24: Breast Flashcards
What percent of lymphatic drainage from the breast goes to the axillary nodes?
97%
[2% goes to the internal mammary nodes]
What complication of axillary lymph node dissection should be suspected in a patient who develops slow swelling over 18 months?
Lymphatic fibrosis
What is the relative risk of developing breast cancer in a patient with Fibrocystic disease with atypical hyperplasia?
Greatly increased risk (relative risk > 4)
[UpToDate: Atypical hyperplasias (ADH and ALH), especially multifocal lesions, confer a substantial increase in the risk of subsequent breast cancer (relative risk [RR] 3.7 to 5.3). AH is associated with an increased risk of both ipsilateral and contralateral breast cancer and thus provides evidence of underlying breast abnormalities that predispose to breast cancer. In a report from the Nurses’ Health Study, only 56 percent of cancers that developed in women with AH occurred in the ipsilateral breast. The cumulative incidence of breast cancer over 30 years approached 35 percent. Some studies have shown that the risk of developing breast cancer is higher with ALH than ADH; however, the data on this are conflicting. There is a higher risk of subsequent breast cancer when the ALH involves both lobules and ducts (RR 6.8) as compared with lobules alone (RR 4.3) or ducts alone (2.1).]
What is the relative risk of developing breast cancer in a patient with DCIS or LCIS?
Greatly increased risk (relative risk > 4)
[DCIS: ipsilateral breast at risk. LCIS: both breasts have same high risk.]
What is the most common organism responsible for infectious mastitis?
Staph aureus
[Associated with breastfeeding]
Is having very large or pendulous breasts an absolute contraindication or a relative contraindication to breast-conserving therapy in invasive carcinoma if reproducibility of patient setup and adequate dose homogeneity cannot be ensured?
Relative contraindication
Breast abscesses are usually associated with what risk factor?
Breast feeding
What should be ruled out in a nonlacting woman with assumed infectious mastitis?
Necrotic cancer
[In nonlactating women, infectious mastitis can be due to chronic inflammatory diseases (eg actinomyces) or autoimmune disease (eg SLE)]
(requires incisional biopsy including the skin)
What percentage of U.S women develop breast cancer in their lifetimes?
12% (1 in 8 women)
[5% in women with no risk factors.]
True or false: almost all women with breast cancer recurrence die of disease?
True
[Increased recurrences and metastases occur with positive nodes, large tumors, negative receptors, and unfavorable subtypes.]
What is the definition of a N3 breast tumor according to TNM classification?
Metastases in 10 or mor axillary nodes
or
In infraclavicular nodes
or
In internal mammary (IM) nodes in the presence of one or more positive axillary nodes
or
In more than 3 axillary nodes with IM metastases
or
In supraclavicular nodes
Are persistent positive margins after reasonable surgical attempts an absolute contraindication or a relative contraindication to breast-conserving therapy in invasive carcinoma?
Absolute contraindication
What is the definition of a Tis breast tumor according to TNM classification?
Carcinoma in situ, ductal, or lobular, or Paget’s disease of the nipple with no tumor
What is the most common site for distant metastasis of breast cancer?
Bone
[Lung, liver, and brain also common]
What is the chance of local recurrence following breast conserving therapy and XRT?
10%
[Usually happens within 2 years of 1st operation. Need to restage with recurrence and need salvage modified radical mastectomy for local recurrence.]
Is a history of scleroderma or active systemic lupus erythematosus an absolute contraindication or a relative contraindication to breast-conserving therapy in invasive carcinoma?
Relative contraindication
What is the risk of blood clots and endometrial cancer with tamoxifen use?
- Blood clot risk: 1%
- Endometrial cancer risk: 0.1%
Male breast cancer is associated with which risk factors?
- Steroid use
- Previous XRT
- Family history
- Klinefelter’s syndrome
[Male breast cancer has an increased risk of pectoral muscle involvement. It has a poorer prognosis because of late presentation. Male breast cancer is usually ductal. Treatment is modified radical mastectomy.]
What is the approach to a breast cyst in a pregnant woman?
Drain it and send FNA for cytology
What is the treatment for inflammatory breast cancer?
Neoadjuvant chemo, then modified radical mastectomy, then adjuvant chemo-XRT
[UpToDate:
- For patients with non-metastatic IBC, we recommend neoadjuvant chemotherapy followed by locoregional treatment (Grade 1B). The optimal neoadjuvant chemotherapy regimen, including the sequence of agents and duration of treatment, is undefined, though anthracycline- and taxane-based chemotherapy regimens are typically recommended. Trastuzumab is indicated for human epidermal growth factor receptor 2 (HER2)-positive disease.
- Additional treatment considerations are similar to non-inflammatory breast cancer, including the use of endocrine therapy for hormone receptor-positive disease, the use of HER2-directed therapy for HER2-overexpressing disease, and the use of systemic agents for metastatic cancer. These issues are discussed in detail elsewhere.
- For patients with IBC, we suggest modified radical mastectomy rather than breast-conserving surgery, even for those with a complete clinical response (Grade 2C).
- For patients with IBC (including patients who achieve pathologic complete response to neoadjuvant chemotherapy), we recommend postmastectomy radiation therapy (Grade 1B).
- Although IBC is associated with a particularly poor prognosis and high risk of early recurrence, there is evidence that outcomes have improved with neoadjuvant chemotherapy followed by locoregional treatment.]
Which breast pathology is usually not palpable and has no calcifications?
lobular carcinoma in situ (LCIS) of the breast
[Primarily found in premenopausal women. Usually an incidental finding; multifocal disease is common.]
What complication of axillary lymph node dissection should be suspected in a patient who develops hyperesthesia of the inner arm and lateral chest wall?
Intercostal brachiocutaneous nerve injury
[Most commonly injured nerve after mastectomy; no significant sequelae.]
What are the 7 indications for XRT following a mastectomy?
- > 4 positive nodes
- Skin or chest wall involvement
- Positive margins
- Tumor > 5 cm (T3)
- Extracapsular nodal invasion
- Inflammatory cancer
- Fixed axillary nodes (N2) or internal mammary nodes (N3)
What is the lifetime risk of the following cancers in a patient with a BRCA I gene?
- Female breast cancer
- Ovarian cancer
- Male breast cancer
- Female breast cancer: 60% lifetime risk
- Ovarian cancer: 40% lifetime risk
- Male breast cancer: 1% lifetime risk
[BRCA II: Female breast cancer: 60% lifetime risk, Ovarian cancer: 10% lifetime risk, Male breast cancer: 10% lifetime risk.]
Is having two or more primary tumors in separate quadrants of the breast an absolute contraindication or a relative contraindication to breast-conserving therapy in invasive carcinoma?
Absolute contraindication
What percent of breast cancer is negative for both progesterone and estrogen receptors?
10%
What is the lifetime risk of the following cancers in a patient with a BRCA II gene?
- Female breast cancer
- Ovarian cancer
- Male breast cancer
- Female breast cancer: 60% lifetime risk
- Ovarian cancer: 10% lifetime risk
- Male breast cancer: 10% lifetime risk
[BRCA I: Female breast cancer: 60% lifetime risk, Ovarian cancer: 40% lifetime risk, Male breast cancer: 1% lifetime risk.]
When is a sentinel lymph node biopsy indicated for a breast mass?
In malignant tumors > 1 cm (well suited for small tumors with low risk of axillary metastases)
[Not indicated in patients with clinically positive nodes as they need an axillary lymph node dissection.]
[UpToDate:
- The status of the axillary lymph nodes is one of the most important prognostic factors in women with early-stage breast cancer. Histologic examination of removed lymph nodes is the most accurate method for assessing spread of disease to these nodes. Evaluation of the axilla is required for treatment decisions in patients with invasive breast cancer, and axillary lymph node dissection (ALND) remains the standard approach for women who are clinically node-positive.
- For patients with early-stage breast cancer who are clinically node-negative, we recommend initial axillary evaluation with sentinel lymph node biopsy (SLNB) rather than ALND (Grade 1B).
- For patients with ductal carcinoma in situ (DCIS) undergoing breast-conserving surgery, we recommend not performing surgical evaluation of the axilla (Grade 1A). For patients with extensive DCIS undergoing a mastectomy, we suggest SLNB (Grade 2B). Patients with DCIS extensive enough to require a mastectomy have a 20 percent chance of having occult invasive disease. If invasive disease is found and an SLNB has not been performed, the patient will require an ALND.
- When an SLNB is not successful or when clinically suspicious nodes are present after all sentinel lymph nodes have been removed, an axillary dissection should be performed.
What is the treatment for lobular breast cancer?
Modified radical mastectomy or breast conserving therapy with postop XRT
[UpToDate: The surgical approach to early-stage breast cancer depends on the size of the tumor, whether or not multifocal disease is present, and the size of the breast. The options include breast-conserving therapy (breast-conserving surgery plus radiation therapy [RT]) or mastectomy (with or without RT). Both approaches result in equivalent cancer-specific outcomes. Most patients with locally advanced, inoperable breast cancer should receive neoadjuvant systemic therapy rather than proceeding with primary surgery. These patients are usually not candidates for breast conservation at their initial presentation. Neoadjuvant treatment improves the rate of breast conservation without compromising survival outcomes.]
What percentage of cystosarcoma phyllodes of the breast is malignant?
10%
[Based on mitoses per high-power field (> 5-10).]
[UpToDate: Metastatic disease has been reported in 13 to 40 percent of patients with phyllodes tumors of the breast. Metastases most frequently involve the lungs. After the development of metastases, mean overall survival is 30 months. As with other soft tissue sarcomas, resection of pulmonary metastases is indicated when technically feasible.]
What percentage of all breast cancer is ductal cancer?
85%
What results in atrophy of breast tissue after menopause?
Lack of estrogen and progesterone
What is Stewart-Treves syndrome?
Lymphangiosarcoma from chronic lymphedema following axillary dissection
What is the workup for a breast cyst in a patient > 40 years old?
Cyst excisional biopsy if bloody, if clear and recures, or if a complex cyst
[UpToDate:
- Simple cysts, clustered microcysts, and cysts with thin septa are considered benign and no intervention is needed. Fine needle aspiration (FNA) can be performed if the cyst is symptomatic (painful) or obscures adjacent breast tissue.
- If a symptomatic simple breast cyst recurs several times after aspiration, another mammogram and ultrasound should be performed to evaluate the area again. Excision is reserved for suspicious lesions or for patients who no longer desire repeat aspirations.
- Complicated cysts are rarely malignant, but should be aspirated to confirm diagnosis or followed with imaging and examination every six months for two years to document stability. Image-guided FNA or biopsy is indicated if the lesion increases in size or changes in characteristics on repeat imaging.
- Complex cysts should be biopsied, particularly those with thickened cyst walls and/or septa, and solid components.
- Surgical intervention is indicated for complex cysts that are not amenable to core needle biopsy and when pathology results from a core biopsy are discordant, atypical, indeterminate, or reveal a malignancy.]
Which artery supplies the latissimus dorsi muscles?
Thoracodorsal artery
What is the relative risk of developing breast cancer in a patient who is obese, uses alcohol, or is on hormone replacement therapy?
Low increased risk (relative risk <2)
What is the relative risk of developing breast cancer in a patient with prior breast cancer or prior radiation exposure?
Moderately increased risk (relative risk 2-4)
Are intraductal papilloma lesions premalignant?
No
What is the approach to a fibroadenoma in a patient < 40 years old?
Observation if all 3 of the below criteria are met
- Mass feels clinically benign (firm, rubbery, rolls, not fixed)
- Ultrasound or mammogram consistent with fibroadenoma
- FNA or core needle biopsy shows fibroadenoma
[If all 3 criteria are not met, needs excisional biopsy. if fibroadenoma continues to enlarge during period of observation, then need excisional biopsy. Avoid resection of breast tissue in teenagers and younger children because it can affect breast development.]
[UpToDate: If a presumed fibroadenoma increases in size or is symptomatic, then excision is mandated to rule out malignant change and confirm the diagnosis. Rapid growth of a lesion raises the suspicion for a phyllodes tumor, unusual fibroepithelial tumors which require more extensive surgical resection, and in some cases may require radiation treatment as well.]
What is the 5-year survival in a breast cancer patient with 0 positive axillary lymph nodes?
75%
[American Cancer Society: Breast cancer survival rates, by stage
- The 5-year relative survival rate for women with stage 0 or stage I breast cancer is close to 100%.
- For women with stage II breast cancer, the 5-year relative survival rate is about 93%.
- The 5-year relative survival rate for stage III breast cancers is about 72%.
- Metastatic, or stage IV breast cancers, have a 5-year relative survival rate of about 22%.]
A scaly skin lesion on the nipple is most likely what?
Paget’s disease of the breast
[Biopsy shows Paget’s cells. Patients will likely have DCIS or ductal breast cancer.]
What is the treatment for a breast abscess?
- Percutaneous or incision and drainage
- Discontinue breastfeeding
- Continue breast pumping
- Antibiotics
[UpToDate:
- In the setting of nonsevere infection in the absence of risk factors for methicillin-resistant S. aureus (MRSA), outpatient therapy may be initiated with dicloxacillin (500 mg orally four times daily) or cephalexin (500 mg orally four times daily), pending culture results. In the setting of beta-lactam hypersensitivity, clindamycin (300 to 450 mg orally three times daily) may be used.
- In the setting of nonsevere infection with risk for MRSA, outpatient therapy with trimethoprim-sulfamethoxazole (1 to 2 tabs orally twice daily) or clindamycin (300 to 450 mg orally three times daily) may be initiated.
- In the setting of severe infection (eg, hemodynamic instability, progressive erythema), empiric inpatient therapy with vancomycin (15 to 20 mg/kg/dose every 8 to 12 hours, not to exceed 2 g per dose) should be initiated; therapy should be tailored to culture and sensitivity results. Gram stain results demonstrating gram-negative rods should prompt empiric antibiotic therapy against these organisms with a third-generation cephalosporin or a combination beta-lactam–beta-lactamase agent.]
What is the appropriate treatment for breast cancer in a woman in her
- 1st trimester
- 2nd trimester
- 3rd trimester
- 1st trimester: Modified radical mastectomy
- 2nd trimester: Modified radical mastectomy
- 3rd trimester: Modified radical mastectomy (unless late in which case breast conserving therapy with axillary lymph node dissection and postpartum XRT are an option.)
[No XRT during pregnancy. No breastfeeding after delivery.]
[UpToDate:
- In general, pregnant women with breast cancer should be treated according to guidelines for nonpregnant patients, with some modifications to protect the fetus.
- Either breast-conserving surgery or mastectomy is a reasonable option in the pregnant woman with breast cancer. A choice between them is guided by tumor characteristics and patient preferences.
- Women with breast cancer during pregnancy should undergo an axillary node dissection. The safety of sentinel lymph node biopsy has not been established.
- For women who require adjuvant radiation therapy (RT), we recommend adjuvant RT be administered after delivery rather than during pregnancy (Grade 1C).
- For women in whom chemotherapy is recommended, we initiate treatment after the first trimester.
- Chemotherapy should be avoided for three to four weeks before delivery to avoid transient neonatal myelosuppression and potential complications of sepsis and death.]
An axillary lymph node dissection must take what level of nodes?
Level I and level II
[Complications include infection, lymphedema, and lymphangiosarcoma.]
What percent of lymphatic drainage from the breast goes to the internal mammary nodes?
2%
[Any quadrant can drain to the internal mammary nodes]
Ductal carcinoma in situ (DCIS) of the breast is defined as malignant cells of the ductal epithelium without what?
Invasion of the basement membrane
[This is a premalignant lesion]
What is the most common breast lesion in adolescents and young women?
Fibroadenoma
[10% are multiple.]
What are 5 clinical features of breast cancer?
- Distortion of normal architecture
- Skin/nipple retraction or distortion
- Hard
- Tethered
- Indistinct borders
What is the treatment for ductal breast cancer?
Modified radical mastectomy or breast conserving therapy with postop XRT
[UpToDate: The surgical approach to early-stage breast cancer depends on the size of the tumor, whether or not multifocal disease is present, and the size of the breast. The options include breast-conserving therapy (breast-conserving surgery plus radiation therapy [RT]) or mastectomy (with or without RT). Both approaches result in equivalent cancer-specific outcomes. Most patients with locally advanced, inoperable breast cancer should receive neoadjuvant systemic therapy rather than proceeding with primary surgery. These patients are usually not candidates for breast conservation at their initial presentation. Neoadjuvant treatment improves the rate of breast conservation without compromising survival outcomes.]
What is stage 1 based on the breast TNM classification?
T1 N0 M0
What is the treatment for mastodynia (breast pain)?
- Danazol
- OCPs
- NSAIDs
- Evening primrose oil
- Bromocriptine
[Discontinue caffeine, nicotine, methylxanthines]
Which nerve innervates the latissimus dorsi muscles?
Thoracodorsal nerve
[Injury results in weak arm pull-ups and adduction.]
What is the definition of a T0 breast tumor according to TNM classification?
No evidence of primary tumor
Which 2 solutions can be injected into the tumor area to identify the sentinel node?
Lympazurin blue dye
Radiotracer
[Type I hypersensitivity reactions have been reported with lympazurin blue dye.]
What is the workup for a breast mass in a patient > 40 years old?
Bilateral mammograms, ultrasound, and core needle biopsy
[If core needle biopsy or FNA is indeterminate, non-diagnostic, or non-concordant with exam findings/imaging studies then an excisional biopsy in required. Clinically indeterminate or suspicious solid masses will eventually need excisional biopsy unless cancer diagnosis is made prior to that.]
Which hormone promotes lobular development of the breast?
Progesterone
What is the most important prognostic staging factor in breast cancer?
Axillary nodes (survival is directly related to the number of positive nodes)
[Other important staging factors are tumor size, tumor grade, progesterone and estrogen receptor status.]
What are the 8 findings on core needle biopsy of the breast that are an indication for surgical biopsy?
- Atypical ductal hyperplasia
- Atypical lobular hyperplasia
- Radial scar
- Lobular carcinoma in situ
- Columnar cell hyperplasia with atypia
- Papillary lesions
- Lack of concordance between appearance of mammographic lesion and histologic diagnosis
- Nondiagnostic specimen
What is the treatment for ductal carcinoma in situ (DCIS) of the breast?
Lumpectomy and XRT with 1 cm margins and possibly tamoxifen (no sentinel lymph node biopsy or axillary dissection is necessary)
[Simple mastectomy if high grade (eg comedo type, multicentric, multifocal), or if it is large and not amenable to lumpectomy, or if not able to get good margins. Again no axillary lymph node dissection.]
[UpToDate:
- Local therapy for DCIS consists of mastectomy or breast-conserving therapy (BCT). BCT for DCIS includes lumpectomy, generally followed by RT, and results in breast cancer-specific survival rates comparable to mastectomy, although the rate of local recurrence is higher with BCT.
- Candidates for BCT include patients with DCIS whose disease is localized to one quadrant and can be resected with negative margins in a cosmetically acceptable manner, taking into account the size of disease relative to the breast size. Re-excision(s), mastectomy, or radiation boost should be performed if close or positive margins are present.
- For patients who are candidates for BCT, we suggest BCT over mastectomy (Grade 2B). We recommend that most women undergoing BCT receive RT in addition to lumpectomy (Grade 1B).
- For patients with very small foci of low-grade DCIS, breast-conserving surgery only (ie, omission of RT) with widely negative margins (ideally 10 mm) is an option. However, prospective randomized evidence to support the omission of adjuvant radiation is limited, even in selected low-risk cases.
- For most patients with DCIS, we recommend not performing surgical evaluation of the axilla (Grade 1A). However, we suggest sentinel lymph node biopsy (SLNB) in patients who do not meet criteria for BCT and thus require mastectomy (Grade 2B).]
What is stage IV based on the breast TNM classification?
Any T Any N M1
What are 4 contraindications to XRT in breast conserving therapy?
- Scleroderma (results in severe fibrosis and necrosis)
- Previous XRT and would exceed recommended dose
- SLE (relative contraindication)
- Active rheumatoid arthritis (relative contraindication
Breast abscesses are most commonly due to which bacteria?
Staph aureus
[Strep is common too]
What is the most common breast anomaly?
Accessory nipples
[Can be found from the axilla to the groin]
What are the 4 subtypes of ductal breast cancer?
Medullary: More favorable prognosis
Tubular: More favorable prognosis
Mucinous: More favorable prognosis
Scirrhotic: Worse prognosis
What percentage of patients with ductal carcinoma in situ (DCIS) of the breast get cancer if it is not resected?
50%
[5% get cancer in the contralateral breast]
Which has a better prognosis: Progesterone receptor-positive tumors or estrogen receptor-positive breast tumors?
Progesterone receptor positive
[Tumors that are both progesterone receptor and estrogen receptor positive have the best prognosis.]
What is the sensitivity/specificity of mammography?
90%
[Sensitivity increases with age as the dense parenchymal tissue is replaced with fat.]
Which surgical option removes all breast tissue including the nipple areolar complex and includes an axillary node dissection (level I nodes)?
Modified radical mastectomy
[UpToDate: A modified radical mastectomy (MRM) is complete removal of the breast and the underlying fascia of the pectoralis major muscle along with the removal of the level I and II axillary lymph nodes. Several randomized trials documented equivalent survival rates with MRM as compared with radical mastectomy, with less morbidity. The equivalent survival outcome of the two procedures was further confirmed in an analysis of 3236 women enrolled in four randomized trials. Modified radical mastectomy is utilized in patients requiring or desiring mastectomy who have biopsy-proven axillary metastases.]
Breast tumors in which 2 locations have increased risk of multicentricity?
- Central
- Subareolar
Which artery supplies the serratus anterior muscles?
Lateral thoracic artery
What is the definition of a T1 breast tumor according to TNM classification?
Tumor 2 cm or less in greatest dimension
What is stage IIA based on the breast TNM classification?
- T0 N1 M0
- T1 N1 M0
- T2 N0 M0
What is stage IIIB based on the breast TNM classification?
- T4 N0 M0
- T4 N1 M0
- T4 N2 M0
What are the boundaries of node levels in axillary nodes?
- Level I: Inferior and lateral to pectoralis minor muscle
- Level II: Beneath the pectoralis minor muscle and below the axillary vein
- Level III: medial to pectoralis minor muscle against the chest wall
[In an axillary dissection, one must take level I and level II nodes (take level III nodes only if grossly involved).]
Branches of which 4 arteries supply the breast?
- Internal thoracic (internal mammary) artery
- Intercostal arteries
- Thoracoacromial artery
- Lateral thoracic artery
Which mammography findings are suggestive of cancer?
- Irregular borders
- Spiculated
- Multiple, clustered, small, thin, linear, crushed-like and/or branching calcifications
- Ductal asymmetry or distortion of architecture
What is the most common cause of bloody nipple discharge?
Intraductal papilloma
[Usually small, nonpalpable, and close to the nipple]
Which kind of breast cancer is automatically considered T4 disease and is very aggressive?
Inflammatory breast cancer
[UpToDate: It is important to rule out inflammatory breast cancer if a suspected breast infection does not respond to antibiotics.]
Breast pain, nipple discharge (usually yellow to brown), lumpy breast tissue that varies with hormonal cycles are symptoms consistent with what?
Fibrocystic disease of the breast
[Many types: Papillomatosis, sclerosing adenosis, apocrine metaplasia, duct adenosis, epithelial hyperplasia, ductal hyperplasia, and lobular hyperplasia.]
What is the treatment for Paget’s disease of the breast?
Modified radical mastectomy if cancer is present
[If no cancer present, simple mastectomy will suffice (need to include the nipple-areolar complex with Paget’s).]
Breast cancer with positive supraclavicular nodes is considered which N stage in TNM staging?
N3 disease
What complication of axillary lymph node dissection should be suspected in a patient who develops sudden, early, postop swelling?
Axillary vein thrombosis
What is the definition of a N1 breast tumor according to TNM classification?
- Metastasis to 1-3 axillary nodes
or
- In internal mammary (IM) nodes with microscopic disease detected by sentinel node biopsy, which is not clinically apparent
Which hormone cyclically increases maturation of glandular tissue, and causes menses when withdrawn?
Progesterone
Which hormone promotes duct development of the breast?
Estrogen
By what percentage does tamoxifen decrease risk of breast cancer?
50%
What is stage IIIA based on the breast TNM classification?
- T0 N2 M0
- T1 N2 M0
- T2 N2 M0
- T3 N1 M0
- T3 N2 M0
What is the relative risk of developing breast cancer in a patient with > 2 primary relatives with bilateral or premenopausal breast cancer?
Greatly increased risk (relative risk > 4)
What is the approach to a fibroadenoma in a patient > 40 years old?
Excisional biopsy to ensure diagnosis
What is the definition of a N0 breast tumor according to TNM classification?
No regional node metastases histologically, no additional examination for isolated tumor cells (ITCs)
What is the definition of a T3 breast tumor according to TNM classification?
Tumor more than 5 cm in greatest dimension
What is the relative risk of developing breast cancer in a patient with proliferative benign disease?
Low increased risk (relative risk <2)
Which two hormones cause ovum release during the menstruation cycle?
FSH and LH surge
Which breast mass is usually painless, slow growing, well circumscribed, firm, and rubbery?
Fibroadenoma
[Often grows to several cm in size and then stops. Giant fibromas can be > 5 cm (treatment is the same). Can change in size with menstrual cycle and can enlarge in pregnancy.]
What are the suspensory ligaments of the breast that divide the breast into segments called?
Cooper’s ligaments
[Breast cancer involving these strands can dimple the skin]
What are the 5 BI-Rads classifications of mammographic abnormalities?
- Category 1: assessment negative (recommendation: routine screening)
- Category 2: Benign finding (recommendation: routine screening)
- Category 3: Probably a benign finding (recommendation: Short interval follow-up mammogram)
- Category 4: suspicious abnormality like indeterminate calcifications or architecture (recommendation: Core needle biopsy to rule out cancer. If benign then 6 month follow up. If insufficient then need needle localization excisional biopsy)
- Category 5: highly suggestive of cancer such as suspicious caclifications or architecture (recommendation: Core needle biopsy to rule out cancer. If malignancy not found then need needle localization excisional biopsy.)
[Core needle biopsy without excisional biopsy allows appropriate staging with sentinel lymph node biopsy since the mass is still present and allows for one-step surgery (avoids 2 surgeries) for patients diagnosed with breast cancer.]
Which type of breast cancer has dermal lymphatic invasion which causes a peau d’orange lymphedema appearance of the breast that is erythematous and warm?
Inflammatory breast cancer
What is stage 0 based on the breast TNM classification?
Tis N0 M0
What is the relative risk of developing breast cancer in a patient with early menarche, late menopause, or nulliparity?
Low increased risk (relative risk <2)
Which nerve innervates the serratus anterior muscles?
Long thoracic nerve
[Injury results in winged scapula]
What is stage IIIC based on the breast TNM classification?
Any T N3 M0
Where are Rotter’s nodes located?
Between the pectoralis major and pectoralis minor muscles
Noncyclical mastodynia, erythema, nipple retraction, and creamy discharge from the nipple that is sometimes associated with sterile or infected subareolar abscesses are symptoms of what?
Periductal mastitis (mammary duct ectasia or plasma cell mastitis)
[Risk factors are smoking and nipple piercings. biopsy demonstrates dilated mammary ducts, inspissated secretions, and marked periductal inflammation.]
Which nerve innervates only the pectoralis major?
Lateral pectoral nerve
What is the definition of a T4 breast tumor according to TNM classification?
Tumor of any size with direct extension to the chest wall (not including pectoralis muscle), skin edema, skin ulceration, satellite skin nodules, or inflammatory carcinoma
What is the definition of a Tx breast tumor according to TNM classification?
Primary tumor cannot be assessed
What is the definition of a T2 breast tumor according to TNM classification?
Tumor more than 2 cm but not more than 5 cm in greatest dimension
What percentage of patients with lobular carcinoma in situ (LCIS) of the breast who develop breast cancer develop ductal carcinoma?
70%
[5% risk of having synchronous breast cancer at the time of diagnosis of LCIS (most likely ductal carcinoma).]
What is occult breast cancer and what is the treatment?
Breast cancer that presents as axillary metastases with an unkown primary
[Treatment is modified radical mastectomy (70% are found to have breast cancer).]
What is Poland’s syndrome?
- Hypoplasia of the chest wall
- Amastia
- Hypoplastic shoulder
- No pectoralis muscle
What is the workup for a breast mass in a patient < 40 years old?
Ultrasound and core needle biopsy (consider FNA)
[If clinical exam or ultrasound is indeterminate or if suspicious for cancer then a mammogram is indicated (although in general one should avoid excess radiation in this group).]
What is the relative risk of developing breast cancer in a patient with a first-degree relative with breast cancer?
Moderately increased risk (relative risk 2-4)
What is Batson’s plexus?
Valveless vein plexus that allows direct hematogenous metastasis of breast cancer to spine
What has prominent fibrous tissue compressing epithelial cells on pathology and can have large, coarse calcifications (popcorn lesions) on mammography from degeneration?
Fibroadenoma
What is the most common location for polythelia (accessory breast tissue) to occur?
The axilla
Which breast pathology is usually not palpable and presents as a cluster of calcifications on mammography?
Ductal carcinoma in situ (DCIS) of the breast
[Can have solid, cribriform, papillary, and comedo patterns.]
[UpToDate:
- Most cases of DCIS are detected only on imaging studies (most commonly by the presence of mammographic microcalcifications).
- Percutaneous core biopsy under stereotactic or ultrasound guidance is preferred in the evaluation of mammographically-identified microcalcifications. Fine needle aspiration biopsy is inadequate for the diagnosis of DCIS, as it cannot distinguish between invasive and in situ disease. In technically challenging stereotactic cases, wire localization biopsy may be preferable.]
What is the relative risk of developing breast cancer for a patient with a BRCA gene mutation and a family history of breast cancer?
Greatly increased risk (relative risk > 4)
Cyclic mastodynia (breast pain) most commonly represents what?
Fibrocystic disease
What is the relative risk of developing breast cancer in a patient who’s age was > 35 when first giving birth?
Moderately increased risk (relative risk 2-4)
Gynecomastia may be associated with which compounds/drugs?
- Cimetidine
- Spironolactone
- Marijuana
[Most often it is idiopathic.]
What is the definition of a N2 breast tumor according to TNM classification?
- Metastases in 4-9 axillary nodes
or
- In clinically apparent internal mammary (IM) nodes in the absence of axillary node metastasis
Which nerve innervates both the pectoralis major and pectoralis minor muscles?
Medial pectoral nerve
What is the median survival of a patient with inflammatory breast cancer?
36 months
[UpToDate: Inflammatory breast cancer (IBC) is associated with a particularly poor prognosis and high risk of early recurrence, although with proper primary and adjuvant therapies, the survival rate is much higher than in the past. Poor prognostic features include triple-negative receptor status, four or more involved lymph nodes prior to therapy, and lack of response to neoadjuvant chemotherapy. Human epidermal growth factor receptor 2 (HER2)-positive IBC may have an equivalent or marginally better prognosis compared with HER2-negative IBC, unlike in the case of non-inflammatory breast cancer.]
What is the most aggressive subtype of ductal carcinoma in situ (DCIS) of the breast?
Comedo pattern
[It has necrotic areas with high risk for multicentricity, microinvasion, and recurrence. Treatment is simple mastectomy.]
What is Mondor’s disease?
Superficial vein thrombophlebitis of the breast (feels cordlike, can be painful)
[Associated with trauma and strenuous exercise. Usually occurs in the lower outer quadrant. Treatment is NSAIDs.]
Which nerve provides sensation to the medial arm and axilla?
Intercostobrachial nerve (lateral cutaneous branch of the 2nd intercostal nerve)
[Encountered just below axillary vein when performing axillary dissection. Can transect without serious consequences.]
Which hormone can cause galactorrhea?
Prolactin
[May be increased as a result of pituitary prolactinoma and is often associated with amenorrhea. Other causes of galactorrhea are OCPs, TCAs, phenothiazines, metoclopramide, alpha-methyl dopa, reserpine]
What syndrome presents as dark purple nodules or lesions on the arm 5-10 years after breast surgery with an axillary lymph node dissection?
Stewart-Treves syndrome
[This is defined as lymphangiosarcoma from chronic lymphedema following axillary lymph node dissection.]
What is stage IIB based on the breast TNM classification?
- T2 N1 M0
- T3 N0 M0
