what is the pathophysiology of sclerosing adenosis
proliferation of stroma and the smallest tubules within the terminal duct-lobular unit.
how can sclerosing adenosis mimic breast carcinoma?
clinically, radiologically, and histologically
what histologic finding confirms the benign nature of sclerosing adenosis?
presence of myoepithelial cells confirms the benign nature of the lesion
what is the pathophysiology of atypical lobular hyperplasia?
proliferation of the epithelium lining the lobules
how does the presence of atypical lobular hyperplasia affect the risk of future breast carcinoma?
associated with increased risk of future carcinoma
what is the pathophysiology of breast ductal hyperplasia?
proliferation of the ductal epithelial lining cells
how is the presence of ductal hyperplasia associated with the risk of breast cancer?
has varying degrees of risk for future cancer
what is the most common disorder of the breast?
fibrocystic breast disease
what are the age groups most frequently diagnosed with fibrocystic breast disease
between ages 20-55, incidence goes down after menopause
what is the underlying pathophysiology of fibrocystic disease
a group of morphologic changes that produce palpable lumps characterized by various combinations of cysts, fibrous overgrowth, and epithelial proliferation
what are the histological findings associated with columnar cell change in the breast?
dilated terminal duct-lobular units, lined by uniform ovoid-to-elongage, nontypical columnar cells, frequently exhibit prominent apical snouts
what breast cancers are associated with columnar cell change?
if associated with atypia, increased risk of atypical ductal proliferations and in situ carcinomas
how is lobular carcinoma in situ (LCIS) associated with future risk of subsequent carcinoma?
marker for increased risk of developing invasive carcinoma, with increased risk for both breasts. Subsequent carcinoma may be ductal or lobular.
how is ductal carcinoma in situ (DCIS) associated with carcinoma?
it IS malignant cells confined within the basement membranes of ducts without invasion of surrounding stroma
what is the best screening test for early detection of breast cancer vs. further dx of masses
mammography; ultrasound is not used for screening but is used as a diagnostic tool
when is MRI indicated when evaluating breast masses? What is it superior at in diagnosing(3)?
Used for screening women at high risk for breast cancer and evaluate extent of disease in ipsilateral and contralateral breast. MRI superior to mammography and ultrasound in determining size of tumor, presence of multifocal/mulitcentric disease, and contralateral disease
which type of breast biopsy: FNA or core, is recommended by the National Comprehensive Cancer Network?
core biopsy recommended: greater sampling accuracy b/c archietecture of the area is preserved, allows pathologist to assess for invasion
what type of biopsy needs to be done for nonpalpable breast lesions?
name four techniques of image-guided biopsy for nonpalpable breast lesions
stereotactic biopsy; ultrasound-guided biopsy; MR)-guided biopsy; surgical excision biopsy (needle or wire localized)
what imaging is obtained after needle localization for surgical excision of non-palpable breast lesions?
mammogram in medial-lateral view and cranial-caudal view to provide 3D guidance of the lesions location
how should you plan the surgical incision to remove a nonpalpable breast mass?
as close to the lesion as possible while creating an incision that can be incorporated into a mastectomy incision - then dissect to the wire and along its course to the incision.
what is the next step after a breast lesion biposy has pathologic results that are discordant from radiological and physical exam findings?
repeat surgical or excisional biopsy to remove the entire lesion
name three relative contraindications to breast conservation therapy
tumors > 5cm, large tumor-to-breast size ratio, and pregnancy
name five absolute contraindications to breast conservation therapy
T4 tumors, multicentric disease, collagen vascular disease, previous history of breast radiation, and inability to access radiation therapy
what is the initial axillary staging procedure of choice for women with clinically node negative invasive breast cancer
what is considered a micrometastasis on SLNB for breast cancer and what is the associated node status? What is the size threshold for considering formal ALND?
<0.2mm micromet on SLNB is considered node negative (N0mic) and should not be considered for completion dissection or adjuvant chemotherapy. If larger than 0.2mm, considered node positive and formal ALND should be considered
what orientation of incision should you make during excisional biopsy and partial mastectomy?
place incision along Langer lines for best cosmetic result; along lower pole use radial incision b/c Langer line incision may shorten the distance between nipple and inframammary fold
what is the orientation of incision for central breast lesions
periareolar incision so scar blends with pigment change
what is the difference in margins between an excisional biopsy and partial mastectomy?
biopsy has the surgical goal of obtaining a diagnosis by removing the lesion while minimizing excessive tissue loss. Partial mastectomy requires wide margins of surrounding normal tissue
name the four borders of the breast that are used as guidelines during mastectomy.
superior: clavicle, medial: lateral border of sternum; lateral: latissmus dorsi; inferior: inframammary fold
what is removed during a mastectomy?
all breast tissue, nipple-areolar complex; fascia overlying pectoralis major (muscle remains intact)
what is removed with a skin-sparing mastectomy
all breast tissue, fascia overlying pectoralis major, and nipple-areolar complex while preserving as much skin as possible
what are the steps of sentinel lymph node biopsy for breast cancer?
inject of technetium-99 +/- isosulfan blue dye into breast; small axillary incision posterior to lateral border of the pectoralis major (planned with gamma probe), orient incision so that it can be easily incorporated into ALND; excise nodes that are blue or radioactive (gamma probe with count >10% of the highest count) and send to pathology intact, also excise palpably firm or enlarged nodes
name the key technical steps for excisional biopsy / partial mastectomy
1) incision placed along Langer lines; 2) biopsy: wide margins not necessary; 3) partial mastectomy with rim of surrounding normal tissue required
name the key technical steps of mastectomy
1) breast tissue, nipple-areolar complex, and pectoralis fascia removed; 2) borders of the breast: clavicle, sternum, latissmus dorsi, infrmammary fold; 3) +/- reconstruction
name the four key steps of SLNB
1) injection of technetium-99 m and/or isosulfan blue dye; 2) axillary incision posterior to lateral border of pectoralis muscle; 3) blue nodes/radioactive nodes excised intact; 4) axilla scanned for remaining blue nodes or with >10% of highest count detected
name the key steps of axillary dissection
en bloc resection of level I and II lymph nodes; ; excise the fat pads that define the borders of the axilla, leave the axillary vein, long thoracic nerve, and thoracodorsal nerve/artery/vein
name the borders of the axilla
subscapularis; latismuss dorsi; chest wall and serratus anterior; axillary vein; underarm skin; subcutaneous tissue
name three potential pitfalls of lumpectomy/mastectomy/ALND
positive margins after lumpectomy; skin dimpling after closure; injury to axillary vein, thoracodorsal nerve, or long thoracic nerve during ALND
what percentage of patients have allergies to isosulfan blue dye and how does it manifest?
1-2% of patients with urticaria, blue hives, pruritus, bronchospasm, and hypotension
what change in patient's vitals can occur with injection of isosulfan blue dye?
pts may have a reduction of pulse oximetry readings after blue dye injection - does not represent hypoxemia
what is the next step if a sentinel node cannot be located via isosulfan blue / technetium 99
if sentinel node cannot be identified, perform ALND with removal of level I and II LNs
what is the current standard of care for postop follow up after lumpectomy/mastectomy
annual H&P, physical exam, and mammogram + breast self exams
what are six indications in the female patient's history that indicate the need for genetic counseling for breast cancer risk?
1) Ashkenazi Jew; 2) personal/family history of ovarian cancer; 3) first-degree relative dx with breast cancer before age 50; 4) 2+ first or second-degree relatives dx with breast cancer; 5) personal or family history of breast cancer in both breasts; 6) hx of breast CA in male relative
what additional step is required for breast CA patients who undergo breast conservation therapy and why?
radiation to achieve local recurrence rates similar to mastectomy
what additional therapy should be considered for patients with hormone receptor-positive breast CA
what is the lifetime prevalence of breast cancer in all women?
1 in 8
what is the overall mortality among women from breast cancer
1 in 33
what three subtypes of lesions can cause calcifications on mammogram?
benign; premalignant; overt invasive carcinoma
what is the best screening test for early detection of breast cancer in most women?
what is the difference in biopsy techniques between palpable and non-palpable breast lesions?
palpable: FNA, core bx, surgical bx; nonpalpable: require image-guided bx
what are the two primary surgical options for breast cancer?
mastectomy or breast conservation