Breast Cancer Review

Question 1

when would you offer palliative care for patient with breast cancer?

Answer 1

for patients not expected to survive 2-3 years secondary to other co-morbidities

Question 2

what kind of hormonal therapy do you consider for pre-menopausal woman with hormone responsive breast cancer?

Answer 2

Tamoxifen

Question 3

what kind of hormonal therapy do you consider for post-menopausal woman with hormone responsive breast cancer? (give example of drug)

Answer 3

Aromatase inhibitor

- anastrozole

Question 4

what are the side effects of Anastrozole?

Answer 4

• osteoporotic fractures
• myalgia
• arthralgia
• lipid profile abnormalities

Question 5

Mechanism of action of Anastrozole

Answer 5

• reversible binding of aromatase enzyme

- blocks conversion of androgens to estrogen in the periphery (extragonadal tissue)

Question 6

Mechanism of action: Tamoxifen

Answer 6

• Selective estrogen receptor modulator

- think of it as a partial estrogen receptor agonist (less response by tissue than binding estrogen itself)

Question 7

Mechanism of action: Trastuzumab

Answer 7

• monoclonal antibody to domain IV of extracellular segment HER2/neu receptor
• arrests cells in G1 phase of cell cycle

Question 8

in general what kind of reconstruction do you propose for a patient with inflammatory breast cancer and why

Answer 8

delayed autologous graft reconstruction

prevents the delay of radiation treatment…also you don’t want to use an implant in a field that has been or will get radiation

Question 9

breast mass looks like fat necrosis on imaging, but no history of trauma…what do you do?

Answer 9

biopsy the lump

Question 10

Rapidly growing breast mass, smooth contour, biopsy shows stromal overgrowth with hypercellularity…what is it?

Answer 10

Phyllodes tumor

Question 11

What margin do you want for a phyllodes tumor

Answer 11

1 cm margin

Question 12

What margin do you want for DCIS excision

Answer 12

2 mm margin

Question 13

Indication for mastectomy in DCIS

Answer 13

• multi-centric
• large/high grade DCIS
• failure to achieve adequate margins with partial mastectomy
• previous radiation/contraindication to radiation (need post op rads when doing lumpectomy)

Question 14

when do you consider adjuvant chemotherapy in IDC?

Answer 14

• tumor > 1 cm
• nodal involvement
• pathologic specimens with aneuploidy

Question 15

What is the chemotherapy regimen of choice for IDC in breast cancer?

Answer 15

• doxorubicin (adriamycin)
• cyclophosphamide
• paclitaxel

Question 16

what test should you get before starting chemotherapy in breast cancer?

Answer 16

• transthoraxic echocardiogram

- the agents used cause cardiotoxicity (doxorubicin, cyclophosphamide, paclitaxel)

Question 17

what test do you do before starting Trastuzumab?

Answer 17

• echocardiogram, it causes cardiac toxicity

Question 18

What is tamoxifen metabolized by in the body?

Answer 18

CYP2D6

Question 19

what drugs should you discontinue before starting tamoxifen?

Answer 19

SSRIs like fluoxetine and paroxetine

Question 20

what is included in a modified radical mastectomy?

Answer 20

• mastectomy

- axillary lymph node dissection

Question 21

how do you treat secondary angiosarcoma from radiation done for breast cancer?

Answer 21

completion mastectomy with adjuvant chemotherapy

Question 22

what does a fibroadenoma look like on mammography?

Answer 22

• well circumscribed mass with coarse calcifications

Question 23

stellate/speculated mass on mammography

Answer 23

• can be a radial scar…can also be cancer

Question 24

on histology showing abundant stromal and epithelial growth from breast biopsy

Answer 24

fibroadenoma

Question 25

breast biopsy shows fat disruption, lipid laden macrophages and chronic inflammation

Answer 25

fat necrosis

Question 26

breast biopsy shows complex and branching fronds lined with epithelial cells

Answer 26

intraductal papilloma

Question 27

Atypical ductal hyperplasia increases risk of cancer by what?

Answer 27

3-5 fold increase

Question 28

Which genetic mutation is male breast cancer most commonly associated with?

Answer 28

BRCA2

Question 29

Cells on breast biopsy show cytologic dyshesion, are small uniform round-to-oval nuclei, with variably distinct borders, what may this be?

Answer 29

DCIS or LCIS depending on location of lesion

Question 30

how does radial scar show up on biopsy?

Answer 30

fibroelastic core with entrapped ducts and surrounding adenosis

Question 31

fibroelastic core with entrapped ducts and surrounding adenosis on breast biopsy

Answer 31

Radial scar

Question 32

infiltrating cells surrounded by thin rim of epithelium on breast biopsy

Answer 32

invasive ductal carcinoma

Question 33

small lesion with mixed stromal and glandular elements on Breast biopsy

Answer 33

fibroadenoma

Question 34

why are most breast cancers seen in the upper outer quadrants?

Answer 34

most of the epithelial tissue is located here

Question 35

when would you do a terminal duct incision in a woman?

Answer 35

if they have pathologic nipple discharge, without a lesion seen on mammography

Question 36

patient who is getting post mastectomy radiation, what would you recommend regarding operative planning if an autologous graft is used?

Answer 36

plan for reconstructive surgery 6-12 months after radiation

Question 37

patient who is getting post mastectomy radiation would like immediate breast reconstruction, what is the best option?

Answer 37

tissue expander followed by implant

Question 38

drugs that can cause gynecomastia

Answer 38

- thiazides - digoxin - estrogen - theophylline

Question 39

biopsy of breast with dermal lymph-vascular invasion

Answer 39

- inflammatory breast cancer

Question 40

scaly, itchy, eczematous, ulcerated crust around areola

Answer 40

Paget disease

Question 41

what is the clinical significance of Paget Disease

Answer 41

95% of the time it is associated with underlying malignancy either IDC or DCIS

Question 42

biopsy of paget disease shows what?

Answer 42

- clear cytoplasm - large nucleoli with oval nuclei - cells located between the normal keratinocytes of the nipple epidermis

Question 43

injury to long thoracic nerve

Answer 43

- winged scapula | - inability to raise arm above shoulder

Question 44

injury to thoracodorsal nerve

Answer 44

- weakened arm pull ups | - weakened adduction