GYN Onc

Question 1

The most common cause of unilateral bloody breast discharge

Answer 1

Intraductal papilloma

Question 2

The most common cause of unilateral serosanguinous breast discharge in the presence of a breast mass

Answer 2

Breast cancer

Question 3

OCPs and breast cancer

Answer 3

OCPs do NOT increase risk for breast cancer. The dose of estrogen is not high enough. They are, in fact, probably protective since they shut down endogenous estrogen production.

HRT, on the other hand, is a risk factor for breast cancer.

Question 4

Non-estrogen-related risk factors for breast cancer

Answer 4

• Hx of chest radiation (classically for lymphoma)
• Genes:
  
  • BRCA1 and 2
  • ATM (Ataxia telangiectasia)
  • p53 mutation
  • CHEK2 (checkpoint 2 kinase mutation)
  • PTEN
  • Cadherin 1
  • STK11 (Serine-threonine kinase 11)

Question 5

Should you recommend self breast exams?

Answer 5

NO. Because women will find something, and it will require workup but it will not be breast cancer.

Question 6

Should you do regular breast exams for your patients (primary care, GYN)?

Answer 6

NO

Evidence has not borne this out to be helpful. Rather, in the same way as self exams, it just dramatically increases workup of benign lesions and leads to unnecessary expense, unnecessary stress, and iatrogenicity.

Question 7

Breast exams are out, ___ is in

Answer 7

Breast exams are out, mammogram is in

Question 8

Best current recommendation for breast cancer screening

Answer 8

Age 40, q2 yrs for mammograms

This is the recommendation to follow right now.

Question 9

When do you use MRI over mammogram for breast cancer screening?

Answer 9

When risk is VERY high.

BRCA patients, BRCA-negative patients with strong family history, patients w/ history of chest irradiation

Question 10

Breast cancer diagnosis

Answer 10

• 1st step: Mammogram
  
  • May arrive at this __ ways:
    
    • Screening mammogram > 30 years
    • Diagnostic mammogram in the setting of suspected breast cancer outside of screening
    • Breast mass (not cyst) on US < 30
    • Bloody FNA on < 30 cyst by US
    • Recurrence of cyst on < 30 by US
• 2nd step: Core needle biopsy (OR excisional if you know it is cancer)
  
  • Necessary for confirmation of diagnosis and for pathological diagnosis

Question 11

Breast mass algorithm

Answer 11

Question 12

Importance of age to breast cancer screening

Answer 12

• Prior to age 30, breast tissue is too firm for mammogram to be useful. Ultrasound is a better test in these patients.
• BUT, we wait 1-2 cycles first to see if the mass goes away, since it is highly unlikely to have breast cancer in this population
• Wait 1-2 cycles, then ultrasound if < 30

Question 13

Possible findings on breast ultrasound for a woman with a breast mass < 30

Answer 13

• Mass: Probably fibroadenoma, possibly breast cancer. Need core needle biopsy.
• Cyst:
  
  • Blood: Probably breast cancer
  • Pus: Probably an abscess
  • Fluid: Probably a benign cyst
• Fibrocystic pattern: Fibrocystic change. Must repeat US on next early follicular phase (cycle day 3)

Question 14

Standard breast cancer chemotherapy

Answer 14

• Doxarubicin
• Cyclophosphamide
• Paclitaxel

Question 15

CHF caused by __ for breast cancer therapy is irreversible, while CHF caused by __ for breast cancer therapy is reversible.

Answer 15

CHF caused by anthracyclines for breast cancer therapy is irreversible, while CHF caused by trastuzumab for breast cancer therapy is reversible.

Question 16

Prognostication for breast cancer receptors

Answer 16

• PR+: good prognosis
• ER+: good prognosis
• HER2/Neu+: poor prognosis

Question 17

Targeting HER2/neu

Answer 17

Trastuzumab

Question 18

Targeting ER/PR

Answer 18

If premenopausal: SERM

If postmenopausal: Aromatase inhibitor

Question 19

BRCA prophylactic measures

Answer 19

• Prophylactic mastectomy and BLSO
• Otherwise, MRI and mammogram every year to screen

Question 20

Adjuvant chemotherapy

Answer 20

Chemotherapy after surgical resection

Question 21

Neoadjuvant chemotherapy

Answer 21

Chemotherapy first to reduce tumor size, then surgery

Question 22

“Triple test” for breast cancer

Answer 22

• Clinical exam
• Imaging
• Pathology
  
  • All three must be negative in order to rule breast cancer out

Question 23

If imaging and clinical exam of a breast mass are concerning, but biopsy findings are benign. . .

Answer 23

. . . excisional biopsy is still warranted in order to avoid the possibility of sampling error

Question 24

Prognostication for inflammatory breast cancer

Answer 24

Lymph node involvement is common

Most cases will require neoadjuvant therapy followed by surgery and radiation

Question 25

If you're gonna give an aromatase inhibitor, you also need to give. . .

Answer 25

. . . **a bisphosphonate**

Question 26

PARP inhibitors are particularly effective in the treatment of . . .

Answer 26

. . . **breast cancers with DNA repair gene mutations** ## Footnote **BRCA1, BRCA2, TNBCs, basal-type cancers**

Question 27

Treatment of breast cancer metastases

Answer 27

As a general rule, radiation and surgery are unlikely to be curative Playing w/ chemotherapeutics is the best option at this stage

Question 28

Aromatase inhibitors vs SERMs for ER/PR+ breast cancer

Answer 28

Aromatase inhibitors do work better for those who are eligible If SERMs fail, it may be time to switch to AIs

Question 29

If a breast FNA detects malignant cells, the next step is . . .

Answer 29

Core needle biopsy

Question 30

If a patient has inconclusive results on mammogram due to breast tissue that is too dense, the next thing to do is. . .

Answer 30

. . . **MRI** Suprisingly, not ultrasound. This is because the patient is older than 30 (since they were screened w/ mammogram)

Question 31

In whom does the American Cancer Society recommend using MRI for screening for breast cancer?

Answer 31

Those with a "high risk" profile, defined as \>20% lifetime risk

Question 32

BIRADS categories of mammogram reading

Answer 32

* BIRADS 4 is subdivided into: * 4A: Low suspicion of malignancy * 4B: Moderate suspicion of malignancy * 4C: High suspicion of malignancy

Question 33

Patient's core needle biopsy is read by pathology as atypical ductal hyperplasia. What is the next step?

Answer 33

**Excisional biopsy** 25-35% of patients with ADH also have ductal carcinoma in situ (DCIS)

Question 34

Indications for breast MRI as annual breast cancer screening test

Answer 34

* Known **BRCA** mutation or **untested first-degree relative** of someone with known BRCA mutation * Known **Li-Fraumeni syndrome** (p53 mut) or **untested first-degree relative** of someone with known Li-Fraumeni * History of **prior chest wall irradiation** * Estimated lifetime breast cancer risk **\> 20%**

Question 35

Interpretation of LCIS vs DCIS on core needle biopsy

Answer 35

DCIS: Likely indicates either a precursor stage of cancer or invasive cancer elsewhere in the breast -- warrants excisional biopsy. LCIS: Indicative of an increased risk of future breast cancer moreso than it is itself a precursor stage of invasive cancer. Managed with SERM prophylaxis and q6-12 month imaging.

Question 36

Prophylactic mastectomy

Answer 36

A reasonable treatment option for those at very high risk -- for example, those with BRCA1 mutations However, all options should be discussed first. This is not reasonable for an individual of average risk.

Question 37

Workup for suspected intraductal papilloma

Answer 37

* Start with bilateral mammogram and/or ultrasound * If positive for suspicious lesion, core needle biopsy * If negative, perform doctography * If ductography is positive for suspicious lesion, core needle biopsy

Question 38

Ductal ectasia etiology and risk factors

Answer 38

* Etiology: Loss of elastin in the duct wall as a result of chronic inflammation * Risk factors: **Ductal ectasia only occurs in smokers**

Question 39

Treatment for ductal ectasia and intraductal papilloma

Answer 39

Ductectomy

Question 40

If a patient has a breast mass/symptoms, your workup order is \_\_\_. If they have are just being screened, you would only do \_\_\_.

Answer 40

If a patient has a breast mass/symptoms, your workup order is **MRI AND ultrasound AND biopsy if indicated** If they have are just being screened, you would only do **mammogram OR ultrasound**.

Question 41

Past what BIRADs score do you consider biopsy?

Answer 41

BIRADS 3: Odds are low (2-3%), but may consider BIRADS 4 or above: You should biopsy

Question 42

Why is core needle biopsy SO much better for breast cancer evaluation than FNA?

Answer 42

FNA is just cytology -- you can't stain to evaluate for ER/PR/HER2

Question 43

90% of breast cancers arise from \_\_\_\_

Answer 43

90% of breast cancers arise from **TDLUs (terminal ductal lubular units)**

Question 44

Axillary node levels

Answer 44

Question 45

In individuals of Ashkenazi ancestry, we evaluate for BRCA mutation in.

Answer 45

. . . **anyone with breast cancer, even without family history** The prevalence in this population is already 1/40, so if they are already presenting with breast cancer the odds are quite high

Question 46

If a symptomatic breast cyst has no malignant features and is present in a young woman. . .

Answer 46

. . . **you aspirate it, but don't need to send the aspirate for cytology**