Breast

Question 1

fibrocystic changes in the breast are benign. What are 3 examples?

Answer 1

1. simple cyst
2. fibrosis
3. apocrine metaplasia

Question 2

Fibrocystic changes to breast that carries high risk of cancer

Answer 2

ATtypical hyperplasia (“likely to ATurn into cancer”)

(epithelial hyperplasia is a proliferative breast disorder and is benign)

Question 3

proliferative breast disorders are benign. what are 3 examples?

(slightly increased risk of cancer)

Answer 3

1. epithelial hyperplasia (increased luminal & myoepithelial cells)
2. sclerosing adenosis (calcification, compressed acini)
3. intraductal papilloma (“finger-like” projections, myoepithelium)

Question 4

breast pathology that presents w/bloody discharge

Answer 4

1. Intraductal papilloma (benign tumor, “Myoepithelium Included”)
2. Papillary carcinoma (“Myoepithelium Popped”)

(myoepithelium=physical and chemical prevention of cancer)

Question 5

Name this breast pathology

Answer 5

fibROadenoma (estROgen sensitive)

(dark grey distinguishes them from breast cysts, benign)

Question 6

3 benign inflammatory conditions of the breast

Answer 6

1. mammary duct ectasia (dirty white, green or black discharge)
2. fat necrosis
3. mastitis (lactation & periductal/smokers)

(inflammatory breast cancer = ductal or lobular cancer that gets into the lymphatic system and causes blockage)

Question 7

Histologic changes that occur in periductal/smokers mastitis

Answer 7

cuboidal epithelium of duct –> squamous –> overgrowth –> blockage

(lactational = d/t tissue damage –> S. aureus infection)

Question 8

6 Breast carcinoma risk factors

Answer 8

1. Female
2. over 80 y/o
3. 1st degree relative w/Breast CA (mother, sister, daughter)
4. increased estrogen exposure (early menarche/late menopause)
5. obesity
6. first child > 35y/o, no children and/or no breast feeding

Question 9

ALL breast cancer comes from which location?

Answer 9

terminal duct lobular unit (ductal & terminal)

(ductal & lobular get their name from the appearance of the cells, NOT the location w/in the breast!)

Question 10

95% of breast tumors are…

Answer 10

adenocarcinoma

Question 11

Why does the nipple form this crust in Paget’s disease of the breast?

Answer 11

DCIS cells penetrate lactiferous ducts –> extends to nipple –> fluid leaks out and forms crust

(rare presentation of breast cancer, usually invasive carcinoma)

Question 12

key hisology findings of lobular carcinoma in situ vs. invasive lobular carinoma

Answer 12

1. “discohesive growth”; Loose intercellular
2. single file cells

Question 13

histology: invasive ductal carcinoma

Answer 13

duct-like structures in desmoplastic stroma

Question 14

location of ductal carcinoma on the breast

Answer 14

superolateral quadrant of breast

(intraductal papillomas are under the aereola and present with nipple discharge)

Question 15

peau d’orange a/w

Answer 15

inflammatroy carcinoma

(presentation of invasive ductal carcinoma, not a sybtype and not a cancer. Treated differently, but not a separate cancer)

Question 16

how does one check for axillary lymph node metastases?

Answer 16

sentinel node bx: injecting tracer into the lymph and following to nodes to check for cancer cells

Question 17

breast cancer tumors can be classified by which 3 predictive markers

Answer 17

1. estrogen (ER+)
2. progesterone (PR+)
3. HER-2 (cell surface tyrosine kinase receptor)

(this gives us info about prognosis & therapy)

Question 18

HER-2 cells have … recptor on the surface

Answer 18

tyrosine kinase

Question 19

define triple negative breast tumors

Answer 19

negative for predictive markers ER, PR and HER2

(these are most aggressive and effect younger women)

Question 20

breast cancer in men always presents as a mass located…

Answer 20

subareolar/near nipple

(intraductal papilloma also located under/near the nipple)

Question 21

male breast cancer is a/w… (2 conditions)

Answer 21

klinefelter (~10%)
BRCA2 gene mutation (15%)

Question 22

Infalmmatory carcinoma of the breast (invasive carcinoma) is often mistaken for Paget’s disease of the breast (noninvasive carcinoma). What is a key difference?

Answer 22

inflammatory carcinomas (E) lack palpable mass

Question 23

Infalmmatory carcinoma of the breast (invasive carcinoma) is d/t …

Paget’s disease of the breast (noninvasive carcinoma) is d/t …

Answer 23

• dermal lymphatic space invasion (E)
• extension of underlying DCIS/invasive breast cancer cells migrate up the lactiferous ducts. (C)

Question 24

“Indian files” or “lines of cells” is a/w which breast pathology?

Answer 24

invasive lobular carcinoma

“Lines of cells = Lobular”

Question 25

breast cancer a/w BRCA1 mutation

Answer 25

medullary breast carcinoma (MBC) (10% of BRCA1 have this)

Question 26

physical exam findings of medullary breast carcinoma (MBC)

Answer 26

* soft-to-firm well-circumscribed breast mass (like a fibroadenoma) * rarely symptomatic

Question 27

histologic findings of medullary breast cancer (subtype of invasive ductal carcinoma) | a/w BRCA1 mutations

Answer 27

1. syncytial growth pattern high nuclear atypia 2. dense lymphohistiocytic infiltration

Question 28

3 Rx that tx ER-positive breast cancer

Answer 28

1. tamoxifen 1. anastrozole 1. letrozole (-"zole" = aromatase inhibitor)

Question 29

Rx for HER-2 positive breast cancer

Answer 29

Trastuzumab ("Her two (HER2) breasts can be treated with tras**two**zumab.") (AE: dilated cardiomyopathy: If you trust trustuzumub, it might break your heart.)

Question 30

microcalcifications on mammography but NO palpable mass is most likely which diagnosis?

Answer 30

DCIS (lobular is NOT seen on mammography)

Question 31

how is the pathophysiology different in inflammatory breast cancer vs. paget's disease of the breast (remember IBC = a **presentation** of lobular or ductal cancer)

Answer 31

breast cancer: malignant migration through **lymph vessels** paget's: neoplastic cells migrate through **mammary ducts**

Question 32

2 histologic features of medullary carcinoma of the breast

Answer 32

1. syncytial growth pattern 1. large lymphocytic infiltrate | (on palpation: soft fleshy masses; MC a/w BRCA)

Question 33

List the 5 types of mastectomies

Answer 33

1. Simple (total): Nipple & breast tissue 1. Modified Radical (MRM): Nipple, breast, Level 1 & 2 Lymph nodes 1. Radical: Nipple, breast, level 1, 2 and 3 Lymph nodes, pectoral muscles 1. Skin-Sparing: breast tissue & nipple 1. Nipple-Sparing: breast tissue only (skin and nipple sparing may or may not hace lymph nodes removed)

Question 34

Breast-Conserving Surgery (Not a Mastectomy, but High-Yield)

Answer 34

Lumpectomy (Wide Local Excision) ✅ Removes tumor with negative margins while preserving most of the breast ✅ Always followed by radiation therapy ✅ Preferred when: * Tumor is small (<5 cm) * Negative margins can be obtained * Patient can tolerate radiation

Question 35

... and ... together have the same survival rate as mastectomy for early-stage breast cancer.

Answer 35

* Lumpectomy * Radiation

Question 36

What is the best mastectomy for patients planning immediate reconstruction?

Answer 36

skin-sparing (entire breast and nipple-areolar comples, but preserves skin envelope)

Question 37

Causes of gynecomastia | "STACKED"

Answer 37

**S**pironolactone **T**estosterone Deficiency **A**nabolic Steroids **C**irrhosis **K**idney Failure **E**ndocrine Tumors **D**rugs (i.e. Cimetidine, Ketoconazole, Finasteride, Digoxin)

Question 38

When is an Axillary lymph node dissection (ALND) necessary during mastectomy?

Answer 38

If more than 3 lymph nodes are positive or palpable (clinically positive)

Question 39

Surgical treatment for DCIS

Answer 39

wide local incision (also radiation)

Question 40

When is a sentinel bx done (3) (technetium-99, blue dye, gamma probe to locate)

Answer 40

1. early breast cancer (T1/T2) w/o palpable lymph nodes 1. melanoma staging 1. other cancers

Question 41

Which type of cancer is treated with neoadjuvant chemo and then surgery?

Answer 41

Inflammatory breast cancer (subtype of lobular or ductal)

Question 42

alcohol can worsen which benign breast mass?

Answer 42

fibrocystic changes (Does NOT increase cancer risk unless associated with epithelial proliferation or atypia, tx is supportive: low-fat diet, supportive bra)

Question 43

what is the main difference on exam between fibrocystic breast changes and fibroadenoma?

Answer 43

fibrocystic = lumpy, tender fibroadenoma = rubbery, non-tender

Question 44

In women with fibrocystic changes or fibroadenoma, what is the next step in management (if they are under 30 y/o vs. over 30 y/o)?

Answer 44

under 30 = ultrasound over 30 = ultrasound + mammogram both = core needle bx if uncertain or growth occuring