Breast

Question 1

What is the difference between simple, modified radical and radical mastectomy?

Answer 1

Simple (total): mammary tissue and pectoralis fascia

MRM: simple mastectomy + axillary dissection (level I and II)

Radical: Simple + pec minor/majory + ax dissection

Question 2

What conditions are associated with BRCA 1 and BRCA 2?

Answer 2

BRCA 1: 60% breast, 40% ovarian risk; often triple negative disease

BRCA 2: 40% breast, 20% ovarian; male breast cancer, prostate cancer, pancreatic cancer, stomach, GB and melanoma; usually ER/PR +

Question 3

What is the screening for BRCA + patients?

Answer 3

MRI @ age 25
Mammogram 30
Ovarian screening 30
Monthly self exam at 18
Biannual clinical breast eval at 25

Question 4

How do you treat BRCA mutations in men?

Answer 4

Do not need high risk screen or prophylactic mastectomy but may benefit from early prostate exams.

Question 5

What margins are needed for resection of phylloides tumors and what do these tumors stain positive for?

Answer 5

WLE with 1 cm margins; stain positive for vimectic and actin similar to sarcoma

Question 6

What is the treatment regimen for inflammatory breast cancer?

Answer 6

Neoadjuvant chemotherapy –> MRM –> radiation to include supra and infraclavicular basins.

DO NOT perform SLNBx bc it will not be accurate

Question 7

What is the key pathologic feature of LCIS?

Answer 7

Lack of epithelial cadherin expression; More likely to be HER-2 negative but hormone receptor +

Question 8

When do you do a SLNBx for DCIS? (4)

Answer 8

Size >4 cm
Palpable mass
Mastectomy
Microinvasion

Question 9

Why do you have to do an axillary dissection with inflammatory breast cancer?

Answer 9

Because lymphatic involvement makes SLNBx unreliable

Question 10

What cancers are the following associated with:
Li fraumeni
Cowden
AT
Muir-Torre

Answer 10

LF: sarcoma, brain tumors, leukemia, breast, adrenal corticoid

Cowden: Thyroid, endometrial, breast, mucocutaneous

AT: breast, cerebellar, lymphoma, leukemia

Muir-Torre: Skin, GI, GU

Question 11

Which nerve innervates the serratus anterior?

Answer 11

Long thoracic nerve
*Injury results in winged scapula

Question 12

Which nerve innervates the latissimus dorsi?

Answer 12

Thoracodorsal
**Injury results in arm weakness and difficulty with adduction

Question 13

What innervates the pec major and minor?

Answer 13

Medial pectoral nerve

Question 14

What nerve innervates the pec major only?

Answer 14

Lateral pectoral nerve

Question 15

What is the most commonly injured nerve in mastectomy?

Answer 15

Intercostobrachial nerve

Question 16

What is a galactocele?

Answer 16

Breast cysts filled with milk

Question 17

What is the most aggresive type of DCIS?

Answer 17

Comedo type
*Mastectomy recommended

Question 18

What margins are needed for DCIS?

Answer 18

> 2 mm; do not need SLNBx unless doing a mastectomy in case the specimen is upstaged

Question 19

What cancer are women with LCIS most likely to get?

Answer 19

Ductal cancer

Pleomorphic LCIS is most aggresive type

Question 20

What is the next step if a core needle biopsy result is discordant with imaging findings?

Answer 20

Need excisional bx

Question 21

What size does a breast mass need to be to be diagnosed on mammogram?

Answer 21

5 mm

Question 22

What is the location of level I-III lymph nodes?

Answer 22

I: lateral to pec minor
II: beneath pec minor
III: medial to pec minor

**Need to take level I and II for an ax dissection

Question 23

What is the most important prognostic factor for breast cancer?

Answer 23

Lymph node status

*Bone is most common spot for distant metastasis

Question 24

What are the T and N staging for breast cancer?

Answer 24

T1: <2
T2: 2-5
T3: 5+
T4: Any size with direct extension to chest wall (not including pec major)

N1: 1-3
N2: 4-9
N3: 10+ or infraclavicular or supraclavicular nodes

Question 25

What cell type is seen with lobular breast cancer?

Answer 25

Signet ring cells, confer worse prognosis

Question 26

For what size tumors is SLNBx usually indicated

Answer 26

Tumor size <5 cm
NOT indicated in clinically positive nodes

Question 27

What size do tumor deposits need to be to be considered malignant?

Answer 27

2 mm

Question 28

What are contraindications to XRT?

Answer 28

Scleroderma, RA, Lupus, previous XRT, pregnancy

Question 29

Who is a candidate for lumpectomy without radiation?

Answer 29

Women >70 YO with early stage breast cancer who are undergoing hormonal therapy

Question 30

What are side effects of taxanes, adriamycin and cyclophosphamide?

Answer 30

Taxanes: peripheral neuropathy
Adriamycin: Cardiomyopathy
Cyclophosphamide: Hemorrhagic cystitis

Question 31

What is the treatment of choice for breast cancer in pregnancy?

Answer 31

First trimester: need MRM
2nd and 3rd: Can get chemo during pregnancy and XRT after delivery

Question 32

Who should get neoadjuvant chemotherapy?

Answer 32

T4 tumors to shrink it.
T3 tumors for women who desire BCT.
Pregnancy