Breast Review

7/17/2019 Breast Review

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1.What is the preferred imaging modality fora 29 yr patient with a palpable breast

mass?

a.Mammographyb.Ultrasound

c. CT scand.MRI

Answer : B- Ultrasound



CT scan – generally not used for evaluation ofbreast lesions.

MRI - false positive rate is 6% leading tounnecessary mastectomy or additionalbiopsies.

Mammography – not ideal for women lessthan 30 years old

because of breast density.



Breast Cancer Screening andDiagnosis

Lump/massAge <30 yr

Ultrasound(preferred)

Needle Sampling

or

or

Observe for 1- 2menstrual cycles (optionfor low clinical

suspicion)



2.What is the preferred imaging modality fora 49y/o female patient with a palpable

breast mass?

a.Mammographyb.Ultrasound

c. CT scand.MRI

Answer : A-Mammography







3.A 28y/o female with a palpable breastmass had an US result of a solid breast

mass suspicious for malignancy. What kindof biopsy is preferred in this case?

a.FNAB

b.Core Bxc. Incisional Bxd.Excisional Bx

Answer : B-Core Bx



FNAB - sensitivity- 95%- Needs an experienced cytopathologist

- False [+]- 0- 0.4% False [-] 0 – 4%- Can not distinguish between in situ

carcinoma and invasive carcinoma

accurately

Core needle bx - biopsy technique of choicespecially in the absence ofan experiencecytopathologist.

- sensitivity – 98.7%- has the ability to distinguish

between in situ carcinomaand invasive carcinoma.



Incisional bx - when open biopsy is indicatedfor large lesions

Excisional bx - indicated when needle biopsyis nondiagnostic and isdiscordant with physical examand imaging findings.

- difficult to do BCS after thistype of biopsy.



Solid:Indeterminateor

suspicious

Tissuebiopsy

Mammo-gram

Core

needlebiopsy(preferred)

Excision

Breast Cancer Screening andDiagnosis

or



4.A 45y/o female underwent mammogramfor breast screening. Mammograms final

assessment was BIRADS Cat. 3. Whatwould you do?

a.do nothing

b.do biopsyc. surveillance/follow up

Answer : C- surveillance/follow up



BIRADS – Breast Imaging Reporting AndData System

BIRADS Cat 3 – Probable benign findings-<2% risks of malignancy

– Follow up – PE every 6 mos.,

mammogram every 6-12mos. until long term stabilityis demonstrated (2 yrs orlonger)



5.A 25y/o female underwent FNA for a breastmass. Aspirate was non bloody fluid and

the mass completely disappeared . Nextstep would be:

a.cytology of aspirateb.excision biopsyc. follow up after 6 weeks

Answer : C- follow up after 6 weeks



Simple cyst are almost never malignant

Aspirated cyst fluid should not be routinelysent for cytologic examination.

• The clinical validity of atypia identified in

a cyst aspirate fluid is questionable andof low yield.

• Hindle et.al. – routine cytologic exam of

cyst aspirate fluid often results inunnecessary surgical biopsy and is notcost effective.



6.A 30y/o female underwent FNA for a breastmass. Aspirated fluid was greenish brown in

color. After aspiration the mass did notcompletely resolve. Next step would be:

a.cytology of aspirated fluid

b.excision biopsyc. follow up after 6 weeks

Answer : B- excision biopsy



Indications for excision biopsy of a cystafter FNA:

• bloody or serosanguineous aspirate• residual mass

• recurrent cyst after 2 aspirations



Breast Cyst - AlgorithmBreast mass

FNA Ultrasound

Cyst

Non-bloody Bloody Residual mass

Follow up after 6 wks. Excisional Bx

Recur

Excisional Bx

Does not recur

Reaspirate Follow up in 1 yr.

Recur

Excisional Bx

2 / f l l d li i



7.A 24y/o female consulted at your clinicbecause of a breast mass of 2mos. duration.On PE mass was found to be 2cms. in size,

well circumscribed, movable, and nontender. There were no palpable axillarymasses. Needle biopsy was done andhistopath result was fibroadenoma.

Management would be:

a.surgical excisionb.observec. total mastectomyd.quadrantectomy

Answer : A & B - Surgical excision or observe



Surgical excision – if patient desires removalof the mass

Breast mass can be observed if:- characteristic (clinically benign),2 – 3cms.in size

- < 25y/o, acceptable for those 25 – 30y/obut probably not there after

Observation is at 3 – 6mos. interval for 1 –

2yrs.

FA usually cease to grow at 2 – 3cms andmay regress in postmenopausal women



8.A 45y/o female with a 5cms. breast massunderwent core biopsy of said mass. Final

histopath showed malignant cystosarcomaphylloides. Appropriate treatment wouldinclude:

a.wide excisionb.adjuvant chemotherapyc. adjuvant hormonal therapyd.MRM

e.adjuvant RT

Answer : A- wide excision



Wide excision with clear margins [ 1cms. ] –appropriate surgical treatment of phyllodes

tumors whether benign or malignant.

Adjuvant chemotherapy- at present has no rolefor CSP

• role of chemotherapy [ Ifosfamide ] formetastatic CSP currently underinvestigation.

Adjuvant hormonal therapy – no role in CSP• ER & PR – [+] in 43% - 84% in epithelialcomponent

• [+] in 5% in stromal component



ALND – 20% with palpable axillary nodes

• <1% to 5% with [+] axillary nodes• minimally invasive nodal sampling done forclinically suspicious axillary nodes.

Adjuvant RT – role is unclear• indicated in recurrent tumors aftermastectomy

• anecdotal cases support the use of

combined chemo RT following CSPrecurrences.



9.A 42y/o female with a 5cms. breast massunderwent FNAB and was diagnosed to havefibroadenoma. However, after excision, finalhistopath turned out to be CSP. Furthermanagement would be:

a. Immediate reexcisionb.Observec. RT to involved breast

Answer : B-Observe



Authors opinion differ on whetherimmediate reexcision is necessary.• Chua, Thomas & Ng [ Singapore ] – 16%

recurrence rate

• Zurrida et al [ Milan ] – 8% recurrence

rate

These authors suggest that a “wait andwatch” policy for benign CSP may be

considered in place of mandatory surgicalreexcision. Specially in cases wherereexcision would be difficult and deforming.



10.A 35y/o female consulted because of breast pain and tenderness. 3 days PTC,

ultrasound was done which showed acomplex mass at the UIQ of the leftbreast. Appropriate treatment would be:

a. I&D + antibioticsb.Repeated aspiration + antibioticsc. Surgical excisiond.Core bx

Answer : B- Repeated aspiration +antibiotics



The combination of repeated aspiration andoral antibiotics is usually effective at resolving

local abscess formation and is the currenttreatment of choice for most breastabscesses. Aspiration should be repeatedevery 2 – 3 days until no further puss is

obtained.

Immediate I&D is done if the skin overlyingthe abscess in thinned and puss is visible onultrasound.



11.Risk of subsequent breast CA amongpatients with this benign breast lesion is

not increased.

a. fibroadenomab.sclerosing adenosis

c. apocrine changed.atypical ductal hyperplasia

Answer : C- apocrine change



Nonprolifetative - NO Risk

Cyst

Papillary apocrine change

Epithelial-related calcifications

Mild hyperplasia of the usual type

Proliferative lesions w/o atypia - 1.5-2x Risk

Moderate or florid ductal hyperplasia of the usual type

Intraductal papilloma

Sclerosing adenosis

Fibroadenoma

Profilerative lesions w/ atypia - 4 -5x Risk

Atypical ductal hyperplasia

Atypical lobular hyperplasia

Categorization of Benign Breast Lesionsaccording to the Criteria of Dupont,

Page, and Rogers



12.32 y/o female diagnosed with LCIS withnegative family history of breast or ovarian

CA. Most appropriate management would be:

a.Observation/ Surveillance

b.Chemoprevention with Tamoxifenc. Prophylactic mastectomyd.Breast conservation surgery

Answer : A- Observation and Surveillance



LCIS – 5% incidence• marker of increased breast cancer risk

but not a disease by itself • App. risk of developing invasive BCA is

1%/ yr.• If with [ + ] family history risk is

increased to 2% / yr.

Observation - strategy selected by mostpatients

• 16.4% developed invasive BCAdisease related mortality – 2.8% vs.0.9% (patients treated withprophylactic mastectomy).



Prophylactic mastectomy indications:

• New LCIS lesions – 16x risk• Strong family history of breast andovarian CA

• BRCA1 & BRCA2 genetic mutations

• Patient preference

Tamoxifen – reduce incidence of BCA by 49%- effect not known in women

<35y/o



13.A 39y/o female consulted with amammogram finding of suspicious calci-fications on the right breast. Stereotactic core

bx was done and histopath revealed LCIS.However, not all calcifications were removedduring the core bx procedure. You would:

a.Observation / surveillanceb.Mammography guided needle

localization bx of remaining calcifications

c. Do RT of right breast

Answer : B-Mammography guided needlelocalization bx of remaining

calcifications



LCIS is an incidental finding on biopsies. Itdoes not account for any physical findings ormammographic/ultrasonographicabnormalities. Primary concern should focuson whether some additional pathologic

process is present that would explain theclinical/ imaging feature that prompted thebiopsy. Although very low rates of significantdisease is found on follow up excision bx ,

the preponderance of the data reveals thatthe completely benign cases can not bereliably predicted, and therefore follow upexcision bx is the definitive management

14 A 50y/o female consulted because of a



14.A 50y/o female consulted because of amammographic result of BIRADS-4. Needlelocalization excision bx was done and

histopath result was DCIS 0.5cms. in sizewith negative margins. Possible surgicalmanagement would include:

a.Excision aloneb.Excision + RTc. Total mastectomyd.Total mastectomy + RT

e.MRM

Answers: A, B & C -Excision alone;Excision + RT; Totalmastectom



Adjuvant RT after total mastectomy is not

indicated in DC IS because totalmastectomy alone has a local recurrence rateof only about 1%.

Axillary dissection is not indicated in DCISbecause the incidence of ALN mets is onlyabout 0.5%.

For many patients with DCIS totalmastectomy is over treatment.



Indications for Mastectomy:

• Large diffuse lesions [>3cms. in size]• Documented multicentric disease• Patient unwilling to take even the

slightest increased risk of death

• Patient with no interest for BCT ormedically unsuited for BCT

• Patient unwilling or unable to undergocareful long term clinical follow up.

• Persistent [+] margins



Marginsnegative

Excision + RT

orTotal mastectomyw/o lymph nodedissection +

reconstruction

Small (<0.5cm),

unicentric, lowgrade

Excision + RTorTotal mastectomyw/o lymph node

dissection +reconstruction orExcision alone

Ductal Carcinoma In Situ



15.A 52y/o female was diagnosed with DCIS.After excision histopath result was; tumor

size was 1.6cms., margins were >1cms.,tumor was non- high grade with comedonecrosis. Based on the Van Nuys PrognosticIndex, treatment of choice would be:

a.Excision aloneb.Excision + RT

c. Total mastectomy

Answer: B-Excision + RT [VNPI score-7]



Van Nuys Prognostic Index:• Size score- 15mm or less- 1 ; 16mm

to 40mm-2; 41mm or more- 3

• Margin score- 10mm or more- 1 ;1mm to 9mm- 2 ; 1mm or less- 3



• Pathological Classification score- non-highgrade w/o comedo necrosis- 1 ; non- highgrade w/ comedo necrosis- 2 ; high gradelesion- 3

• Age score- >60y/o- 1 ; 40y/o to 60y/o- 2

;<40y/o- 3

Old New Recommendation

3 to 4 4 to 5 to 6 Excision alone5 to 6 to 7 7 to 8 to 9 Excision + RT

8 to 9 10 to 11 to 12 Total mastectomy

Treatment Recommendations:

16 A 45 /o patient cons lted in o clinic



16.A 45y/o patient consulted in your clinicbecause of a 4cms. breast mass fixed tothe pectoralis muscles. There were

palpable movable axillary nodes in theipsilateral axilla. Biopsy was done andhistopath result was IDCA. There were noclinical evidence of metastases. What is

the clinical stage?

a.Stage III-Bb.Stage IVc. Stage III-Ad.Stage II-B

Answer: D-Stage II-B [T2 N1]



T4a - Extension to chest wall , not includingpectoralis muscle

T2 - Tumor >2cms. but not >5cms. ingreatest dimension

N1- Metastasis to movable ipsilateral axillarylymph node[s]

Stage II-B – T2 N1 M0T3 N0 M0



17.A 57y/o patient has a 2cms. breast massdiagnosed as IDCA. Nipple retraction andskin dimpling was noted on the ipsilateralbreast. There were no palpable ipsilateralaxillary nodes and there were no clinicalevidence of metastasis. What is the clinical

stage?

a.Stage IVb.Stage III-C

c. Stage Id.Stage III-B

Answer: C- Stage I [T1 N0



Skin of breast - Dimpling of the skin, nippleretraction, or any other skin

change except those describedunder T4b and T4d may occurin T1,T2,orT3 without changingthe classification

T4b - Edema [including peau d’orange] orulceration of the skin of the breast,or satellite nodules confined to the

same breast.

T1c -tumor >1cm. but not >2cms. in

greatest dimension



18.A 61y/o patient has a 1.5cms. breast massdiagnosed as IDCA. A palpable

supraclavicular node was also noted. What isthe clinical stage?

a.Stage IVb.Stage III-Ac. Stage III-Bd.Stage III-C

Answer: D- Stage III-C [T1 N3c M0]



N3a - Metastasis in ipsilateral infraclavicularlymph node [s]

N3b - Metastasis in ipsilateral internalmammary lymph node[s] and axillary lymphnode [s]

N3c - Metastasis in ipsilateral supraclavicularlymph node [s]

Invasive Breast Cancer – PreOp



Invasive Breast Cancer – PreOpWork up

Stage I

Stage IIAStage IIBT3, N1, M0

• H & P• CBC, platelets• Liver function tests• Chest x-ray• Diagnostic billateral mammogram,ultrasound as necessary• Pathology review• Determination of tumorestrogen/progesterone receptor (ER/PR)status and HER-2 status• Breast MRI w/ dedicated breast coil may

be considered for breast conserving therapyfor preoperative evaluation of extent ofdisease and detection of mammographicallyoccult disease in the breast (optional).• Bone scan (optional)

• Abdominal CT or US or MRI (optional)



19.A 55y/o female consulted in your clinicbecause of a 2cms. breast mass which wassubsequently diagnosed as IDCA. There wereno palpable axillary nodes. Possible surgicaltreatment would include:

a.Lumpectomy + ALNDb.Lumpectomy alonec. Total mastectomyd.MRM

Answer: A & D -Lumpectomy + ALND; MRM



BCS- Lumpectomy + ALNDBCT- Lumpectomy + ALND + RTIncidence of [+] ALN mets in IDCA measuring2cms.-> 25%

20 A 62 / ti t ith 2 5 b t



20.A 62y/o patient with a 2.5cms. breastmass at the UOQ of the right breastunderwent bx which showed IDCA.

Mammography showed clusteredcalcifications in the IUQ & LOQ of the rightbreast. Bx of said lesions showed DCIS.Surgical treatment of choice would be:

a.BCSb.MRM

c. Radical mastectomyd.Extended radical mastectomy

Answer: B-MRM



Absolute Contraindications to BCT:• Women with 2 or more primary tumors in

separate quadrants of the breast or withdiffuse, malignant appearingmicrocalcifications are not consideredcandidates for BCT.

• A history of previous therapeuticirradiation to the breast region that,combined with the proposed treatment,

would result in an excessively high totalradiation dosage to asignificantvolume.

b l d



• Pregnancy is an absolute contraindicationto the use of breast irradiation. However,in many cases, it may be possible toperform BCS in the 2nd & 3rd trimester andtreat the patient with irradiation afterdelivery.

• Persistent [+] margins after reasonablesurgical attempts absolutely contraindicateBCT. The importance of a single, focally [+]microscopic margin needs further study and

may not be an absolute contraindication.



Relative Contraindications to BCT:• A history of collagen vascular disease isa relative contraindication to BCT, becausepublished reports indicate that suchpatients poorly tolerate irradiation. Most

radiation oncologists will not treat patientswith scleroderma or active lupuserythematosus, considering either anabsolute contraindication. In contrast,

rheumatoid arthritis is neither a relativenor an absolute contraindication.



• Patients with multiple gross tumors in the

same quadrant and indeterminatecalcifications must be carefully assessed forsuitability because studies in this area are notdefinitive.



• Tumor size is not an absolutecontraindication to BCT, although few reports

have been published about treating patientswith tumors larger that 4 to 5cms. However arelative contraindication is the presence of alarge tumor in a small breast, in which an

adequate resection would result in significantcosmetic alteration. In this circumstance,preoperative chemotherapy or endocrinetherapy or the use of partial breastreconstruction should be considered if thepatient desires BCT.



• Breast size can be a relativecontraindication. Women with large or

pendulous breasts can be treated withirradiation if reproducibility of patientsetup can be ensured and if it istechnically possible to obtain adequate

dose homogeneity.

•Women 35 y or younger.

•Premenopausal women with a knownBRCA ½ mutation.



Non Mitigating Factors:• The presence of clinical or pathologic

involvement in axillary nodes.Tumorlocation is not a factor in the choice oftreatment. Tumors in a superficialsubareolar location occasionally may

require resection of the nipple areolarcomplex so that [-] margins can beachieved, but this does not affect outcome.The patient and her physicians need toassess whether such a resection ispreferable to mastectomy.



• A high risk of systemic relapse is not a

contraindication for BCT but it is adeterminant of the need for adjuvanttherapy.



21.A 52y/o female underwent screeningmammography which showed

microcalcifications on her left breast. Itwas read as a BIRADS Cat 5 lesion.Management would include:

a.US guided core bxb.Mammography guided needle

localization excision bxc. Stereotactic core bxd.If dx as malignant- determination of

hormone receptor statuse.Frozen section

Answer: C, B, D - Stereotactic core



Stereotactic core bx- preferred bx techniquefor mammographic calcificationsbecause its accuracy is the same as

that of MGNLB and is less invasive.

US core bx- ultrasound can not detectmammographic calcifications

bx;Mammography guided needle

localization bx ; If dx asmalignant-

determination of

hormone receptor status



Frozen sections should not be performed on

non palpable lesions because of the loss oftissue caused by the FS process. In addition,because most of the specimen is fat [whichdoes not freeze well], they are technically

difficult to perform, often inaccurate, and maybe extremely difficult to interpret. Most impt.,definitive treatment should not be decided onuntil permanent sections have been

thoroughly evaluated.



With

Tamoxifen

W/o

TamoxifenNSABP B14 -10 yr. rate of

recurrence in ipsilateral

breast 4.3% 14.7%

Stockholm grp -3.0% -12.0%

W/ RT

RT +

Tamoxifen

NSABP B21 - 8 yr. rate of

ipsilateral recurrence 9.3% 2.8%

22.A 52y/o female who was diagnosed with



IDCA is undergoing MRM. During axillarydissection the surgeon was able to palpate

enlarged nodes posterior to the pectoralisminor muscle. Appropriate axillary dissectionwould be:

a.Axillary samplingb.Level I dissection onlyc. Level 1&2 dissectiond.Total axillary lymphadenectomy

[level1,2,3]

Answer: D- Total axillarylymphadenectomy

f



Types of ALND:• Axillary sampling- provides 4 to 7 nodes,

includes axillary tail of Spence and level 1nodes

• Low level 1, dissection stops superiorly

at the level of the major intercostobrachialnerve

• Level 1, up to axillary vein superiorly;

mean # of nodes is 10; lateral border isthe latissimus dorsi and medial border isthe pectoralis minor muscle



• Level 1&2, includes nodes posterior tothe pectoralis minor muscle and Rotter’s

nodes.

• Level 1,2,3 [Total axillarylymphadenectomy] medial border is thesubclavius muscle[Halsteds ligament]



Surgical Extent:ALND is therapeutic by reducing the

risk of axillary recurrence to <5% andprognostic, by allowing even moreaccurate determination of nodalmetastasis.

Clearly 80% - 90% of ALN are foundin levels 1&2

A level 1&2 dissection is adequate inthe absence of gross disease.

Incidence of skip mets to level 3 - 1% to 3%



Werner [MSKCC]The level of node dissection was notstatistically related to the development of armedema, the only factor that was significantly

associated was obesity.

Incidence of skip mets to level 3 1% to 3%[+] level 1 nodes - 28% risk of mets to level2&3

Skip mets to level 2- 1.2% - 5%Level 1&2 [+]- 33% of level 3 nodes are [+]

Axillary sampling 0 – 2.8%

Level 1&2 2.7% - 7.4%

Level 1,2,3 3.1% - 8%

Axillary RT 2.1% - 8.3%

Axillary RT + Total ALND 3 – 7 fold increase in incidence

Incidence of lymphedema:



Armando Giuliano [John Wayne Cancer

Inst.]When surgery is the treatment selected,

level 1&2 dissection is sufficient for stagingand local control, with dissection of level 3

reserved for extensive gross disease toimprove local control.



23.A 55y/o female with a 4.5cms mass at theleft breast was diagnosed by core bx to

have IDCA. Patient underwent MRM.Margins were >1mm and ALN were [-] formets. Would you give adjuvant RT?

a.Yesb.No

Answer: B-No



Indications for PMRT:• Patients with 4 or more [+] ALN

• Patients with 1 to 3 [+] ALN- there isinsufficient evidence to makerecommendations or suggestions for theroutine use of PMRT in these patients.



• Patients with T3 or Stage III tumors- PMRT issuggested for patients with T3 tumors with

[+] ALN and patients with operable Stage IIItumors

• Patients undergoing preop systemic therapy-

there is insufficient evidence to makerecommendations or suggestions on whether

all patients initially treated with preopsystemic therapy should be given PMRTfollowing surgery.

Invasive Breast Cancer – LocoRegionalf Cli i l S 3 0



Treatment of Clinical Stage I,II or T3,N1, M0

Totalmastectomyw/ surgicalaxillary staging(category 1) +reconstruction

> 4 positiveaxillary nodes

1- 3 positiveaxillary nodes

Negative axillarynodes and tumor>5cm T3,No ormargins positive

RT to chest wall +supraclaviculararea(category1). ConsiderRT to IMN (category 3)

Consider RT to chest wall +

supraclavicular area(category1) if RT is given,consider internal mammaryRT (category 3)

RT to chest wall. ConsiderRT to supraclavicular area(category 2B) Consider RTto internal mammary

nodes (category 3).

Invasive Breast Cancer – LocoRegional



Treatment of Clinical Stage I,II orT3,N1, M0

Totalmastectomyw/ surgical

axillarystaging(category 1)+

reconstruction

Negativeaxillary nodesand tumor<5cm andmargins close(<1mm)

Consider RT to chestwall

Negativeaxillary nodes

and tumor<5cm andmargins>1mm

No RT

A 70 / f l ith 9 i ht b t



24.A 70y/o female with a 9mm. right breastmass was diagnosed b y core bx to have

IDCA. Lumpectomy + ALND was done.Axilla was [-] for mets. Tumor wasER+/PR+. Adjuvant treatment must include:

a.Adjuvant RTb.Adjuvant chemotherapyc. Adjuvant hormonal therapy

Answer: C- Adjuvant hormonaltherapy

Adj RT h ld l



Adjuvant RT should always accompanyBCS. However, in those 70 yrs. of age or

older with ER+, node[-], T1 tumors breastRT may be omitted.

There is no indication for chemotherapy

in this case. There is insufficient data tomake chemotherapy recommendation forthose 70y/o and over. Always considercomorbid recommendations.

Adjuvant hormonal therapy is indicatedin all patients with ER+/PR+ tumors.

25.A 50y/o female has an 8mm breast mass



y/diagnosed as IDCA. She underwent BCS.Axilla had 2[+] nodes out of 10. Tumor was

ER-/PR-. Adjuvant treatment would include:


Answers: A,B - Adjuvant RT & Adjuvant chemotherapy

For node [+] patients chemotherapy is givenregardless of age and hormone receptor

status.

26.A 42y/o female with a 1.5cms. breast



mass was diagnosed to have IDCA. Sheunderwent MRM. Axillary nodes were [-]

for mets. Tumor was ER-/PR-, HER 2 +.Appropiate adjuvant treatment would be:

a.Adjuvant RT

b.Adjuvant chemotherapyc. Adjuvant hormonal therapyd.No adjuvant therapye.Adjuvant chemotherapy +

trastuzumab

Answer: E-Adjuvant chemotherapy

+ trastuzumab

Invasive Breast Cancer – Systemic



Adjuvant Treatment – Hormone Non-Responsive Disease

ER-negativeand PR-negativeand

HER2positive

Histology•

Ductal,NOS•Lobular•Mixed•Metaplastic

pT1,pT2, orpT3 andpN0 orpN1mi (<2mmaxillary

nodemetastasis)

Invasive Breast Cancer – Systemic



Adjuvant Treatment – Hormone Non-Responsive Disease

pT1,pT2,

or pT3and pN0or pN1mi(< 2mmaxillary

nodemetastasis)

Tumor<0.5

cm orMicroinvasice

Tumor 0.6-

1.0cm

Tumor >1cm

pN0

Adjuvantchemotherapy +trastuzumab

Considerchemotherapy

(category1)

pN1mi Considerchemotherapy

No adjuvanttherapy

27 A 39y/o female premenopausal with a



27.A 39y/o female, premenopausal, with a2cms. breast mass was diagnosed with IDCA.BCT was done. Tumor was ER+/PR+. What isthe most appropriate adjuvant hormonaltreatment?

a.Ovarian ablationb.Tamoxifen 20mgs. X 10yrs.c. Tamoxifen 20mgs. X 5yrs.d.Aromatase inhibitors

e.Megestrol acetate [Megace]

Answer: C-Tamoxifen 20mgs. X 5yrs.



Level II, grade A evidence supports no added

benefit of ovarian ablation in women withnode negative or node positive BCA who aretreated with chemotherapy. Whether there isbenefit for women who do not become

amenorrheic following chemotherapy is notknown.

T if i f h 5



Tamoxifen given for more than 5yrs.does not improve LRR and DFS compared

to Tamoxifen given for a maximum of 5yrs.

Aromatase inhibitors at present aregiven only to postmenopausal patients.

Megestrol acetate [Progerstin], isgenerally not used because of theavailability of better agents for hormonal

treatment.

28 A 46y/o premenopausal patient undergoes



28.A 46y/o premenopausal patient undergoesBCS for a 2cms. tumor diagnosed as IDCAof the left breast. The margins are clearand 5 out of 15 ALN are [+] for mets.Tumor was ER-/PR+. Recommendedadjuvant treatment should be:

a.RT + Chemotherapyb.RT + Hormonal therapyc. Chemotherapy + Hormonal therapy

d.RT alonee.Chemotherapy + RT + Hormonal

therapy



Answer: E- Chemotherapy + RT +

Hormonal therapy

Chemotherapy- tumor size is >1cm.RT- as part of BCT; >4 [+] ALN for mets

Hormonal Tx- tumor is PR+

29.What is the most appropriate sequence in



giving adjuvant therapy?

a.RT then Chemotherapy then HormonalTx

b.Hormonal Tx then Chemotherapy thenRT

c. [RT + Chemotherapy] then Hormonald.Chemotherapy then RT then Hormonal

Txe.Chemotherapy then Hormonal Tx then

RT

Answer: D-Chemotherapy then RT

then Hormonal Tx

Chemotherapy is given initially because itseffect are both on locoregional and systemic



Chemotherapy and RT are usually notcombined because of higher morbidity rates.

Hormonal treatment is given last and isgiven for 5yrs. It is usually not combined with

chemotherapy because theoretically it inhibitscell proliferation.

Chemotherapy is more effective on

proliferating cells.

effect are both on locoregional and systemiccontrol.

RT is given next for locoregional control.

American Society of Clinical Oncology ForBreast Cancer Follow Up Care



Test Frequency

Recommended

History (eliciting of symptoms) and physicalexamination

Every 3-6 mo for 3 years;

every 6-12 mo for 2 years;

then annually

Breast self-examination Monthly

Mammography Annually

Pelvic examination Annually

Patient educate regarding symptoms ofrecurrence NA

Coordination of care NA

Not recommended

Complete blood cell count

Automated chemistry studies

Chest roentgenographyBone scan

Ultrasound of the liver

Computed tomography of chest, abdomen,

and pelvis

Tumor marker CA-15-3

Tumor marker carcinoembryonic antigen

Breast Cancer Follow-Up Care

30.A 61y/o female consulted in your clinic



y/ ybecause of a 7cms. ulcerating, fixed mass ofthe left breast. There were palpable movable

ALN in the left axilla. Biopsy of the massrevealed IDCA. What would be theappropriate initial management?

a.MRMb.RTc. Radical mastectomy

d.Extended radical mastectomye.Neoadjuvant chemotherapy

Answer: E-Neoadjuvant chemotherapy

The historical experience of surgically



treated patients with LABC was poor.Although surgical resection was technically

possible, 10yrs. after diagnosis >80% of patients had succumbed to the disease.

After giving neoadjuvant chemotherapy

a major reduction in tumor volume occurredin most [60% to 80%] patients. Clinicalcomplete remissions were reported in 10% to20% of patients so treated in most clinicaltrials. In one multicenter trial, the increase inclinical and pathologic complete responserate was associated with improved disease-

free and overall survival rates.

Invasive Breast Cancer –Treatment forLABC



LABC

Doxorubicin-orepirubicin-based or

paclitaxel-ordocetaxel-basedpreoperative

chemotherapypreferred

Response

MRM +

RT or BCTor Highdose RTalone

(category3)

Noresponse

Additional

chemotherapy +hormonaltherapy ifestrogenreceptorpostive orunknown

Consider additionalsystematicchemotherapyand/or preoperative

radiation

31.A 62y/o female underwent BCT of the left



breast because of a 2cms. mass diagnosedas IDCA. 5yrs. later, a 2.5cms. mass was

noted again on the left breast. Core bx wasdone and histopath result was IDCA. What isthe preferred surgical management?

a.MRMb.BCSc. Total mastectomyd.Radical mastectomy

Answer: C-Total mastectomy



Management of LRBC after BCT:Radiologic evaluation

• Bilateral mammography• Other imaging studies as indicated [US

and MRI]

Establish diagnosis• Core biopsy or surgical biopsy

[preferred]• FNA cytology



Metastatic workup for patients with invasive

carcinoma Treatment• Mastectomy [preferred]• Less than mastectomy [ local excision,

reirradiation] for highly selected patients

Consider systemic therapy [ chemotherapyand/or hormonal therapy] for high risk patients[short disease free interval, high gradetumor,[+] ALN].

32.A 49y/o patient underwent MRM for a4 i ht b t di d IDCA



4cms. right breast mass diagnosed as IDCA.There were no nodes [+] for mets. 2yr.

later, patient noted a 3cms. fixed mass onthe chest wall. Biopsy of the mass showedIDCA. Tumor was hormone receptor [+].Appropriate management would include:

a.Excision of chest wall massb.RTc. Chemotherapyd.Hormonal therapye.All of the above

Answer: E-All of the above

Management of LRBC aftermastectomy:



mastectomy:• Establish diagnosis

• Metastatic work up• Treatment

Local excision if operable RT, generally to minimum volumes

of chest wall and supraclavicular fossa Consider chemotherapy and/orhormonal therapy For inoperable local recurrence,

consider radiation [or reirradiation],systemic therapy, other modalities[hyperthermia, photodynamictherapy].

Invasive Breast Cancer –Treatment of



LRBC

Localrecurrence

Initialtreatment w/mastectomy

Initialtreatment w/

lumpectomy+ RT

Surgicalresection (ifpossible) +RT (if

possible)

Mastectomy

Considersystemictherapy

Considersystemic

therapy

A 30 / ti t t AOG 10 11 k



33.A 30y/o patient, pregnant AOG-10-11wks.,consulted because of a 1.5cms. mass on the

left breast. Core bx result was IDCA.Appropriate surgical treatment would be:

a.Lumpectomy + ALND

b.Lumpectomy alonec. Total mastectomyd.MRM

Answer: D-MRM



BCT is contraindicated in pregnancy during

the 1st

trimester.

ALND should always be a part of definitivesurgical procedures for the treatment of

invasive BCA.

34 Recommended adjuvant treatment for the



34.Recommended adjuvant treatment for theabove case would be:


d.None of the abovee.All of the above

Answer: D - None of the above

Management of PABC:



Management of PABC:• MRM is the standard management of a

patient with BCA during pregnancy.

• RT should be avoided during any trimesterbecause of the dose, due mainly to

internal scatter, absorbed by the fetus.

• Chemotherapy during pregnancy must beconsidered on a case by case basis



considered on a case by case basisbecause of the risk of fetal damage,

including the effort to avoid chemotherapyin the 1st trimester. There is an 11.5% to12.7% incidence of teratogenicity duringthe 1st trimester. Although chemotherapy

may be started during the 2nd

trimester,there are reports of impaired CNSdevelopment and delayed cognitivedamage during this period.

• Hormonal therapy is not indicated duringpregnancy because there is positiveevidence of human fetal risk [teratogenic

or embryocidal etc.].

35.A 50y/o woman consulted because of a6cms mass at the right breast Core biopsy



6cms. mass at the right breast. Core biopsyshowed IDCA. Mammography was done

which showed a 0.8cms. mass at the leftbreast. Biopsy result of the left breast masswas DCIS. Both tumors were hormonereceptor [+]. Management would include:

a.MRM right, Lumpectomy leftb.Bilateral MRMc. MRM right, Lumpectomy + ALND left

d.Adjuvant RT both sidese.Adjuvant chemotherapy + hormonal

therapy

Answer: A D E MRM right



Answer: A,D, E - MRM right,Lumpectomy left;

Adjuvant RT both sides ; Adjuvant chemotherapy+ hormonal therapy

Manage each lesion individually.



Manage each lesion individually.

ALND is not necessary for DCIS lesions

Adjuvant RT is indicated for lesions 5cms. ormore in size and as part of management for

DCIS lesions.

Adjuvant chemotherapy is indicated forinvasive lesions 1cm. or more in size.

Adjuvant hormonal therapy is indicated for allhormone receptor [+] breast cancer.

Criteria for the diagnosis of a secondprimary breast cancer



primary breast cancer

1.The demonstration of a situ change in thecontralateral tumor is considered absoluteproof that the contralateral lesion isprimary tumor.

2.The tumor in the second breast isconsidered to be a new primary if it ishistologically different from the cancer in

the first breast.

Criteria for the diagnosis of a secondprimary breast cancer



primary breast cancer

3.The carcinoma in the second breast is

considered to be a new primary if its degreeof histologic differentiation is distinctlygreater that that of the lesion in the firstbreast.

4.In the absence of definite histologicdifference, a contralateral carcinoma is

considered to be compatible with anindependent lesion provided there is noevidence of local, regional, or distantmetastases from the cancer in the ipsilateral

breast.

36.A 25y pregnant woman consulted in your



clinic because of a firm 2.5cms. left breastmass which is tender and sometimes

painful. Core bx showed granulomatouslobular mastitis. Management would be:

a.Excision Biopsyb.Antibioticsc. I & Dd.Observation

e.Steroids

Answer: Observation

Excision of the mass in granulomatous



• Excision of the mass in granulomatouslobular mastitis should be avoided because it

is often followed by persistent wounddischarge and failure of the wound to heal.

• Antibiotics- the role of organisms in the

etiology of this condition is unclear and untilthis is confirmed antibiotics is not clearlyindicated in this condition.

• I&D- indicated only in the presence of anabscess.



• Current tx involves establishing the dx and

observation because the condition usuallyresolves w/o specific tx.

• Steroids have been tried w/o consistent

success.

37 The only group of patients w/ benign non



37.The only group of patients w/ benign nonproliferative breast lesions with an

increased risk for development of BCA arethose patients with:

a.Papillary apocrine change

b.Mild hyperplasia w/ + family history ofBCA

c. Epithelial related calcificationsd.Cyst w/ + family history of BCA

Answer: D – Cysts w/ + familyhistory of BCA



According to Dupont and Page, the risk of

subsequent BCA in px w/ non proliferativebreast lesions even with + family history of BCA compared to women who have had nobreast bx is not increased. The only group of

px in the non proliferative category w/ anincreased risk for development of BCA wasthat of gross cysts + a family history of BCA.The relative risk was increased to 3.0.

38.60y woman underwent MGNLB. Histopathh d DCIS / l i l i



showed DCIS w/ close surgical margins(<1mm) at the fibroglandular boundary of

the breast. The appropriate subsequent txis:

a.Surgical re-excision is a mustb.Higher boost dose radiation is

indicated to the lumpectomy site.c. Chemotherapy

d.Total mastectomy

Answer: B- Higher boost doseradiation to lumpectomy site

• With respect to pathologic margins between



p p g g1–10mm, wider margins are generally

associated w/ lower recurrence rates.However, close surgical margins (<1mm) atthe fibroglandular boundary of the breast(chest wall and skin) do not mandate surgical

re-excision but is an indication for higherboost dose radiation to the involvedlumpectomy site. (Cat.2B)

• Chemotherapy- not indicated

•Total mastectomy- not indicated

39.The following are relative contraindicationst BCT t



to BCT except:

a.Active connective tissue diseaseinvolving the skin.

b.Tumors > 5cms.c. Diffuse suspicious or malignant

appearing calcifications involving morethan 1 quadrant of the breast.

d.Women 35y and younger

e.Premenopausal women w/ a knownBRCA ½ mutation.

Answer: C- (Absolute

contraindication)

40.53y female was dx w/ DCIS after core



needle bx. She underwent lumpectomy ofthe remaining lesion. Histopath of thelesion showed a concomitant invasivedisease w/ adequate negative margins.Further surgical management would be:

a.Total mastectomyb.Total mastectomy w/ ALNDc. Axillary staging

d.No further surgical mx

Answer: C- Axillary staging



• Total mastectomy- not necessary becauseexcision of the lesionrevealed adequatenegative margins.

• Axillary staging- necessary for all invasivelesions. ( ALND & SLNB )

41.48y woman underwent MRM for a 2cms.



Left breast mass w/c turned out to be ILCA.ALND revealed 16 axillary nodes w/ 11 (+)for micrometastases. There was noevidence of distant metastases. Pxpathologic stage is:

a.Stage III-Cb.Stage II-Ac. Stage III-A

d.Stage II-B

Answer: B- Stage II-A (T1N1M0)



• Micrometastases are defined as tumordeposits > 0.2mm but not > 2.0mm inlargest dimension. Cases in w/c onlymicromets are detected are classified aspN1mi.

• pN3a- Metastases in 10 or more ALN w/ atleast 1 tumor deposit > 2.0mm, or mets tothe infraclavicular lymph nodes.

42 57y female w/ a right breast mass



42.57y female w/ a right breast massmeasuring 3cms. in size. Core bx done

showed IDCA. MRM was done. Tumor wasER+/PR+, HER2+ w/ negative ALN. All ofthe foll. are indicated adjuvant tx except:

a.Chemotxb.Radiotxc. Hormonal Txd. trastuzumab

Answer: B- Radiotx

Adj chemotx indicated for tumor size



• Adj. chemotx- indicated for tumor size>1cm.

• Adj. hormonal tx- ER+/PR+

•Adj. trastuzumab- HER2 +

•Adj postmastectomy RT- indicated in px w/T3N1 tumors and in

px w/ 4 or more +for mets ALN.

43.42 y female dx w/ BCA is on adjuvantf h b h f



tamoxifen. She became amenorrheic after3yrs of tamoxifen and was later shifted toLetrozole (AI). After 4 mos. on Letrozoleshe begun to menstruate again. You would:

a.Continue Letrozoleb.Shift to other AI (Anastrozole orExesmestane)

c. D/C Letrozole & resume tamoxifen

d.D/C hormonal tx

Answer: C- D/C Letrozole & resumetamoxifen

NCCN Some women who appear to



• NCCN- Some women who appear tobecome postmenopausal on tamoxifen tx

have resumption of ovarian function after d/ctamoxifen and initiation of an AI. Therefore,serial monitoring of plasma estradiol and FSHlevels is encouraged in this clinical setting .Should ovarian function resume, the AIshould be discontinued and tamoxifenresumed.

44.65y woman w/ a 5cms. Left breast mass



44.65y woman w/ a 5cms. Left breast massunderwent core bx. Histopath showes IDCA

and the tumor was ER+/PR+ and HER2 +.She desires BCT. All are accepted tx prior toBCT except:

a.Neoadjuvant chemotxb.Neoadjuvant hormonal txc. Neoadjuvant chemotx + trastuzumabd.None of the above

Answer: D- None of the above

• Neoadjuvant chemotx- Anthracycline based



j yregimens or taxanes are usually used for 3 to

4 cycles.

•Neoadjuvant hormonal tx- Hormonal txalone may be considered for receptor +

disease in postmenopausal px. Aromataseinhibitor is preferred.

•Neoadjuvant chemotx + trastuzumab- Px w/

HER2 + tumors should be considered forpreoperative chemotx incorporatingtrastuzumab.

45.A 60y female w/ a 6cms. ulcerating massof the left breast w/ palpable axillary nodes



of the left breast w/ palpable axillary nodeswas dx w/ IDCA. Neoadj chemotx was done

x 3cycles. The ulceration and palpable ALNdisappeared and the mass decreased to2cms. in size. Px underwent MRM. Isadjuvant RT still indicated in this case?

a.Yesb.No

Answer: A- Yes



• Adjuvant RT postmastectomy is based onprechemotx tumor characteristics.

46.Criteria for determining menopause includeany of the following except:



any of the following except:

a.Prior bilateral oophorectomyb.Age 60y and abovec. Age <60y but amenorrheic for 12

mos. or more.

d.Age <60y, amenorrheic for 12mos andon chemotx.

e.None of the above

Answer: D- Age <60y, amenorrheicfor 12mos. and on chemotx



• For women <60y and amenorrheic for 12 or

more mos. in the absence of chemotx,tamoxifen, toremifene, or ovariansuppression and FSH and estradiol are in thepostmenopausal range, they are considered

as menopausal.

47.A 45y woman underwent MRM for ahormone receptor + BCA. She was given



p gadj. chemotx for 6 cycles after w/c she

became amenorrheic. What would you doto ensure postmenopausal status if youwant to use aromatase inhibitors?

a.Surgical oophorectomyb.TAH-BSOc. Serial measurement of FSH &/or

estradiold.RT oophorectomy

Answer: A,C,D

• In women premenopausal at the beginning



• In women premenopausal at the beginningof adjuvant chemotx, amenorrhea is not a

reliable indicator of menopausal status asovarian function may still be intact or resumedespite anovulation/amenorrhea afterchemotx. For these women w/ chemotx

induced amenorrhea, oophorectomy or serialmeasurement of FSH and/or estradiol areneeded to ensure postmenopausal status if

the use of AI is considered as a component of endocrine tx.

48.45y female consulted because of a non-healing eczema of the NAC. Mammographyd h d b t l i / t d t



done showed a breast lesion w/c turned outto be DCIS after core bx.Bx of the NACshowed Paget’s disease. Surgical mx wouldinclude:

a.MRMb.Mastectomy + SLNBc. Wide excision of breast lesion and NACd.Wide excision of breast lesion and NAC

+ RT of ipsilateral breast

Answer: B&D- Mastectomy + SLNB;Wide excision of breast lesion and

NAC + RT of ipsilateral breast

Paget’s Disease Treatment



Breast and

NAC biopsynegative

Breast DCISand NACPaget’s

Breastinvasivecancer andNAC Paget’s

Breastnegative forcancer andpositive NACPaget’s

Clinical follow up

Re-biopsy if not healing

Mastectomy + axillary staging or Excision ofbreast tumor and excision NAC with wholebreast radiation, consider boost to breast

and NAC sitesMastectomy + axillary staging or Excision ofbreast tumor and excision NAC with wholebreast radiation, consider boost to breastand NAC sites

Mastectomy + axillary staging or Excision ofNAC with whole breast radiation, considerboost to breast and NAC sites

49.The following surgical procedures can be



g g pdone during the late 2nd trimester of

pregnancy except:

a.MRM- Total mastectomy + ALNDb.BCS- Lumpectomy + ALND

c. Total mastectomy + SLNBd.Lumpectomy + SLNBe.None of the above

Answer: E- None of the above

MRM can be done in all trimester of PABC



• MRM- can be done in all trimester of PABC

• BCS- can be done during the 2nd trimesterw/ RT being done in the postpartum period.

• SLNB- w/ radioactive tracer(eg, technetium99m sulfur colloid) should be safe. Isosulfanblue dye for SLNB is not recommendedduring pregnancy

50 The following adjuvant tx can be given



50.The following adjuvant tx can be givenduring the 2nd trimester of pregnancy:

a.FACb.Taxanes

c. trastuzumabd.Hormonal txe.Adjuvant RT

Answer: A- FAC

• The greatest experience in pregnancy hasbeen with anthracycline and alkylating agent



y y g gchemotherapy. Fetal malformation risks in

the 2nd & 3rd trimester are approx. 1.3%, notdifferent than that of fetuses not exposed tochemotx during pregnancy.

• There are limited data on the use of taxanes during pregnancy. As a consequencethey are not recommended for use duringpregnancy.

There are only 2 case reports of



• There are only 2 case reports of trastuzumab use during pregnancy. Both casereports indicated oligohydramnios w/administration of trastuzumab. Trastuzumabshould be used in the post delivery setting.

• Endocrine tx and RT are contraindicatedduring pregnancy.

51.A 45y px consulted because of a palpableirregular mass at the UOQ of the left



irregular mass at the UOQ of the leftbreast. Mammography was requested w/c

showed a BIRADS 4 lesion at the UIQ of thesame breast. What would be your nextstep:

a.Bx of palpable lesionb.Bx of mammographic lesionc. Ultrasound of the breast

d.Bx of both lesions Answer: C- Ultrasound of the breast



• It is important to assess the geographic

correlation between clinical and imagingfindings. If there is a lack of correlation doother imaging studies for further workup of the palpable lesion.

52.A 45y female has a right breast mass w/cis 2cms. In size, irregular in shape, firm



and slightly movable. Mammogram showed

a Birads 3 category lesion. US wasrequested and the result was that of a solidlesion suspicious for malignancy. Core bxresult was benign. Next step would be:

a.Observeb.Repeat mammogramc. Repeat ultrasoundd.Surgical excision

Answer: D- Surgical Excision

Breast Cancer Screening and Diagnosis



MammogramLump/mass

Age > 30 y

BI-RADSCategory 1-3 Ultrasound

Solid

Indeterminateor suspicious

Probablybenign

finding




Tissuebiopsy

Solid:Indeterminateor suspicious

Core needle

biopsy(preferred)

Benignand imagediscordant

Surgicalexcision

53.A 50y female w/ a left breast mass,2.5cms. In size, smooth, movable and non-



tender underwent mammogram. Result was

a BIRADS 2 lesion. US done showed aprobably benign finding. Next step wouldbe:

a.MRIb.Observe (PE+US+mammogram every

6-12mos.)c. Tissue dx (Core bx or Open bx)d.BCS

Answer: C- Tissue Dx




MammogramLump/mass

Age > 30 y

BI-RADSCategory 1-3 Ultrasound

Solid

Indeterminateor suspicious

Probablybenign

finding




Observation

(if<2cm with lowclinical suspicion)

Solid:Probablybenignfinding

Tissuediagnosis

Core needlebiopsy

(preferred)

Excision (ifcore needlebiopsy not

possible)



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