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63 Cards in this Set
- Front
- Back
What is the treatment recommendation for LCIS noted on core needle biopsy? |
There is debate regarding optimal management, with both follow up imaging and surgical excision as reasonable options. Note that aggressive features of LCIS include: pleomorphic LCIS, any associated necrosis. Usual type LCIS (<4 terminal ductal lobular units in a single core) can likely be safely followed every 6-12 months provided there is no clinical or radiographic discordance. Consider tamoxifen for risk reduction. |
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What is the treatment recommendation for DCIS? |
- Lumpectomy + radiation (preferred as radiation halves risk of local recurrence) - Lumpectomy alone (if deemed "low" risk) - If ER positive and pt opts for lumpectomy/XRT, add tamoxifen to reduce ipsilateral breast cancer |
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What is the recommended surveillance after treatment for DCIS? |
- H&P and imaging q6-12 months x 5 years - For patients undergoing lumpectomy/XRT, first mammogram should be done 6 months after completion of radiation |
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What is the rate of finding invasive carcinoma on lumpectomy specimens performed for DCIS? |
At least 25% |
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What are absolute and relative contraindications to lumpectomy for the treatment of invasive breast cancer? |
Absolute: - Pregnant women who would require RT during pregnancy - Diffuse suspicious microcalcifications - Widespread disease that cannot be incorporated by local excision with a single incision with satisfactory cosmetic result - Positive pathologic margins (consider re-excision followed by mastectomy if still positive) Relative: - Prior radiation to breast/chest wall (check dose) - Active connect tissue disease, ie scleroderma and lupus - Tumors > 5cm - Focally positive pathologic margins (consider re-excision vs higher radiation boost) |
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What did NSABP B-4 show? |
"The 25-year findings from that study showed that there was no significant difference in survival between women treated with the Halsted radical mastectomy and those treated with less extensive surgery." -Fisher 2002 |
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What did NSABP B-6 show? What other trial showed similar findings? |
RCT to see whether lumpectomy with or without radiation therapy was as effective as total mastectomy for the treatment of invasive breast cancer --> No OS difference Milan trial - lumpectomy + ax dissection vs Halsted mastectomy for early cancer --> breast conservation was equivalent |
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When should you obtain a metastatic workup beyond close history, physical exam, and LFTs? What should you order? |
Metastatic workup is indicated for clinical Stage IIIA and above disease (T3 N1) Obtain bone scan OR PET scan, CT OR MRI abdomen/pelvis, and CT chest |
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Who benefits from a tumor bed boost dose of radiation? |
Positive axillary nodes, lymphovascular invasion, young age, high grade disease |
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Who should get radiation therapy to the infra- and supra-clavicular area? |
Positive lymph nodes (Definitely 4+, strongly consider for 1-3) Consider internal mammary node bed radiation to all patients with positive nodes (NCIC-CTG MA20 - RCT showed lower LR and trend towards lower OS) |
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Of patients undergoing lumpectomy for invasive breast cancer, which do not require postoperative radiation? |
Women >/= 70 years old with clinically negative lymph nodes and ER-positive, T1 breast cancer Must prescribe hormonal therapy for these patients! |
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What did ACOSOG Z0010 show? |
In patients with H&E negative SLN, further examination by IHC was not associated with improved OS Thus H&E alone is sufficient, but if equivocal should perform IHC |
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What did ACOSOG Z0011 show? |
RCT which compared SLN biopsy alone vs ALN dissection in women with T1/T2 tumors, 1 or 2 positive SLNs, and undergoing lumpectomy with radiation --> No difference in LR, DFS, or OS between groups Thus completion axillary dissection may be omitted in these patients |
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Discuss technical aspects of axillary LN dissection for breast cancer. |
ALN should include level I and level II nodes. All tissue inferior to the axillary vein from the latissimus dorsi muscle laterally to the medial border of the pectoralis minor muscle should be removed. Level III nodes should be removed only if there is gross disease in Level II. |
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What did NSABP B-18 show? |
Breast conservation rates are higher after neoadjuvant chemotherapy There is no demonstrated survival advantage over adjuvant therapy |
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What are indications of post mastectomy radiation? |
Node-positive disease (Definitely for 4+, strongly considered for 1-3) Tumor size > 5cm Close (<1mm) or positive margins |
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What are the major subtypes of breast cancer that have been identified by DNA microarray gene expression profiling? |
Luminal A/B: ER+, HER2- Basal subtype: ER-, HER2- (triple negative) HER-2 positive |
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For whom should you consider running the Oncotype 21 gene RT-PCR assay? Can you use Oncotype 21 for HER2 + or triple negative tumors? Define areas for these tumors where there is relative uncertainty about benefit of chemotherapy. |
ER/PR+, HER2-: T1b or higher (>0.5cm), N0 Use the score to estimate likelihood of recurrence and benefit of chemotherapy Don't send Oncotype on triple negative or HER2 positive tumors. Most should get chemo. However areas of uncertainty include: HER2+: T1a, N1mi or T1b, N0 ER/PR-, HER2-: T1a, N1mi or T1b, N0 In these patients consider other risk factors. For example patients above 70 may not benefit. |
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What is the preferred regimens for adjuvant chemotherapy for breast cancer? |
Doxorubicin, cyclophosphamide, paclitaxel: AC x 4 cycles (8 wks), then T x 4 cycles (8 wks) (16 weeks total)
Paclitaxel, cyclophosphamide: TC x 4 cycles (12 weeks total) Trastuzumab for any HER2 positive patients with tumors >1cm (AC x 4 cycles (12 weeks)--> TH weekly (12 weeks) or TCH given cardiotoxicity risk with trastuzumab and doxorubicin), and consider pertuzumab |
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What is the preferred treatment for patients who develop local recurrence following lumpectomy? Following mastectomy? |
Following lumpectomy: Mastectomy with level I/II dissection Consider repeat SLN biopsy Following mastectomy: Local excision if negative margins achievable |
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When is surgery indicated in metastatic disease? |
Surgery after initial systemic therapy should be considered for women requiring palliation or with impending complications such as skin ulceration, bleeding, fungation, and pain Radiation can be considered as alternative |
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What is the preferred treatment of Paget's disease? |
Removal of NAC and underlying tumor if present, can do total mastectomy or central lumpectomy with SLN biopsy If no associated tumor/mass, perform central lumpectomy (no need for SLN biopsy) |
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What is the preferred treatment of phyllodes tumors? |
Wide local excision with 1 cm margin No SLN biopsy No adjuvant chemotherapy Adjuvant radiation (50-60 Gy) for malignant tumors > 5cm |
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What are acceptable margins in DCIS? |
At least 2mm If less <1mm at borders such as skin or chest wall consider boost of radiation instead of re-excision |
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Discuss the relative indications of breast MRI. |
**There are no studies to date that demonstrate improved survival with addition of MRI. - Define extent of cancer in the presence of multifocal or multicentric cancer in the ipsilateral breast - Screen contralateral breast in high risk patients - Before/after neoadjuvant therapy to determine disease extent, response, and potential for breast conservation - Dense breast - Identify occult primary in patients with axillary nodal adenoCA or Paget's with no primary identified on mammo/US/exam - False positives are common so must get core biopsy of suspicious areas seen only on MR - F/u surveillance in women with second primary breast cancer risk > 20% |
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Define T stages for breast cancer. |
Tis - DCIS/LCIS T1mi - <0.1cm T1a - 0.1-0.5cm T1b - 0.5cm - 1cm T1c - 1cm-2cm T2 - 2cm-5cm T3 - >5cm without direct chest wall extension T4 - Tumor of ANY size with direct chest wall or skin invasion -- T4a - Extension to chest wall -- T4b - Ulceration or satellite nodules or peau d'orange of the skin -- T4c - BOTH T4a + T4b -- T4d - Inflammatory carcinoma |
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Define clinical N stages of breast cancer. |
N0 - no positive nodes N1 - Movable ipsilateral level I or II axillary nodes N2a - Mets in ipsilateral level I or II axillary nodes fixed or matted N2b - Mets in only clinically detected ipsilateral internal mammary nodes in the absence of other nodal mets N3a - Ipsilateral infraclav node N3b - Ipsilateral internal mammary node AND axillary node N3c - Ipsilateral supraclavicular lymph node |
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Define stages of breast cancer |
Stage IA - T1 N0 M0 Stage IB - T0 N1mi M0; T1 N1mi M0 Stage IIA - T0 N1 M0, T1 N1 M0 Stage IIB - T2 N1 M0, T3 N0 M0 Stage IIIA - T0 N2 M0, T1 N2 M0, T2 N2 M0, T3 N1 M0, T3 N2 M0 Stage IIIB - T4 N0 M0, T4 N1 M0, T4 N2 M0 Stage IIIC - Any T N3 M0 Stage IV - Any T Any N M1 |
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Define inflammatory breast cancer and its treatment regimen. |
IBC is a clinical diagnosis based on erythema AND peau d'orange of a third or more of the skin of the breast with a palpable border to the erythema. Typically ER/PR - and often HER2 +. Full staging workup. Neoadjuvant chemotherapy. Modified radical mastectomy. Adjuvant radiation and additional chemotherapy (chemotherapy sandwich approach). |
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What are major indications for breast cancer genetic assessment? |
Any individual with breast cancer diagnosis AND: - Known mutation in cancer susceptibility gene within the family - Early age onset breast cancer (< 50 years) - Triple negative breast cancer < 60 years - 2 breast cancer primaries - Family history: 1 or more close blood relative with BC < 50, 1 or more close blood relative with ovarian cancer at any age, 3 or more close blood relatives with BC or panc cancer at any age, population at increased risk For additional criteria see NCCN guidelines |
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What are the major genetic conditions leading to breast cancer risk? |
About 10% of breast cancer is linked to mutations in single genes BRCA1/2 Li-Fraumeni (p53) Cowden (PTEN) Hereditary diffuse gastric cancer (CDH1) - lobular breast ca |
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What should be the management of discordant pathologic/imaging findings? |
Repeat core biopsy If no imaging finding remains, consider wire localized excisional biopsy for definitive diagnosis |
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What is the treatment for pseudoangiomatous stromal hyperplasia? |
Lesions often recur but they are not associated with cancer risk. Can observe and perform surveillance Consider excision if strong family history of breast CA or any suspicious clinical features
Case report of tamoxifen to limit growth (NOT for cancer risk). Lesion will usually increase in size again when tamoxifen is stopped. |
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What is the treatment for chronic granulomatous mastitis? |
Common in young, Asian women within 5 years post pregnancy. Do NOT excise as may get persistent wound healing problems. Reassure. Usually self-limited. |
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What is the treatment of bloody nipple discharge? |
Usually due to intraductal papilloma but need to exclude malignancy - Mammogram & ultrasound to evaluate for underlying mass - Ductogram to identify intraductal lesion if present. Can only be done if discharge can be reproduced on exam and the affected duct can be cannulated - (Ductoscopy, rarely used in US) - Central duct excision |
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What is the management of ADH? |
When atypical ductal hyperplasia is found on core needle biopsy, subsequent excisional biopsy will demonstrate invasive cancer 15% of the time (compare to about 25% upstaging of DCIS). Therefore excision is recommended as well as tamoxifen. NSABP P-1 showed that tamoxifen reduces risk of developing breast cancer in half in women with atypia without breast cancer on final pathology. |
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What mutation and cancers are associated with Cowden syndrome? |
PTEN mutation Breast cancer (up to 50%) Endometrial cancer Follicular thyroid cancer Think of milking (breast) 10 (pTEN) female (endometrial) cows (Cowden) in a FOLiage (follicular thyroid) green field |
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What mutation and cancers are associated with Peutz Jehger syndrome? |
STK11 mutation Breast cancer (up to 50%) Ovarian cancer Uterine cancer Hamartomatous GI polyps Melanin deposits in mouth/lips/fingers/toes 11 (STK11) women praying from the pews with GI hamartomatous Polyps, Even more melanin deposits, and Unfortunate triad of breast, ovarian, and uterine cancers |
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What mutation and cancers are associated with Li-Fraumeni syndrome? |
P53 mutation **Frequently have radiation induced tumors so mastectomy preferred **Strikingly high rates of cancer Adrenal corticocarcinomas Breast cancer Brain cancer Leukemias Sarcomas & osteosarcomas Leukemias In your head (Brain) cancers Filled with sarcoma & osteosarcoma Radiation induced tumors (so do mastectomy) Adrenal corticocarcinoma Unforunate breast cancer Mutation in p53 Evil Number of Icky cancers |
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Define locally advanced breast cancer. |
• Tumor >5 cm • Direct extension to chest wall or skin-ulceration, edema, skin nodules in ipsilateral breast • Inflammatory breast cancer • Fixed or matted axillary nodes • Supraclavicular nodes • Internal mammary nodes • Infraclavicular nodes |
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Lobular carcinoma lacks which molecule on histopathology? |
Small cells which infiltrate mammary stroma and adipose tissue in a single file pattern due to absence of E-cadherin. |
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How do invasive lobular and ductal carcinomas compare in terms of ER/PR positivity, prognosis, response to neoadjuant chemotherapy? |
Lobular carcinoma is usually ER/PR+, HER2-, but HER2+ subtypes do exist. Lobular cancers respond less well to neoadjuvant chemotherapy than ductal carcinomas. Prognosis is similar |
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What are contraindications to nipple sparing mastectomy? |
- large tumor size - close proximity to NAC / centrally located - multifocal or multicentric disease - poorly differentiated - lymphovascular invasion - extensive intraductal component - stage of tumor - positive nodes Relative - BRCA mutation carrier or family history - presence of ptosis - history of prior surgery at or around the NAC. |
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In BRCA+ patients, bilateral prophylactic mastectomy reduces the risk of breast cancer by...? |
~ 90% |
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What is the risk of ovarian cancer with BRCA1? |
40% lifetime risk |
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How do you interpret Oncotype Dx scores? |
Score < 18 --> little benefit of adjuvant chemotherapy Score 18-30 --> intermediate benefit of adjuvant chemotherapy Score > 30 --> likely benefit of adjuvant chemotherapy |
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What is the recommend treatment for a patient who presents with ipsilateral ER+/PR+/HER2- recurrence 10 years after breast conservation with adjuvant radiation? |
Completion mastectomy (since you cannot give more radiation) Repeat sentinel lymph node biopsy if it was done the first time, no axillary surgery if axillary dissection completed previously Hormone therapy Benefit of systemic chemotherapy for ipsilateral recurrence not well demonstrated, can decide based on nodal disease |
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Define N0(i+) and N1mi |
pN0(i+) = tumor deposit ≤ 0.2 mm pN1mi = tumor deposit > 0.2 mm but ≤ 2 mm |
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Define Stage IA and IB breast cancer. |
Stage IA - T1 N0 M0 Stage IB - T0 N1mi M0 or T1 N1mi M0 |
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Define Stage IIA and IIB breast cancer. |
Stage IIA - T0 N1 M0, T1 N1 M0 Stage IIB - T2 N1 M0, T3 N0 M0 |
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Define Stage IIIA, Stage IIIB, and Stage IIIC breast cancer. |
Stage IIIA - T0 N2 M0, T1 N2 M0, T2 N2 M0, T3 N1 M0, T3 N2 M0 Stage IIIB - T4 N0 M0, T4 N1 M0, T4 N2 M0 Stage IIIC - Any T N3 M0 |
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Which two landmark trials showed us that sentinel lymph node biopsy has same outcomes as axillary dissection in patients with clinically negative nodes? |
NSABP-32 ALMANAC |
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What bacteria is usually responsible for acute lymphangitis? |
Streptococcus pyogenes |
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What is the histology of a fibroadenoma? |
Even amount of stromal and epithelial cells, uniform stroma |
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How helpful is FNA of fibroadenoma? |
Rarely helpful Lots of false positives and negatives Can't tell fibroadenoma vs phyllodes on FNA alone, so get core |
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Describe histologic characteristics of atypical ductal hyperplasia. |
Ducts completely filled and exhibit sharp punched out spaces or micropapillae - Lack uniform cytologic features - Columnar cells or focal streaming of cells OR Ducts filled by a uniform population of cells with cytologic features of low grade DCIS but lack architectural features - Partial filling of ducts - Lack of uniformly sharp punched out spaces, microacini or characteristic micropapillae (Solid low grade DCIS is rare but must be excluded before using this feature to diagnose ADH) OR Cytologic and architectural features met but failure to meet size criteria - Fewer than two duct spaces involved or less than 2-3 mm in aggregate dimension |
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Specify the management of phyllodes tumor based on classification as benign, malignant, and borderline. |
All get wide local excision with 1cm Malignant tumors >5cm --> adjuvant RT |
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What bacteria is typically involved in mastitis in the breastfeeding woman? |
Staph aureus (including MRSA) |
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Can you advise patient to continue to breastfeeding after abscess drainage? |
Yes |
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Should milk be routinely cultured in cases of mastitis? |
No, but should be considered in refractory cases |
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Chemoprophylaxis with tamoxifen should be considered in women who have a 5-year risk of developing breast cancer of at least what numer? |
~3% (USPSTF) |
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Should patients with 4cm triple negative tumors with clinical negative axilla get metastatic workup? |
No. Reserve metastatic workup for IIIA disease: T3 N1 M0 (>5cm) or Any T N2 disease, regardless of hormonal status. |
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Who should get screening MRI based on evidence and expert opinion? |
Breast MRI Screening recommended: - BRCA carrier, Li Fraumeni, Cowden - First degree relative of BRCA carrier, untested - Lifetime risk > 20% based on risk model - Hx of radiation to chest wall in childhood (ACS guidelines) |