question

Quadrants of the breast

answer

Upper outer quadrant, lower outer quadrant, upper inner quadrant, lower inner quadrant

question

major blood supply to the breast

answer

internal and lateral thoracic arteries

question

lymph nodes responsible for draining a majority of the breast

answer

axillary lymph node (97%) - remaining 3% is by internal mammary nodes

question

Nerves at risk of damage during surgical breast dissection

answer

- intercostobrachial nerve (sensation to upper medial arm) - long thoracic nerve (serratus anterior muscle) - thoracodorsal nerve (latissimus dorsi muscle) - lateral pectoral nerve (pectoralis major and minor muscles)

question

Estrogen effect on breasts

answer

ductal development and fat deposition

question

Progesterone effect on breasts

answer

promote the lobular alveolar (stromal) development that makes lactation possible

question

breast changes in postmenopausal women

answer

tissue atrophy, loss of stroma, and replacement of atrophied lobules with fatty tissue

question

3 major components of breast cancer screening of women at average risk

answer

- clinical breast examination - breast self- examination - screening mammography

question

At what age should clinical breast examination be done annually?

answer

40 - before then its every 1-3 years

question

ACS guidelines for screening mammograms

answer

annual mammograms starting at age 40

question

Women at high risk for breast cancer

answer

- those who have BRCA1 or BRCA2 mutation or a first degree relative w/ either mutation - those who underwent radiation to the chest b/w the ages of 10-30 - those who have a hereditary syndrome associated w/ multiple cancer diagnoses

question

Women at moderate risk for breast cancer

answer

- those w/ a personal hx of breast cancer or its precursor lesions - those who have particularly dense breast tissue on mammogram

question

Screening recommendations for women at high and moderate risk for breast cancer

answer

- teach breast self- awareness - clinical breast exam q 6-12 months - annual mammography starting at age 25 or 5-10 years before the age of the youngest cancer diagnosis - interval breast MRIs is also a possibility

question

Better imaging modality compared to film mammography in women w/ dense breasts, women younger than 50, and premenopausal or perimenopausal women

answer

digital mammography

question

Clinicians should assess breast pain by asking about what type of features?

answer

- cyclic or noncyclic - bilateral or unilateral - diffuse or focal - associated sx (back/neck pain, erythema, fever) - use of medications (OCPs and HRT) - any hx of trauma, radiation or surgery to the breas, famhx, constitutional sx (e.g. weight loss or gan)

question

FDA approved medication for mastalgia

answer

danazol

question

characteristics of a nipple discharge that is most concerning for malignancy

answer

- spontaneous (ie not w/ manual expression) - bloody or serosanguineous - unilateral - persistent - from a single duct - associated w/ a mass

question

most common cause of bloody nipple discharge

answer

intraductal papilloma

question

Physical examination to evaluate nipple discharge complaint should include

answer

looking for: - skin changes - associated masses or lymphadenopathy attempt to elicit secretion by applying pressure to base of the areola

question

bloody or serosanguineous nippular discharge should be tested on a

answer

guaiac card and sent for cytologic evaluation

question

Women w/ nipple d/c, amenorrhea, menstrual irregularities, headaches, or visual disturbances should have there _____ and ____ levels drawn

answer

prolactin and thyroid

question

women w/nippular d/c w/ associated masses should have

answer

ultrasound and/or mammography evaluation

question

What percentage of new breast cancers are not seen or detected via mammography?

answer

10-15%

question

Most common causes of breast masses

answer

fibroadenomas and breast cysts

question

When a breast mass is being evaluated, it is important to ascertain

answer

- manner in which it was discovered - associated tenderness or trauma - relationship of changes to the menstrual cycle - location, size, shape, consistency, and mobility - overlying skin changes

question

Malignant breast masses are usually characterized as

answer

single, firm, nontender, and immobile w/ irregular borders

question

Characteristics of a lymph node that make it worrisome

answer

- >1cm - fixed - irregular - firm - multiple

question

Collaborative scoring system for breast masses is called

answer

BI-RADS: Breast imaging reporting and database system

question

Imaging evaulation for a breast mass found in a woman <30 years

answer

u/s

question

imaging evaluation for a breast mass found in a woman >/=30 years

answer

mammogram

question

A breast cyst should be excised if

answer

- fluid is bloody - mass persists after fluid is removed - cyst is persistent after 2 aspirations - fluid reaccumulates w/in 2 weeks

question

In a woman <30 years old with a palpable solid mass, what is the primary method of choice for sampling tissue?

answer

fine needle aspiration - if this fails, then excisional biopsy is attempted

question

In a woman >/= 30 with a palpable solid mass, what is the primary method of choice for sampling tissue?

answer

core- needle biopsy

question

If a nonpalpable lesion is found on mammography, what is the next step?

answer

excisional biopsy under needle or wire guidance - all the abnormal tissue should be excised along w/ a 1-cm rim of normal tissue

question

Fibrocystic breast changes is due to

answer

exaggerated stromal response to hormones and growth factors

question

typical presentation of fibrocystic breast change

answer

- painful breast masses - multiple and bilateral

question

Peak incidence of fibrocystic breast change is seen in women ages

answer

30-40

question

When is pain associated w/ fibrocystic change worse?

answer

during the premenstrual part of the cycle

question

treatment of fibrocystic breast change

answer

pain is ameliorated w/ reduction of caffeine, tea, and chocolate avoid trauma and wear support bra evening primrose, vit E and B6, danazol, progestins, bromocriptine, and tamoxifen

question

Fibroadenoma def

answer

benign tumors w/ glandular and stromal components

question

most common benign tumors of the breast

answer

fibroadenomas

question

P/E findings of a breast fibroadenoma

answer

round, well- circumscribed, mobile, firm lesions that are rubbery and nontender

question

cystosarcoma phyllodes def

answer

rare variant of fibroadenoma that involves epithelial and stromal proliferation. Can be benign or malignant

question

preferred method of diagnosis for cystosarcoma phyllodes

answer

core needle biopsy

question

treatment for cystosarcoma phyllodes

answer

wide local excision w/a 1 cm margin for small tumors; mastectomy for large lesions not amenable to wide local excision

question

P/E finding of cystosarcoma phyllodes

answer

large, bulky, mobile mass that is painless overlying skin is warm, erythematous, shiny, and engorged.

question

Intraductal papilloma def

answer

benign solitary lesion that involves the epithelial lining of lactiferous ducts

question

How are intraductal papillomas identified?

answer

open involved duct to visualize the tumor

question

treatment for intraductal papilloma

answer

excision of the involved ducts after localization by physical examination and core needle biopsy

question

mammary duct ectasia aka

answer

plasma cell mastitis

question

mammary duct ectasia def

answer

subacute inflammation and fibrosis of the ductal system causes dilated mammary ducts; there is also concurrent infiltration of plasma cells and significant periductal inflammation

question

When during a woman's life is mammary duct ectasia most likely to occur?

answer

at or after menopause

question

Presentation of mammary duct ectasia

answer

- nipple d/c (multicolored, sticky, originating from multiple ducts, bilateral) - noncyclic breast pain - nipple retraction - subareolar masses

question

A person presenting w/ mammary duct ectasia symptoms should have what test done?

answer

mammogram and excisional biopsy to r/o carcinoma

question

treatment for mammary duct ectasia

answer

- usually does not require treatment - can be treated w/ local excision of inflamed area

question

breast cancer is the leading cause of death in US women aged

answer

40-59

question

Risk factors for breast cancer

answer

- increasing age - personal hx of breast cancer - fam hx of gynecologic malignancies or breast cancer - exposure to ionizing radiation of the chest at a young age - alcohol abuse - diagnosis of atypical ductal or lobular hyperplasia on biopsy - presence of ductal or lobular carcinoma in situ or noninvasive carcinomas - factors that increase lifetime estrogen exposure (not including OCPs, HRT, or ERT) ** HRT may increase risk slightly if used for >5 years

question

What percentage of women w/ breast cancer have a positive family hx?

answer

10%

question

Medications that help prevent breast cancer

answer

tamoxifen

question

common sites of metastasis for breast cancer

answer

bone, liver, lung, pleura, brain, and lymph nodes

question

peau d'orange appearance of breast cancer is caused by

answer

dermal lymphatic invasion and blockage

question

most common area of breast w/ breast cancer

answer

UOQ

question

What is the importance of LCIS?

answer

indicator for subsequent risk of invasive breast cancer (25-30% w/in 15 years) in either breast

question

lobular carcinoma in situ def

answer

proliferation of malignant epithelial cells contained w/in breast lobules w/ no invasion of the stroma

question

LCIS is usually diagnosed

answer

on accident while doing biopsy for another finding. - it is not palpable nor is it seen on mammograms.

question

Treatment for LCIS

answer

3 options - observation w/o further therapy - prophylactic chemoprevention w/ SERMs such as tamoxifen or raloxifene - bilateral mastectomy *before deciding on treatment, invasive cancer or ductal carcinoma in situ must be ruled out*

question

Ductal carcinoma in situ def

answer

proliferation of malignant epithelial cells in mammary ducts w/o spread to the breast stroma

question

Which has a higher potential for progression to invasive carcinoma: DCIS or LCIS?

answer

DCIS

question

Mammography of a woman w/ DCIS reveals

answer

clustered microcalcifications

question

Treatment for DCIS

answer

- surgical excision of all microcalcifications w/ wide margins - simple mastectomy - radiation therapy if resection margins are inadequate (<10mm)

question

Most common breast malignancy

answer

infiltrating ductal carcinoma

question

Invasive breast cancers include

answer

- infiltrating ductal carcinoma - invasive lobular carcinoma - paget disease of the nipple - inflammatory breast carcinoma

question

inflammatory breast carcinoma def

answer

- extremely aggressive - poorly differentiated tumor characterized by dermal lymphatic invasion -> peau d'orange

question

Sentinel lymph node biopsy procedure

answer

- intradermal injection of dye or radioactive colloid prior to surgery around the primary tumor -> identify sentinel lymph nodes - sample sentinel lymph nodes or send sentinel lymph node exicisons for frozen section at time of surgery - if nodes are negative for cancer, the remaining nodes are left alone and the patient is spared axillary lymph node dissection (ALND)

question

Factors that indicate a high risk of recurrence that necessitates radiation therapy post radical mastectomy

answer

- >/= 4 positive nodes - large primary tumor - positive resection margins - grossly evident extracapsular nodal resection

question

in terms of prognosis, ER and PR positive tumors vs negative hormone receptor tumors

answer

ER and PR positive tumors carry more favorable prognosis

question

HER2/neu expression in breast tumor indicates

answer

more aggressive tumor

question

Fulvestrant

answer

- newly FDA approved ER antagonist used for postmenopausal women w/ hormone receptor positive breast cancer - also has positive treatment effects on HER2- positive breast cancer

question

HER2/neu positive breast tumors can be medically treated post mastectomy with

answer

trastuzumab

question

a typical chemotherapy regimen will include

answer

cyclophosphamide, methotrexate, and 5-FU

question

most reliable predictor for survival of breast cancer

answer

stage of breast cancer at time of diagnosis

question

Staging of breast cancer is determined by

answer

size of primary tumor and the absence or presence of regional lymph node involvement and/or distant metastases

question

F/u after breast cancer treatment

answer

- physical exam q 3-6 months for 3 years - P/E every 6-12 months for year 4 and 5 and annually thereafter - women who received a mastectomy should recieve annual mammograms on remaining breast

question

Women who received breast conserving surgery recieve first follow up mammogram after

answer

6 months from completion of lumpectomy and radiation treatment and annually thereafter

question

recommendations on pregnancy in premenopausal patients post breast cancer treatment

answer

studies show there is no difference in survival rates in women who become pregnant after breast cancer treatment - the concern was that pregnancy-related estrogens may stimulate dormant cancer cells

question

recommendations on OCP use post breast cancer treatment

answer

- no adverse effect has been shown w/ the use of OCPs containing estrogen

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