Breast

Question 1

List of benign breast masses

Answer 1

Fibroadenoma Cyst Fat necrosis Fibrocystic changes Phylloides tumor

Question 2

Elements of breast mass history

Answer 2

timing

meds history (hormones)

Risk factors (age of menstruation, pregnancies, previous biopsies)

Family history

Question 3

Bi-RAds

Answer 3

1: Negative for mass 2. Benign 3. Probably benign (6 mo follow up) 4: Suspicious (tissue dx) 5: Highly suspicious (tissue dx) 6. Known malignancy.

Question 4

How to deal with palpable lymph nodes on initial examination

Answer 4

FNA

Question 5

Diagnostic mammogram views

Answer 5

Cradiocaudal mediolateral oblique

Question 6

Immunohistochemistry equivicol for Her2 then request…

Answer 6

FISH testing.

Question 7

Requirements for SLNB in patient with clinically positive nodes prior to neoadjuvant chemotherapy. (ACOSOG 1071)

Answer 7

1. Dual tracer
2. 2, and ideally, 3 SLN
3. Removal of clipped, clinically positive node. (If residual disease identified in SLN, then completion ALND)

Question 8

SLNB removal criteria

Answer 8

Highest radioactivity - get number palpable blue > 10% of max SLN.

Question 9

Post op considerations regarding cancer treatment

Answer 9

1. Multidisciplinary approach 2. Hormones 3. Radiation 4. Chemotherapy (typically prior to radiation) 5. Mammogram 6 months after completion of therapy 6. Annual visit, exam, and mammogram

Question 10

Breast mass algorithm

Answer 10

Question 11

Findings on CNB that confer increased risk of breast cancer

Answer 11

1. Atypical ductal hyperplasia
2. Lobular neoplasia
3. Papillomas with or without atypia

Question 12

Margin required for DCIS

Answer 12

2 mm

Question 13

Contraindications for radiation therapy

Answer 13

1. Collagen vascular dissease
2. Previous radiation
3. Pregnancy

Question 14

Extent of dissection in mastectomy

Answer 14

1. clavicle superiorly
2. sternum medially
3. Latissimus laterally
4. inframammary fold inferiorly.

Question 15

Length of adjuvant hormonal therapy to achieve risk reduction

Answer 15

5 years

Question 16

consideration for SLNB in DCIS

Answer 16

lesions > 4 cm

comedonecrosis

Mastectomy

Question 17

Benefits of adjuvant radation in DCIS partial mastectomy

Answer 17

Decreased local recurrance. No survival benefit.

Question 18

Size of needle for core needle biopsy

Answer 18

14 or 16 gauge (must place clip if doing it yourself)

Question 19

Breast cancer risk for LCIS

Answer 19

1% per year (need tamoxifen or raloxifene for 5 years)

Question 20

Side effects of estrogen receptor antagonists

Answer 20

tamoxifen (night sweats, hot flashes, increased uterine cancer risk in post menopausal women)

Question 21

Treatment for DCIS

Answer 21

1. Biopsy with determiniation of receptor status
2. discussion at MD conference
3. Lumpectomy with whole breast radiation
4. Risk reduciton with tamoxifen
5. H&P Q6 mo for 5 years, then annually with annual mammogram

Question 22

Work up when diagnosis of breast cancer made

Answer 22

1. Receptor status
2. MD conference meeting
3. consider genetic counseling
4. pregnancy test
5. Focused H&P looking for abdominal symptoms or neurological symptoms, and LN exam, followed by possible labs, CXR, head MRI

Question 23

When should neoajuvant chemotherapy be considered

Answer 23

T2 (greater than 2 cm) or N1 lesions

Question 24

What to do if nodes found on SLNB

Answer 24

ZII trial?

Consider staging work up if not obtained before.

Question 25

Only real case where post op radiation is NOT indicated

Answer 25

Mastectomy with no positive nodes, tumor \< 5 cm, and margin \> 1 mm

Question 26

Favorable histologic subtypes

Answer 26

1. Pure tubular 2. Pure mucinous 3. Pure cribiform 4. encapsulated or solid papillary Important if also node negative, then don't need adjuvant chemotherapy. All others get adjuvant chemo considered.

Question 27

2 scenarios that may not need adjuvant chemotherapy

Answer 27

Favorable histologic subtypes with node negative disease Standard subtypes with node negative disease ER/PR positive HER2 negative, \< 0.5 cm Above \> 0.5 cm, consdier 21-gene assay

Question 28

Work up prior to neoajuvant chemotherapy

Answer 28

Standard H&P, diagnostic mammogram, U/s of breast, biopsy, receptor status, MD conference, consider genetics should also consider axillary U/S with FNA of suspicious nodes followed by possibly labs, chest/a/p CT, bone scan

Question 29

General treatment strategies for recurrence of breast cancer

Answer 29

Try to resect and stage axilla if possible If axilla already dissected, resect recurrence If havn't recieved RT, gets resection and RT If recurrent supraclavicular or internal mammary - RT

Question 30

Z11 requirements

Answer 30

1. T1 or T2 tumor 2. 1 or 2 positve Sentinel lymph nodes 3. Breast conserving surgery 4. WBRT planned 5. No pre-op chemo

Question 31

What if can't identify sentinel lymph node?

Answer 31

Must do axillary LN disseciton

Question 32

What prompts concern for phyllodes tumr

Answer 32

U/S characteristics of fibroadenoma but \> 3cm

Question 33

Treatment of phyllodes tumor

Answer 33

Excision with 1 cm margins. (small % are malignant) no need for axillary staging.

Question 34

Physical exam findings raising concern for Paget's disease

Answer 34

areolar ezcema, bleeding, ulceration, itching

Question 35

Work up for Paget's disease

Answer 35

Clinical history and exam diagnostic mammogram and u/s Core needle biopsy of mass and full thickness skin biopsy of NAC

Question 36

Treatment for Paget's disease

Answer 36

Atleast central lumpectomy including NAC with WBRT if cancer, may need SLNB

Question 37

Work up for inflammatory breast cancer

Answer 37

1. H&P with axillary exam 2. Bilateral diagnostic mammogram and ultrasound 3. CbC, CMP 4. CT chest/abdomen/pelvis 5. bone scan 6. Biopsy with recetor status 7. Disccussion at MD board 8. Genetic counseling

Question 38

Treatment for inflammatory breast cancer

Answer 38

1. Neoadjuvant chemotherapy (anthracycline plus taxane) +/- trastuzumab/pertuzumab if HER2 positive 2. Modified radical mastectomy 3. Post op radiation, completion of HeR2 chemo, and endocrine therapy for receptor positive.

Question 39

Cumulative risk of cancer with ADH

Answer 39

30% in 25 years (4.5X normal risk)

Question 40

% DCIS upstaged on pathology

Answer 40

10-20%

Question 41

% ADH diagnosed with concurrent cancer

Answer 41

up to 40%

Question 42

Lifetime risk of breast cancer in BRCA1 or 2

Answer 42

40-90%

Question 43

Risk of ovarian cancer in BRCA 1 and 2

Answer 43

BRCA 1 up to 60% BRCA2 up to 30%

Question 44

Treatment for Stewart Treves syndrome

Answer 44

amputation, chemotherapy for metastatic disease.

Question 45

Margin needed if specimen has both invasive ductal carcinoma and DCIS

Answer 45

just no tumor on ink (do not need 2 mm margin if both in specimen)

Question 46

Pale staining cells between keratinocytes

Answer 46

Paget's disease

Question 47

Well circumscrobed mass which may have calcifications

Answer 47

fibroadenoma

Question 48

Eggshell calcifications

Answer 48

fat necrosis

Question 49

Clustered microcalcifications on mammogram

Answer 49

DCIS

Question 50

Other name for complex sclerosing lesion

Answer 50

radial scar

Question 51

better prognosis Luminal A or B

Answer 51

Luminal A

Question 52

Sometimes mammogram of inflammatory breast cancer can appear as mastitis, this is necessary if course of Abx has failed

Answer 52

skin biopsy

Question 53

most common etiology of fat necrosis

Answer 53

most are idiopathic