A 65-year-old female presented with a 2.5-cm mass in her right breast that on core-needle biopsy had high-grade DCIS. She is taken to the operating room for lumpectomy and SLN biopsy. The patient was injected with both blue dye and radiotracer but no SLN could be identified. What will this patient’s treatment include?
B. Lumpectomy and radiation only
C. Mastectomy and axillary lymph node dissection only
D. Lumpectomy and radiation and axillary lymph node dissection
E. Mastectomy and axillary lymph node dissection and radiation
If no tracer or blue dye is taken up by the lymph nodes, then a lymph node dissection must be performed along with your breast-conserving therapy (ie, lumpectomy) and radiation.
A premenopausal 42-year-old female has been diagnosed with ER+/PR+ invasive ductal carcinoma. Her lesion is 2 cm in size and she has 2 positive lymph nodes. She had chosen to undergo breast-conserving therapy. What will her postsurgical treatment include?
B. Radiation therapy only
D. Radiation therapy and tamoxifen
E. Chemotherapy, radiation therapy, and tamoxifen
Since the patient has positive nodal status, chemotherapy is necessary. Also undergoing breast-conserving therapy, the patient must receive radiation. Since she is premenopausal and her nodal status is positive, tamoxifen would also be given.
A 62-year-old female presents with scaly skin surrounding her nipple that has not resolved. A biopsy including skin was performed at this area. Pathology returns with large vacuolated cells in the epithelium and no other atypical cells or cancerous cells are present. Her treatment should be:
A. Modified radical mastectomy
D. Simple mastectomy with SLN
E. Wide excision of the skin involved
The patient has Paget disease that involves more than the nipple without evidence of malignancy; thus, the treatment is simple mastectomy.
A 36-year-old female who is 20 weeks’ pregnant presents with a palpable mass. Ultrasound-guided core needle biopsy reveals a 3-cm invasive ductal carcinoma. She wishes to undergo breast-conserving therapy. What treatment is indicated for her?
A. Perform the lumpectomy and wait until postpartum for radiation therapy.
B. Give neoadjuvant therapy and wait until after delivery for breast-conserving surgery and radiation.
C. The patient’s condition is a contraindication to breast-conserving therapy and must undergo a modified radical mastectomy.
D. Perform a lumpectomy, SLN biopsy, and radiation therapy after delivery.
Since the patient is in her second trimester, chemotherapy and radiation are contraindicated. She will need a modified radical mastectomy.
A 47-year-old female presents with a palpable mass on physical exam. A mammogram was obtained and her lesion was characterized as a BIRADS3. Your next step is:
D. Repeat mammogram in 6 months, since her mammogram result was a BIRADS3
Even though her mammogram is BIRADS3, indicating a repeat mammogram in 6 months, the patient has a palpable mass. This alone necessitates immediate further work-up with core needle biopsy.
A 70-year-old female presents with multiple nodules on her left arm that has been chronically swollen since her axillary lymph node dissection 7 years ago. How would you diagnose and treat this patient?
A. Fine-needle biopsy and treat with radiation therapy
B. Fine-needle biopsy with wide excision
C. CT scan and chemotherapy
D. Open biopsy and wide excision
E. Open biopsy with radiation therapy
The patient has developed Stewart-Treves syndrome (lymphangiosarcoma). Her treatment would include an open biopsy to confirm diagnosis followed by wide excision.
A 46-year-old female presents with a 4-cm palpable mass. Pathology and ultrasound-guided core needle biopsy reveal an invasive ductal carcinoma. The patient desires breast-conserving therapy. What treatment is indicated for her?
A. Tell her that she is not a candidate for breast-conserving therapy and requires a modified radical mastectomy
B. Neoadjuvant chemotherapy followed by breast-conserving therapy
C. Tell her that she is not a candidate for breast-conserving therapy and requires a simple mastectomy with SLN biopsy
D. Neoadjuvant chemotherapy followed by breast conservation and SLN biopsy if tumor has an appropriate response to chemotherapy
Given the patient’s wish for breast conservation, neoadjuvant chemotherapy can be given in an attempt to downsize the tumor. After neoadjuvant chemotherapy if there is an appropriate response by the tumor, breast conservation can be undertaken. An SLN biopsy should also be performed to assess the lymph node status.
A 64-year-old female presents with spontaneous, unilateral, bloody nipple discharge. The rest of her exam is unremarkable, and mammogram and ultrasound do not reveal any abnormalities. What is the next step in management?
B. Reassurance since nipple discharge is rarely associated with malignancy
D. Repeat mammogram and ultrasound in 6 months
This patient has spontaneous, unilateral, bloody nipple discharge, which is suspicious for an underlying malignancy. The most common cause of bloody nipple discharge is a benign, intraductal papilloma. Major duct excision is warranted because of the risk of malignancy in this patient. Ductography has only a 60% sensitivity for malignancy, but could be a consideration in a patient who wishes to preserve breast-feeding.
A 39-year-old female presents with a 2-cm palpable breast mass. On exam, she is also noted to have a warm, erythematous breast with peau d’orange changes. Biopsy of the mass reveals infiltrating ductal carcinoma. What is the next step in management?
A. Breast-conserving surgery with SLN biopsy
B. Modified radical mastectomy
C. Breast-conserving surgery with SLN biopsy followed by chemotherapy
D. Neoadjuvant chemotherapy followed by modified radical mastectomy
E. Neoadjuvant chemotherapy followed by breast-conserving surgery
This patient has inflammatory breast cancer and breast-conserving surgery is contraindicated. The management of inflammatory breast cancer is neoadjuvant chemotherapy followed by chemotherapy and radiation therapy.
A 45-year-old female after a needle biopsy of a nonpalpable breast mass reveals LCIS. What is the next step in the management of this patient?
A. Breast-conserving surgery with SLN biopsy
B. Bilateral modified radical mastectomies
C. Needle localized excisional biopsy of the lesion
D. No further surgery is indicated
E. Treat the patient with tamoxifen and close follow-up
In this patient with LCIS and an imaging abnormality she will need a wider biopsy to rule out an associated cancer. A negative margin is not required at the excisional biopsy, since LCIS can be extensive. The goal of the biopsy is to obtain a larger specimen. If a malignancy is found, then it should be appropriately treated.