2. Diagnostic Studies Diagnostic MGM
Breast US – cystic or solid ; does not show microcalcifications!!!
Breast MRI - younger pts with very dense breasts
Percutaneous Bx
FNAB - cytology
Needle core bx
Image guided vs non image guided
Open bx – take to the OR

3. Diagnostic MGM Done when signs or symptoms are present
Review of previous images when available
Often includes specialized views such as
spot compression and magnification

4. Breast US Not used for screening
Distinguishes a solid from cystic lesion
Adjunct to MGM
Used for guiding percutaneous bx of solid
nodules palpable and nonpalpable
Not useful for bx of microcalcifications

5. Breast MRI Very limited use—no role for routine screening
High risk young women with very dense
breasts with nondiagnostic MGM
Post neoadjuvant chemotherapy to assess
for BCT
Pts with silicon breast implant
Must be done in a dedicated center with
experience in interpreting breast MRI and
capable of MRI directed bx

6. FNAB Image guided—US or stereotactic but not absolutely necessary
Simple, low morbidity and expeditious- - can have the result at time of visit if a cytopathologist is available
Sensitivity 65-98%
False positives rare, about, 0.2%
Requires a skilled cytopathologist
Gives cytology and NOT histology- -cannot distinguish invasive from noninvasive ca
Unless it is clearly benign, suspicious, or shows cancer cells, it is nondiagnostic;
Repeat FNA or use alternative bx technique
High n/c ratio; very rude pile on top of each other, pleomorphism\

7. Needle Core Bx
Image guided—stereotactic or US but not necessary for an easily palpable mass
Gives histology, thus, can distinguish in situ from invasive cancer
Requires at least 24hrs to have the result

8. Stereotactic Bx Smaller scar than open bx and minimal anesthesia
Accuracy=99%, similar to wire localized excisional bx; however, if malignant, wire localized excision will be required
Discordant results require further evaluation
MGM follow up of benign bx at 6 months
Contraindicated if pt cannot lie prone, lesion too faint or superficial for digital imaging

9. US Guided BX More comfortable and quicker than stereotactic bx
Not useful for lesions not seen on US such as microcalcifications
Discordant results require further evaluation
US and MGM follow up benign bx at 6 months

10. Excisional Open Bx The highest accuracy for DX but more
invasive than percutaneous bx
Combined with wire localization for
nonpalpable lesions
Specimen imaging mandatory for wire
localized excision

11. Wire localized Specimen MGM

12. Specific Benign Entities
Fibrocystic condition – very common
Mastodynia
Simple cyst
Complex cyst
Fibroadenoma
Gynecomastia
Nipple Discharge
Breast Abscess

13. Fibrocystic Condition (Changes)
Clinical manifestations of breast tissue
response to cyclical hormonal changes
Often associated with mastodynia or
mastalgia

14. Question 9
A 42-year-old woman with a history of "fibrocystic condition" undergoes excision of microcalcifications in her breast which were detected on mammography. The histologic finding associated with the highest risk of developing subsequent breast cancer is:
A. duct ectasia
B. squamous metaplasia
C. sclerosing adenosis
D. florid hyperplasia
E. atypical ductal hyperplasia

15. Pathological Changes Sometimes Associated with Fibrocystic changes
Non-proliferative changes (RR=1.0)
-cysts, mild hyperplasia of the usual type
Proliferative lesions without atypia
(RR= )-moderate or florid
hyperplasia, intraductal papilloma,
sclerosing adenosis
Atypical hyperplasia(RR= )
-ADH, ALH

16. Question 10
Which of the following treatments has been shown to provide relief of symptoms in more than 50% of patients with cyclical breast pain?
A. Evening primrose oil
B. Vitamin E
C. Ginger supplements
D. Elimination of caffeine
E. Weight loss

17. BLOODY NIPPLE DISCHARGE

18. Question 11
A 23 y.o lady presents with fever and breast abscess; she has NKDA. The BEST treatment is:
A. Empiric cephalexin
B. Empiric trimethoprim/sulfamethoxazole (TMX)
C. Incision and drainage alone
D. Incision and drainage, C & S, empiric cephalexin
E. Incision and drainage, C & S, empiric TMX

19. Question 12
The following statements are true regarding ductal carcinoma in situ EXCEPT :
A. Precursor of invasive ductal cancer
B. Usually presents as microcalcifications
on MGM
C. Never presents as palpable mass
D. Incidence is rising probably due to
increasing use of MGM
E. Dx’d by stereotactic core or wire localized bx

20. Noninvasive Breast Cancer-Ductal Carcinoma in Situ (DCIS)
Precursor of invasive ductal cancer
Age of occurrence same as for invasive cancer
Usually presents as microcalcifications
on MGM
Rarely presents as palpable mass
Incidence is rising probably due to
increasing use of MGM
Dx’d by stereotactic core or wire localized bx

21. Question 13
A 39-year-old woman has a 1x1x1-cm focus of microcalcifications in the lower outer quadrant of her left breast. No mass is palpable. Stereotactic core biopsy shows ductal carcinoma in situ, non-comedo type. The next step in management should be:
A. total mastectomy
B. a mirror image biopsy of the right breast
C. axillary sentinel node dissection
D. radiation therapy to the left breast
E. wide excision of the microcalcifications with assessment of the margins

22. Treatment of DCIS BCT consisting of breast conserving
surgery (margin free excision) if pt has
unicentric disease and RT or
total mastectomy if BCT is contraindicated
Axillary staging not needed
Recurrences after BCT can be invasive
ca or noninvasive
Tamoxifen if pt is hormone receptor positive.

23. Question 14
Which of the following is least likely to be diagnosed by mammography?
A.Comedocarcinoma
B. Lobular carcinoma in situ
C. Radial scar
D. Phyllodes tumor
E. Ductal carcinoma in situ

24. Lobular Carcinoma In Situ- -LCIS
Marker of pts at increased risk of having
invasive breast cancer
>80% occur in premenopausal women
Not apparent on CBE or MGM
Incidental microscopic finding
Relative risk 6-12 for developing invasive
breast cancer in either breast
1% per yr risk of developing invasive ca
Family hx may further increase the risk

25. Question 15 Which of the following statements about LCIS is NOT true?
A.Tamoxifen decreases the risk of invasive cancer
B. Pts. have an increased risk of bilateral breast cancer
C. Calcifications or a palpable mass are usually absent
D. Resection with negative margins is required
E. It is most common in premenopausal women

26. Management of LCIS Close observation (CBE Q 6 months,
annual MGM, monthly BSE)
Tamoxifen
Bilateral, prophylactic mastectomy with
or without reconstruction in select pts

27. Question 16
The most common histologic type of invasive breast cancer is which of the following?
A. Lobular carcinoma.
B. Papillary carcinoma.
C. Colloid carcinoma.
D. Medullary carcinoma.
E. Ductal adenocarcinoma

28. Invasive Breast Cancer (IBC)
Invasive ductal (70-75%)
Invasive lobular (5-10%)
Special types: medullary, tubular, mucinous
or colloid, papillary (less biologically
aggressive)

29. Question 17
In a 60-year-old woman, US guided core biopsy of a 1-cm in diameter breast mass shows infiltrating ductal carcinoma. At the minimum, therapy should include:
A. excision of the mass with negative margins only
B. total mastectomy
C. partial mastectomy, sentinel lymph node biopsy, and radiation therapy to the breast
D. chemotherapy with cyclophosphamide and doxorubicin
E. radiation therapy to the breast only

30. Neoadjuvant, Induction or Primary Chemotherapy- -Indications
Locoregionally advanced breast cancer as
part of multimodality therapy, then MRM
followed by RT; enhanced survival
To downsize a tumor for BCT, particularly
for tumors large relative to the breast- -
no survival advantage

31. Question 18
A 45 yo woman had multicentric breast cancer the largest focus 1.3 cm infiltrating ductal cancer, ER+, PR-, HER/2 neu neg; 1/3 SLN was +; the next BEST operative option is:
A.Total mastectomy
B. Modified radical mastectomy
C. Radical mastectomy
D. Simple mastectomy

32. Treatment of Invasive Breast Cancer (IBC)
Dependent on TNM stage, hormone
receptor status, menopausal state,
overexpression HER2/neu receptor
Locoregional and Systemic

33. AJCC Staging (Early Stage, 2010; 7th edition)
Stage 0 TisN0M0
Stage IA T1N0M0
Stage IB T0-T1 N1miM0
Stage IIA T0-1N1M0, T2N0M0
Stage IIB T2N1M0, T3N0M0

34. AJCC Staging (Advanced)
Stage IIIA T0-3N2M0, T3N1M0
Stage IIIB T4 N 0-2M0
Stage IIIC Any T N3M0
Stage IV Any T Any N M1

35. Locoregional Therapy Locoregional: Surgery + Radiation Therapy (RT)
Breast Conserving Therapy (BCT) =
Breast Conserving Surgery (BCS) + RT
Total mastectomy (if BCT is
contraindicated)+reconstruction
Axillary staging- sentinel lymph node bx
and/or level 1 and 2 ALND

36. Contraindications to BCT
Multicentric cancers
Diffuse malignant appearing
microcalcifications
Previous breast irradiation
Pregnancy (unless radiation is provided
after delivery)
Collagen vascular disease
(relative contraindication)

37. Mastectomy for Primary Operable Breast Cancer
Patient preference for mastectomy
Multicentric tumor
Difficulty with follow-up anticipated
Inability to achieve negative margin
with BCS
Contraindication to radiation therapy

38. Indications for Postmastectomy Radiation
Tumor > 5cm T4
> 4 +LNs

39. Sentinel Lymph Node

40. Systemic Therapy Chemotherapy- -CMF; AC; AC + Taxol
Hormonal– Tamoxifen(anti-estrogen);
Arimidex (aromatase inhibitor); Femara (AI)
Immunologic—Trastuzumab (Herceptin)—
monoclonal Ab vs HER2/NEU receptors;
Bevacizumab (Avastin)-humanized
monoclonal Ab vs VEGF

41. Neoadjuvant, Induction or Primary Chemotherapy- -Indications
Locoregionally advanced breast cancer as
part of multimodality therapy, then MRM
followed by RT; enhanced survival
To downsize a tumor for BCT, particularly
for tumors large relative to the breast- -
no survival advantage

42. Question 19
A 55 yo woman had left partial mastectomy for a 2.2 cm ER+, PR+, HER2/neu –ve infiltrating ductal cancer; 0/3 SLN was positive; resection margins were negative. The BEST postoperative management is:
A. Adjuvant chemotherapy followed by radiation therapy
B. Adjuvant chemotherapy followed radiation therapy and then hormonal Rx
C. Radiation therapy followed by hormonal therapy
D. Chemotherapy followed by hormonal therapy
E. Oncotype Dx detrmination to help in selecting the best treatment combination

43. Adjuvant Systemic Therapy
Cytotoxic
Hormonal
Biologic

44. Oncotype DX
A multigene assay to predict recurrence of tamoxifen-treated, node-negative breast cancer
3 risk categories
Low risk—6.8%
Intermediate risk—14-3%
High risk—30.5%
Paik et al: NEJM 2004; 351:

45. Breast Cancer in Pregnancy
Infrequent
California registry study-1.3 breast ca
Dx’d per 10,000 live births
Delay in Dx results in late stage at Dx
Neither the pt nor physician suspects cancer
Stage for stage, prognosis not different
Most tumors poorly differentiated, ER and
PR neg and approx 30% HER-2/neu pos

46. Evaluation for Breast Cancer in Pregnancy
CBE
MGM with shielding-accuracy > 80%
US to assess the breast and RLN and to
guide bx
Core bx preferred to FNA
Maternal fetal medicine consultation
Sentinel LNbx with radionuclide safe but
blue dye

47. Question 20
A 30 y.o. woman who is 14 weeks pregnant has a 2.5 cm. dominant slightly tender mass in the left breast. Biopsy shows grade II infiltrating ductal carcinoma. She has no palpable adenopathy. The best treatment now would be:
A. Partial mastectomy with sentinel lymph node bx followed by radiotherapy
B. Partial mastectomy with ALND, followed by adjuvant chemotherapy
C. Modified radical mastectomy
D. Modified radical mastectomy followed by adjuvant chemotherapy
E. Neoadjuvant chemotherapy followed by partial mastectomy

48. Question 21
A 34 y.o.woman who is 20 weeks pregnant has a 2.3 cm dominant, slightly tender mass in the LT breast. Core bx shows infiltrating ductal carcinoma. She should be advised that:
A. Preopearative Tamoxifen Rx is safe and effective
B. Chemotherapy is contraindicated
C. Breast conservation is an option
D. Sentinel node biopsy is a significant risk to the fetus
E. She should avoid all future pregnancies

49. Management of Breast Cancer in Pregnancy
RT contraindicated during pregnancy,
can be delayed until postpartum if ca Dx’d
2nd or 3rd trimester as part of BCT
Indications for chemotherapy the same but
NOT to be given during the 1st trimester
Chemotherapy may be given during 2nd
and 3rd trimesters but not after week 35 to
avoid the potential for hematologic
complications at time of delivery
Taxanes, trastuzumab and hormonal drugs should
not be used during pregnancy