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Flashcards in Breast Deck (53):
1

DCIS is defined as...

a clonal proliferation of malignant epithelial cells that are confined within the basement membrane of the mammary ducts

2

There are two major histologic subtypes of DCIS: 

  • Comedo: notable for the presence of central necrosis, large pleomorphic nuclei, numerous mitotic figures and microcalcifications. This subtype is associated with the worst prognosis.
  • Noncomedo: notable for the presence of papillary, micropapillary, or cribriform architecture. This subtype does not demonstrate central necrosis or mitotic figures. 

3

Nuclear grade is classified as... 

low, medium, or high

based on both the morphology of the nucleus and by the mitotic index

High-grade DCIS is associated with the worst prognosis as it has the most aggressive biologic characteristics and is associated with the highest local recurrence rates.

4

Discuss the incidence of DCIS and natural history

  • Incidence: 32.5 cases per 100,000 women25% of all breast cancers diagnosed are DCIS
  • Psx: suspicious microcalcifications on mammography
  • DCIS left untreated: invasive cancer oftentimes develops near the same site

5

Identify risk factors associated with development of DCIS

  • Risk factors for DCIS are similar to those for invasive breast cancer - increased estrogen exposure
  • FHx of breast cancer
  • nulliparous
  • children at a later age
  • obesity
  • BCRA1 and BRCA2 genes

6

Describe the primary approaches to breast cancer (DCIS and invasive types) prevention.

  • Screening mammogram: start at 50 yrs, every 2 yrs, stop 74 yrs
  • >20% lifetime risk (high risk): mammogram and breast MRI q1yr, breast exam q6mo
  • Significant FHx: screen 5 - 10 yrs prior to youngest age of family dx
  • BRCA mutation: screening at 25 yrs with an annual breast MRI, add mammography at 30 yrs

7

Describe the most common presenting signs (mammographic abnormality most common) and symptoms (usually asymptomatic) for DCIS.

  • ~90% of DCIS psx: abnormal screening mammography
  • Mammography: grouped, pleomorphic, fine linear microcalcifications
  • Rarely, patients with DCIS will present with symptoms including a palpable breast mass, skin changes, or nipple discharge

8

Given a patient presenting without breast symptoms and physical findings such as a mass or nipple discharge, order the appropriate workup for a patient with an abnormal screening mammogram. 

  • Abnormal screening mammogram  diagnostic mammogram
    • inc magnifx, different angles, characterize lesion, BI-RADS
  • Diagnostic US may be required: differentiate solid and cystic
  • W/u for abnormal lesion dependent on BI-RADS category:
    • BI-RADS 1/2  return to routine screening mammograms
    • BI-RADS 3  probably benign f/u 6 mo w/ mammogram
    • BI-RADS 4/5  image-guided biopsy → tissue diagnosis

9

Given a patient with a cluster of suspicious microcalcifications seen on mammography, discuss biopsy options to further evaluate this abnormality.

  • Stereotactic biopsy is the preferred method of biopsy: outpatient setting, breast placed into stereotactic device that localizes the lesion on a 2D plane using mammograph, 3-mm core needle
  • Breast lesion vague on mammography, US, and MRI; or too posterior or too close to the nipple  needle-localized breast biopsy: guide wire placed into breast over site of lesion  surgical biopsy

10

Given a patient with newly diagnosed DCIS, discuss the advantages and disadvantages of the use of MRI prior to surgery.

  • MRI increasingly used in the pre-operative evaluation of patients with known DCIS: determine extent, evaluate for tumors in contralateral breast, and evaluate for multicentric tumors
  • Advantages to pre-op breast MRI: evaluate tumor physiology, enhanced on contrasted MRI studies which makes them very detectable
  • Disadvantage to breast MRI: low specificity, high false-positive rate

11

Discuss the TNM staging for DCIS

  • TNM system: size of primary, lymph node involvement, metastases
  • DCIS is a pre-cancerous lesion as the dysmorphic cells are confined within the basement membrane of a mammary duct and have not invaded into the surrounding cell layers
  • Since DCIS is a pre-cancer, it is considered to be TisN0M0 or Stage 0 breast cancer

12

Given a patient with DCIS identified following core needle biopsy, counsel the patient regarding treatment options, including breast conservation therapy versus mastectomy with or without reconstruction, and describe the role of sentinel node biopsy in DCIS.

  • The aim of breast conservation surgery in the setting of DCIS: negative marginscosmetically acceptable result. 
  • DCIS pts candidates for BCS: limited to one quadrant/section, cosmetically acceptable results, negative margins 
  • Total mastectomy considered: multicentric DCIS, centrally located disease, large lesions, inadequate surgical margins s/p BCS, prefer mastectomy, if adjuvant radiation is contraindicated
  • Total mastectomy for DCIS → offer immediate breast reconstruction
  • Risk of nodal mets with DCIS is less than 3%. However, eval of axillary nodes via SLNBx may be considered with lesions >4 cm, palpable breast lesions, microinvasive disease, high-grade disease, or with suspicious axillary lymph nodes on exam or US. 
  • All patients undergoing a total mastectomy for DCIS should undergo a concomitant SLNBx - this procedure not possible s/p mastectomy

13

Given a patient with DCIS undergoing breast conservation therapy, discuss the need for adjuvant radiation therapy and the use of tamoxifen in hormone receptor-positive patients.

  • Radiation therapy: standard of care in DCIS s/p BCT
  • may be omitted if small foci of low-grade, neg margins, adv age, extensive co-morbidities. 
  • After lumpectomy, radiation therapy reduces the risk of local recurrence of both invasive and non-invasive breast cancer
  • S/p BCT - hormonal therapy (tamoxifen) depends on receptor status
  • ER-positive DCIS s/p BCT - post-operative tamoxifen for 5 yrs
    • Prevent ipsilateral recurrences, new events of breast cancer

14

Given a patient with palpable asymmetric breast density and excisional biopsy demonstrating DCIS measuring 3 cm in diameter and multiple positive margins, recommend either re-excision versus total mastectomy with or without reconstruction for margin control to obtain negative margins.

  • 2 mm or larger margin - lower risk of a local recurrence
  • S/p BCT w/ + margins: re-excision versus total mastectomy
    • extent of DCIS, amount of breast removed, margin involvement
    • one marginre-excision + adj radiation therapy
    • multiple marginstotal mastectomy considered

15

Given a patient with suspicious microcalcifications seen on screening mammogram, describe the appropriate workup based on the latest NCCN guidelines.

Treatment should be based on the BI-RADS category 

  • BI-RADS 0 (incomplete) → dx mammogram or breast US
  • BI-RADS 1 (negative) or 2 (benign)  regular screening mammograms
  • BI-RADS 3 (likely benign) → dx mammogram in 6 mo, q6-12 mo x2
    • resolved or stable → normal screening mammograms
    • more suspicious core needle bx
  • BI-RADS 4 (suscpicious) or 5 (suggests cancer) → core needle bx

16

Given a patient with a 5-mm, low-grade DCIS treated with segmental mastectomy with widely negative margins, discuss the potential of omission of radiotherapy in favor of observation based on low predicted recurrence rates without the use of radiotherapy.

  • Radiation therapy: reduce recurrence in ipsilateral breast; does not reduce risk of recurrence in the contralateral or decrease mortality
  • Low-risk disease + negative margins: radiation therapy can be omitted
  • Omission of radiation therapy should be considered in patients with an ipsilateral risk of recurrent disease that is approximately equal to their risk of developing contralateral disease. 

17

In a patient with hormone receptor-positive DCIS treated with segmental mastectomy and radiation therapy, discuss the risks/benefits of adjuvant tamoxifen therapy.

50% to 75% of DCIS have estrogen or progesterone receptors

  • Tamoxifen for ER-positive DCIS s/p breast-conserving treatment.
  • Therapy for 5 years to prevent ipsilateral and contralateral recurrence
  • Risks: endometrial cancer and thromboembolic events
  • Added endocrine therapy: less risk of recurrence, no mortality benefit

18

Following initial treatment for DCIS, recommend that the patient undergoes annual mammographic examination following breast-conserving surgery.

  • Following BCT for DCIS: PE q6mo x5 yrs → q1 yr PE 
  • The patient should also undergo an annual diagnostic mammogram
  • Special attention should be paid to the ipsilateral breast following breast conserving surgery as the majority of DCIS recurrences occur in close proximity to the site of initial disease. 

19

Identify risk factors associated with recurrence of disease, including use of the Van Nuys scoring system, and the risk of the recurrence being invasive versus non-invasive breast cancer.

The Van Nuys scoring system is a scoring system which determines whether patients are at an increased risk of developing recurrent breast cancer. 

  • The scoring system takes into account the age of the patient, the size of the primary tumor, the margins following surgical resection, and the findings on pathologic examination. Factors associated with a higher risk of recurrence include younger age, a large primary tumor, close margins, and higher grade tumors as seen on pathology.
  • Patients with scores of 4-6 have an average recurrence rate of 2%, of which 0% of cancers were invasive breast cancer. 
  • Patients with scores of 7-9 have an average recurrence rate of 22%, of which 46% of cancers were invasive breast cancer.
  • Patients with scores 10 and higher had an average recurrence rate of 53%, of which 43% of cancers were invasive. 

20

Describe the blood supply to the breast

The breast receives 2/3 of its blood supply from the inferior mammary artery and 1/3 from the lateral thoracic artery.

21

Describe the lymphatic drainage from the breast.

  • 75% through axillary nodes; 25% through internal mammary nodes.
  • Three levels of axillary lymph nodes:
    • Level I – lateral to the pectoralis minor
    • Level II – deep to the pectoralis minor
    • Level III – medial to the pectoralis minor

22

In regards to the breast, describe glandular tissue.

Glandular tissue forms the duct system. The milk glands are present in terminal lobules and milk drains into terminal ductules, then progressively larger ducts until it reaches a major duct and then the nipple.

23

In regards to the breast, describe stromal tissue. 

Stromal tissue surrounds the lobules and contains capillaries and connective tissue.

24

In regards to the breast, describe epithelial tissue. 

Epithelial cells line the ductal system and contain myoepithelial cells to allow for contraction.

25

Describe the development and different types of breast lobules. 

  • During puberty, ductules grow and branch to develops into lobules.
  • Defined by the number of buds and by size (Type 1 < Type 2 < Type 3).
  • Nulliparous women and women nearing menopause have mostly type 1.
  • Parous women in the early reproductive years have mostly type 3.
  • Menopause: lobular units involute, breast tissue replaced with fat tissue.

26

Elicit a relevant clinical history in a patient with a breast mass.

  • pain, skin changes, nipple discharge, recent trauma
  • ID risk factors: obesity, alcohol, smoking HRT; age, race, gender, age of menarche/menopause, fam hx, personal hx, radiation

27

Most likely dx of a firm, mobile mass in a young woman

fibroadenoma

28

Most likely dx of a fluid filled breast mass in a young woman

cyst

29

Most likely dx in a yong woman w/ cyclic breast pain

fibrocystic changes

30

What is a "milk cyst" seen in breastfeeding women?

galactocele 

31

Most likely diagnosis of breast mass temporally associated with trauma to the breast

fat necrosis

32

What are the physical exam features of a malignant breast mass?

firm, fixed mass

thickening of the breast with associated pain and erythema

33

Perform a breast exam on a patient with a new mass

Begin the exam with the patient sitting up and assess for symmetry, skin changes, and nipple disease. While sitting, palpate for axillary lymph nodes.

With the patient supine and arm raised above the head, palpate all of the breast tissue including the nipple areolar complex and axillary tail.

34

Given a particular BI-RADS score, what is the next step in management?

  • BI-RADS 0 lesions need additional imaging.
  • BI-RADS 1-2 likely benign, need routine screening.
  • BI-RADS 3 probably benign, but need shorter-interval screening.
  • BI-RADS 4-5 need intervention.
  • BI-RADS 6 known malignancy.

35

Describe the diagnostic workup and associated management of a palpable mass found to be cystic on ultrasound.

  • A breast cyst should be aspirated.
  • Normal-appearing fluid doesn't need culture.
  • Bloody fluid should be sent for culture.
  • Recurrent cysts should undergo biopsy. 

36

Describe the diagnostic workup and associated management of a palpable mass that is clinically indeterminate or suspected solid.

  • Diagnostic mammogram - first for new palpable mass.
  • If the mass is in a young patient and is suspected to be benign, US may be used as an initial diagnostic study.
  • MRI is NOT recommended in the workup of a new mass.

37

Compare the differences between fine-needle aspiration, core needle biopsy, and excisional biopsy, and discuss the advantages/disadvantages associated with each approach.

  • Fine-needle biopsy – Aspiration of cells for cytologic evaluation. Cannot differentiate between noninvasive and invasive lesions. Used to help determine if additional suspicious lesions are also malignant or to evaluate for lymph node disease.
  • Core needle biopsy – Sample of breast tissue. Can provide histologic subtype, grade, and receptor status.
  • Excisional biopsy – Excision of concerning tissue. More costly than core needle biopsy. Used if biopsy non-diagnostic or conflicting with imaging findings.

38

Distinguish the pathological features of all variants of invasive breast cancer. 

Invasive ductal carcinoma

most common breast cancer

gross: gray, gritty, hard, irregular, stellate

micro: cords and nests of tumor cells

39

Distinguish the pathological features of all variants of invasive breast cancer.

Infiltrating lobular carcinoma

gross: no mass lesion, excised tissue may look normal

micro: small cells that infiltrate stroma in single file, abnormal cells can grow in a target like fashion around ducts

more often multicentric, bilateral, ER positive

40

Distinguish the pathological features of all variants of invasive breast cancer.

Tubular carcinoma

well-formed tubular structures that infiltrate stroma

low-grade cuboidal or columnar cells w/ atypical cytoplasmic protrusions 

41

Distinguish the pathological features of all variants of invasive breast cancer.

Mucinous carcinoma

gross: well-circumscribed, gelatinous

micro: nests of tumors dispersed in pools of mucus

42

Profile a luminal A breast cancer 

begin in the luminal lining of mammary ducts, best prognosis, lowest recurrence, tender to be ER+ but HER2-

43

Profile a luminal B breast cancer

begin in the luminal lining, ER+, HER2-

unlike luminal A: younger pts, worse grade, larger, often positive nodes

44

Profile a triple negative breast cancer

tend to be dx in younger pts

aggressive 

BRCA-1 cancers tend to be triple negative

45

Profile a HER2 breast cancer

tend to be worse tumor grade, have positive lymph nodes, negative ER/PR, affect younger women; interestingly, can be HER2 negative

46

For breast cancer, is breast-conserving therapy better or worse in terms of survival when compared to mastectomy?

both are equivalent

47

Breast-conserving therapy should not be recommended for...

patients who are pregnant, have multicentric disease, a large tumor size in relation to the breast, a prior history of chest radiation, the presence of diffuse malignant calcifications on imaging, or persistent positive margins despite attempts at re-excision. 

48

Patients with suspicious axillary nodes on clinical exam need what before surgery?

axillary ultrasound and biopsy

if positive, do axillary lymph node dissection during surgery

if negative, do sentinel lymph node biopsy

if > 3 nodes positive postop, do completion axillary lymph node dissection

49

In breast cancer patients who get mastectomy, who should get adjuvant radiation

positive deep surgical margins, axillary node disease

50

Based on stage, what is the 5-year survival rate for breast cancer?

  • stage 0-1: ~100%
  • stage 2: 93%
  • stage 3: 72%
  • stage IV: 22%

51

How do you determine the need for systemic adjuvant therapy in breast cancer patients?

tumor characteristics: ER, PR, HER2

52

Do patients with triple-negative breast cancer need systemic adjuvant chemo?

if >0.5 cm

53

Do breast cancer patients that are hormone receptor positive need adjuvant chemo?

Patients with hormone receptor-positive breast cancer should undergo endocrine therapy. Adjuvant chemotherapy is also recommended for cancers with high-risk characteristics including high-grade tumors, tumors larger than 2 cm, positive axillary lymph nodes, and a high 21-gene recurrence score.