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Breast - Dr. Hammouri
Breast - Dr. Hammouri
A. Fibrocystic mastopathy.
B. Severe hyperplasia.
C. Atypical hyperplasia.
D. Papillomatosis
Answer: C
Answer: A
DISCUSSION: Tubular, mucinous, and medullary carcinomas are histologic
variants of infiltrating ductal cancer and are all invasive malignancies. Infiltrating
lobular cancer is a particular histologic variant of invasive breast cancer
characterized by permeation of the stroma with small cells that resemble those
found in the breast lobule or acinus. Intraductal carcinoma refers to a malignancy
of ductal origin that remains enclosed within duct structures. This noninvasive
proliferation can undergo central necrosis, which frequently calcifies to form the
microcalcifications seen on mammography. The central necrosis within enlarged
and back-to-back ductal structures resembles comedoes and gives rise to the term
“comedocarcinoma,” now reserved for this histologic variety of intraductal
carcinoma.
Which of the following are the most important and clinically useful risk factors for
breast cancer?
1
Answer: C
DISCUSSION: The most important risk factors for breast cancer are the patient's
age, gender, and a family history of breast cancer in immediate relatives (sisters,
mother, daughter). The age-adjusted incidence of breast cancer increases with age.
Breast cancer does occur in males, but the disease is far more common in women.
Family history is important when breast cancer occurs within the immediate family;
history of breast cancer in more distant relatives (grandmothers, cousins, aunts) is
less important. In addition, age factors into the risk associated with family history.
An affected young primary relative is far more significant as a risk factor than an
older relative with breast cancer. The other important risk factor not listed here is a
history of breast cancer, either within the conserved ipsilateral breast or in the
contralateral breast. Again, age plays an important modifying role; as the age at
which breast cancer was first diagnosed increases, the risk of a subsequent second
cancer decreases. Although patients with fibrocystic disease are at increased risk for
breast cancer, risk concentrates in those patients with fibrocystic disease who show
atypical epithelial hyperplasia within breast ducts. Obesity, nulliparity, and alcohol
all appear to increase risk slightly and are important to the epidemiologic study of
breast cancer; however, the effect of these factors is not sufficient to warrant their
use in common clinical practice.
9. The proper treatment for lobular carcinoma in situ (LCIS) includes which of the
following components?
A. Close follow-up.
B. Radiation after excision.
C. Mirror-image biopsy of the opposite breast.
D. Mastectomy and regional node dissection.
Answer: A
DISCUSSION: LCIS is best thought of as a precursor lesion that confers increased
risk for eventual cancer.
The magnitude of this risk appears to be in the range of seven- to ninefold over
baseline risk.
The chance of breast cancer is equal in both breasts, not just in the biopsied breast,
and the type of cancer is not confined to a lobular histology.
After a diagnosis of LCIS, patients are at increased risk for invasive and
noninvasive ductal carcinoma in both breasts.
Therefore, mirror-image biopsy as practiced in the past has little to offer. Since
LCIS is purely noninvasive, nodal dissection is not required if mastectomy is chosen.
There are no data on the use of breast radiation therapy for LCIS. Most surgical
oncologists recommend close follow-up for patients who have LCIS only; the
alternative surgical treatment that makes most sense is bilateral simple
mastectomies, with or without reconstruction.
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• Which of the following statement(s) is/are true concerning the anatomy of the
breast?
The lymphatic anatomy of the breast is of interest to the surgeon because of the
tendency of breast cancer to involve the regional lymph nodes. Studies using
radioactive tracers demonstrate at least 97% of lymphatic flow from the breast is
into the axilla; the remainder courses into the internal mammary nodes. These
studies also show that lymph flowing into the internal mammary gland chain is not
restricted in origin to the medial half and sub-areolar region of the breast, as was
thought, but can originate in any quadrant of the breast. In the axilla, lymphatic
vessels terminate in the lymph nodes embedded within the axillary fat pad. Also
within the axillary fat pad are the intercostal brachial nerves (a sensory nerve
supply in the under arm), the long thoracic nerve (a motor nerve to the serratus
anterior and subscapularis muscles) and the thoracodorsal nerve (a motor nerve to
the latissimus dorsi adjacent to its accompanying arteries and veins).
• Which of the following statement (s) is/are true concerning the recurrence of
breast cancer?
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c. Pulmonary metastases are the most common initial site of distant
recurrence
d. The local recurrence rate following breast-conserving procedures
varies from 10% to 40% whether or not radiation was used
e. Recurrent disease will be seen in at least 35% of node-negative
patients undergoing appropriate primary breast therapy
Answer: a, b, d
Metastatic disease following primary therapy for breast cancer can recur at any
time. However, of those who relapse, 50% to 70% do within two years and over
85% relapse within five years. More than 70% of recurrences are distant, but
anywhere from 10% to 30% of recurrences are local. Bone and lung are the most
common initial sites of distant relapse (50% and 25%), respectively. A breast-
conserving procedure can be associated with a local tumor recurrence rate. The rate
of local recurrence falls from 40% to 10% if postoperative radiation therapy is
given to the entire breast. Despite potentially curative resection, at least 20% of
node-negative and 60% of node-positive breast cancer patients have recurrence of
their disease at some time after surgery.
Answer: a, c, d
Although mammography has been available for years, it did not become widely used
until the findings of the Health Insurance Plan of New York and the Breast Cancer
Detection Demonstration project studies of screening mammography were
disseminated. These and other investigators demonstrated that 10%–50% of
cancers detected mammographically are not palpable. Conversely, palpation
recognizes 10%–20% of tumors not detectable mammographically. The incidence of
breast cancer begins to rise sharply at age 40, and the sensitivity of mammograms
increases with age as the dense parenchymal tissue of young women is progressively
replaced by fatty tissue. Routine screening mammography has been shown to
decrease breast cancer-related mortality in asymptomatic women over the age of 50.
Controversy exists concerning the role of screening in younger woman. However,
currently the American Cancer Society recommends that mammographic screening
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begin at age 40. Although sensitive, mammography is not specific. Only about 25%
of nonpalpable lesions detected mammographically are found to be malignant at
biopsy. A spiculated density with ill-defined margins on mammogram is almost
certainly malignant. Most commonly, features are seen that are suggestive but not
diagnostic of cancer. These include clustered microcalcifications, asymmetric
density, ductal asymmetry, and distortion of normal breast architecture and/or skin
or nipple distortion.
5
Pathologic staging begins with the initial biopsy. Unless previously secured, fresh
tumor needs to be obtained for hormone receptor analysis prior to placement into
formalin solution. A period of warm ischemia as short as 30 minutes may cause
underestimation of estrogen receptor levels. The need to remove axillary nodes must
be determined preoperatively. Axillary lymph node metastasis will be found in
approximately one-third of clinically negative axillae, but only if proper axillary
dissection is performed. Removal of only level I nodes or “sampling” of axillary
lymph nodes in a haphazard fashion increases the risk of injury to major axillary
neurovascular structures and may understage up to 25% of women. Proper staging
of axillary lymph nodes should include en bloc removal and examination of level I
and level II nodes. When conducted for staging, axillary lymph node dissection
should not include removal of level III axillary nodes; in fewer than 2% are
metastases present in level III nodes when level I and level II nodes are negative.
Removal of level III nodes, however, does increase the incidence of postoperative
arm lymph edema almost fivefold. Therapeutic axillary lymph node dissection
performed for palpable disease in the axilla should include removal of all levels to
clear gross disease.
Chemotherapy for metastatic breast cancer is more likely to be employed for young
women, those with ER-negative tumors, those with visceral organ involvement and
those with rapidly advancing or life-threatening disease. Generally, combinations of
agents are used in treating metastatic breast cancer with the response rate usually
dose-dependent. All regimens are slightly less active in post-menopausal women.
Response rates are highest in women who have not received prior treatment for
metastatic disease. Prior adjuvant therapy is not consistently associated with a
poorer response to therapy, particularly if a long interval has lapsed between
adjuvant therapy and the development of metastases. Endocrine therapy is
appropriate as the first-line treatment for nearly all women with ER-positive
metastatic breast disease. Tamoxifen is the agent of choice for first-line hormonal
therapy for metastatic breast cancer. Both pre-menopausal and post-menopausal
patients can receive this agent and side effects are minimal.
6
• A 21-year-old woman presents with an asymptomatic breast mass. Which of
the following statement(s) is/are true concerning her diagnosis and
treatment?
Answer: b
Answer: c
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that of the underlying cancer. Standard treatment is mastectomy with axillary
lymph node dissection only if invasive cancer is present.
Answer: c
Answer: a
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Adjuvant tamoxifen leads to a prolonged disease-free interval in post-menopausal
ER-positive women with histologically positive nodes and in pre-menopausal and
post-menopausal ER-positive women with negative nodes. Because of similar results
and, because tamoxifen is generally less toxic than chemotherapy, this treatment is
the treatment of choice for post-menopausal, node-positive, ER-positive women.
CMF (cyclophosphamide, methotrexate, and 5-fluorouracil) is associated with both
a longer disease-free survival and overall survival time in pre-menopausal patients
with positive lymph nodes. In post-menopausal women with positive nodes, there is
an improved disease-free survival, but there is no significant difference in overall
survival. Several trials of adjuvant chemotherapy with CMF or related regimens
have been conducted in node-negative patients. The early results of all of these trials
have been similar: disease-free survival is definitely improved with adjuvant
chemotherapy. These studies are definitely not mature enough to draw definitive
conclusions regarding overall survival. Therefore, the National Cancer Institute has
recommended the use of adjuvant chemotherapy for all patients with tumors large
enough to have hormonal receptor levels measured.
At one time or another, many women notice a nipple discharge. The most common
physiologic basis for nipple discharge is lactation. Milk may continue to be secreted
intermittently for as long as two years after breast feeding has stopped, particularly
with breast stimulation. A milky whitish discharge, usually bilateral, that is not
related to lactation or breast stimulation is termed “galactorrhea.” The presence of
bilateral galactorrhea should prompt an evaluation for underlying endocrinopathy
causing increased prolactin secretion by the pituitary. Classically, this is associated
with amenorrhea, but galactorrhea may be the only sign of hypoprolactinemia.
Nipple discharges associated with fibrocystic disease are generally, green, yellow, or
brown, Intraductal papillomas and cancer lead to a bloody or blood-tinged serous
discharge. The brownish discharge of fibrocystic disease can easily be confused with
old blood. A guaiac test or simply dabbing the discharge with a gauze pad and
examining the stain can usually differentiate the two. A bloody or blood-tinged
discharge must be promptly evaluated to exclude carcinoma. If the discharge is
expressible at the time the patient is seen, a contrast ductogram may be obtained.
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a. If the disease is unilateral, it is unlikely drug-related
b. The standard surgical treatment is subcutaneous mastectomy
c. The presence of gynecomastia is often associated with the subsequent
development of breast cancer
d. A formal endocrine evaluation is indicated in most patients with
gynecomastia
Answer: b
6. Axillary lymph node dissection is routinely used for all of the following
conditions except:
A. 2-cm. pure comedo-type intraductal carcinoma.
B. 1-cm. infiltrating lobular carcinoma.
C. 8-mm. infiltrating ductal carcinoma.
D. A pure medullary cancer in the upper inner quadrant.
Answer: A
DISCUSSION: Intraductal carcinoma is carcinoma in situ and does not metastasize
to regional or distant sites. Lymph node dissection is not routinely required for a
pure in situ cancer of the breast. In contrast, all of the other cancers listed above
(infiltrating lobular, infiltrating ductal, and medullary carcinoma) are invasive
malignancies that are capable of nodal and distant metastasis. Lymph node
dissection is commonly recommended for these invasive malignancies. Intraductal
lesions that have grown larger than 5 cm. are more apt to have become focally
invasive. Since this invasive component might be missed histologically, many
surgeons advocate selective use of axillary node dissection for large intraductal
lesions, particularly high-grade tumors such as the comedo variant. However, a
purely intraductal 2-cm. cancer would most likely be treated without performing
node dissection.
10
Failure to perform radiation after wide excision of an invasive cancer risks which
of the following outcomes?
Answer: A
DISCUSSION: Retrospective reviews and prospective surgical trials agree that
omission of breast radiation after wide excision leads to a higher rate of ipsilateral
breast recurrence. However, survival and the risk of distant disease are not altered
in patients treated by excision alone, within the follow-up time of the studies and
given their inherent power to detect differences in outcome. Regional node
metastasis is not affected by the choice of mastectomy versus wide excision and
radiation
Which of the following statement(s) is/are true concerning the surgical staging of
breast cancer?
Pathologic staging begins with the initial biopsy. Unless previously secured, fresh
tumor needs to be obtained for hormone receptor analysis prior to placement into
formalin solution. A period of warm ischemia as short as 30 minutes may cause
underestimation of estrogen receptor levels. The need to remove axillary nodes must
be determined preoperatively. Axillary lymph node metastasis will be found in
approximately one-third of clinically negative axillae, but only if proper axillary
dissection is performed.
. Removal of only level I nodes or “sampling” of axillary lymph nodes in a
haphazard fashion increases the risk of injury to major axillary neurovascular
structures and may understage up to 25% of women. Proper staging of axillary
lymph nodes should include en bloc removal and examination of level I and level II
nodes. When conducted for staging, axillary lymph node dissection should not
include removal of level III axillary nodes; in fewer than 2% are metastases present
in level III nodes when level I and level II nodes are negative. Removal of level III
nodes, however, does increase the incidence of postoperative arm lymph edema
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almost fivefold. Therapeutic axillary lymph node dissection performed for palpable
disease in the axilla should include removal of all levels to clear gross disease.
12