs further workup

Question 34

what is lactational mastitis

Answer 34

secondary infection due to obstructed milk ducts

Question 35

management of lactational mastitis

Answer 35

directed massage to facilitate emptying, continued nursing, abx to cover staph aureus may progress to an asbcess, requiring serial aspirations and continued abx

Question 36

how do you manage a breast abscess

Answer 36

typically requires drainage with serial aspirations or incisions may need IV abx if systemically unwell culture fluid to guide abx can continue nursing

Question 37

how do you manage simple breast cysts

Answer 37

leave them alone and follow | dont need to do anything

Question 38

what is non lactational mastitis

Answer 38

much less common and associated with smoking tends to be recurrent ad associated with draining sinuses at the areolar margin typically has periareolar mastitis and abscess formation treat recurrent disease with surgical resection of involved ducts

Question 39

what causes gynecomastia

Answer 39

imbalance of estrogen and testosterone, may be unilateral or bilateral

Question 40

what is the etiology of gynecomastia

Answer 40

1. natural increases in estrogen due to puberty, aging etc or extra causes of increased estrogen i.e obesity 2. meds--> antiandrogens, anti ulcer meds, anxiolytics, tricyclics, digoxin, CCBs, some abx 3. drugs--> alcohol, anabolic steroids, marijuana, amphetamines, heroin, methadone 4. disease--> hypogonadism, hormone producing tumours, hyperthyroidism, renal or liver failure

Question 41

how do you investigate gynecomastia

Answer 41

U/S anf mammogram looking for breast tissue

Question 42

how do you manage gynecomastia

Answer 42

reassurance if developmental otherwise treat underlying disease or stop drug use not associated with increased cancer risk symptom control surgical resection of requested

Question 43

what abx to use for mastitis/breast abscess

Answer 43

keflex

Question 44

what is the most common cause of spontaneous, unilateral, uniductal serious or bloody nipple discharge with normal mammogram?

Answer 44

intraductal papilloma (98%)

Question 45

what is intraductal papilloma

Answer 45

benign growth in the duct

Question 46

how do you investigate intraductal papilloma

Answer 46

U/S and mammogram to exclude underlying cancer--> do mammogram with all bloody discharge galactogram is optional (mammogram study with contrast to look at ductal system) cytology of discharge doesnt change management so not necessary

Question 47

treatment of intraductal papilloma

Answer 47

surgical excision of the involved duct (also helps exclude intraductal papillary cancer)

Question 48

what is bilateral milky discharge?

Answer 48

galactorrhea--> physiologic, drug related, or pituitary prolactinoma (must do serum prolactin to rule out prolactinoma)

Question 49

what is bilateral green/yellow multiductal sometimes foul nonspontaneous discharge

Answer 49

dialted retroareolar ducts filled with debris, related to fibrocystic changes stop smoking and stop squeezing

Question 50

how would you investigate a 55 year old woman with enlarging mass in right breast over months with indrawing of overlying skin

Answer 50

1. bilateral diagnostic mammogram 2. U/S of involved breast 3. core biopsy--> important! (FNA cant confirm invasive disease) 4. then confirm STAGING to exclude mets disease--> bone scan only if patient has lymph node spread

Question 51

what is the management for breast cancer

Answer 51

1. lumpectomy/partial mastectomy with radiation treatment (reduce risk of recurrence) -or- 2. mastectomy with or without reconstruction (if multiple cancer sites, cant do radiation etc) AND 3. management of axilla --> sentinel node biopsy if clinically node negative on exam or U/S, axillary dissection if node positive

Question 52

how do you do a sentinel node biopsy

Answer 52

inject with radioactive technetium and dye that maps nodes and then gamma probe to find the radioactive nodes

Question 53

what is the adjuvant therapy for breast cancer

Answer 53

treatment given without evidence of cancer to decrease recurrence risk given after lumpectomy to reduce recurrence risk, to axilla or breast or chest wall after mastectomy with positive nodes or other high risk of recurrence adjuvant chemo/systemic therapy is given to patients who are at high risk for occult mets (tumour larger than 2cm, grade 2-3, lymphovascular invasion, positive nodes) adjuvant tumour factors include menopausal status, comorbidities and ability to tolerate treament, tumour ER status, tumour Her 2 status

Question 54

are lumpectomy and mastectomy equal in cure rates?

Answer 54

only when you do lumpectomy PLUS adjuvant radiation...if you do both its equal and mastectomy lumpectomy alone isnt the same --> chance of recurrence with lumpectomy alone is about 30% (compared to 5-7% with radiation) higher risk of complications with mastectomy so usually offer lumpectomy

Question 55

who can't get radiation (and thus need mastectomy)

Answer 55

connective tissue disorders (SLE especially...get vasculitis) or previous radiation i.e or lymphoma

Question 56

how do you stage breast cancer

Answer 56

TNM staging stage 1--> small with negative nodes stage 2--> 2-5 cm with or without positive nodes stage 3--> any tumour with fixed nodes, maybe supraclavicular, maybe fixed in muscle or skin stage 4--> cancer with distant mets

Question 57

how do invasive ductal carcinoma and invasive lobular carcinoma differ

Answer 57

ductal--> malignant cells originate from the ductal epithelium lobular--> malignant cells originate from the lobular cells (higher chance of bilateral malignancy and can be harder to see on mammogram)

Question 58

who needs chemo?

Answer 58

if there is lymph node involvement--> i.e if sentinel node biopsy shows an active node also probably hormone treatment

Question 59

how do you stage cancer

Answer 59

with CXR and liver enzymes --> further investigations if abnormal bone scan only if patient has lymph node involvement

Question 60

how common is male breast cancer

Answer 60

less than 1% of breast cancer usually in older men with major risk factors being BRCA mutation and family history investigation same as for women (U/S and mammogram)

Question 61

management of male breast cancer

Answer 61

surgery is mastectomy with SLNB or ALND depending on clinical node status adjuvant therapy is same as for women

Question 62

what is ductal carcinoma in situ

Answer 62

malignancy cells in the ducts that have not crossed the basement membrane if untreated--> progression to invasive cancer (but otherwise survival rate is 98%) most DCIS is NOT palpable and is diagnosed from an abnormal mammogram--> typical features are pleomorphic, clustered, branched, microcalcifications without a mass

Question 63

investigations for DCIS

Answer 63

in non palpable lesions--> mammographic core biopsy to get a diagnosis and excision at once can also use fine wire guided excisional biopsy

Question 64

how do you manage DCIS

Answer 64

not usually invasive so SLNB not always needed unless high grade, extensive, palpable, suspicious for invasion surgical excision with clear margins and adjuvant radiation may need mastectomy and reconstruction if extensive

Question 65

what is lobular carcinoma in situ

Answer 65

usually incidental finding on core biopsy done for something else not visible on imaging associated with increased further risk of breast cancer anywhere in breast--> 20-30% over 15 years

Question 66

management of LCIS

Answer 66

ongoing screening (most common) chemoprevention--> i.e tamoxifen (only reduces risk... to about 10-15% bilateral mastectomies

Question 67

what is paget's disease of the nipple

Answer 67

rare (1%) pathologic diagnosis of a typical malignant cell (paget's cells) in the epidermis of the nipple presents with unilateral scaling, flaking, crusting or thickening of the nipple or areola looks like dermatitis or other skin lesions often accompanied by unilateral redness, tenderness, discharge, maybe nipple inversion

Question 68

how do you assess paget's disease of the nipple

Answer 68

biopsy the nipple (scrape, punch, incision etc) mammogram to exclude underlying breast cancer (most have underlying cancer) with unilateral nipple skin symptoms, especially if unresponsive to steroids, needs to be biopsied

Question 69

how do you manage paget's disease of then nipple

Answer 69

if all imaging is negative, treat with central lumpectomy with or without radiation underlying cancer is treated like any other cancer with mastectomy and SNLB