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Breast Flashcards

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1
Q

What is Triple Assessment?

A
  1. History + clinical examination
  2. Radiological Ix:
    > <40 years: USG
    > >40 years: Mammogram
  3. Histopathological Ix:
    > FNAC
    >Biopsy
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2
Q

What is Dimpling?

A

When the skin on breast appears to be pulled inward or puckered
Structure involved: Ligaments of Cooper
Skin involvement in breast cancer: -ve

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3
Q

What is Retraction?

A

Condition where the nipple turns inward or lies flat against the breast
Structure involved: Lactiferous ducts
Skin involvement in breast cancer: -ve
Shape:
1. Circumferential: Malignancy
2. Slit-like: Duct ectasia

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4
Q

What is Peau d’orange?

A

Skin of breast becoming wrinkled like an outer peel of an orange
Structure involved: Superficial (Subdermal) lymphatics
Skin involvement in breast cancer: +ve (T4b ds)
Seen in inflammatory breast cancer

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5
Q

Best way to examine breast

A

Dial clock method

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6
Q

What is the diagnostic modality of Breast cancer?

A

Breast Imaging Reporting and Data Systems (BIRADS)

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7
Q

BIRADS Score 0

A

Inference: Incomplete Ix
Mx: Additional imaging

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8
Q

BIRADS Score 1

A

Inference: Negative
Mx: No Bx; Follow up after 1 year

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9
Q

BIRADS Score 2

A

Inference: Benign
Mx: No Bx; Follow up after 1 year

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10
Q

BIRADS Score 3

A

Inference: Probably benign
Mx: Follow up after 6 months (Risk of cancer: <2%)

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11
Q

BIRADS Score 4

A

Inference: Suspicious
4a: Low suspicion
4b: Moderate suspicion
4c: High suspicion
Mx: Biopsy

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12
Q

BIRADS Score 5

A

Inference: Highly suggestive of malignancy
Mx: Biopsy

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13
Q

BIRADS Score 6

A

Inference: Biopsy proven malignancy
Mx: Sx excision when appropriate

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14
Q

What is Mammography?

A

Breast X ray

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15
Q

Screening for Breast is known as

A

ASBRS Breast Cancer Screening Guidelines

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16
Q

Screening if there is average risk of breast cancer

A

Annual screening mammography from 40 years of age

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17
Q

Screening if higher than average risk
BRCA mutation: +ve
Prior chest wall radiation

A

Annual MRI at 25 years
3D Mammography at 30 years

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18
Q

Screening if higher than average risk
Predicted lifetime risk >20%
Strong family history

A

Annual 3D mammography/MRI at 35 years old

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19
Q

Screening when life expectancy becomes <10 years

A

Stop screening

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20
Q

2 views of Mammograph

A
  1. Craniocaudal
  2. Medio-lateral oblique (MLO)
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21
Q

Advantages of MLO

A

Axillary can be visualized
Max breast tissue seen

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22
Q

Indications of MRI

A
  1. Breast implants
  2. Multifocal and multicentric lumps
  3. Detection of local recurrence or scar recurrence
  4. Screening modality: Young and high risk patients
  5. Suspected ducal lesions with inconclusive USG
    1st 3: Imaging IOC
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23
Q

USG finding in Intracapsular breast implant rupture

A

Stepladder

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24
Q

USG finding in Extracapsular breast implant rupture

A

Snowstorm

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25
What is Linguini sign?
MRI finding of Intracapsular breast implant rupture
26
What are the biopsy techniques of breast?
1. Punch biopsy 2. TRU-cut/core needle biopsy
27
Punch biopsy is done for
1. Skin lesions/cancers 2. Paget’s ds of breast
28
IOC for Incisional biopsy
TRU-cut/core needle biopsy
29
Risk factors of Breast cancer
1. Inc in age 2. Early menarche, late menopause 3. Nulliparty 4. Smoking 5. Obesity, alcohol 6. Family history 7. HRT (Estrogen + Progesterone) 8. Maternal age at 1st life birth: >30 years
30
Factors dec breast cancer risk
1. Breastfeeding (For 1 year) 2. Maternal age at 1st live birth <20 years
31
Most common type of breast cancer
Invasive ductal carcinoma
32
Ouadrants of breast affected
M/C: Upper outer L/C: Lower inner
33
M/C gene mutation in Sporadic cases of breast cancer
M/c: p53
34
M/C gene mutation in Familial cases of breast cancer
BRCA-1
35
M/C gene mutation in ER +, PR + breast cancer
P13CK
36
M/C gene mutation in Triple negative/HER-2 neu + breast cancer
M/c: p53
37
Indications for BRCA testing for all patients
1. Deleterious BRCA 1/2 gene mutation in blood relative 2. History of ovarian, fallopian tube and/or primary peritoneal Ca
38
Indications for BRCA testing for patients with breast cancer
1. >=1 blood relatives diagnosed with breast at <=45 years 2. H/o B/L breast cancer at <=50 years 3. H/o triple negative breast (TNBC) at <=60 years 4. H/o male breast cancer
39
Difference b/w staining in ER,PR and HER 2 neu
ER,PR: Nucleus stains brown (Steroid receptor) HER 2 neu: Cell membrane stains brown (Membranous receptor)
40
Results of HER 2 neu +
0,1+: -ve 2+: Equivocal -> FISH: Amplified: +; Non-amplified: - 3+: +ve
41
What is the Proliferation index marker (Cell multiplication)?
Ki-67
42
Molecular subtypes of Breast cancer
1. Luminal A 2. Luminal B 3. HER 2 enriched 4. Basal like (TNBC) 5. Unclassified/Claudin-low
43
Profiling of Luminal A BC
ER: +VE PR: +VE HER 2: -VE Ki-67: Low CK 5/6: -VE
44
Profiling of Luminal B BC
ER: +VE PR: +VE HER 2: -VE Ki-67: High or Any CK 5/6: -VE
45
Profiling of HER 2 enriched BC
ER: -VE PR: -VE HER 2: +VE Ki-67: Any CK 5/6: -VE
46
Profiling of Basal like (TNBC)
ER: -VE PR: -VE HER 2: -VE Ki-67: Any CK 5/6: +VE
47
Profiling of Unclassified/Claudin-like BC
ER: -VE PR: -VE HER 2: -VE Ki-67: Any CK 5/6: -VE
48
M/C molecular subtype of Breast cancer
M/C type Best prognosis
49
Molecular subtype of BC seen in young patients
Basal like (TNBC) Exhibit TNBC paradox: Initial good response to chemo Rx -> Inc chances to recur Worst prognosis
50
Tumor staging of BC is done by
PET-CT: 18-FDG
51
T staging of BC
T is: Cancer in situ (DCIS, Paget’s disease) T1: <=2 cm T2: >2 cm T3: >5 cm T4a: Involvement of chest wall (Serratus ant, ribs, intercoastal muscles) T4b: Involvement of skin T4c: T4a + T4b T4d: Inflammatory cancer- >1/3rd of breast involvement + PDO
52
N staging of BC
N0: No regional LN metastasis N1: Mobile I/L Axillary LN N2a: Fixed I/L Axillary LN N2b: Internal mammary LN, in absence of Axillary LN N3a: Infraclavicular LN N3b: Internal mammary + Axillary LN N3c: Supraclavicular LN
53
M staging of BC
M0: No distant metastasis M1: Distant metastasis
54
M/C site of metastasis in BC
Bones -> Lumbar vertebrae (M/C) d/t Batson’s plexus
55
Bony metastasis in BC Just study
Osteolytic > Osteoblastic
56
Surgery for BC Management
1. Breast Conservative Surgery (BCS)/Lumpectomy 2. Mastectomy
57
What is BCS?
Tumor removal: 1. With 1 mm margin 2. F/b mandatory radiotherapy (D/t inc local recurrence rate)
58
C/I for BCS (C/I for radiotherapy)
1. Pregnancy 2. Prior RT to chest wall 3. Collagen vascular disease (SLE, RA)
59
Technical C/I for BCS
1. Multicentric 2. Lobular cancer (If multicentric) 3. Large tumor:breast ration Relative C/I: 1. Locally advanced breast cancer 2. Multifocal disease
60
Types of Mastectomy
1. Radical/Halsted’s mastectomy 2. Modified radical mastectomy 3. Simple mastectomy
61
Structures removed in Radical mastectomy
1. Breast 2. Nipple areolar complex 3. Pectoralis major and minor 4. Level 1,2,3 Axillary LN
62
Incision made in Modified radical mastectomy
Elliptical Stewart incision
63
Structures removed in Modified radical mastectomy
1. Breast + NAC 2. Pectoral fascia 3. Level 1,2,3 Axillary LN 4.+/- Pectoralis minor
64
Structures removed in Simple mastectomy
Breast + NAC removed LN not removed
65
Max LN removed during Axillary LN clearance
10
66
Key to Axillary LN clearance Just study
SLMI: S: Superior L: Lateral M: Medial I: Inferior
67
Complications of MRM
1. Injury to nerves 2. Seroma 3. Lymphedema (Post-mastectomy) of upper limb 4. Hemorrhage 5. Recurrence
68
Injury to which nerves can occur during MRM
1. Intercoscobrachial nerve (M/C) > Numbness + Paraesthesia > Phantom breast syndrome 2. Long thoracic nerve/Nerve of Bell: Winging of scapula
69
M/C complication of MRM
Seroma
70
Management and Prevention of Seroma after MRM
Prevention: Romovac drain Mx: Aspirate under aseptic conditions
71
Long standing lymphedema leads to
Angiosarcoma (AKA Stewart Treves syndrome) -> Reddish or bluish nodules
72
M/C cause of Upper limb lymphedema
Post mastectomy lymphedema of Upper limb
73
Increased incidence of Post-mastectomy lymphedema if
1. LN removed above Axillary vein 2. RT given to axilla after clearance
74
Types of flaps used for Reconstructive Sx
1. TRAM flap 2. DIEP flap
75
What is TRAM flap?
Transverse rectus abdominals myocutaneous flap Inc abdominal wall morbidity (Muscle removed)
76
What is DIEP flap?
Deep inferior epigastric artery perforator flap (Best flap) Dec abdominal wall complications (Muscle not removed)
77
What is Sentinel LN biopsy?
1st draining LN in cancer
78
Cancers where SLNB is used
1. Malignant melanoma 2. Breast cancer 3. Penile cancer 4. Vulval cancer 5. Head and neck cancer
79
M/C nerve injured in SLNB
Intercostobrachial nerve
80
Identification of Sentinel LN
1. Blue dye technique 2. Radionucleotide technique 3. Indigocyanide green 4. Dual technique (Best)
81
What is Blue dye technique?
Isosulfan blue/methylene blue dye used Injected in periareolar region (S/C plane)
82
Complications of Blue dye technique
1. Skin tattooing (M/C) 2. Anaphylaxis 3. Bluish discolouration Of urine
83
What is Radionucleotide technique?
Tc99 tagged sulphur colloid injected (Periareolar region) | V Hot nodes (Radioactive) identified on gamma camera
84
What is the Dual technique?
Radionucleotide + Blue dye or Blue dye + ICG
85
Indications for Chemotherapy
1. LN +ve 2. Locally advanced breast cancer 3. ER -,PR - tumors 4. HER 2 neu + tumors
86
Indications for Neoadjuvant chemoradiation
1. Locally advanced breast cancer 2. TNBC 3. HER 2 neu + 4. Large tumor with patient desirous of BCS
87
What is Response Evaluation Criteria in Solid Tumors (RECIST)? Just study
Single largest diameter (SLD) measured: Assess tumor shrinkage 1. Complete response: Disappearance of all lesions + pathological LN 2. Partial response: >=30% dec in SLD 3. Progressive disease: >=20% inc in SLD while/despite chemo Rx or new lesions forming 4. Stable disease: Neither PR or PD
88
Device used to deliver chemo Rx medication
Chemoport
89
Avoidance of Chemotherapy when
Patient not fit for chemo Rx /poor performance status Early breast cancer (T1,T2/N0/M0) + Hormone +ve but HER 2 neu - | V Molecular tests show no risk | V No chemorx
90
Indications of Radiotherapy
1. LN +ve 2. Tumor >5 cm 3. Locally advanced breast cancer 4. After BCS
91
Hormonal Rx is only given in
ER +, PR + breast cancer
92
Drug given to Premenopausal women with BC
SERM: Tamoxifen Duration: 10 years
93
Drug given to Postmenopausal women with BC
Aromatase inhibitor (Letrozole/Anastrozole) Duration: 10 years
94
Side effects of SERM
Hot flashes, DVT, endometrial hyperplasia
95
Side effect of Aromatase inhibitor
Osteoporosis (M/C)
96
What is LABC?
T3N1M0 Any T4 Any N2 Any N3 With M0
97
Management of LABC
NACT -> MRM/BCS -> RT
98
What is Pregnancy associated BC?
Develop during pregnancy/within 1 year of delivery Aggressive tumors (usually ER, PR-)
99
Ix for Pregnancy associated breast cancer
Core biopsy (Diagnostic)
100
Mx of Pregnancy associated breast cancer
1. Sx: BCS in 2nd/3rd trimester only -> RT after delivery; MRM (1st trimester) 2. Chemo: C/I in 1st trimester; Best: 2nd trimester 3. Hormonal Rx + RT: C/I in all trimesters
101
What is Phyllodes tumor/Cystosarcoma phyllodes?
Rapidly enlarging breast lump Dilated veins over chest wall 3rd/4th decades
102
Spread of Phyllodes tumor
<10%: Metastasize to LN Hematogenous spread (If malignant): Lungs (M/C)
103
HPE for Phyllodes tumor
Arborizing pattern and slit-like cystic areas
104
Management of Phyllodes tumor
Surgery: 1. Lumpectomy 2. Simple mastectomy for malignant phyllodes, recurrence
105
M/C cause of Mastalgia
Fibrocystic disease/fibroadenosis
106
What is Mastalgia in breast?
Common condition characterized by tenderness, throbbing or discomfort in breast tissue
107
C/F of Mastalgia
Cyclical Mastalgia (Inc before menses, settles after periods) + breast nodularity
108
Scale used to assess breast nodularity
Cardiff-Lucknow scale
109
Management of Mastalgia
1. Maintain pain diary 2. Reassure that it is not malignancy 3. Flaxseed/evening primrose oil If no benefit after 2 months: Treatment of pain + nodularity: 1. Tamoxifen 2. Ormeloxifen 3. Dana oil
110
Types of Breast cyst
1. Simple cyst 2. Complex cyst 3. Complicated cyst
111
Simple cyst Just study
No solid component (BIRADS 2) Mx: Observation
112
Complex cyst Just study
Solid component + (BIRADS 4a) Mx: Solid component biopsied (To rule out carcinoma)
113
Complicated cyst Just study
Intracystic floating debris (Infective) Mx: Antibiotics
114
What is Mondor’s disease?
Thrombophlebitis of chest wall Always rule out carcinoma
115
C/F of Mondor’s disease
Mastalgia O/E: Cord-like swelling
116
Management of Mondor’s disease
Anti-inflammatory agents (Settles in few weeks)
117
D/d of Nipple discharge
1. Duct ectasia 2. Periductal mastitis (Zuska’s disease) 3. Duct papilloma
118
What is Duct Ectasia?
Dilated duct + Greenish discharge M/C pathological cause for nipple discharge
119
Periductal mastitis seen in
Perimenopausal women (A/w smoking)
120
Periductal mastitis presents with
Pain + Greenish discharge Periareolar abscess/sinuses (Aerobic + Anaerobic)
121
IOC for Periductal mastitis
Ultrasound
122
Management of Periductal mastitis
Antibiotic Not responding: Sx: Hadfield procedure (Cone excision of all affected ducts)
123
M/C cause of bloody nipple discharge
Duct papilloma
124
HPE of Duct papilloma
Central fibrovascular core + Papillary projections (Epithelial and myoepithelial cells)
125
Types of Duct papilloma
1. Solitary papilloma 2. Papillomatosis (>=5 papillomas) 3. Juvenile papillomatosis: Multiple papillomas
126
Relative risk of cancer in Duct papilloma
Solitary papilloma: 1.5-2 Papillomatosis: >=3
127
Investigation of Duct papilloma
USG -> Dilated duct + introduction growth
128
Management of Duct papilloma
Microdochectomy (Single affected duct + lump removed)

Surgery (10 decks)

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