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Surgical Recall > Chapter 55: Breast- Breast Cancer > Flashcards

Chapter 55: Breast- Breast Cancer Flashcards

1
Q

What is the incidence of breast cancer?

A

12% lifetime risk

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2
Q

What percentage of women with breast cancer have no known risk
factor?

A

75%!

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3
Q

What percentage of all breast cancers occur in women younger than
30 years?

A

≈2%

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4
Q

What are the major breast cancer susceptibility genes?

A

BRCA1 and BRCA2

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5
Q

What option exists to decrease the risk of breast cancer in women
with BRCA?

A

Prophylactic bilateral mastectomy

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6
Q

What is the most common motivation for medicolegal cases
involving the breast?

A

Failure to diagnose a breast carcinoma

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7
Q

What is the “TRIAD OF ERROR” for misdiagnosed breast cancer?

A
  1. Age <45 years
  2. Self-diagnosed mass
  3. Negative mammogram

Note: >75% of cases of MISDIAGNOSED breast cancer have these three characteristics

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8
Q

What are the history risk factors for breast cancer?

A

“NAACP”:

  • Nulliparity
  • Age at menarche (<13 years)
  • Age at menopause (>55 years)
  • Cancer of the breast (in self or family)
  • Pregnancy with first child (>30 years)
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9
Q

What are physical/anatomic risk factors for breast cancer?

A

“CHAFED LIPS”:

  • Cancer in the breast (3% synchronous contralateral cancer)
  • Hyperplasia (moderate/florid) (2× risk)
  • Atypical hyperplasia (4× risk)
  • Female (100× male risk)
  • Elderly
  • Dcis
  • LCIS
  • Inherited genes (BRCA I and II)
  • Papilloma (1.5×)
  • Sclerosing adenosis (1.5×)
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10
Q

Is “run of the mill” fibrocystic disease a risk factor for breast
cancer?

A

No

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11
Q

What are the possible symptoms of breast cancer?

A

No symptoms
Mass in the breast
Pain (most are painless)
Nipple discharge
Local edema
Nipple retraction
Dimple
Nipple rash

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12
Q

Why does skin retraction occur?

A

Tumor involvement of Cooper’s ligaments and subsequent traction on ligaments pull skin inward

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13
Q

What are the signs of breast cancer?

A
  • Mass
    • 1 cm is usually the smallest lesion that can be palpated on examination
  • Dimple
  • Nipple rash
  • Edema
  • Axillary/supraclavicular nodes
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14
Q

What is the most common site of breast cancer?

A

≈50% of cancers develop in the upper outer quadrants

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15
Q

What are the different types of invasive breast cancer?

A
  • Infiltrating ductal carcinoma (≈75%)
  • Medullary carcinoma (≈15%)
  • Infiltrating lobular carcinoma (≈5%)
  • Tubular carcinoma (≈2%)
  • Mucinous carcinoma (colloid) (≈1%)
  • Inflammatory breast cancer (≈1%)
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16
Q

What is the most common type of breast cancer?

A

Infiltrating ductal carcinoma

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17
Q

What is the differential diagnosis?

A
  • Fibrocystic disease of the breast
  • Fibroadenoma
  • Intraductal papilloma
  • Duct ectasia
  • Fat necrosis
  • Abscess
  • Radial scar
  • Simple cyst
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18
Q

Describe the appearance of the edema of the dermis in
inflammatory carcinoma of the breast.

A

Peau d’orange (orange peel)

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19
Q

What are the screening recommendations for breast cancer:
Breast exam recommendations?

A
  • Self-exam of breasts monthly
  • Ages 20 to 40 years: breast exam every 2 to 3 years by a physician
  • >40 years: annual breast exam by physician
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20
Q

What are the screening recommendations for breast cancer:

Mammograms?

A

Mammogram every year or every other year after age 40

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21
Q

When is the best time for breast self-exams?

A

1 week after menstrual period

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22
Q

Why is mammography a more useful diagnostic tool in older women
than in younger?

A

Breast tissue undergoes fatty replacement with age, making masses more visible; younger women have more fibrous tissue, which makes mammograms harder to interpret

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23
Q

What are the radiographic tests for breast cancer?

A

Mammography and breast ultrasound, MRI

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24
Q

What is the classic picture of breast cancer on mammogram?

A

Spiculated mass

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25
Q

Which option is the best initial test to evaluate a breast mass in a
woman <30 years?

A

Breast ultrasound

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26
Q

What are the methods for obtaining tissue for pathologic
examination?

A

Fine-needle aspiration (FNA), core biopsy (larger needle core sample), mammotome stereotactic biopsy, and open biopsy, which can be incisional (cutting a piece of the mass) or excisional (cutting out the entire mass)

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27
Q

What are the indications for biopsy?

A
  • Persistent mass after aspiration
  • Solid mass
  • Blood in cyst aspirate
  • Suspicious lesion by mammography/ultrasound/MRI
  • Bloody nipple discharge
  • Ulcer or dermatitis of nipple
  • Patient’s concern of persistent breast abnormality
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28
Q

What is the process for performing a biopsy when a nonpalpable
mass is seen on mammogram?

A

Stereotactic (mammotome) biopsy or needle localization biopsy

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29
Q

What is a needle localization biopsy (NLB)?

A

Needle localization by radiologist, followed by biopsy; removed breast tissue must be checked by mammogram to ensure all of the suspicious lesion has been
excised

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30
Q

What is a mammotome biopsy?

A

Mammogram-guided computerized stereotatic core biopsies

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31
Q

What is obtained first, the mammogram or the biopsy?

A

Mammogram is obtained first; otherwise, tissue extraction (core or open) may alter the mammographic findings (fine needle aspiration may be done prior to the mammogram because the fine needle usually will not affect the mammographic findings)

32
Q

What would be suspicious mammographic findings?

A

Mass, microcalcifications, stellate/spiculated mass

33
Q

What is a “radial scar” seen on mammogram?

A

Spiculated mass with central lucency, ± microcalcifications

34
Q

What tumor is associated with a radial scar?

A

Tubular carcinoma; thus, biopsy is indicated

35
Q

What is the “workup” for a breast mass?

A
  1. Clinical breast exam
  2. Mammogram or breast ultrasound
  3. Fine needle aspiration, core biopsy, or open biopsy
36
Q

How do you proceed if the mass appears to be a cyst? (US)

A

Aspirate it with a needle

37
Q

Is the fluid from a breast cyst sent for cytology?

A

Not routinely; bloody fluid should be sent for cytology

38
Q

When do you proceed to open biopsy for a breast cyst?

A
  • In the case of a second cyst recurrence
  • Bloody fluid in the cyst
  • Palpable mass after aspiration
39
Q

What is the preoperative staging workup in a patient with breast cancer?

A
  1. Bilateral mammogram (cancer in one breast is a risk factor for cancer in the contralateral breast!)
  2. CXR (to check for lung metastasis)
  3. LFTs (to check for liver metastasis)
  4. Serum calcium level
  5. alkaline phosphatase (if these tests indicate bone metastasis/“bone pain,” proceed to bone scan)
  6. Other tests, depending on signs/symptoms (e.g., head CT scan if patient hasfocal neurologic deficit, to look for brain metastasis)
40
Q

What hormone receptors must be checked for in the biopsy specimen?

A

Estrogen and progesterone receptors—this is key for determining adjuvant treatment; this information must be obtained on all specimens (including fine-needle aspirates)

41
Q

What staging system is used for breast cancer?

A

TMN:Tumor/Metastases/Nodes (AJCC)

42
Q

Describe the staging (simplified):

Stage I

A

Tumor ≤2 cm in diameter without metastases, no nodes

43
Q

Describe the staging (simplified):

Stage IIA

A
  • Tumor ≤2 cm in diameter with mobile axillary nodes
  • Tumor 2 to 5 cm in diameter, no nodes
44
Q

Describe the staging (simplified):

Stage IIB

A
  • Tumor 2 to 5 cm in diameter with mobile axillary nodes
  • Tumor >5 cm with no nodes
45
Q

Describe the staging (simplified):

Stage IIIA

A
  • Tumor >5 cm with mobile axillary nodes
  • Any size tumor with fixed axillary nodes, no metastases
46
Q

Describe the staging (simplified):

Stage IIIB

A
  • Peau d’orange (skin edema)
  • Chest wall invasion/fixation
  • Inflammatory cancer orBreast skin ulceration
  • Breast skin satellite metastases
  • Any tumor and + ipsilateral internal mammary LNs
47
Q

Describe the staging (simplified):

Stage IIIC

A

Any size tumor, no distant metastases

POSITIVE: supraclavicular, infraclavicular, or internal mammary LNs

48
Q

Describe the staging (simplified):

Stage IV

A

Distant metastases (including ipsilateral supraclavicular nodes)

49
Q

What are the sites of metastases?

A
  1. LNs (most common)
  2. Lung pleura
  3. Liver
  4. Bones
  5. Brain
50
Q

What are the major treatments of breast cancer?

A
  • Modified radical mastectomy
  • Lumpectomy and radiation + sentinel LN dissection
  • (Both treatments either ± postop chemotherapy/tamoxifen)
51
Q

What are the indications for radiation therapy after a modified radical mastectomy?

A
  1. Stage IIIA
  2. Stage IIIB
  3. Pectoral muscle/fascia invasion
  4. Positive internal mammary LN
  5. Positive surgical margins
  6. ≥4 positive axillary LNs
  7. postmenopausal
52
Q

What breast carcinomas are candidates for lumpectomy and radiation (breast-conserving therapy)?

A

Stages I and II (tumors <5 cm)

53
Q

What approach may allow a patient with stage IIIA cancer to havebreast-conserving surgery?

A

NEOadjuvant chemotherapy—if the preop chemo shrinks the tumor

54
Q

What is the treatment of inflammatory carcinoma of the breast?

A

Chemotherapy first! Then often followed by radiation, mastectomy, or both

55
Q

What is “lumpectomy and radiation”?

A
  1. Lumpectomy (segmental mastectomy: removal of a part of the breast)
  2. axillary node dissection
  3. and a course of radiation therapy after operation, over a period of several weeks
56
Q

What are other contraindications to lumpectomy and radiation?

A
  • Previous radiation to the chest
  • Positive margins
  • Collagen vascular disease (e.g., scleroderma)
  • Extensive DCIS (often seen as diffuse microcalcification)
  • Relative contraindications:
    • ​Lesion that cannot be seen on the mammograms (i.e., early recurrence will be missed on follow-up mammograms)
    • Very small breast (no cosmetic advantage)
57
Q

What is a modified radical mastectomy?

A
  1. Breast
  2. axillary nodes (level II, I)
  3. and nipple–areolar complex are removed
  4. Pectoralis major and minor muscles are not removed (Auchincloss modification)
  5. Drains are placed to drain lymph fluid
58
Q

Where are the drains placed with an MRM?

A
  1. Axilla
  2. Chest wall (breast bed)
59
Q

When should the drains be removed?

A

<30 cc/day drainage

60
Q

How can the long thoracic and thoracodorsal nerves be identified during an axillary dissection?

A

Nerves can be stimulated with a forceps, which results in contraction of the latissimus dorsi (thoracodorsal nerve) or anterior serratus (long thoracic nerve)

61
Q

What is a sentinel node biopsy?

A

Instead of removing all the axillary LNs, the primary draining or “sentinel” LN is removed

62
Q

How is the sentinel LN found?

A

Inject blue dye and/or technetium-labeled sulfur colloid (best results with both)

63
Q

What follows a positive sentinel node biopsy?

A

Removal of the rest of the axillary LNs

64
Q

What is now considered the standard of care for LN evaluation in women with T1 or T2 tumors (stages I and IIA) and clinically negative axillary LNs?

A

Sentinel LN dissection

65
Q

What do you do with a mammotome biopsy that returns as “atypical hyperplasia”?

A

Open needle localization biopsy as many will have DCIS or invasive cancer

66
Q

How does tamoxifen work?

A

Binds estrogen receptors

67
Q

What is the treatment for local recurrence in breast after lumpectomy and radiation?

A

“Salvage” mastectomy

68
Q

Can tamoxifen prevent breast cancer?

A

Yes. In the Breast Cancer Prevention Trial of 13,000 women at increased risk of developing breast cancer, tamoxifen reduced risk by ≈50% across all ages

69
Q

What are common options for breast reconstruction?

A
  • TRAM flap
    • Transverse Rectus Abdominis Myocutaneous flap
  • implant
  • latissimus dorsi flap
70
Q

What are side effects of tamoxifen?

A
  1. Endometrial cancer (2.5× relative risk)
  2. DVT
  3. pulmonary embolus
  4. cataracts
  5. hot flashes
  6. mood swings
71
Q

Give the common adjuvant therapy for the following patients withbreast cancer:

Premenopausal, node +, ER −

(These are rough guidelines; check for current guidelines, as they are always changing.)

A

Chemotherapy

72
Q

Give the common adjuvant therapy for the following patients with breast cancer:

Premenopausal, node +, ER −

A

Chemotherapy and tamoxifen

73
Q

Give the common adjuvant therapy for the following patients withbreast cancer.

Premenopausal, node −, ER +

A

Tamoxifen and/or chemotherapy

74
Q

Give the common adjuvant therapy for the following patients withbreast cancer:

Postmenopausal, node +, ER +

A

Tamoxifen, ± chemotherapy

75
Q

Give the common adjuvant therapy for the following patients withbreast cancer:

Postmenopausal, node +, ER −Chemotherapy, ± tamoxifen

A

Chemotherapy, ± tamoxifen

Surgical Recall (168 decks)

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