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Flashcards in NMS Breast Deck (98):
1

Breast cancer treatment for Stage 0, I, II?

Stage 0-I with small <1 cm tumors: lumpectomy, axillary sampling, radiation, hormonal treatment if ER+

Stage I with larger 1-2 cm tumors: lumpectomy, sentinel node biopsy, radiation, hormonal treatment + chemo if ER+ and premenopausal

Stage II: lumpectomy, sentinel node biopsy, radiation, hormonal treatment + chemo if ER+ and premenopausal
+ option for radical mastectomy

2

Breast Cancer treatment for Stage III, IV?

Stage III: must get preop chemo and MRI for surgical planning (usually modified radical mastectomy) + further chemo and radiation

Stage IV: chemo + palliative radiation + surgery if painful/infected

3

Breast Cancer staging/metastatic workup

CBC, LFT, alk phos, Ca, Tbili, CT chest + liver, bone scan, renal function

4

When to get MRI?

Surgical planning of advanced breast ca, poor renal function (cant do CT with contrast), evidence of spinal/brain mets (steroids, cord decompression, radiation, surgery if possible)

5

What drugs can cause gynecomastia?

Diuretics, estrogens, INH, marijuana, digoxin, alcohol

6

Important risk factors for breast ca?

Prev hx (in self), fam hx (premenopausal), older age, ovarian or endometrial ca hx, older first full-term pregnancy, oopherectomy (check this), obesity, rich North American, hx fibrocystic dz, single, urban, white, early menarche and late menopause

7

Screening recommendations for breast ca

Disclaimer: breast exams are not recommended anymore I don't think

Non high risk: monthly self exams at 20, professional breast exams 20-39 2 2 years, yearly after 40, mammograms q 1-2 years at 30-40, yearly after 40

8

False negative rate of mammograms

7-20%

9

BIRADS 0-5 definitions

0: needs additional eval
1: normal
2: benign, recommend routine screening
3: prob benign, recommend 6 month followup
4: suspicious, recommend bx
5: highly suggestive of malignancy

10

Difference between screening and diagnostic mammography

1. screening cranio-caudal and mediolateral oblique views
2. diagnostic can do magnification mammography; diagnostic is cranio-caudal + mediolateral oblique views PLUS mediolateral and lateromedial

11

Types of calcifications on mammogram that are suspicious of malignancy

Pleomorphic, heterogeneous, fine/linear/branching

12

2 entities that look like DCIS histopathologically but have higher cancer risk

1. sclerosing adenosis
2. atypical ductal hyperplasia

13

Treatment for fibrocystic disease

elimination of caffeine, vitamin E supplement, cyst aspiration, f/u in 3 months

14

What could a 14 cm mass in a young woman be

cystosarcoma phyllodes: large, occasional ulceration of skin.
excise with generous margins

15

Most common cause of bloody discharge and treatment

intraductal papilloma: mammography + ductogram + excision

16

Prognostic indicators in breast cancer

histologic type: IDC (invasive ductal ca), ILC (invasive lobular ca), inflammatory ca
worse than
tubular, papillary, mucinous, or Paget's

ER+ better; progesterone (?), aneuploidy worse prognosis
Ki-67+ (higher S phase fraction or mitotic index) = worse prognosis
Her-2 Neu+ (human epidermal growth factor receptor) = worse prognosis and shorter relapse time
younger at dx tend to do worse

17

What does inflammatory carcinoma of breast look like

ulcerated, edema of breast, peau d'orange, retraction of skin

18

What does retraction of skin overlying the mass mean?

suggests invasion of breast support structures and lymphatics

worse prognosis!

19

what do you do when fluid cysts recur

excise cyst to rule out cancer.

prognosis depends on pathology

20

what does it mean when mass is fixed to deeper tissues

invasion to tissue outside breast = worse prognosis

21

significance of lymph node palpable in supraclavicular area

= distant metastasis

M1=stage IV
unresectable and incurable

22

arm edema means: ?

obstruction of axillary lymphatics = worse prognosis

23

What to do with crusty lesion in nipple?

1. biopsy nipple lesion and subareolar mass to rule out Paget's disease
2. if Paget's + and confined to nipple then excision of nipple areolar complex or primary radiotherapy
3. if underlying DCIS: excision and radiotherapy

24

Surgical principles in mgmt of breast ca
(what does it mean if you have >10 LN involved)

1. establish diagnose
2. completely eradicate primary tumor
3. regional nodes or distant mets?
4. wide excision + radiation good for localized tumor with clear margins
5. mastectomy usually for larger/multicentric tumors
6. removal of axillary LNs are for staging, not treatment
7. decrease in survival correlates with increase in # of LNs involved;
poor prognosis: >10 LNs = 10-year survival of 14%
8. systemic adjuvant treatment in breast ca with axillary node involvement decreases risk of recurrence by 30%

25

Blood supply to breast

arterial: internal mammary (thoracic) and lateral thoracic
venous: axillary and internal mammary vein

26

Lymphatic drainage of breast? divisions?

axillary LN chain

Level I: lateral to pec minor
Level II: posterior to pec minor
Level III: medial to pec minor

27

Radical mastectomy

removal of: breasts, skin, pec major and minor, axillary LNs

only for tumors that extend into the muscle!

28

Modified radical mastectomy

spares pec major!

removes breasts, skin, pec minor, axillary LNs

29

Auchincloss modification of radical mastectomy

spares pec minor!

removes breasts, skin, axillary LNs

30

Patey modification

transection of pec minor and dissection of level III nodes (medial to pec minor)

31

Simple mastectomy

removal of breast, nipple-areolar complex, skin.

usually for LCIS and DCIS

32

When to radiate after mastectomy

1. tumors > 5 cm that involve margin of resection or invade pec fascia or muscle
2. axillary radiation when > 4 LN involved
3. radiation of internal mammary nodes if apparent on sentinel node imaging
4. supraclavicular nodes if extranodal extension into axillary fat

33

Limits of dissection for mastectomy

clavicle, lat(issimus dorsi?), costal margin, lateral border sternum

34

Lumpectomy? Segmental mastectomy?

For 4 nodes are positive or positive extracapsular invasion

Note: radiation after lumpectomy greatly reduces chance of local recurrence

35

Does lumpectomy with radiation affect survival rates

not compared to modified radical mastectomy in stages I and II

36

What measurements do you need for staging

tumor size, LN bx, histology

37

What is standard method for LN bx

remove nodes at levels I (lateral to pec minor) and II (posterior to pec minor)

38

How do you do a sentinel LN bx

1. inject dye or radiotracer around primary tumor
2. wait for dye or tracer to reach node
3. take it out and perform histo/path

39

If sentinel node negative for tumor, what are chances that other nodes are negative?

>90%

40

Most physicians dont advocate modified radical mastectomies for tumors less than what?

<2 cm

41

Does radiation increase survival

no, only decreases local recurrence

42

Contraindications to radiation treatment

1. prior radiation to chest or breasts
2. connective tissue disease
3. positive margins
4. extensive DCIS (often seen as diffuse microcalcifications)

also: pregnancy

43

4 methods of breast reconstruction

1) TRAM (transverse rectus abdominus myocutaneous) flap
2) lat (issimus doris?) flap
3) DIEP (deep inferior epigastric perforator)
4) free flap

44

Flaps not as successful in which patients

obese and smokers

45

Contraindications for mastectomies

1. primary lesions involving chest wall
2. extensive local or regional dz
3. stage III or IV cancer

46

Mgmt of stage 0 and I BC with <1 cm tumors (no nodes)

lumpectomy + axillary sampling + radiation + hormonal tx if ER+ (Aromatase inhibitor for postmenopausal, Tamoxifen for premenopausal)

47

At what stage of BC do you check for mets

Stage I

48

What is in the workup for mets

-CXR for lung and bone mets;
- liver enzymes for liver mets--> abdominal CT if liver -enzymes or bilirubin or alk phos abnormal
- bone scan and/or head CT if bone pain or neuro complaints,

49

Mgmt of stage I br ca with larger (1-2 cm) tumor and no nodes

lumpectomy + axillary sampling + radiation + hormonal tx if ER+ and chemo only if premenopausal

50

Mgmt stage II br ca

lumpectomy + axillary sampling + radiation + hormonal tx if ER+ and chemo if node positive or premenopausal without node negative (table 11-8, p. 342)

51

Chemo is poorly tolerate in what population?

elderly

52

Who responds better to chemo

premenopausal patients

53

Who responds better to hormonal treatment

postmenopausal

54

Follow-up surveillance protocol for Stage I and II

1. see dr. 2x/yr
2. annual CXR + LFTs
3. if lumpectomy, mammogram that breast q6 mo for 2 years then annually
4. if mastectomy. mammogram the other breast (how frequently?)

55

After mastectomy what are chances of Ca developing in remaining breast

15%

56

Stage I, 5-year

93%

57

Stage II, 5-year survival

72%

58

Mgmt Stage III Breast Ca

1) consult onc for neoadjuvant chemo (before surg)
2) surg

59

Mgmt stage IV breast ca

1) palliative radiation and chemo
2) surg only reserved for local control of primary tumor (painful or infected)

60

Imaging modality to plan for surg

MRI

61

Stage III 5 yr survival

41%

62

Stage IV 5 yr survival

18%

63

Breast mass with cellulitis and edema =

Inflammatory carcinoma

64

Tx for inflammatory carcinoma

1. staging workup: CBC, liver enzymes, alk phos, Ca, Tbili, CT chest, bone scan, CT liver with contrast or MRI w/gadolinium if poor renal function
2. chemo
3. modified radical mastectomy
4. adjuvant chemo
5. hormonal tx for ER+
6. radiation for chest and regional LN basins

65

What should you do if you have pathological fracture from cancer

Due to bony mets, control the cancer locally with radiation and orthopedic repair, radiation shouldn't interfere with fracture union

66

If after dx breast ca you get neuro sx like decreased sensation or motor function, what do you do

MRI, steroids, cord decompression, radiation

67

If after dx of breast ca you get new seizures, what do you do

CT/MRI to dx brain mets, immediate steroids to decrease ICP, surgery or irradiation

68

Coma/confusion with hx of breast ca could be what

acute hypercalcemia due to bony mets or PTH-related peptide release (usually breast ca or lung cancer)

69

Abx for mastitis?

dicloxacillin/cefalexin (usually S.aureus or coag neg staph)

70

If a mastitis doesn't heal with abx, what are we worried about

inflammatory ca

71

Mgmt of breast ca in pregnancy

Stage I and II mastectomy or lumpectomy with radiation after birth is safe.

Lumpectomy discouraged in early pregnancy bc of need for radiation.

Stage III and IV: rapid radiation and chemo, may need to abort

72

Is ER or prog status reliable during pregnancy

No

73

What do you do for breast mass in a man

mammogram to diff gynecomastia from cancer, mastectomy, and radiation

74

when do men usually present with breast ca

after 60; tend to present at later stage

75

What can cause gynecomastia

diuretics (spironolactone), estrogens, INH, weed, dig, etoh

76

Most common sites of metastasis

lungs, liver, bone, brain, ovaries

77

what cancers predisposed by BRCA1 mutation (2)

breast and ovarian

78

screening recommendations for breast cancer (based on level of risk)

NORMAL RISK: q1y mammo with clinical exam starting at age 40; HIGH RISK: q1y mammo with q6m exam starting at age 30

79

what study should follow finding of microcalcifications on mammogram

MAGNIFICATION mammogram --> stereotactic vs. open biopsy depending on low vs. high suspicion (open bx allows excision)

80

tx for DCIS

if unifocal: lumpectomy;
if multifocal: simple mastectomy

81

when to combine radiation with mastectomy

NEVER; no need for radiation if breast has been resected

82

implications and tx of LCIS

LCIS is an incidental finding on breast bx that is an INDICATOR, NOT PRECURSOR of malignancy --> no role for resection, only for close surveillance (q6m exam/mammo)

83

workup of simple cyst in breast

aspiration --> if resolves, NTD; if bloody or persistent, need cytology --> excision

84

characteristics and workup of fibrocystic dz

often multiple, bilateral, fluctuates with menstrual cycle;
TREATMENT: cyst aspiration --> 3mo f/u --> bx/excision if persistent

85

characteristics and tx of fibroadenoma

most common lesion in young females (<25 y); benign; TREATMENT: multiple, including excision, bx, or observation (if small)

86

characteristics and tx of phyllodes tumor

LARGE, BULKY mass --> excision

87

mgmt of bloody nipple discharge

suggests intraductal papilloma; need surgical bx +/- excision

88

mgmt of clear, non-milky nipple discharge from multiple ducts

likely fibrocystic dz --> observation

89

how does age affect breast cancer prognosis

younger women do worse :(

90

what types of skin changes cant be seen with breast cancer (3)

ALL ARE BAD

1. ULCERS: suggest inflammatory carcinoma;
2. PEAU D'ORANGE/EDEMA: suggests lymphatic involvement
3. SKIN/NIPPLE RETRACTION: suggests invasion of support structures

91

what does eczematoid lesion of nipple suggest? what is mgmt

Paget's dz of nipple, almost always a/w underlying malignancy --> mammo/PE --> mastectomy + staging if mass, bx nipple if not

92

when to do lumpectomy/simple mastectomy vs. modified radical mastectomy

depends on size of solitary tumor.
if 5 cm, need to do modified radical mastectomy

93

how to tx metastatic breast cancer

stages III and IV --> palliative chemo/rads/surg + hormonal tx

94

how does menopause change adjuvant treatment for breast cancer

premenopausal: chemo;
postmenopausal: hormonal

95

how to deal with local recurrence following breast surgery

if 1st surgery was mastectomy, do local excision; if 1st surgery was lumpectomy, do mastectomy

96

what do you suspect in pt with h/o breast cancer who presents with coma

hypercalcemia

97

tx for mastitis

warm compresses, antibiotics (for staph and strep)

98

tx of breast abscess

surgical drainage (incision and drainage), NOT needle drainage