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SWG Repro Exam 1: Clinician's Approach to Breast Disease - Lin (P900/IC)

Terms in this set (62)

What are the 3 principle tissue types of the breast?
1) Glandular epithelium: Lobular and ductal tissue

2) Fibrous stroma

3) Adipose tissue
Which tissue type contains connective tissue that provides the structural integrity and shape of the breast, and what is this connective tissue called?
Within the FIBROUS STROMA, there are COOPER'S LIGAMENTS
Younger patients have (more/less) dense breasts which are composed more of _______ tissue and _______ ______.

As women age, this will be replaced by _____
Younger patients have MORE dense breasts which are composed more of GLANDULAR tissue and FIBROUS STROMA.

As women age, this will be replaced by FAT.
Breast tissue is (well/poorly) supplied by blood. What is one advantage and one disadvantage of this?
WELL supplied:
- Advantage: Heals quicker
- Disadvantage: Can easily bleed during surgery
List some of the blood supply to the breast
- Internal Mammary Artery (IMA)
- Axillary artery
- Costocervical Trunk
- Thoracic Aorta
75% of the breast drains to ______ lymph nodes, which has three levels. These levels are named relative to the pectoralis (major/minor) muscle. List where each level is relative to this muscle and which levels are usually removed during a radical mastectomy
AXILLARY, with three levels named relative to the pectoralis MINOR muscle:
- Level I: LATERAL to pec minor
- Level II: DEEP to pec minor
- Level III: MEDIAL to pec mino

Level I and II are usually removed during a radical mastectomy
Patients with a more advanced staging of breast cancer will often show swelling in which two lymph nodes?
1) Supraclavicular (Virchows)

2) Internal Mammary
TEST: What are four nerves that are very important to preserve during dissection of the breast? List what each nerve innervates and what could happen if each of the four nerves were damaged in surgery.
1) Long thoracic n. - Serratus anterior
- Winged scapula

2) Thoracodorsal n. - Latissimus Dorsi
- Can't abduct upper extremity

3) Medial pectoral n. - Pec major/minor
- Muscle atrophy

4) Intercostal Brachial Cutaneous
- Loss of sensation under armpit, making shaving dangerous
RECALL: What is one venous plexus that surrounds the vertebrae and can be a potential site for metastatic breast cancer?
BATSON'S plexus
- Same plexus for prostate cancer metastasizing to vertebra
- directly communicates with posterior intercostal arteries
For patients with an average risk of breast cancer, by what age is breast screening recommended?
40 years
When performing a breast exam, the patient must be in what position?
upright sitting and supine position
Is breast pain a major sign of breast cancer? Is discharge a major sign of breast cancer?
No! 7/10 women develop breast pain at some stage in life, but only in 5.4% of cancer patients

Also, discharge is also rarely associated with underlying carcinoma (4-6% with coexisting cancer)
What are 3 main imaging studies for screening/diagnose breast cancer?
1) Mammogram
2) Ultrasound
3) MRI (especially useful when mass not seen on mammogram, like lobular cancer)
(Mammogram/ultrasound) allows evaluation of the axillary lymph nodes
ULTRASOUND
TRUE or FALSE: An asymmetric area seen on a mammogram is indicative of a developing mass
FALSE, an asymmetric area could mean a variation of normal breast tissue, or poor positioning during imaging, or post-op change
What are the two standard views of a mammogram?
1) Cranio-caudal (CC) view
2) Mediolateral-oblique (MLO)
TEST: How many categories of breast density is there according to the ACR? Which category is almost entirely fat?

Which category would appear white on mammogram?
FOUR categories:
I = almost entirely fat
IV = extremely dense

IV is dense and would thus appear white on mammogram
Ultrasound can allow you to differentiate between a ____ lesion vs a _____
SOLID lesion vs CYST (fluid-filled)
TRUE or FALSE: MRI is useful as an initial screening tool for breast cancer
FALSE
- It is expensive
- Picks up too much information

main use is to assess implant integrity or to assess extent of tumor after pt has already been diagnosed
What are some lesions that may be visualized on MRI but not mammogram or ultrasound?
- young and dense breast tissue
- BRCA mutation (early detection)
- invasive lobular cancer
Which modality has been increasingly used for screening patients with BRCA1 mutation?
MRI
What are some histologic descriptors for breast disorders?
concern for cancer rises when atypia is present (4-5x ↑ risk)
Describe the epidemiology of breast cysts. Does cyst development become more common in older age?
1/3 of woman age 35 - 50 have cysts

Related with hormonal stimulation

After menopausal, cyst development ↓ steadily
Are breast cysts cancerous? How do they appear on ultrasound?
Breast cysts are not typically cancerous
- No risk factor for cancer,
- Intra-cystic carcinoma exceeding rare 0.1%

clearly defined margins on ultrasound
When is it important to biopsy a breast cyst?
Aspiration, Fine-needle or core needle biopsy :

- If no fluid can be aspirated,

- If recurs after 2-3 aspirations

- If complex having solid component or if there is residual mass after aspiration.
What is the epidemiology of fibroadenoma?
often in younger women (< 30) and regresses with menopause

develops under the influence of estrogen
Describe regression of fibroadenomas. How are they characterized on mammogram?
"the noncalcified appearance changes and calcifications develop.

The typical involuting fibroadenoma contains "popcorn-like" macrocalcifications and is easily identified on a mammogram"
TEST: What is a very common benign solid breast tumor in young women? What causes these to develop?
FIBROADENOMAS
- Usually develop under the influence of estrogen
TRUE or FALSE: Fibroadenomas require surgical excision
FALSE, depends on whether the patient has symptoms (pain) or if its fast growing
- If it is really small, we can just monitor and follow-up
TEST: What are two types of fibroadenomas?
1) Giant (> 5 cm)
2) Juvenile
TEST: What tumor can resemble a giant fibroadenoma? What is the main difference? Are the majority of these tumors benign or malignant?
PHYLLODE tumor
- Most are BENIGN
Major difference with giant fibroadenoma: phyllode tumor GROWS MORE QUICKLY
What is the main difference between Phyllode tumors and regular breast cancer?
Phyllode tumors behave like SARCOMAS and don't really spread to lymph nodes

They metastasize hematogenously (vs regular breast cancer, which usually spreads to the lymphatic system)
Ultrasound of phyllode tumors reveals what? How are phyllode tumors treated?
ultrasound: discrete structure with cystic space

treat with local excision or simple mastectomy
RECAP: What are the three treatments for managing fibroadenomas?
1) Monitor
2) Cryotherapy (in-clinic)
3) Surgical excision
RECAP: Fibroadenomas tend to have a ______ texture and often regress with _________
Fibroadenomas tend to have a RUBBERY texture and often regress with MENOPAUSE
TEST: What condition, which causes proliferation of ductal epithelial tissue and polyps of the breast ducts, is commonly associated with a BLOODY nipple discharge?
INTRA-DUCTAL PAPILLOMA
TRUE or FALSE: Intra-ductal papilloma is not a risk factor for cancer
TRUE!
- However, usually need to excise it to exclude cancer
How do intra-ductal papillomas present on mammogram?
They usually are TOO SMALL for mammograms

may occasionally grow large enough to appear as circumscribed masses; can even obstruct the duct to create ductal dilatation
TEST: Mastitis, or breast ______, is often related to breast _______ and should be diagnosed and treated with ______ ________.
Mastitis, or breast ABSCESS, is often related to breast FEEDING and should be diagnosed and treated with NEEDLE ASPIRATION
- The milk ducts don't clear up, and it is a nice environment to harbor bacteria

Note: Ultrasound is also useful for Dx
With mastitis, when is it necessary to make an incision and drain it?

Generally describe the protocol for treating mastitis.
If multiple attempts of simple aspiration cannot remove all the fluid out

Protocol:
- Start Antibiotics
- Aspiration
- Incision and Drainage
- Culture and Sensitivity
- Biopsy to rule out cancer if not improved
TRUE or FALSE: Lobular carcinoma in situ is a type of breast cancer
FALSE, it is an INDICATOR that identifies a high risk woman for breast cancer
- These are usually incidentally found
TEST: If a patient has LCIS, what test must be done and why?
An EXCISIONAL BIOPSY, because you MUST rule out the presence of breast cancer (as LCIS increases the risk by greater than 7 times)

For actually treating LCIS, can do chemo or mastectomy (if required)
What are some risk factors for breast cancer?
- Age (higher risk with older age)
- Family history of breast/ovarian cancer
- Genetic predisposition
- Estrogen exposure
- Chest wall radiation
- History of one breast cancer --> contralateral breast cancer
- Proliferative breast disease
TEST: What are three proliferative breast diseases that increases the risk for developing breast cancer?
1) Ductal hyperplasia
2) Atypical hyperplasia (ductal, lobular)
3) Lobular carcinoma in situ (LCIS)

Ductal hyperplasia without atypia is less of a risk for breast cancer than either of the atypical hyperplasias
- And LCIS has the highest risk of developing breast cancer
TEST: 80% of all inherited breast cancer is caused by ______ and _____ gene mutations
BRCA1 (chr 17)
BRCA 2 (chr 13)

These are tumor suppressor genes, so mutations will shut these genes down and cause the tumor to proliferate
What are some of the different types of breast cancer?
- Infiltrating ductal carcinoma
- "in-situ" carcinoma
- Infiltrating lobular carcinoma
- Tubular carcinoma
- Mucinous carcinoma
- Medullary carcinoma
- Papillary carcinoma
- Adnoid cystic carcinoma
- Metaplastic carcinoma
- Inflammatory breast cancer
What is the hallmark of inflammatory breast cancer?
grows in nests or sheets (Rather than as a confined tumor)

"Orange peel" skin around the breast

lymphatic blockage can cause swelling and erythema of the breast
TEST: What is the most common type of breast cancer?
INFILTRATING DUCTAL CARCINOMA (50-70% of breast cancer cases)
TEST: What is the gold standard in confirming the diagnosis of breast cancer? How many types of this test are there, and which one is recommended by surgeons?
BIOPSY:

1) Fine needle aspiration
2) Core needle biopsy - Recommended
3) Incisional biopsy
4) Excisional biopsy
TEST: What is the most common system used to stage breast cancer?
TNM system:
T = Size of Tumor
- T1: < 2 cm
- T2: 2-5 cm
- T3: >5 cm
- T4: Skin or chest wall involvement

N = Lymph node involvement
M = Metastasis
Describe Stage 0 of breast cancer.
Stage 0: Atypical cells have NO spread outside ducts or lobules, carcinoma in-situ
Describe Stage I of breast cancer.
Stage I: Small (<2 cm) tumor, NO spread to lymph node
Describe Stages IIa and IIb of breast cancer.
Stage IIa: either small tumor + lymph node OR no tumor + lymph node

Stage IIb: either medium size + lymph node OR large size tumor
Describe Stages IIIa and IIIb of breast cancer.
Stage IIIa: any size tumor, spread to multiple lymph nodes

Stage IIIb: spread to chest wall, ulcerated skin, inflammatory breast disease
Describe Stage IV of breast cancer.
Stage IV: Distant metastases
What are the two types of breast carcinoma in-situ?

AGAIN: Which stage do carcinomas in-situ fall under?
1) Ductal carcinoma in situ (DCIS)
2) Paget's disease

Falls under STAGE ZERO! (no spread outside of ducts)
TRUE or FALSE: The survival rate of stage 0 breast cancer is 100%.
TRUE!
AGAIN: Which stage of breast cancer is there lymph node spread?
Stage II (and up)
Generally, once breast cancer diagnosis is established, _______ is the initial treatment
SURGERY

However, it is a very small part of the overall treatment of breast cancer
RECAP: How many stages are in the TNM system for breast cancer? Briefly define the criteria for each stage
FIVE stages:
- Stage 0: Atypical cells have NO spread outside ducts or lobules, carcinoma in-situ

- Stage I: Small (<2 cm) tumor, NO spread to lymph node

- Stage II: Either IIA (no-small tumor), IIB (large tumor), LYMPH NODE spread

- Stage III: Any size tumor, MULTIPLE LYMPH NODE spread

- Stage IV: Distant metastases
What are some adjuvant therapies that can accompany surgical treatment of breast cancer?
- Chemotherapy (neoadjuvant vs adjuvant)

- Radiation therapy (high energy, intra-operative radiation)

- Hormonal therapy
What is the difference between neoadjuvant vs adjuvant chemotherapy?
Neoadjuvant: Chemo BEFORE surgery

Adjuvant: Chemo AFTER surgery
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