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Answer : B- Ultrasound
Lump/
mass
Age <30 yr
Needle Sampling
or
Observe for 1- 2
menstrual cycles (option
for low clinical
suspicion)
Answer : A-Mammography
Lump/
mass
Age >30 yr
Mammogram
Final
Assessment
category 4- 5
Answer : B-Core Bx
Core
needle
biopsy
(preferred)
Solid:
Indeter
minate
or
suspicious
Mam
mogram
Tissue
biopsy
or
Excision
Answer : C- surveillance/follow up
Ultrasound
Cyst
Bloody
Non-bloody
Follow up after 6 wks.
Recur
Reaspirate
Recur
Excisional Bx
Excisional Bx
Residual mass
Excisional Bx
Answer : B-Observe
11.Risk
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 most
patients
16.4% developed invasive BCA
disease related mortality 2.8% vs.
0.9% (patients treated with
prophylactic mastectomy).
Margins
negative
Excision + RT
or
Total mastectomy
w/o lymph node
dissection +
reconstruction
Small (<0.5cm),
unicentric, low
grade
Excision + RT
or
Total mastectomy
w/o lymph node
dissection +
reconstruction or
Excision alone
Treatment Recommendations:
Old
New
Recommendation
3 to 4
4 to 5 to 6
Excision alone
5 to 6 to 7 7 to 8 to 9
Excision + RT
8 to 9
10 to 11 to 12 Total mastectomy
III-B
IV
III-A
II-B
IV
III-C
I
III-B
IV
III-A
III-B
III-C
Stage I
Stage IIA
Stage IIB
T3, N1, M0
Answer: B-MRM
Breast
size
can
be
a
relative
contraindication.
Women with large or
pendulous breasts can be treated with
irradiation if reproducibility of patient
setup can be ensured and if it is
technically possible to obtain adequate
dose homogeneity.
Women
35 y or younger.
Premenopausal
women
BRCA mutation.
with
known
localization excision bx
c. Stereotactic core bx
d. If dx as malignant- determination of
hormone receptor status
e. Frozen section
With
Tamoxifen
NSABP B14 -10 yr. rate of
recurrence in ipsilateral
breast
Stockholm grp
4.3%
-3.0%
W/ RT
9.3%
W/o
Tamoxifen
14.7%
-12.0%
RT +
Tamoxifen
2.8%
[level1,2,3]
Types of ALND:
Axillary sampling- provides 4 to 7 nodes,
includes axillary tail of Spence and level 1
nodes
Low level 1, dissection stops superiorly
at the level of the major intercostobrachial
nerve
Surgical Extent:
ALND is therapeutic by reducing the
risk of
axillary recurrence to <5% and
prognostic,
by allowing even more
accurate determination of nodal
metastasis.
Clearly 80% - 90% of ALN are found
in levels 1&2
A level 1&2 dissection is adequate in
the absence of gross disease.
of lymphedema:
0 2.8%
2.7% - 7.4%
3.1% - 8%
2.1% - 8.3%
3 7 fold increase in incidence
Werner [MSKCC]
The level of node dissection was not
statistically related to the development of arm
edema, the only factor that was significantly
associated was obesity.
Answer: B-No
Total
mastectomy
w/ surgical
axillary staging
(category 1) +
reconstruction
> 4 positive
axillary nodes
1- 3 positive
axillary nodes
Negative axillary
nodes and tumor
>5cm T3,No or
margins positive
RT to chest wall +
supraclavicular
area(category1). Consider
RT to IMN (category 3)
Negative
axillary nodes
and tumor
<5cm and
margins close
(<1mm)
Negative
axillary nodes
and tumor
<5cm and
margins
>1mm
Consider RT to chest
wall
No RT
trastuzumab
ERnegative
and PRnegative
and
HER2
positive
Histology
Ductal,
NOS
Lobular
Mixed
Metaplastic
pT1,pT2, or
pT3 and
pN0 or
pN1mi (<
2mm
axillary
node
metastasis)
Tumor<0.5
cm or
Micro
invasice
Tumor 0.61.0cm
Tumor >1cm
pN1mi
No adjuvant
therapy
Consider
chemotherapy
Consider
chemotherapy
(category1)
Adjuvant
chemotherapy +
trastuzumab
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+
Tx
b. Hormonal Tx then Chemotherapy then
RT
c. [RT + Chemotherapy] then Hormonal
d. Chemotherapy then RT then Hormonal
Tx
e. Chemotherapy then Hormonal Tx then
RT
Answer: D-Chemotherapy then RT
then Hormonal Tx
Frequency
Recommended
History (eliciting of symptoms) and physical
examination
Breast self-examination
Mammography
Pelvic examination
Patient educate regarding symptoms of
recurrence
Coordination of care
Not recommended
Complete blood cell count
Automated chemistry studies
Chest roentgenography
Bone scan
Ultrasound of the liver
Computed tomography of chest, abdomen,
and pelvis
Tumor marker CA-15-3
Tumor marker carcinoembryonic antigen
No
response
MRM +
RT or BCT
or High
dose RT
alone
(category
3)
Additional
chemothera
py +
hormonal
therapy if
estrogen
receptor
postive or
unknown
Consider additional
systematic
chemotherapy
and/or preoperative
radiation
Local
recurrence
Initial
treatment w/
mastectomy
Initial
treatment w/
lumpectomy
+ RT
Surgical
resection (if
possible) +
RT (if
possible)
Mastectomy
Consider
systemic
therapy
Consider
systemic
therapy
Answer: D-MRM
a. Adjuvant RT
b. Adjuvant chemotherapy
c. Adjuvant hormonal therapy
d. None of the above
e. All of the above
Management of PABC:
MRM is the standard management of a
patient with BCA during pregnancy.
therapy
Answer: Observation
BCA
c. Epithelial related calcifications
d. Cyst w/ + family history of BCA
Total
to BCT except:
III-C
II-A
III-A
II-B
Answer: B- Radiotx
Adj.
Adj
trastuzumab- HER2 +
Exesmestane)
c. D/C Letrozole & resume tamoxifen
d. D/C hormonal tx
Neoadjuvant
chemotx + trastuzumab- Px w/
HER2 + tumors should be considered for
preoperative
chemotx
incorporating
trastuzumab.
Answer: A- Yes
mos. or more.
d. Age <60y, amenorrheic for 12mos and
on chemotx.
e. None of the above
Answer: D- Age <60y, amenorrheic
for 12mos. and on chemotx
estradiol
d. RT oophorectomy
Answer: A,C,D
+ RT of ipsilateral breast
Clinical follow up
Re-biopsy if not healing
Breast DCIS
and NAC
Pagets
Breast
invasive
cancer and
NAC Pagets
Breast
negative for
cancer and
positive NAC
Pagets
Answer: A- FAC
Mammogram
Probably
benign
finding
Ultrasound
Tissue
biopsy
Benign
and image
discordant
Surgical
excision
2.5cms. In size, smooth, movable and nontender underwent mammogram. Result was
a BIRADS 2 lesion. US done showed a
probably benign finding. Next step would
be:
a. MRI
b. Observe (PE+US+mammogram every
6-12mos.)
c. Tissue dx (Core bx or Open bx)
d. BCS
Answer: C- Tissue Dx
Mammogram
Probably
benign
finding
Ultrasound
Solid:
Probably
benign
finding
Tissue
diagnosis
Core needle
biopsy
(preferred)
Excision (if
core needle
biopsy not
possible)