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Flashcards in breast Deck (248):
1

polythelia

accessory nipple; can occur anywhere along the milk line from axilla to inguinal region

2

polythelia

accessory nipple; can occur anywhere along the milk line from axilla to inguinal region

3

polymastia

accessory breast tissue; mostly occurs in the axilla

4

amastia

congenital absence of the breast

5

amazia

lack of breast tissue development with perseverance of the nipple

6

what does inc hormonal production by the ovary at puberty cause

ductal budding and initial formation of acini; proliferations of the terminal ducts lined w secretory cells for milk production

7

what effects do estrogen and progesterone have

full maturation of the ductal and lobular components of the breast

8

gynecomastia

enlarged breasts may be asym and tender secondary to a physiologic excess of plasma estradiol relative to plasma testosterone; age 20 male

9

what should be considered for a solid mass in a postmenopausal woman

cancer until proven otherwise

10

risk of hormone replacement therapy

inc risk of breast cancer; esp estrogen plus progestin

11

major risk factors for breast cancer

females, inc age, fhx, proliferative pathology with atypic on bx (atypical ductal or lobular hyperplasia)

12

what familial cancer syndromes are assoc w greater risk of breast cancer

Li-Fraumeni and Cowden's

13

what genes are assoc with breast cancer

BRCA 1 long arm of chromosome 17 and BRCA 2 long arm of chromosome 13

14

guidelines on referral for genetic counseling

Individuals from a family with a known BRCA1 or BRCA2 mutation;Personal history of breast cancer with one of the following:

• Diagnosed at or before age 45

• Diagnosed at or before age 50 with one or more close family relatives diagnosed with breast cancer or ovarian cancer at or before 50a

• Diagnosed at or before age 50 with two or more synchronous primary breast cancers

• Diagnosed at any age and two or more close family relatives with breast or ovarian cancera

• Two or more close family relatives with breast or ovarian cancera

• Personal history of ovarian cancer

• Close male relative with breast cancer

• High-risk ethnic background (i.e., Ashkenazi Jewish)

-Personal history of male breast cancer

-Close family member with one or more of the above criteria

15

what two drugs showed a reduction in incidence of breast cancer for high risk pt

tamoxifen and raloxifene

16

what two surgeries lowers the risk of developing breast cancer

mastectomy and salpino-oophorectomy

17

what is the best palpating method that has the lowest incidence of missed abnormalities

vertical strip

18

spontaneous nipple discharge

discharge on clothing in the absence of breast stimulation; in contrast, elicited discharge is noted after the nipple or breast is squeezed, or after vigorous mammography; only spontaneous discharge requires evaluation.

19

what type of discharge is more likely a result from an underlying malignancy

unilateral bloody single duct spontaneous discharge especially if there is an assoc mass

20

mc cause of unilateral spontaneous bloody nipple discharge

benign papilloma

21

what is the foundation of breast cancer screening

annual mammogram

22

American Cancer Society Guidelines for Breast Cancer Screening

Yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health.

Women should know how their breasts normally feel and report any breast change promptly to their health care providers. BSE is an option for women starting in their twenties.

Women at high risk (>20% lifetime risk) should get an MRI and a mammogram every year. Women at moderately increased risk (15%–20% lifetime risk) should talk with their doctors about the benefits and limitations of adding MRI screening to their yearly mammogram. Yearly MRI screening is not recommended for women whose lifetime risk of breast cancer is

23

what are the two views of a mammography

craniocaudal (CC) and median lateral oblique (MLO)

24

Breast imaging reporting and data system classification score for need for additional studies or interval follow up

0 (add imx eval)
1(negative)
2 (benign finding)
3 (probably benign, short interval f/u)
4 (suspicious abn, bx)
5 (highly sugg malig, approp action)

25

additional dx views

tissue compression and magnification

26

2 technological advances for imaging

computer assisted detection (CAD) software and digital mammography

27

what is a imaging adjunct to mammography

us- good at characterizing a mammography density or palpable mass as cystic or solid, and in guiding core needle bx

28

benign sonographic features of masses on us include

well demarcated borders, posterior enhancement, absence of internal echoes (characteristic of cysts)

29

what features are suspicious for malignancy on us

poorly demarcated borders, posterior shadowing, heterogeneous internal echoes, and a taller than wide orientation that invades across tissue planes

30

what does an mdi use to produce breast images w improved resolution of soft tissues

fat, water, and iv gadolinium contrast in magnetic fields

31

what imaging test is appropriate in women who carry deleterious BRCA1/2 mutation, or who by fhx and other risk factors

mri- if lesion is detected can do an mri directed bx

32

what is the definitive dx of breast lesions

microscopic examination of tissue by either cytology (individual cells obtained by fine needle aspiration) or histology (samples of tissue obtained by core needle or surgical bx)

33

which tissue sampling gives a rapid dx of suspected malignancy

cytology

34

what do histologic specimens provide

invasive vs in situ carcinoma, type of cancer, expression of estrogen/progesterone/HER2/neu

35

difference between bx of palpable lesion and one detected radiologically

palpable can be needle bx directly; radiologic must be under guidance

36

bx of mass lesions

us guidance

37

bx microcalcifications and subtle abnorm

stereotactic localization in mammography suite

38

triple test to say lesion is benign

concordance between clinical exam, radiographic appearance, and pathology

39

what is the needle bx results are discordant

excisional bx guided by localizing wire placed under radiological guidance is necessary

40

why shouldn't an open excisional bx without a prior needle bx be done

possible positive margins, cosmetically unfavorable incision placement, need to go back to the operating room for lymph node staging

41

when should a pt be reeval if pe and imaging show typical areas of fibroglandular tissue without discrete mass

6-12weeks

42

what do all pt who have a discrete persistent mass require

tissue dx

43

dx test for age

us

44

dx test for age >30 w palpable breast mass

mammogram and us

45

palpable breast mass that is cystic on imaging and asymptomatic simple

re examine 2-3months

46

palpable breast mass that is cystic on imaging and symptomatic or complex

aspirate and if no residual mass then 2-6m f/u; if there is a residual mass then bx

47

palpable breast mass that is solid on imaging

fna or core bx: non dx (action depends on clinical correlation), benign, malignancy (definitive therapy)

48

what is a common experience a few days preceding menses

mild, cyclic b/l breast tenderness and swelling; rarely prompts medical consultation

49

in the absence of any physical or radiological abnormality what is the next step

reassurance and follow up exam in a few months

50

what is thought to be the underlying cause of mastalgia

hormonal stimulation of glandular breast tissue

51

what is recommended to be stopped in postmenopausal women w breast pain

HRT

52

therapeutic measures for breast pain/tenderness

compressive elastic style bra (sport or minimizer bra), dec caffeine consumption, non steroidal anti inflammatory analgesics, evening primrose oil capsules

53

what androgen analogue is effective in relieving breast pain and tenderness and when is it used

danazol and used only after failure of prev measures because of adverse effects such as deepening the voice and hirsutism

54

fibroadenoma

very common benign tumor of the breast usually occurring in young women

55

typical pe findings of fibroadenoma

1-3cm in size and palpated as a freely movable, discrete, firm round mass in the breast

56

histologically what are fibroadenomas composed of

fibrous stromal tissue and tissue clefts lined w normal epithelium

57

what establishes dx of fibroadenomas

fns or core bx

58

tx of fibroadenomas

59

tx rapid growing fibroadenomas during pregnancy

due to hormonal stimulation and tx is excision

60

tx giant fibroadenoma

core needle bx prior to excision to distinguish the relatively rare phyllodes tumor

61

phyllodes tumor

usually a benign tumor of the stromal elements requiring wide margins of resection to prevent local recurrence

62

mc cause of breast mass in women in 4/5th decade of life

cyst

63

how do cysts present

solitary or multiple, firm, mobile, slightly tender masses often with less defined borders

64

what fluctuates w menstrual cycle and cysts

size and degree of tenderness

65

imaging of cysts

mammography will detect nonpalpable cysts; us in simple cyst as well demarcated hypo echoic mass w posterior enhancement of transmission

66

does the us finding of a cyst require bx

no

67

tx cyst

aspiration on large symptomatic cyst; fluid may be straw colored or greenish and no cytologic analysis needed

68

us appearance of complex cyst and tx

shows internal echoes or an assoc solid component; mammography and core needle bx needed prior to excision

69

mc cause of nipple discharge

duct ectasia- nonneoplastic condition characterized by multiple dilated ducts in subareolar space

70

eval of nipple discharge

apply to occult blood test paper and further evaluation performed when blood is present

71

what nipple discharge is considered pathological

persistent, spontaneous discharge from a single duct and bloody discharge

72

intraductal papilloma

local proliferation of ductal epithelial cells that typically presents in women in their 4/5th decade of life

73

what is important to be done to evaluate for malignancy w nipple discharge

mammography

74

tx nipple discharge in the absence of clinical or radiological evidence of malignancy

duct excision through a circumareolar incision allows definitive histological dx and eliminates discharge

75

breast that is warm, edematous and erythematous represents ddx revolves around

infx process

76

what is mastitis mc assoc w

lactation

77

what may occur in nonlacting women who smoke

recurrent retroareolar abscess may occur w chronic inflammation and fistula formation between the skin and the duct

78

pe findings of breast w erythema

erythema spreading in lymphangitic pattern from areola toward the axilla, skin thickening w accentuation of the pores (peau d'orange), lymphadenopathy, overall breast enlargement and heaviness, mass that may be fluctuant

79

difference of pain w malignancy and abscess

malig has no pain while abscess is very tender

80

dx imaging with erythematic breast

mammography and us; mri is no mass is demonstrated

81

what will us show w erythema breast

drainable fluid collections

82

tx breast abscess

repeated aspiration combined w abx may allow resolution of the abscess without open drainage

83

tx of chronic retroareolar inflammation and mammary duct fistula

abx then excision of subareolar ducts including fistula tract

84

what is mastitis in lactating women usually caused by

staphylococci or streptococci

85

what abx used for abscess

dicloxacillin or clindamycin

86

earliest sign of breast cancer

abnormality on a mammogram

87

what happens as breast cancers grow

produce palpable mass that is often hard and irregular

88

signs of breast cancer

thickening, swelling, skin irritation, dimpling

89

nipple changes due to breast cancer

scaliness, dryness, ulceration, retraction, discharge

90

preinvasive form of ductal cancer

ductal cancer in situ (DCIS); intraductal carcinoma

91

typical appearance of DCIS on mammography

microcalcifications; rarely a mass on pe or mammography

92

histologic types od DCIS

solid, cribiform, micropapillary, comedo type

93

classification of DCIS

based on nuclear grades 1-3 with 1 being most favorable

94

what constitutes approx 80% of invasive breast cancers

infiltrating ductal carcinoma

95

higher incidence of mulicentricity in same breast and by its presence in contralateral breast; difficult to detect

infiltrating lobular carcinoma

96

higher incidence of mulicentricity in same breast and by its presence in contralateral breast; difficult to detect

infiltrating lobular carcinoma

97

polymastia

accessory breast tissue; mostly occurs in the axilla

98

amastia

congenital absence of the breast

99

amazia

lack of breast tissue development with perseverance of the nipple

100

what does inc hormonal production by the ovary at puberty cause

ductal budding and initial formation of acini; proliferations of the terminal ducts lined w secretory cells for milk production

101

what effects do estrogen and progesterone have

full maturation of the ductal and lobular components of the breast

102

gynecomastia

enlarged breasts may be asym and tender secondary to a physiologic excess of plasma estradiol relative to plasma testosterone; age 20 male

103

what should be considered for a solid mass in a postmenopausal woman

cancer until proven otherwise

104

risk of hormone replacement therapy

inc risk of breast cancer; esp estrogen plus progestin

105

major risk factors for breast cancer

females, inc age, fhx, proliferative pathology with atypic on bx (atypical ductal or lobular hyperplasia)

106

what familial cancer syndromes are assoc w greater risk of breast cancer

Li-Fraumeni and Cowden's

107

what genes are assoc with breast cancer

BRCA 1 long arm of chromosome 17 and BRCA 2 long arm of chromosome 13

108

guidelines on referral for genetic counseling

Individuals from a family with a known BRCA1 or BRCA2 mutation;Personal history of breast cancer with one of the following:

• Diagnosed at or before age 45

• Diagnosed at or before age 50 with one or more close family relatives diagnosed with breast cancer or ovarian cancer at or before 50a

• Diagnosed at or before age 50 with two or more synchronous primary breast cancers

• Diagnosed at any age and two or more close family relatives with breast or ovarian cancera

• Two or more close family relatives with breast or ovarian cancera

• Personal history of ovarian cancer

• Close male relative with breast cancer

• High-risk ethnic background (i.e., Ashkenazi Jewish)

-Personal history of male breast cancer

-Close family member with one or more of the above criteria

109

what two drugs showed a reduction in incidence of breast cancer for high risk pt

tamoxifen and raloxifene

110

what two surgeries lowers the risk of developing breast cancer

mastectomy and salpino-oophorectomy

111

what is the best palpating method that has the lowest incidence of missed abnormalities

vertical strip

112

spontaneous nipple discharge

discharge on clothing in the absence of breast stimulation; in contrast, elicited discharge is noted after the nipple or breast is squeezed, or after vigorous mammography; only spontaneous discharge requires evaluation.

113

what type of discharge is more likely a result from an underlying malignancy

unilateral bloody single duct spontaneous discharge especially if there is an assoc mass

114

mc cause of unilateral spontaneous bloody nipple discharge

benign papilloma

115

what is the foundation of breast cancer screening

annual mammogram

116

American Cancer Society Guidelines for Breast Cancer Screening

Yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health.

Women should know how their breasts normally feel and report any breast change promptly to their health care providers. BSE is an option for women starting in their twenties.

Women at high risk (>20% lifetime risk) should get an MRI and a mammogram every year. Women at moderately increased risk (15%–20% lifetime risk) should talk with their doctors about the benefits and limitations of adding MRI screening to their yearly mammogram. Yearly MRI screening is not recommended for women whose lifetime risk of breast cancer is

117

what are the two views of a mammography

craniocaudal (CC) and median lateral oblique (MLO)

118

Breast imaging reporting and data system classification score for need for additional studies or interval follow up

0 (add imx eval)
1(negative)
2 (benign finding)
3 (probably benign, short interval f/u)
4 (suspicious abn, bx)
5 (highly sugg malig, approp action)

119

additional dx views

tissue compression and magnification

120

2 technological advances for imaging

computer assisted detection (CAD) software and digital mammography

121

what is a imaging adjunct to mammography

us- good at characterizing a mammography density or palpable mass as cystic or solid, and in guiding core needle bx

122

benign sonographic features of masses on us include

well demarcated borders, posterior enhancement, absence of internal echoes (characteristic of cysts)

123

what features are suspicious for malignancy on us

poorly demarcated borders, posterior shadowing, heterogeneous internal echoes, and a taller than wide orientation that invades across tissue planes

124

what does an mdi use to produce breast images w improved resolution of soft tissues

fat, water, and iv gadolinium contrast in magnetic fields

125

what imaging test is appropriate in women who carry deleterious BRCA1/2 mutation, or who by fhx and other risk factors

mri- if lesion is detected can do an mri directed bx

126

what is the definitive dx of breast lesions

microscopic examination of tissue by either cytology (individual cells obtained by fine needle aspiration) or histology (samples of tissue obtained by core needle or surgical bx)

127

which tissue sampling gives a rapid dx of suspected malignancy

cytology

128

what do histologic specimens provide

invasive vs in situ carcinoma, type of cancer, expression of estrogen/progesterone/HER2/neu

129

difference between bx of palpable lesion and one detected radiologically

palpable can be needle bx directly; radiologic must be under guidance

130

bx of mass lesions

us guidance

131

bx microcalcifications and subtle abnorm

stereotactic localization in mammography suite

132

triple test to say lesion is benign

concordance between clinical exam, radiographic appearance, and pathology

133

what is the needle bx results are discordant

excisional bx guided by localizing wire placed under radiological guidance is necessary

134

why shouldn't an open excisional bx without a prior needle bx be done

possible positive margins, cosmetically unfavorable incision placement, need to go back to the operating room for lymph node staging

135

when should a pt be reeval if pe and imaging show typical areas of fibroglandular tissue without discrete mass

6-12weeks

136

what do all pt who have a discrete persistent mass require

tissue dx

137

dx test for age

us

138

dx test for age >30 w palpable breast mass

mammogram and us

139

palpable breast mass that is cystic on imaging and asymptomatic simple

re examine 2-3months

140

palpable breast mass that is cystic on imaging and symptomatic or complex

aspirate and if no residual mass then 2-6m f/u; if there is a residual mass then bx

141

palpable breast mass that is solid on imaging

fna or core bx: non dx (action depends on clinical correlation), benign, malignancy (definitive therapy)

142

what is a common experience a few days preceding menses

mild, cyclic b/l breast tenderness and swelling; rarely prompts medical consultation

143

in the absence of any physical or radiological abnormality what is the next step

reassurance and follow up exam in a few months

144

what is thought to be the underlying cause of mastalgia

hormonal stimulation of glandular breast tissue

145

what is recommended to be stopped in postmenopausal women w breast pain

HRT

146

therapeutic measures for breast pain/tenderness

compressive elastic style bra (sport or minimizer bra), dec caffeine consumption, non steroidal anti inflammatory analgesics, evening primrose oil capsules

147

what androgen analogue is effective in relieving breast pain and tenderness and when is it used

danazol and used only after failure of prev measures because of adverse effects such as deepening the voice and hirsutism

148

fibroadenoma

very common benign tumor of the breast usually occurring in young women

149

typical pe findings of fibroadenoma

1-3cm in size and palpated as a freely movable, discrete, firm round mass in the breast

150

histologically what are fibroadenomas composed of

fibrous stromal tissue and tissue clefts lined w normal epithelium

151

what establishes dx of fibroadenomas

fns or core bx

152

tx of fibroadenomas

153

tx rapid growing fibroadenomas during pregnancy

due to hormonal stimulation and tx is excision

154

tx giant fibroadenoma

core needle bx prior to excision to distinguish the relatively rare phyllodes tumor

155

phyllodes tumor

usually a benign tumor of the stromal elements requiring wide margins of resection to prevent local recurrence

156

mc cause of breast mass in women in 4/5th decade of life

cyst

157

how do cysts present

solitary or multiple, firm, mobile, slightly tender masses often with less defined borders

158

what fluctuates w menstrual cycle and cysts

size and degree of tenderness

159

imaging of cysts

mammography will detect nonpalpable cysts; us in simple cyst as well demarcated hypo echoic mass w posterior enhancement of transmission

160

does the us finding of a cyst require bx

no

161

tx cyst

aspiration on large symptomatic cyst; fluid may be straw colored or greenish and no cytologic analysis needed

162

us appearance of complex cyst and tx

shows internal echoes or an assoc solid component; mammography and core needle bx needed prior to excision

163

mc cause of nipple discharge

duct ectasia- nonneoplastic condition characterized by multiple dilated ducts in subareolar space

164

eval of nipple discharge

apply to occult blood test paper and further evaluation performed when blood is present

165

what nipple discharge is considered pathological

persistent, spontaneous discharge from a single duct and bloody discharge

166

intraductal papilloma

local proliferation of ductal epithelial cells that typically presents in women in their 4/5th decade of life

167

what is important to be done to evaluate for malignancy w nipple discharge

mammography

168

tx nipple discharge in the absence of clinical or radiological evidence of malignancy

duct excision through a circumareolar incision allows definitive histological dx and eliminates discharge

169

breast that is warm, edematous and erythematous represents ddx revolves around

infx process

170

what is mastitis mc assoc w

lactation

171

what may occur in nonlacting women who smoke

recurrent retroareolar abscess may occur w chronic inflammation and fistula formation between the skin and the duct

172

pe findings of breast w erythema

erythema spreading in lymphangitic pattern from areola toward the axilla, skin thickening w accentuation of the pores (peau d'orange), lymphadenopathy, overall breast enlargement and heaviness, mass that may be fluctuant

173

difference of pain w malignancy and abscess

malig has no pain while abscess is very tender

174

dx imaging with erythematic breast

mammography and us; mri is no mass is demonstrated

175

what will us show w erythema breast

drainable fluid collections

176

tx breast abscess

repeated aspiration combined w abx may allow resolution of the abscess without open drainage

177

tx of chronic retroareolar inflammation and mammary duct fistula

abx then excision of subareolar ducts including fistula tract

178

what is mastitis in lactating women usually caused by

staphylococci or streptococci

179

what abx used for abscess

dicloxacillin or clindamycin

180

earliest sign of breast cancer

abnormality on a mammogram

181

what happens as breast cancers grow

produce palpable mass that is often hard and irregular

182

signs of breast cancer

thickening, swelling, skin irritation, dimpling

183

nipple changes due to breast cancer

scaliness, dryness, ulceration, retraction, discharge

184

preinvasive form of ductal cancer

ductal cancer in situ (DCIS); intraductal carcinoma

185

typical appearance of DCIS on mammography

microcalcifications; rarely a mass on pe or mammography

186

histologic types od DCIS

solid, cribiform, micropapillary, comedo type

187

classification of DCIS

based on nuclear grades 1-3 with 1 being most favorable

188

what constitutes approx 80% of invasive breast cancers

infiltrating ductal carcinoma

189

firm irregular mass on pe

infiltrating ductal carcinoma

190

higher incidence of mulicentricity in same breast and by its presence in contralateral breast; difficult to detect

infiltrating lobular carcinoma

191

forms small tubules, randomly arranged, each lined by a single uniform row of cells; tends to occur in slightly younger patients

tubular carcinoma

(form of ductal carcinoma)

192

extensive tumor invasion by small lymphocytes; tends to be rapidly growing and large and assoc w DCIS; less commonly metastasizes to regional lymph nodes

medullary carcinoma

193

clumps and strands of epithelial cells in pools of mucoid material; grows slowly and occurs more often in older women

colloid or mucinous carcinoma

194

what type of carcinoma is hard to differentiate histologically from intraductal papilloma (benign lesion)

true papillary carcinoma

195

presents with skin edema (peau d'orange) and erythema; skin edema is secondary to dermal lymphatics congested w malignant cells

inflammatory carcinoma

poor prognosis

196

what malignancies rarely occur in the breast

sarcomas, lymphomas, leukemia

197

cutaneous nipple abnormality, which may be moist and exudative, dry and scaly, erosive or just thickened area; +/- itching, burning, or sticking pain in the nipple; over times spreads from the duct orifice

Paget's ds of the nipple

(dermis is infiltrated by Paget's cells, which are of ductal origin, large and pale, with large nuclei, prominent nucleoli, and abundant cytoplasm

198

mc areas of breast cancer metastasis

bone, lung, liver, brain

199

TNM staging system for breast cancer

Primary tumor (T): tis (carcinoma in situ), t1 (5cm), t4 (any size with extension to chest wall or skin)


Lymph Nodes (N): no( no nodes), n1 (1-3 axillary nodes), n2 (4-9 axillary nodes), n3 (>10 axillary)

M0= no distant metastasis

M1= distant metastasis

200

stage 0 of breast cancer using tnm scale

tis, no, mo

201

stage 1 of breast cancer using tnm scale

t1, no, mo

202

stage 2a of breast cancer using tnm scale

(to, n1, mo), (t1,n1,mo), (t2,no,mo)

203

stage 2b of breast cancer using tnm scale

(t2,n1,mo) (t3,no,mo)

204

stage 3a of breast cancer using tnm scale

t0-3 with n2 (one t3 can be w n1) with mo

205

stage 3b of breast cancer using tnm scale

t4 with n0-2, mo

206

stage 3c of breast cancer using tnm scale

any t, n3,mo

207

stage 4 of breast cancer using tnm scale

any t, any n, m1

208

what tests are needed before surgery when the pt's risk for metazoic ds is low (

chest radiograph and cbc

(more adv need chest and abd ct plus bone scans)

209

what is the single most important factor in determining ds free and overall survival

axillary lymph node status; then tumor size and estrogen receptor status

210

what does f/u for breast cancer pts include

b/l mammogram 6m after completion of radiation therapy following lumpectomy and yearly thereafter

211

what should be performed annually after mastectomy

contralateral breast mammogram

212

pe f/u breast cancer

every 3-6m for 3 yrs then annually

213

local tx of breast cancer

surgery and radiation

214

systemic tx of breast cancer

iv and oral medicines

215

what size tumor is lumpectomy feasible

216

lumpectomy, wide excision, segmental, and partial mastectomy

excision of malignancy w circumferential margin of microscopically normal tissue

217

simple or total mastectomy

removes entire breast w pectoralis major fascia

218

modified radical mastectomy

simple mastectomy w axillary dissection

219

indications for mastectomy

dermal lymphatic involvement, diffuse or multiple tumors, unwillingnes or inability to undergo radiation therapy, cosmetically unacceptable

220

what should be discussed with all pt undergoing mastectomy

breast reconstruction using prosthetic implants or autologous tissue

221

what has become the standard of care for early breast cancer

sentinel node bx

222

what allows surgeon to id the first lymph node that receives drainage from the breast

radioactive colloid and or blue dye in quadrant of tumor

223

what are absolute contraindications to radiation therapy

pregnancy and previous radiation to same field

224

relative contraindications to radiation therapy

prev radiation to same general area, underlying pulmonary ds or cardiomyopathy, significant vasculitis, inability to lie flat

225

when should omitting radiation be considered

at least 70yo, single cancer

226

whole breast external beam radiation

take few min and given 5d/wk for a period of at least 4-6wks, usually w a boost to the tumor bed

227

partial breast irradiation

local area of the lumpectomy is radiated more intensively w external beams, radioactive material in a balloon, or radioactive seeds

228

selective estrogen receptor modulators (SERMs)

-tamoxifen; act as estrogen receptor antagonists in breast tissue and as estrogen agonists in bone

229

what are SERMs used to tx

estrogen receptor positive (ER+) tumors, dec incidence of contralateral breast cancer and dec recurrence

230

aromatase inhibitors (AIs)

letrozole, anastrozole, exemestane; dec circulating estrogen levels in postmenopausal women

231

indications for chemotherapy

node positive ds or tumors >1cm in greatest diameter

232

most commonly used chemo regimen

anthracycline, a taxane (paclitaxel and docetaxel), and possibly an alkylating agent

233

cytotoxic chemo

chemical agents that kill cells; never given as a single agent

234

what improves survival in pts w HER 2 positive tumors

trastuzumab

235

tx of operable breast cancer in men

mastectomy

236

what is the tx for recurrence of local tumor after lumpectomy

mastectomy

237

tx for recurrence of tumor after mastectomy

excision and radiation

238

what are brain metastases tx w

radiation

239

tx bony metastases

radiation and surgical fixation; bisphosphonates give bone strength

240

common side effects of tamoxifen

fatigue, night sweats, hot flashes, fluid retention, vaginitis, thrombocytopenia

241

side effects AIs

osteoporosis, fractures, muscle and join pains, hot flashes

242

se chemo

n,v, bone marrow suppression, stomatitis, alopecia

243

se trastuzumab

usually mild but may include significant cardiac or pulmonary toxicity as well as fever, nausea, vomiting, diarrhea, weakness, headache, anemia, neutropenia, tumor pain, cough, dyspnea, and infusion reactions. Combining trastuzumab with chemotherapy increases cardiac risk.

244

A 35-year-old woman comes to clinic because of right breast pain for the past 3 months. The pain Is cyclical in nature. Her mother and two maternal aunts were all diagnosed with breast cancer In their 30s. There are no abnormal findings on exam and a recent diagnostic mammogram and ultrasound are normal. Which of the following would be the most appropriate option for management?

high risk screening and genetic counseling

245

A 35-year-old woman comes to clinic because of a 2-month history of thickening In the upper outer quadrant of her left breast. The patient’s mother had breast cancer at age 48. Physical examination shows a slight retraction of the skin in the upper outer quadrant when the patient is upright. The breast tissue In that quadrant is rather firm, with the Impression of a poorly demarcated thickening. A mammogram also shows dense tissue with no distinct mass or suspicious microcalcifications. What Is the next step In the evaluation?

Ultrasound Is an adjunct to mammography that is useful to characterize palpable masses; ultrasound of the palpable area may give the most useful information at this time. The radiographic finding Is discordant with suspicious clinical presentation; further diagnostic workup is required. Excislonal biopsy without prior attempted needle biopsy can lead to suboptimal management of a breast cancer. Stereotactic biopsy can only be performed on a lesion demonstrated by mammography. A breast abscess Is exquisitely tender and demonstrable by ultrasonography. Section: Evaluation of the patient with breast mass.

246

A 51 -year-old woman comes to clinic because of a mass In the left breast for 2 weeks. She has no previous history of breast problems. Her last menstrual period was 1 week ago, menarche was at age 12 and she had her first child at age 30. She has no history of any major medical Illness. Her paternal aunt had breast cancer at age 75. On physical examination, she has a 1 -cm mass in the upper outer quadrant of the left breast. The mass is firm and freely movable with Indistinct borders. There is minimal tenderness and skin dimpling over the mass. There is no nipple discharge and no axillary lymphadenopathy. The mammogram and breast ultrasound are normal. A biopsy shows cancer. Which of the following Is the most likely histologic type of cancer causing these findings?

Infiltrating lobular often presents as described In this patient. Inflammatory breast cancer will have red edematous skin. Infiltrating ductal carcinoma will be hard with irregular borders and will usually be seen on mammogram and ultrasound. Lobular carcinoma in situ does not usually present as a mass. It is usually found incidentally when excising other breast pathology. Paget’s disease Involves the nipple.

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A 45-year-old woman is seen in clinic because of skin nodules on the upper portion of the breast and over the clavicle. One year ago, she underwent lumpectomy and sentinel node biopsy for Stage HA invasive ductal carcinoma, ER+, PR-, and HER-2/neu-. She then received a full course of whole-breast radiation with a boost to the tumor bed. After four cycles of cytotoxic chemotherapy, she was started on tamoxifen by her oncologist. Physical exam shows several clusters of firm nodules In the skin over the clavicle and along the upper portion of the left breast. Biopsy of one of these nodules shows metastatic breast cancer. What is the best treatment now?

Cytotoxic chemotherapy should be started as soon as possible. An aromatase inhibitor Is not Indicated. The patient has already failed hormonal treatment, as her cancer has advanced while she was taking tamoxifen. This is not a single skin nodule but rather several clusters extending beyond the breast. Mastectomy is a local treatment and may be considered, including excision of the entire area of Involved skin and possible skin graft, if she responds to systemic treatment (cytotoxic chemotherapy). The breast has already been radiated once and should not be radiated again. Trastuzumab is only effective in HER2/neu-positlve breast cancers; it is a monoclonal antibody that binds selectively to the Her-2 protein, a regulator of cell growth. This patient is HER-2/neu negative.

248

A 52-year-old woman comes to clinic because of a bloody nipple discharge. She has noticed spontaneous bloody nipple discharge from her left breast every 2 to 3 days for the last month. She has no pain and takes no medications. Menarche was at age 12. She has four children and was 22 years old when her first child was born. There Is no family history of breast cancer. There are no palpable breast masses, but a small amount of bloody discharge can be expressed from the upper Inner quadrant of the left nipple. A mammogram done earlier today was read as normal. What Is the most Important next step in her evaluation?

-duct excision

MRI Is not useful in the evaluation of nipple discharge. Ductography will not avoid the need for duct excision. Cytology has been shown to be unhelpful In the workup and diagnosis of nipple discharge. A significant percentage of patients with nipple discharge have no mammographic abnormalities.