1- Breast Disorders

Question 1

What views are used for screening and diagnostic mammography?

Answer 1

Screening = 2 craniocaudal (CC) + 2 mediolateral oblique (MLO)

Diagnostic = CC + MLO + more views

Question 2

What technique is used for mammography in women who have breast implants?

Answer 2

Implant displacement

Question 3

Why is timely eval with mammography important?

Answer 3

R/o cancer and relieve pt anxiety

Question 4

What are the indications for diagnostic testing with US? (breast disorders) (5)

Answer 4

Inconclusive MMG results, young women, dense breast tissue, differentiation between solid and cystic mass, guiding for tissue core-needle biopsies

Question 5

When is an MRI used for diagnostic testing? (breast disorders)

Answer 5

Detecting breast CA in high risk women, staging disease in women w/ breast CA

Question 6

When is MRI diagnostic testing NOT recommended? (breast disorders)

Answer 6

Eval of a breast mass

Question 7

What is important to note about use of MRI that could have contraindications?

Answer 7

IV gadolinium dye used

(check BUN and creatinine)

Question 8

What diagnostic test is the acceptable initial method for evaluating a mass with low pretest probability of CA and is useful in determining if a palpable lump is a simple cyst?

Answer 8

Fine-needle aspiration

Question 9

What diagnostic test is used to obtain samples from larger, solid breast masses?

Answer 9

Core-needle biopsy

Question 10

What are the 2 types of possible surgical biopsy? (breast disorders)

Answer 10

Incisional (portion of mass) and excisional (take entire mass)

Question 11

What are 2 of the more important history questions to ask when evaluating breast sxs?

Answer 11

A/w menstrual cycle, RFs that increase likelihood of malignancy

Question 12

What is mastalgia and what are its etiologies/ classifications?

Answer 12

Breast pain; cyclical, non-cyclical, extra-mammary

(non-cyclicalrelated to internal anatomical changes like injury, surgery, cyst)

Question 13

What are the characteristics of cyclical pain (mastalgia)? (4)

Answer 13

Luteal phase, bilateral, diffuse, fibrocystic changes

Question 14

What type of mastalgia may be unilateral or focal, and may be caused by meds (hormonal contraceptives, HRT, SSRIs, Spironolactone)?

Answer 14

Noncyclical

(ex. large, pendulous breast causes ligamentous pain)

Question 15

Pt who is younger than 30 yrs presenting with focal breast pain should proceed with what diagnostic studies?

Answer 15

Targeted US

Question 16

Pt who is older ≥ 30 yo and presents with focal pain should proceed with what diagnostic studies?

Answer 16

Targeted US and MMG

Question 17

What is 1st line treatment for mastalgia if normal findings on exam and imaging? (4)

Answer 17

Reassurance, physical support, compresses, analgesics (acetaminophen/ NSAIDS)

Question 18

What is 2nd line treatment for mastalgia (only if failed 1st line for > 6 mos)?

Answer 18

Danazol or Tamoxifen for 1-3 mos

(caution w/ SEs)

Question 19

Woman who is lactating presents with hard, red, tender, swollen area of one breast. VS show fever. What are you concerned for?

Answer 19

Mastitis

Question 20

What is the most common etiology of mastitis?

Answer 20

S. aureus

Question 21

What is an important ddx for mastitis that you do not want to miss?

Answer 21

Inflammatory breast CA

Question 22

What is the tx for mastitis?

Answer 22

Dicloxicillin or cephalexin

Question 23

What pt edu should be provded for a woman with mastitis?

Answer 23

Continue breastfeeding

Question 24

What is the management for breast abscess if there is evidence of skin compromise?

Answer 24

I+D

Question 25

What is important to consider in the management of benign vs malignant breast masses?

Answer 25

PE cannot distinguish, need imaging

Question 26

What characteristics are indicative of a benign breast masses? (5)

Answer 26

Discrete margins, no skin changes, smooth, soft to firm, mobile

Question 27

What characteristics are indicative of a malignant breast masses? (4)

Answer 27

Poorly defined margins, possible skin changes, hard, immobile/ flexed

Question 28

What is defined as a fluid-filled round or ovoid mass?

Answer 28

Breast cyst

Question 29

Pt presents with smooth, firm (due to fluid), mobile mass that is well-defined on palpation and +/- tenderness. What are you concerned for? (can also be ballotable- not firm)

Answer 29

Breast cyst

Question 30

A cluster of cysts may palpate as what?

Answer 30

Ill-defined mass

Question 31

What is the management for simple breast cysts?

Answer 31

Typicall no intervention unless: * Sx, then FNA * Recurrent, then repeat imaging

Question 32

What is the management for complicated breast cysts (\< 1% risk of malignancy)?

Answer 32

FNA or follow w/ imaging q 6 mos x 2 yrs

Question 33

What is the management for complex breast cysts (1-23% risk of malignancy)?

Answer 33

Bx + possible surgical excision

Question 34

What is defined as a benign, solid tumor containing glandular and fibrous tissue?

Answer 34

Fibroadenoma

Question 35

Pt presents with round, well-defined, mobile mass that is firm and non-tender. Hx of increasing in size during pregnancy and w/ estrogen use. What are you concerned for?

Answer 35

Fibroadenoma

Question 36

What is the management for a fibroadenoma?

Answer 36

Core needle bx +/- surgical excision/ cryoablation OR If benign features on US- 3-6 mo repeat CBE and US

Question 37

If a fibroadenoma increases in size, what is the management?

Answer 37

Excision (r/o malignancy)

Question 38

What should be considered with rapid growth of a fibroadenoma?

Answer 38

Phyllodes tumor

Question 39

What is defined as a fibroepithelial tumor classified as benign, borderline or malignant?

Answer 39

Phyllodes tumor

Question 40

Pt presents with suspicious breast mass. What is the next step?

Answer 40

Dx MMG and directed US → bx

Question 41

Pt presents with indeterminate lesion/ breast mass and is ≥ 30 yo. What is the management?

Answer 41

Dx MMG w/ or w/o directed US

Question 42

Each duct of the breast drains what?

Answer 42

A separate portion of the breast

Question 43

What type of nipple discharge is typically **spontaneous, unilateral, from a single duct**, bloody, serous, clear, or a/w a mass?

Answer 43

Pathologic discharge

Question 44

What is the most common cause of patholgic nipple discharge?

Answer 44

Intraductal papilloma (others: duct ectasia, CA, infection)

Question 45

What type of nipple discharge is typically **bilateral, from multiple ducts**, and associated with stimulation?

Answer 45

Physiologic discharge

Question 46

What is the most common cause of physiologic nipple discharge?

Answer 46

Galactorrhea (others: med related, neurogenic stimulation)

Question 47

What characteristics of nipple discharge indicate a surgical referral?

Answer 47

Single duct or bloody

Question 48

What are the strongest RFs for breast CA?

Answer 48

Female gender and advancing age

Question 49

The following are RFs for what? Female gender, advancing age, BRCA 1 and 2 genetic mutations, hx of DCIS, first birth \> 30 yo or nulliparity, FH of breast/ ovarian CA, early menarche, late menopause, high BMI, postmenopausal hormone therapy

Answer 49

Breast CA

Question 50

What are BRCA1 and BRCA2 genes are how are they linked to breast and ovarian CA?

Answer 50

Tumor suppressors, mutation linked to CA

Question 51

What are the management options if BRCA + (mutation present)?

Answer 51

Increased surveillance, chemoprevention (Tamoxifen if \> 35 yo), surgical prevention (prophylactic mastectomy)

Question 52

Does BRCA (-) (mutation not present) mean the a female with NOT get breast CA?

Answer 52

NO

Question 53

What are the methods of breast cancer screening and what is the most highly recommended?

Answer 53

**"Breast awareness" (most recommended)**, clinical breast exam (CBE), screening MMG

Question 54

When is the best time to perform a clinical breast exam (CBE) and what are the key features to the exam?

Answer 54

In follicular phase; systematic approach and cover entire area

Question 55

What are the breast CA MMG screening recommendations for average risk women? (no personal/ family hx of breast CA, no genetic mutation, no chest chest radiation \< 30 yo)

Answer 55

* Consider @ 40-49 yo * Screen all women @ ≥ 50 yo * Stop screening @ 75 yo * Frequency: every 1-2 yrs

Question 56

When is annual breast CA screening w/ MRI recommended?

Answer 56

High risk of breast CA and high sensitivity of MRI

Question 57

How is breast CA classified?

Answer 57

Anatomical location (lobular or ductal), hormone receptivity (E and P), HER2 expression

Question 58

How does breast CA most commonly present clinically?

Answer 58

Palpable mass (+/- skin changes, nipple discharge)

Question 59

Breast lesions with malignant cells that have not penetrated the basement membrane of the mammary ducts or lobules is defined as what?

Answer 59

Noninvasive (in situ) breast CA

Question 60

What are the 2 types of noninvasive (in situ) breast CA?

Answer 60

Lobular (LCIS) and ductal (DCIS) (ductal localized inside mammary ducts)

Question 61

What type of breast CA is treated as a malignancy because it has the potential to develop into invasive CA?

Answer 61

DCIS

Question 62

What type of breast CA appears on MMG as clustered pleomorphic calcifications, has a PE WNL and can be multifocal or multicentric?

Answer 62

DCIS (ductal)

Question 63

What type of breast CA does not become an invasive CA if left untreated?

Answer 63

LCIS (lobular)

Question 64

What type of breast CA presents with PE and imaging WNL, is usually an incidental finding but can be an indicator for increased risk of invasive carcinoma?

Answer 64

LCIS (lobular)

Question 65

What is the treatment for DCIS? (ductal)

Answer 65

* Breast- conserving surgery w/ radiation vs mastectomy +/- sentinel lymph node bx * Adjuvant hormone therapy if E+P positive (Tamoxifen and Arimidex)

Question 66

What is the treatment for LCIS? (lobule)

Answer 66

* Typically none recommeded (not a true CA) * Lifelong surveillance * Chemoprevention (Tamoxifen, Arimidex) * Bilateral prophylactic mastectomy

Question 67

What is the most common breast malignancy (80%)?

Answer 67

Infiltrating ductal carcinoma (IDC)

Question 68

How does infiltrating ductal carcinoma (IDC) typically present?

Answer 68

Palpable mass or MMG abn "Oh damn, not good"

Question 69

What type of breast CA usually presents as a palpable mass or MMG abn, is more apt to be bilateral, and is usually hormone receptor positive?

Answer 69

Infiltrating lobular carcinoma (ILC) "You're lucky"

Question 70

Stellate lesions, irregularly shaped mass, spiculation, pleomorphic calcifications and anatomical distortion of MG + taller than wide on US is indicative of what?

Answer 70

Invasive breast carcinomas

Question 71

Pt presents with unilateral scaly, raw, vesicular or ulcerated lesion that begins on the nipple and spreads to the areola +/- blood discharge. Pt notes hx of pain, burning and pruritis before the lesions appeared. What are you concerned for?

Answer 71

Paget Disease of the Breast (PDB) | (rare cause of breast CA but majority have underlying breast CA)

Question 72

What type of breast cancer is very aggressive and presents clinically as pain w/ rapidly progressing, tender, firm, enlarged breast, skin warm, thickened, peau d'orange appearance, and erythema?

Answer 72

Inflammatory breast CA (IBC)

Question 73

Inflammatory breast CA (IBC) is typically considered very aggressive with almost all having what?

Answer 73

Lymph node involvement, 1/3 with distant metastasis

Question 74

What is the primary location for lymphatic spread of breast CA?

Answer 74

Axillary (also can spread to internal mammary nodes, supraclavicular w/ late disease)

Question 75

What are the most common locations for hematogeneous spread of breast CA?

Answer 75

Lung and liver (can also go to bone, ovaries, brain)

Question 76

What is the management for breast CA?

Answer 76

Surgery (BCS- lumpectomy, mastectomy), radiation, chemo, endocrine therapy

Question 77

The following characteristics of breast CA determine what? Tumor size, lymph node involvement, mets, E+P status, HER2 status, oncotype dx breast recurrence score, BRCA status

Answer 77

Surgical management

Question 78

What surgical management of breast CA is defined as part of the breast containing the CA is removed w/ or w/o selective sampling of axillary nodes?

Answer 78

BCS (breast conserving surgery) = lumpectomy

Question 79

What is typically considered to be the appropriate treatment for stage I or II breast CA due to decreased morbidity and comparable survival/ recurrence rates compared to more invasive procedures?

Answer 79

BCS with post-op radiation

Question 80

What is removed in a simple (aka total) mastectomy?

Answer 80

Entire breast including nipple and areola

Question 81

What is removed in a modified radical mastectomy?

Answer 81

Entire breast including nipple and areola + axillary lymph nodes

Question 82

What is removed in a radical mastectomy?

Answer 82

Entire breast, lymph nodes, pec muscle (rarely performed)

Question 83

Radiation is almost always used (more commonly after surgery) in the treatment of breast CA. WHat are the 2 types?

Answer 83

External beam and brachytherapy (radiation to breast, chest wall, regional LN/ axillary)

Question 84

When is chemotherapy included in the management of breast CA?

Answer 84

Primary and metastatic breast cancers, (+) lymph nodes, high oncotype dx recurrence scores

Question 85

When is neoadjuvant chemo?

Answer 85

Given before surgery to shrink size of tumor (may allow for breast conservation surgery)

Question 86

What is adjuvant chemo?

Answer 86

After surgery, kills CA cells left behind

Question 87

What type of breast cancer is responsive to HT?

Answer 87

Estrogen (+) and progesterone (+) breast CA (as compared to hormone negative CA)

Question 88

What HT drugs are included in the management of breast cancer as a supplement to chemo and radiation?

Answer 88

* SERM- Tamoxifen (if pre-menopausal) * Aromatase inhibitors- Arimidex (if post-menopausal)

Question 89

How long is endocrine/ hormone therapy typically given for in the treatment of breast CA?

Answer 89

5-10 years

Question 90

What is HER2 and what is it's association to breast CA?

Answer 90

Growth-promoting protein; CA a/w overexpression of HER2

Question 91

What breast CA treatment targets HER2 and when is it effective in combo with chemo?

Answer 91

Herceptin; effective in early stage CA's and metastatic disease

Question 92

When is chemoprevention recommended for breast CA prevention?

Answer 92

Asx women aged ≥ 35 w/o a prior dx of breast CA who are at increased risk Give Tamoxifen or Arimidex/ Raloxifene