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Breast Flashcards

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1
Q

Palpable Breast Mass HPI?

A

HPI- cyclic pain, nipple dc, skin color changes, personal hx, family hx of breast or ovarian, reproductive hx, hormonal or HRT, trauma, ASK Bone pain, XRT

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2
Q

Palpable Breast Mass PE?

A
  • PE- bilateral breast, size, nipple dc, erythema, adenopathy (ax, supraclavicular nodes, cervical), Palpate the liver
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3
Q

Palpable Breast Mass Ddx?

A
  • DDx- Cyst, fibroadenoma, fat necrosis, ca, lipoma, fibrocystic dz
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4
Q

Palpable Breast Mass Gail, Triple test, needle bx doesn’t match up?

A
  • Note-
    • GAIL- 5 yr and lifetime risk could benefit from chemoprevention 50% risk prevention
    • Triple Test =US/MMG/CNB is std, 100% accuracy dx benign lesions
    • Be careful when the needle biopsy does not match clinical or MMG-need to still excise
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5
Q

BIRADS?

A

BIRADS- 0- indeterminate 1-Normal (repeat 1yr) 2-Benign (no bx) 3-likely benign (f/u MMG 6mo, follow for 2 yrs then downgrade to 2) 4 - suspicious (needs a bx 40% malignant) 5- Malignant (5% will be normal) 6 - known

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6
Q

Palpable Breast Mass imaging?

A
  • Imaging
    • US-for any palpable mass (not good for screening but diagnostic), cyst vs solid
    • MMG-Still need, and bilateral
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7
Q

Palpable Breast Mass CNB?

A
  • CNB (clips, receptor status) ((If Palpable)) - at least 14 G multiple passes 10-14 typically all removed (no need for imaging if palpable), better than a surgical bx just as accurate, cheaper, less cosmetic effects, leave clips
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8
Q

Palpable Breast Mass CNB indeterminate ?

A

CNB results indeterminate, LCIS, atypical hyperplasia, RADIAL scar, papilloma —>excision (30% have DCIS or cancer) and send of ER/PR receptors can be done under local or general

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9
Q

Palpable Breast Mass fibroadenoma?

A
  • Fibroadenoma -most can be left alone AFTER confirmation of core biopsy. May excise if growing, painful, or large >3cm
  • Fibroadenoma, Fat Necrosis, Sclerosis (can mimic BCA clinically and path) require local excision and f/u
  • prepubescent fibroadenoma >3 cm
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10
Q

Palpable Breast Mass that is a cyst?

A

Cyst (simple) - clear fluid if collapses f/u in 6mo after FNA aspiration and repeat unto 3 times, if solid component- bx solid component, Bloody fluid send to path

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11
Q

Palpable Breast Mass that is fibrocystic dz?

A
  • Fibrocystic dz - need to r/o cancer or solid mass, Mondors dz, costochondritis and pregnancy once dx-
    • 1st decrease caffeine, fat intake, better support, take NSAIDs for pain 2nd primrose oil (prolactin inhibitor), danazol, bromocriptine, tamoxifen (thought increase risk of endometrial cancer-
      • f/u 6mo, SBE,CBE, annual MMG
    • last resort is mastectomy segmental or total
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12
Q

Palpable Breast Mass thats an abscess?

A
  • Abscess- I and D. may try aspirate with abx c staph coverage
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13
Q

Palpable Breast Mass phyllodes tumor?

A
  • Phylloides tumor (90% benign) no LN- 1-2 cm margins (unless clinically malignant and invading surrounding tissue (20% at which time mastectomy and no LND), CXR, and chemo only if >5cm doxorubicin and ifosfamide
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14
Q

Palpable Breast Mass plasma cell mastitis? Granulomatous mastitis? lactation mastitis? Non lactation mastitis?

A
  • Plasma cell mastitis, duct ectasia and subareolar chronic abscess require I&D, ABX, Subareolar Excision
  • Granulomatous mastitis - steroids no surgery
  • lactation mastitis - usually staph- tx increase breast pump (dispose) and ABX and if abcess perc drain it
  • Non lactation mastitis- usually anaerobe - drainage plus abx
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15
Q

Palpable Breast Mass c palpable LN?

A
  • If palpable LN then need FNA for staging (can help avoid SLNB if + ) - Note
    • Can consider neoadj therapy for larger tumors for BCT consideration 80% effective in conv mastectomy —> BCT
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16
Q

Palpable Breast Mass c SLNB steps?

A
  • SLNB
    • should be consider with node neg invasive breast cancer and woman undergoing mastectomy for DCIS
    • micromets =10% of the hottest node or suspicious palpated LN
    • if more than 5 LN and the hottest was removed than stop at five
    • if failed mapping then ALND
    • Methylene blue can cause anaphylaxis, skin necrosis
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17
Q

Palpable Breast Mass post mastectomy ? and follow up?

A
  • Oncotype- assessed postop for postmen ER positive cases c borderline tumor characteristics assess the benefit of chemo
  • triple neg can benefit from chemo
  • post mastectomy XRT improve survival and decreases survival in pts c >4 mets LN, >5 cm
    • 5000 rads in divided doses
  • BCT postop
  • 20 yo SBE monthly, CBE q 3yrs
  • 40 yo SBE monthly, CBE annually, MMG annually until 70 yrs
  • BRCA 25 yrs MMG and consider alt MRI
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18
Q

Suspicious Mammography Abnormality if path dx doesnt match up?

A
  • if path dx doesn’t account for other findings then repeat or do an excisional bx
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19
Q

Suspicious Mammography Abnormality relative CI to BCT?

A
  • BCT must have postop XRT to match the local recurrence rates as a mastectomy
  • relative CI to BCT >5cm, large tumor to breast ratio, pregnancy; absolute is T4 (Inflammatory), multi centric, collagen vascular, previous XRT, central subareolar location, breast too small
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20
Q

Suspicious Mammography Abnormality surgical approach?

A
  • surgical approach - Langer lines, periareolar incision (centrally located), if lower half then radial incision
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21
Q

Suspicious Mammography Abnormality mastectomy borders?

A
  • mastectomy borders
    • elliptical incision including NAC, bx site and skin over lesion
    • develop superior and inferior flap
    • Clavicle, lateral border sternum, latissimus dorsi, inframammary fold
    • remove all breast tissue, nipple areolar complex and fascia overlying the pec major
    • +/- immediate reconstruction - PRS surgeron, tissue expanders, TRAM
    • leave drains
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22
Q

Suspicious Mammography Abnormality c axillary dissection?

A
  • Axillary dissection
    • en bloc resection level 1/2 LN
    • borders- Posteriorly -subscapularis, latissimus dorsi, Medially- chest and serratus anterior, superiorly- axillary vein laterally -Skin
    • avoid injury over skeletonize axillary vein, thoracodorsal nerve, long thoracic nerve
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23
Q

DCIS (stage 0) w/u?

A
  • Hx, Dx, RF, Triple test
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24
Q

DCIS (stage 0) what to ask for on imaging?

A
  • usually pleomorphic changes on MMG
    • questions to ask path
    • How large is it the tumor, multifocal (mastectomy and SLNB because you won’t be able to do one after) or unifocal
    • comedo necrosis in the specimen
    • How well differentiated (high grade is worst), grade
    • ER/PR receptor status
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25
DCIS (stage 0) what if stereotactic bx can't be done?
- Need tissue dx | - if stererotactic biopsy can’t be done then wireloc bx
26
DCIS (stage 0) surgery?
- Surgery - BCT vs Simple (total) mastectomy + SLNB (cuz you won’t have another chance and you may find invasive cancer in the specimen)
27
DCIS (stage 0) BCT CI?
- Contraindications - Large size, small breast - previous radiation - T4 lesions - central subareolar mass
28
DCIS (stage 0) c SLNB???
- SLNB can be considered for high grade lesions (controversial) >4cm comedonecrosis, microinvasion. its a must for invasive cancer, o/w no need - wire loc if needed, check imaging - create gross 1 cm margins, amputate and orient specimen (permanent) and check X-ray to verify clip and wire - palpate for any residual disease - leave clips for whole breast radiation
29
DCIS (stage 0) c XRT??
- XRT is mandatory
30
DCIS (stage 0) notes?
- Mastectomy (risk reduction in recurrence but no survival benefit to a BCT) - Optimal DCIS margin unknown, but a width of 1 mm or more is associated with decreased chance of recurrence - Stage is upgraded from 0 if micro invasion or occult invasive dz and treat like invasive disease - Hormone therapy for ER,PR, HER - Whole breast radiation - Std follow up CBE and MMG 6mo for 2 years and annual - Isolated tumor cells in LN- considered node negative, may have gotten there from biopsy manipulation rather than mets
31
LCIS (detected on bx as usually as an incidental finding)
- High risk path detected incidental finding on CNB (LCIS, atypical hyperplasia) indicates the need for f/u dx surgical wire localization bx which will reveal coexisting cancer 15% of the time so need to do something
32
LCIS high risk path?
- High risk path detected incidental finding on CNB (LCIS, atypical hyperplasia) indicates the need for f/u dx surgical wire localization bx which will reveal coexisting cancer 15% of the time so need to do something
33
LCIS margins?
- when detected incidentally margins free aren’t needed
34
LCIS marker?
- Marker for increase lifetime risk of cancer (1% per year)
35
LCIS options?
- 3 options after you confirm its just LCIS after your resection - 1st- close observation / surveillance alone (annual or biannual CBE, annual MMG, possible annual MRI) - 2nd - chemoprevention tamoxifen pre or raloxifene for post - 3rd- bilateral Px mastectomy (No axillary staging) -high risk
36
LCIS with tamoxifen side effect?
- tamoxifen - avoid getting pregnancy - nights sweats, hot flashes, DVT, uterine problems, decreased libido
37
Advanced Breast Cancer w/u?
- Work up - CBC, Renal, CXR - Bone scan if alkaline phosphatase or calcium elevated - CT scan if LFT elevated
38
Advanced Breast Cancer TNM?
- TNM - T - T0 -in situ - T1- 5cm - T4 skin/chest (inflammatory) - N - N1- axillary nodes - N2-matted axillary nodes - N3- infra/supraclavicular nodes or inframmary - Stage 0 - DCIS - Stage 1 -T1NO - Stage 2A- T0-1N1, T2N0 - Stage 2B- T2N1, T3N0 - Stage 3A- T0-2N2, T3N1-2 - Stage3B- T4N1-2, TN3
39
Advanced Breast Cancer BRCA testing?
- BRCA testing- | - first degree dx BCA
40
Advanced Breast Cancer risk and benefits BCS vs MRM?
- Discuss risk and benefits - BCS pros- - preserve breast, smaller operation, cons-increased recurrence and risk of positive margins requiring more surgery - MRM- - decreased recurrence, only one operation unless recon cons-removal of breast, need recon
41
Advanced Breast Cancer neo adjuvant tx?
- neoadj- no diff in seroma rates, wound infxn, delayed wound healing
42
Advanced Breast Cancer SLNB vs Mastectomy?
- Mastectomy should try SLNB however after neoadj therapy slight increase in false-negative rates - if invasion into pec muscle need to resect with specimen - leave drains
43
Advanced Breast Cancer when chemo?
- chemo if >1 cm
44
Advanced Breast Cancer when XRT?
- radiation if 4 or more LN, tumor >5cm
45
Advanced Breast Cancer - Stage 2B, 3A Tx?
- 1. MRM or 2. Neoadjuvant & if responds —> BCT c SLNB | - Documented LN disease even if complete response no SLNB
46
Advanced Breast Cancer - Stage 3A-C?
Primary (Neoadjvant chemo) 6 wks or 4 cycles and if become resectable —>MRM and postop chemo 8 cycles, radiation, hormonal and f.u
47
Advanced Breast Cancer - Stage 4 (mets)?
- premenapausal- oopherectomy, tamoxifen and if no response then taxol - postmen- aromatase inhibitor
48
Advanced Breast Cancer Stage 1 =
- Stage 1 = 0.5cm because usually more aggressive - all post menopausal with invasive BCA should receive tamoxifen. chemo if >2cm or LN positive - Postop chemo usually 6 mo of CMF (cyclophosphamide, methotrexate, 5-FU) or AC (adriamycin, cytoxan)
49
Advanced Breast Cancer - Stage 2b= 2-5cm c regional nodes or >5cm - Stage 3a >5cm c nodes or bulky but operable ax adenopathy tx?
- Stage 2b= 2-5cm c regional nodes or >5cm - Stage 3a >5cm c nodes or bulky but operable ax adenopathy - Neoadj to shrink tumor (downstage it) to try BCS - Examine for nodes and FNA if palpable - Consider PET and CT - If doesn’t shrink than mastectomy followed by irradiation
50
advanced BCA- Local Recurrence?
- Local Recurrence - Stage c CT/PET scan - Parencyhmal recurrence re excise - If skin recurrence after radiation determine if can have more XRt and excise +XRT if possible
51
BRCA testing?
- BRCA testing- | - first degree dx BCA
52
Inflammatory Breast Cancer T4 HPI?
- HPI- non lactating women, erythema and edema over more than one third of breast that doesn’t get better c abx
53
Inflammatory Breast Cancer T4 Ddx?
- DDX- Mondors dz (inframammary cord), mastitis, abscess)
54
Inflammatory Breast Cancer T4 characteristics?
- Characteristics- peau d orange
55
Inflammatory Breast Cancer T4 tx and dx?
- Tx and Dx- Try antibiotics one week if good patient - U/S and MMG (and if mass CNB) receptor status - Punch biopsy or incisional bx, FNA the LN if palpable, - Mets w/u- CXR, Liver CT, Bone scan
56
Inflammatory Breast Cancer T4 multimodality tx?
- Multimodailty treatment - Three cycles of neoadjuvant chemo and once complete resolution (however if no good response give XRT 5000 rads) - Then an “interval” MRM (total c 1/2 LN), - BCT is CI, (unacceptably high false neg for SLNB) - if residual dz is left behind mark it with clips for xrt - Followed by 8 cycles of chemtherapy - And + Chest Wall XRT - Tamoxifen - ongoing abx not recommended
57
Inflammatory Breast Cancer T4 complications?
- Complications - bleeding from lack of ctrl of the internal mammary perforators, axillary vein, thoracodorsal branches which bleeding from these sites usually requires reexploration - skin flap necrosis start prompt ABX, wait until clear demarcation
58
Inflammatory Breast Cancer T4 chemo?
- Chemo- neoadj Taxol 12 weeks, followed by CAF (cyclophoshamide, Adriamycin, 5-FU) 4 cycles and if no response then XRT upfront prior to MRM and add 4 more wks of Taxol
59
Inflammatory Breast Cancer T4 notes?
- Note- If initial inflammatory breast cancer is eroding through the skin or is infected we have to start the treatment actually by XRT tx - Note- adriamycin cardiotoxic get an echo prior
60
Inflammatory Breast Cancer T4 mets every where?
mets every where - start aromatase inhibitor and if no response then add tamoxifen, only do surgery if tumor becomes too painful or infectious
61
Inflammatory Breast Cancer T4 5 YS?
- 5 YS- poor 5%
62
Breast Cancer During Pregnancy ddx?
- DDx- fibroadenoma, lipoma, phyllodes, fat necrosis, fibrocystic dz, galactocele, cyst, abscess, accessory breast tissue
63
Breast Cancer During Pregnancy galacotocele?
- galactoceles develop months after d/c lactation
64
Breast Cancer During Pregnancy w/u?
- Std w/u is preferred | - Alk Phosp is typically elevated in pregnancy
65
Breast Cancer During Pregnancy imaging things to remember?
- Abdominal shielding MMG or digital MMG premenapuasal pts dense breast - U/S more sensitive than MMG detecting breast cancer in pregnancyf - MRI not good gadolinium, and prone position not safe - U/S guided CNB - gestational age and stage is important
66
Breast Cancer During Pregnancy terminate a pregnancy?
- never terminate a pregnancy - doesn’t improve outcomes, early delivery may be considered if felt to help maternal oncological outcome
67
Breast Cancer During Pregnancy staging?
- stage - CXR, U/S liver; CT scan PET scan deferred till after delivery
68
Breast Cancer During Pregnancy when is chemo ok?
- systemic chemo 2,3rd ok - usually MRM is preferred or (total mastectomy c SLNB) - DCIS vs Invasive think about it??
69
Breast Cancer During Pregnancy 1st trimester?
- 1st trim - attempt to defer to second trim, o/w surgery but not BCT, risk effects of ogranogenesis and poss spontaneous abortion
70
Breast Cancer During Pregnancy 2nd trimester?
- 2nd trimester optimal-where organogenesis is complete and risk of preterm labor is low- MRM
71
Breast Cancer During Pregnancy 3rd trimester?
- 3rd trimester- attempt to defer surgery til postpartum period 2/2 risk preterm labor - MRM vs a slight possibility of BCT with post part radiation after the chemo
72
Breast Cancer During Pregnancy avoid?
- avoid methotrexate and 5 FU? - Radio isotope tech 99 ok for SLNB - no tamoxifen or Herceptin in pregnancy only postpartum
73
Breast Cancer Recurrence (see How to Win) wu?tx?
- review reports, examine - essentially need a diagnosis and then restage it - FNA, cxr, CT a/p routine blood work, alkaline phosp, LFTs - basically upstage your treatment BCT—>MRM or MRM—> systemic tx - axillary nodes immobile then chemo and hormonal therapy (XRT if not already given)
74
Dissemminated BCA and Recurrences if ER/PR +?
- If ER/PR receptor positive - tamoxifen - Luteinizing hormones releasing analog (LHRH) suppresses pituitary gland , medical oophorectomy - Aminoglutethimide- aromatase - androgens
75
Dissemminated BCA and Recurrences if ER/PR - ?
- If ER/PR negative - chemo - chemo plus bone rescue - bisphosphonates treating bone mets
76
Bloody Nipple D/C hx?
- Hx- spontaneous, unilateral, clear or bloody, quadrant
77
Bloody Nipple D/C ddx?
- DDx- intraductal papilloma
78
Bloody Nipple D/C w/u?
- MMG, US, CNB if a mass
79
Bloody Nipple D/C tx?
- observe if colored for 6 weeks, stop caffeine, smoking if cytology is negative - cytology (if benign doesn’t mean anything) - milky check prolactin level - If there is a mass then resection of it with a subareolar wedge excision if you know what quadrant - if you don’t know where it is have the patient go home and see if can find it o/w total subareolar ductal system resection - no ductoscopy
80
Bloody Nipple D/C operation?
- operation - cannulize duct and inject methylene blue or leave probe - semicircular areolar incison - locate it and dissect out the ducts in this area - tie off the proximal and distal ends (avoid seroma) - take 1 cm area of tissue around duct and orient for pathology for permanents - 10% malignant
81
Gynecomastia Men (How to Win) HPI?
- Ask about Marijuanna, steroids, meds, liver dz, change in libido
82
Gynecomastia Men (How to Win) w/u?
- MMG, US, HCG, LFTs - Mass then triple test - check receptors usually receptor positive tamoxifen should be given, chemo and XRT same
83
Gynecomastia Men (How to Win) diffuse enlargement
- Diffuse enlargement probably pseudogynecomastia
84
Gynecomastia Men (How to Win) causes?
- testicular tumors (High HCG), Hyperthyroidism (high LH and testosterone), prolactin secreting tumors (low LH, Low testosterone), adrenal and Leydig tumors (high estradiol)
85
Enlarged Axillary Node ddx?
- DDx-Breast Cancer, Infection, Hydradenitis, Cat Scratch, Lymphoma, GI mets, melanoma, ENT mets
86
Enlarged Axillary Node HPI?
- Ask infections, B sx, GI cancers, Skin cancer
87
Enlarged Axillary Node thats an adenoma?
- 25% adenoma in axillary is BCA
88
Enlarged Axillary Node w/u?
- Triple test, ER/PR, Mucin r/o melanoma, CXR, CT Scan, upper and lower endoscopy, CEA, MRI
89
Enlarged Axillary Node tx?
- tx- most likely breast- maybe get an MRI to see if MMG, US missed something - options MRM or just ALND and observe
90
Enlarged Axillary Node ALND?
- ALND - take levels 1 and 2 not 3 (medial to pec minor) - lateral to and underneath the pectorals minor muscle - Transverse incision in axilla - incise clavipectoral fascia - ID lateral border of pec major - dissect onder pec major preserving pec neurovascular bundle - ID and dissect under pec minor - ID axillary vein - upper limit - ID long thoracic and thoracodorsal neuromuscular bundle and preserve - take all fatty tissue bounded by axillary vein/serratus anterior/lat dorsi - place drains and close
91
Enlarged Axillary Node SLNB?
- SLNB - preop pt has radiotracer lymphoscintigraphy - isosulfan blue injection - 1-5 cc intradermally over lesion - gamma probe to ID maximal radioactivity - transverse axillary incision - use gamma probe and blue dyt to ID sentinel node - excise palpable large nodes - Frozen section- if + proceed with ALND
92
Pagets what is it?
- Cells that migrated from DCIS or Invasive Cancer | - 50% association with the above
93
Page's using steroids?
- Don’t use steroids can cause regression of the disease
94
Pagets w/u?
- Don’t use steroids can cause regression of the disease - MMG, US possible CNB - make sure no underlining mass
95
Page's treatment?
- wedge resection of NAC check pathology if shows pagets then do a Simple Mastectomy consider SLNB o/w if cancer in specimen do a ALND - No steroids - causes regression - Central lumpectomy, SLNB, XRT ??
96
Pagets No palpable mass, no mass on imagin
- wedge resection of the NAC under local anesthesia c sedation and send to pathology - if pages cells patient should have a simple mastectomy +/- XRT - If invasive breast cancer patient should have a complete ALND unless SLNB was done at initial surgery
97
Pagets - Identifiable breast mass?
- Identifiable breast mass - excisional biopsy of mass and wedge resection of the NAC - if invasive breast cancer and paget cells in NAC then need a MRM plus postoperative tx as indicated
98
Pagets SLNB?
- consider SLNB initial surgery if patient higher risk
99
Enlarged Axillary LN benign causes?
- infection, hidradenitis, cat scratch, ascending lymphagcinitis, generalized lymphadenopathy, viral, fungal
100
Enlarged Axillary LN c adenocarcinoma causes?
- Malignant causes - ipsilateral breast cancer - lymphoma - melanoma - lung Ca - GI cancer (rare)
101
Enlarged Axillary LN c adenocarcinoma PE?
- exam both breast, other LN, skin upper half of body, listen to chest , test stool guaiac and palpate live
102
Enlarged Axillary LN c adenocarcinoma - Everything negative with adenocarcinoma?
- Everything negative with adenocarcinoma - MMG, CXR, CT A/P, Bone scan, UGIS/BE? - Excisional biopsy to confirm FNA done in office - path - ER/PR - Mucin stain (melanoma, lymphoma) - still negative - MRM treat if she had cancer with mets from breast
103
Large Mass >5cm adhered to chest wall Breast Cancer and or fixed enlarged ALN what to do?
- Start c H&P - FNA and MMG - FNA is + non-inflammatory BCA - Do metastatic w/u - Generous Incisional Bx and send ER/PR rec - Give induction chemotherapy (3-4 cycles) and follow U/S for response - MRM - followed by R.T - then completion Chemo (6-12 wks) - Tamoxifen
104
Large Mass >5cm adhered to chest wall Breast Cancer and or fixed enlarged ALN if cancer is fungating and ulcerative?
- If cancer is fungating and ulcerating - Forced to do Salvage Mastectomy or R.T - Because giving chemo in the presence of infected ulceration can kill the patient from sepsis
105
Male Breast Cancer HPI?
- HPI- Lump under his nipple
106
Male Breast Cancer Ddx?
- Ddx- Gynecomastia or normal subareolar “disk” seen in puberty - Liver dz/ cirrhosis - Meds - Mainly anti-HTN - testicular mass (some HCG secreting tumors cause it) - bilateral or unilateral , firm, central, and tender vs hard, irregular, non tender
107
Male Breast Cancer w/u?
- W/U - Full PE - LFTs, HCG - FNA and even incisional bx - US, MMG
108
Male Breast Cancer tx?
- Tx - Wide MRM (may include pec if involved) - Tamoxifen - Chemo and XRT same indications as woman - If disseminated disease - orchiectomy and hormonal manipulations have good palliative effects - SLNB c Total Mastectomy - valid option in smaller tumors and negative ALN
109
BCA Notes on SLNB micromets?
- need to go back
110
BCA Notes on SLNB isolated tumor cells?
- considered node negative, don’t go back (probably from biopsy manipulation rather than mets)
111
BCA c CT shows mets all over, bone and liver etc?
aromatase inhibitor, if no response add tamoxifen, and finally chemo only do surgery if becomes painful or infectious because the cancer is going to kill her

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