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78 Cards in this Set
- Front
- Back
Breast cancer treatment for stage 0,I,II? |
Stage 0-I with small <1cm tumors: lumpectomy, ax sampling, rad, hormonal tx if ER+
Stage I with larger 1-2 cm tumors: lumpectomy, sentinel node biopsy, rad, hormonal tx + chemo if ER+ and premenopausal Stage II: same as stage I + option for radical mastectomy (no rad). |
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Breast cancer treatment for stage III, IV?
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Stage III: Must get preop chemo and MRI for surgical planning (usually modified radical mastectomy) + further chemo and rad
Stage IV: chemo + Pall rad + surgery if painful/infected |
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Breast cancer staging/ metastatic workup?
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CBC, LFTs, AlkPhos, Ca, Tbili, CT chest+liver, bone scan, renal function.
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When to get MRI?
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Surgical planning of advanced breast ca, poor renal function, evidence of spinal/brain mets (steroids, cord decompression, radiation, surgery if possible)
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What drugs can cause gynecomnastia?
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Diuretics, estrogens, INH, marijuana, digoxin, alcohol
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Important risk factors for breast ca?
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Prev Hx, Fam Hx, Older age, ovarian or endomet ca Hx, older first full-term pregnancy, oophorectomy, obesity, rich N. American, Hx of fibrocystic dz, single, urban, white, early menarche and late menopause
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Screening recommendations for breast ca?
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Non high risk: monthly self exams @ 20, professional breast exam 20-39 q 2 years, yearly after 40, mammograms q 1-2 years 40-50, yearly after 50
High risk: monthly self exams @ 20, professional breast exam q 6 mo at 25 and onward, mammogram q1-2 years at 30-40, yearly after 40 |
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false neg rate of mammograms?
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7-20%
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BIRADS 0-5 definitions?
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0: Needs additional eval
1: Normal 2: benign, recommend routine screening 3. Prob benign, recommend 6 mo followup 4. Suspicious, recommend biopsy 5. Highly suggestive of malignancy |
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Diff b/w screening and diagnostic mammography?
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1. screening cranio-caudal and mediolateral oblique views. Diagnostic is these views plus mediolateral and lateromedial
2. Diagnostic can do magnification mammography |
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Types of calcifications on mammogram that are suspicious of malignancy?
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Pleomorphic, heterogeneous, fine/linear/branching
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2 entities that look like DCIS histopathologically but have higher cancer risk?
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sclerosing adenosis, atypical ductal hyperplasia
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Treatment for fibrocystic dz?
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Elimination of caffeine, VitE supplement, cyst aspiration, f/u in 3 mo
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What could a 14cm mass in young woman be?
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Cystosarcoma phyllodes: large, occasional ulceration of skin. Excise w/ generous margins
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Most common cause of bloody discharge and treatment?
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Intraductal papilloma: Mammography + ductogram + excision
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Prognostic indicators in BC?
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Histologic type: IDC, ILC, inflammatory carcinoma worse than tubular, papillary, mucinous, or Paget's, +ER=better prog, aneuploidy=worse prog, Ki-67+ (higher S phase fraction or mitotic index)= worse prog, Her-2-Neu+ (human epidermal growth factor receptor)= worse prog and shorter relapse time, younger at diagnosis tend to do worse
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What does inflammatory carcinoma of the breast look like?
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Ulcerated, edema of breast, peau d'orange, retraction of skin
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What does retraction of skin overlying mass mean?
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suggests invasion of breast support structures and lymphatics. worse prognosis.
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what do you do when fluid cysts recur?
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excise cyst to rule out cancer. prog depends on path
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What does it mean when mass is fixed to deeper tissues?
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Invasion to tissue outside breast=worse prognosis
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Significance of LN palpable in supraclavicular area?
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=distant met. M1= stage IV. unresectable and incurable
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Arm edema means?
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obstruction of axillary lymphatics= worse prognosis
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What to do with crusty lesion in nipple?
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1. Biopsy nipple lesion and subareolar mass to rule out Paget's dz
2. If Paget's + and confined to nipple then excision of nipple areolar complex or primary radiotx. 3. If underlying DCIS excision and radiotx |
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Surgical principles in mgmt of BC? What does it mean if you have >10 LN involved?
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1. establish diag
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 tx 7. Decrease in survival correlates with increase in # of LNs involved poor prog: >10 LNs=10 year survival of 14% 8. Systemic adjuvant tx in BC with axillary node involvement decreases risk of recurrence by 30% |
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Blood supply to breast?
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Arterial: Internal mammary (thoracic) and lateral thoracic
Venous: Axillary and internal mammary V |
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Lymphatic drainage of breast? Divisions?
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Axillary LN chain.
Level I: lateral to pec minor Level II: posterior to pec minor Level III: Medial to pec minor |
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Radical mastectomy?
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Removal of breasts, skin, pec major and minor, axillary LNs. Only for tumors that extend into muscle
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Modified radical mastectomy? |
spares pec major and minor |
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Auchincloss modification?
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spares pec minor
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Patey modification?
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transection of pec minor and dissection of level III nodes
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Simple mastectomy?
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removal of breast, nipple-areolar complex, skin. Usually for LCIS and DCIS
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When to radiate after mastectomy?
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1. tumors >5cm that involve margin of resection or invate pec fascia or muscle
2. Axillary radiation when >4LN involved 3. Rad of internal mammary nodes if apparent on sentinel node imaging 4. Supraclavicular nodes if extranodal extension into axillary fat |
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Limits of dissection for mastectomy?
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Clavicle, Lat, costal margin, lateral border of sternum
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Lumpectomy? Segmental mastectomy?
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For <5cm solitary tumors
1. removal of primary lesion with clear margins 2. axillary node sampling 3. local radiotx to the breast 4. Radiotx to axillary, internal mammary, or supraclavicular nodes if >4 nodes are positive or + extracapsular invasion Note: radiation after lumpectomy greatly reduces chance of local recurrence |
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Does lumpectomy with rad affect survival rates?
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Not compared to mod radical mastectomy in stages I and II.
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Tumor staging
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table 11-6 p. 330 memorize
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What measurements do you need for staging?
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Tumor size, LN biopsy and histology
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What is standard method for LN biopsy?
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Remove nodes at levels I and II
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How do you do a sentinal node biopsy?
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1. Inject dye or radiotracer around primary tumor
2. wait for dye or tracer to reach node 3. take it out and perform histology |
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If sentinel node is negative for tumor, what are the chances that other nodes are negative?
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>90%
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Most physicians do not advocate mod radical mastectomies for tumors less than what?
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<2cm
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Does radiation increase survival?
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No, only decreases local recurrence
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2 contraindications to radiation tx
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1. Prior radiation to chest or breasts
2. connective tissue dz |
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4 Methods of breast reconstruction?
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TRAM (transverse rectus abdominus myocutaneous flap), Lat flap, DIEP (Deep inferior epigastric perforator) flap, free flap
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Flaps not as successful in which patients?
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Obese and smokers
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Contraindications for mastectomies?
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1. Primary lesions involving chest wall
2. extensive local or regional disease 3. stage III or IV cancer |
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Mgmt of stage 0 and I BC with <1cm tumors? (no nodes)
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Lumpectomy+axillary sampling+radiation+hormonal Tx if ER positive like aromatase inhibitor or Tamoxifen
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At what stage BC do you check for mets?
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Stage I
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What's the workup for mets?
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CXR for lung and bone mets, Liver enzymes for liver mets, bone scan and/or head CT if bone pain or neuro complaints, abdominal CT if liver enzymes or bilirubin or alk phos is abnormal
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Mgmt of stage I with larger (1-2 cm) tumor and no nodes?
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Lumpectomy+axillary sampling + radiation+ hormonal tx if ER + + chemo only if premenopausal
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Mgmt of stage II?
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Lumpectomy+axillary sampling + radiation+ hormonal tx if ER + + chemo if node positive or premenopausal w/node negative (table 11-8 p.342)
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Chemo is poorly tolerated in what population?
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elderly
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Who responds better to chemo?
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Premenopausal pts
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Who responds better to hormonal tx?
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postmenopausal
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Follow-up surveillance protocol for Stage I and II?
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1. see physician 2x/yr
2. annual CXR +LFTs 3. If lumpectomy mammogram that breast q 6mo for 2 years then annually 4. If mastectomy mammorgram the other breast, dunno freq |
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After mastectomy what are the changes of Ca dev in remaining breast?
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15%
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Stage I 5 year survival rate?
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93%
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Stage II 5 year survival?
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72%
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Mgmt of Stage III BC?
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1. Consult oncology for neoadjuvant chemo (before surg)
2. surgery |
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Mgmt of stage IV BC?
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palliative radiation and chemo. surgery only reserved for local control of primary tumor (painful or infected)
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Imaging modality to plan for surgery?
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MRI
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Stage III 5 year survival?
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41%
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Stage IV 5 year survival?
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18%
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Breast mass with cellulitis and edema =?
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Inflammatory carcinoma
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Tx for inflammatory carcinoma?
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1. Staging workup: CBC, liver enzymes, alk phos, Ca, Tbili, CT chest, bone scan, CT liver w contast or MRI w/ gadolinium if poor renal function
2. chemo 3. modified radical mastectomy 4. adjuvent chemo 5. hormonal tx for ER + 6. radiation for chest and regional LN basins |
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What should you do if you have pathological fracture from cancer?
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Due to bony mets, control the cancer locally with radiation and orthopedic repair. radiation shouldn't interfere with fracture union
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If after diag of BC you get neuro sxs like decreased sensation or motor function, what do you do?
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MRI, steroids, cord decompression, radiation
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If after diag of BC you get new seizures, what do you do?
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CT/MRI to diagnose brain mets, immediate steroids to decrease ICP, surgery or irradiation
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Coma/confusion with hx of BC could be what?
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Acute hypercalcemia due to bony mets or PTH-related peptide release (usually BC or LC)
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Antibiotics for Mastitis?
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Dicloxacillin/Cefalexin (usually S.aureus or coag neg staph)
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If a mastitis doesn't heal with abx, what are we worried about?
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Inflammatory carcinoma
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Mgmt of BC in pregnancy?
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Stage I and II mastectomy or lumpectomy w radiation after birth is safe. Lumpectomy discouraged in early pregnancy because of need for radiation.
Stage III and IV: rapid radiation and chemo. may need to abort. |
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Is ER or prog status reliable during pregnancy?
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NO
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What do you do for breast mass in a man?
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Mammogram to diff gynecomnastia from cancer, mastectomy and radiation
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When do men usually present with BC?
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after 60. Tend to present at later stage
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What can cause gynecomnastia?
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Diuretics, estrogens, INH, Weed, Dig, EtOH
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Most common sites of metastasis?
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Lungs, liver, bone, brain, ovaries
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How to biopsy bc? |
Core needle biopsy |