Breast

Question 1

management of DCIS

Answer 1

core needle biopsy + for DCIS

lumpectomy with XRT (or a mastectomy if diffuse)

No SNB unless doing a mastectomy

if ER/PR + either tamoxifen or anastrazole x 5 years

if post menopausal, then anastrazole

no Her2neu analysis for DCIS

Question 2

Treatment of a recurrent breast cancer after having breast conservation therapy with XRT

Answer 2

mastectomy

Question 3

describe management of ADH

Answer 3

if get ADH on bx: need WLE t r/o DCIS or invasive ca

Question 4

management of ALH

Answer 4

if on bx: dont need to WLE

Question 5

management of LCIS

Answer 5

if on CNB: dont need excision unless it pleomorphic or with necrosis. but can excise if want to

if found on excision: no need for further excision unless pleomorphic

*risk of cancer is 1% per year

Question 6

management of early breast cancer (stage I, IIA or subset of stage IIB (T2N1))

Answer 6

BCT with XRT with SNB

If 1-3 LN + do nothing.

if 3 LN +, ALND

if you do a mastectomy with +LN, then RT

but if there is no +LN, then no RT

ER/PR+ tamoxifen or anastrazole

Her2neu + : herceptin

Question 7

how do you treat someone with clinically + LN

Answer 7

perform U/S FNA or CNB

if + then do ALND

if - then do SNB

Question 8

what are contraindications for BCT

Answer 8

• multicentric disease
• diffuse malignant appearing calcifications on imaging
• prior h/o chest RT
• pregnancy
• persistent + margin despite re-excisions

Question 9

when do you give chemo to early stage breast cancer

Answer 9

• high risk
  
  • high grade tumor
  • tumor size >2cm
  • pathologically +LNs
  • high 21-gene recurrence score (oncotype)
• ER/PR -, Her2neu - (triple negative cancer)
  
  • if < 0.5cm do nothing
  • if > 0.5 cm give chemo
  • if her2neu + and > 1cm, give chemo and Herceptin

Question 10

locally advanced breast cancer

(any T3/T4 and any N2 or N3 disease)

Answer 10

• neoadjuvant chemo
• if ER/PR+ then chemo pre-op, tamoxifen post-op
• if her2neu +, give both chemo and herceptin pre-op. give herceptin post op x 1 year
• if tumor progresses during neoadjuvant tx, give adjuvant chemo

Question 11

management of breast cancer in pregnancy

Answer 11

• stage it with CXR, U/S of liver, MRI without contrast of spine
• can use BCT with RT delayed
• SLB: only use technetium sulfur colloid
• can give chemo (2nd or 3rd trimester)

Question 12

STAGES breast cancer

Answer 12

0 Tis

Ia T1N0

Ib T0N1mic, T1N1mic

IIa T0N1, T1N1, T2N0

IIb T2N1, T3N0

IIIa T0N2, T1N2, T2N2, T3N1, T3N2

IIIb T4N0, T4N1, T4N2

IIIc N3 disease (anyT)

IV M1 (any T, any N)

Question 13

what are the chemotherapy agents used in breast ca

Answer 13

• TAC
  
  • taxanes
  • adriamycin
  • cyclophosphamide
• 6-12 weeks

Question 14

T stages for breast cancer

Answer 14

• T1 <2cm
• T2 2-5 cm
• T3 >5cm
• T4
  
  • involved chest wall
  • ulcerated
  • peau d’orange

Question 15

N stages breast cancer

Answer 15

• N1
  
  • 1-3 axillary nodes
• N2
  
  • 4-9 axillary nodes
• N3
  
  • 10 nodes or greater or infraclavicular

Question 16

Pagets disease of the breast

signs and symptoms

work up

stages

treatment

Answer 16

• sxs: scaly skin rash, burning, ulceration, retraction of nipple
• work up: mammogram, biopsy (punch or excisional)
• stages
  
  • 1. confined to epidermis
  • 2. associate withDCIS just under nipple
  • 3. associated with extensive DCIS
  • 4 associated with invasive ductal ca
• if DCIS
  
  • simple mastectomy with SNB
• if invasive ca on bx:
  
  • MRM, mastectomy with SNB

Question 17

Bloody Nipple Discharge

Answer 17

• H/P: menarche, FH, menses, pregnancies
• work up: mammo, cytology, galactogram
• DDX: ca, intraductal papilloma, fibrocystic dx
• treatment: wide duct excision