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🏥 BREAST - RAPID REVISION NOTES

For NEET PG & INICET | Based on Bailey & Love 28e, Sabiston 21e, S Das 13e

Prepared as taught by an MBBS Professor | High-Yield | PYQ-Integrated

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SECTION 1 - ANATOMY (HIGH-YIELD)

Breast Anatomy

1. Glandular epithelium
2. Fibrous stroma
3. Adipose tissue

• 15-20 lobes, each draining through a lactiferous duct at nipple
• Below nipple: lactiferous sinus (dilated segment)
• End unit: Terminal Duct Lobular Unit (TDLU) = acini + terminal ductules
• TDLU is the site of origin of most breast carcinomas

• Run from chest wall fascia to dermis
• Provide shape and structure
• When infiltrated by cancer → skin dimpling / peau d'orange (orange peel appearance)

Professor's Pearl: "Peau d'orange = Cooper ligament infiltration = NEVER forget this association. It has appeared in NEET PG almost every cycle."

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Blood Supply

• Medial: Internal mammary (internal thoracic) artery - main supply
• Lateral: Lateral thoracic artery + thoracoacromial artery
• Intercostals: 2nd-4th perforators

Lymphatic Drainage (MOST IMPORTANT for MCQs)

BREAST LYMPHATIC DRAINAGE

Upper outer quadrant (most common site of cancer)
         |
         v
   Axillary nodes (75% of drainage)
   [Level I → Level II → Level III]
         |
         v
   Subclavian vein → Right lymphatic/thoracic duct

   Medial quadrant → Internal mammary nodes
   Lower → Subdiaphragmatic → Liver (metastasis route)

Mnemonic - "I'm LBM" (Lateral, Behind, Medial)

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SECTION 2 - ANDI (ABERRATIONS OF NORMAL DEVELOPMENT AND INVOLUTION)

The ANDI Concept (Bailey & Love - Chapter 58)

ANDI FRAMEWORK

PHASE         NORMAL PROCESS          ABERRATION          DISEASE
----------------------------------------------------------------------
Development   Lobule formation        Fibroadenoma        Giant FA
(15-25 yr)    Duct development        Nipple inversion     --

Cyclical      Cyclical changes        Cyclical mastalgia   Incapacitating pain
(25-40 yr)    Lobular involution      Cyclical nodularity  Diffuse fibroadenosis

Involution    Lobular involution      Macrocysts           Tension cyst
(35-55 yr)    Duct involution         Sclerosing adenosis  
              Fibrosis                Duct ectasia         Periductal mastitis

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SECTION 3 - BENIGN BREAST DISEASES

3.1 Fibroadenoma

• Simple FA: RR = 1.5-1.7
• FA + epithelial hyperplasia: RR = 3.4-3.7
• Complex FA + family history: RR = 3.0-4.0 (especially lobular carcinoma)

• Age >30 years
• Suspicious features on imaging (microlobulation)
• Atypia on histology
• Size >5 cm
• Family history of breast cancer
• Patient's preference

Mnemonic for FA excision: "SAFE-P" - Size >5cm, Age >30, Features atypical, Evidence of atypia, Preference of patient

3.2 Phyllodes Tumour

• High recurrence rate if inadequate margin

PYQ 2019 - NEET PG: "Treatment of choice for cystosarcoma phyllodes?" - Wide local excision with 2 cm clear margin. NOT simple enucleation.

3.3 Breast Cysts

• Common in 35-50 age group (involution phase)
• Macro-cysts: >3 mm, may be multiple, bilateral
• Management: Aspiration - if clear fluid and lump disappears, no further action needed
• Re-aspiration or excision if: blood-stained aspirate, mass doesn't disappear, recurrence after 2 aspirations

3.4 Breast Abscess

• Organism: Staph aureus (most common)
• Entry: via crack in nipple
• Treatment: Continue breastfeeding + antibiotics; if fluctuant → incision & drainage (radial incision, away from areola)

• Periductal mastitis (young women, smokers) → organism: mixed aerobic + anaerobic
• Subareolar abscess: recurrent, associated with duct ectasia

PYQ - AIIMS: "Incision for breast abscess?" - Radial incision (Langer's lines radiate from nipple). Circumareolar only for central/subareolar abscess.

3.5 Duct Ectasia (Plasma Cell Mastitis)

• Perimenopausal women
• Dilated major ducts filled with inspissated material
• Presents with: thick, greenish/creamy nipple discharge; nipple retraction; sub-areolar mass
• Discharge color: green/brown (NOT bloody unlike duct papilloma)

3.6 Duct Papilloma

• Most common cause of bloodstained nipple discharge
• Usually solitary, in major duct
• Located just behind the nipple
• Treatment: Microdochectomy (excision of affected duct)
• Multiple papillomas → slightly increased cancer risk

PYQ (NEET PG 2021): "Most common cause of bloodstained nipple discharge?" Answer: Duct papilloma (intraductal papilloma)

3.7 Galactocele

• Milk-filled cyst during/just after lactation
• Subareolar, solitary
• Treatment: Single aspiration (usually curative); encourage continued breastfeeding
• Surgery rarely needed

3.8 Mastalgia (Breast Pain)

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SECTION 4 - BREAST CANCER

4.1 Epidemiology

• Most common cancer in women worldwide
• Most common cancer causing cancer death in women (second after lung in West; first in India)
• Lifetime risk in general population: ~12% (1 in 8)
• Peak incidence: postmenopausal (55-65 years)
• Male breast cancer: rare, ~1% of all breast cancers; BRCA2 mutation most commonly implicated

4.2 Risk Factors

RISK FACTORS MNEMONIC: "FARM BEL HORMONES"

F - Family history (1st degree relative doubles risk; BRCA1/BRCA2)
A - Age (increases with age)
R - Radiation exposure (chest irradiation in childhood)
M - Menarche early / Menopause late (prolonged estrogen exposure)
B - BRCA mutations (BRCA1: 65-80% lifetime risk; BRCA2: 40-70%)
E - Estrogen use (HRT, OCP)
L - Lobular carcinoma in situ (LCIS) - RR 8-10x
H - History of breast cancer (contralateral risk)
O - Obesity (postmenopausal, BMI >30)
R - Race (White > Black; but Black women diagnosed at younger age)
M - Mammographic density (dense breast = ↑risk)
O - Oral contraceptives (slight increase)
N - Nulliparity / No breastfeeding
E - Early first live birth protective (before age 20)
S - Smoking, alcohol

4.3 Pathology of Breast Cancer

Origin: TDLU (Terminal Duct Lobular Unit) is site of origin for most carcinomas

BREAST CARCINOMA

NON-INVASIVE (In situ)                 INVASIVE (Infiltrating)
        |                                        |
   _____|_____                        ___________|___________
   |          |                       |                     |
  DCIS       LCIS              IDC (NST)              ILC
(ductal)   (lobular)       (No Special Type)      (Lobular)
                               (Most common)

Special Types of IDC:
- Mucinous (colloid) - Good prognosis
- Tubular - Best prognosis
- Medullary - Better prognosis (despite high grade)
- Papillary
- Cribriform

DCIS (Ductal Carcinoma In Situ):

• Malignant cells confined to ducts, no basement membrane breach
• Subtypes: comedo (most aggressive), cribriform, micropapillary, solid
• Treatment: Wide excision + radiation; mastectomy for extensive disease
• Comedo DCIS: necrosis + calcification visible on mammogram

LCIS (Lobular Carcinoma In Situ):

• Not a true cancer - a marker of bilateral cancer risk
• Usually incidental finding on biopsy
• Risk: 8-10x increased risk of cancer in EITHER breast (not just ipsilateral)
• Treatment: Observation or chemoprevention (tamoxifen/raloxifene); prophylactic mastectomy in high-risk patients
• Does NOT need wide excision with clear margins

IDC (NST) - Most Common (70-80%):

• Hard, stellate, irregular mass
• "Schirrous" type (most common sub-type with dense fibrous stroma)
• Fixation to Cooper ligaments → dimpling
• Fixation to skin → peau d'orange
• Fixation to pec major → immobility on tensing pec

ILC (Invasive Lobular Carcinoma):

• Single file arrangement ("Indian file" pattern)
• Loss of E-cadherin expression
• Multicentric and bilateral more common than IDC
• Metastasizes to peritoneum, GI tract, meninges (unusual sites)
• Poorer detection on mammogram (no distinct mass)

Paget's Disease of Breast:

• Eczema-like eruption of nipple + areola with underlying DCIS or invasive cancer
• Paget cells: large cells with clear halo in epidermis
• Always investigate for underlying cancer
• Key differentiator from eczema: unilateral, starts at nipple (eczema spares nipple)

PYQ (NEET PG 2018): "A woman presents with unilateral eczematous lesion of nipple. What is the diagnosis?" Answer: Paget's disease of breast - must undergo biopsy.

Inflammatory Breast Cancer:

• Diffuse erythema + edema + warmth + peau d'orange (NO discrete lump)
• Due to tumor emboli blocking dermal lymphatics
• Clinically staged T4d
• Worst prognosis
• Treatment: Neoadjuvant chemotherapy FIRST (surgery not primary treatment)

4.4 Molecular/Receptor Classification

BREAST CANCER MOLECULAR SUBTYPES

LUMINAL A              LUMINAL B              HER2-enriched        TRIPLE NEGATIVE
ER+, PR+               ER+, PR+               ER-, PR-             ER-, PR-, HER2-
HER2-                  HER2+ or HER2-         HER2+++              BRCA1 mutations
Low Ki67               High Ki67              --                   Basal-like
Best prognosis         Intermediate           Intermediate         Worst prognosis
Hormone therapy        Hormone +              Anti-HER2            Chemo only
                       Chemo ± anti-HER2

Professor's Teaching Point: "Triple-negative breast cancer (TNBC) is the worst. No targeted therapy available. Only chemotherapy. Associated with BRCA1 mutations. Young, premenopausal women. Medullary carcinoma is often TNBC but paradoxically has better prognosis."

4.5 Staging - TNM (AJCC 8th Edition)

T Staging:

PYQ (NEET PG 2025): "Identify the stage of breast cancer depicted in image showing diffuse erythema, peau d'orange of entire breast." - Answer: T4d (Inflammatory carcinoma)

N Staging:

M Staging:

• M0: No distant metastasis
• M1: Distant metastasis (bone most common site of metastasis in breast cancer)

OVERALL STAGING:

• Stage I: T1N0M0
• Stage II: T1N1M0 or T2N0M0 or T2N1M0 or T3N0M0
• Stage III: T3N1M0 / Any T4 / N2/N3
• Stage IV: Any M1

• Bone (most common overall - osteolytic > osteosclerotic)
• Liver
• Lung
• Brain

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SECTION 5 - TRIPLE ASSESSMENT

The Gold Standard Workup

TRIPLE ASSESSMENT

    Clinical examination
           +
    Imaging (Mammography / USG)
           +
    Tissue diagnosis (FNAC / Core biopsy)

ALL THREE must be concordant
If any ONE is suspicious → proceed to biopsy/surgery

• <35 years: USG (dense breast, less radiation)

• 35 years: Mammography (better for microcalcifications)

• Equivocal findings / dense breast: MRI breast

PYQ (INICET 2022): "A 28-year-old female with a breast lump. Best initial investigation?" - USG breast (not mammography, due to dense breast in young women)

BI-RADS Classification

• Solid mass (not cystic)
• Taller than wide (anti-parallel orientation) - most specific
• Angular/irregular/spiculated margins
• Posterior acoustic shadowing
• Hyperechoic rim

• Irregular, spiculated opacity
• Microcalcifications (sand-grain, clustered) - hallmark of DCIS
• Skin thickening, nipple retraction
• Architectural distortion

Tissue Diagnosis Options

Professor's Point: "FNAC tells you IF it's cancer (cytology). CNB tells you WHAT TYPE of cancer (histology + receptors). For treatment planning, always prefer CNB."

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SECTION 6 - SCREENING

PYQ (AIIMS 2019): "Gold standard screening modality for breast cancer?" - Mammography

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SECTION 7 - TREATMENT OF BREAST CANCER

7.1 Surgical Options

SURGERY FOR BREAST CANCER

CONSERVATIVE (BCS)                    MASTECTOMY
      |                                     |
Wide Local Excision (WLE)         __________|__________
+ Radiation MANDATORY             |                   |
                                 Simple           Modified Radical
                                Mastectomy      Mastectomy (MRM)
                                (skin + breast    + axillary clearance
                                 NO axillary)     Level I, II, III
                                
                              Radical Mastectomy (Halsted)
                              (MRM + pec major + pec minor)
                              Historical - rarely done now

Halsted's Radical Mastectomy (Historical):

• Removal: entire breast + pec major + pec minor + axillary LNs (Level I, II, III)
• Developed by William S Halsted in 1894
• Complication: lymphedema, restricted shoulder movement

Modified Radical Mastectomy (Patey's operation - MRM):

• Removal: entire breast + Level I, II, III axillary LNs + pec minor
• Pec major preserved
• Operation of choice for invasive breast cancer when BCS not suitable

Simple Mastectomy (Total mastectomy):

• Breast only, no axillary clearance
• Used for: DCIS, prophylactic, Paget's disease

Breast Conserving Surgery (BCS / Lumpectomy / WLE):

• Excision of tumor with clear margins (>2 mm)
• ALWAYS followed by radiation therapy
• Contraindications to BCS:
  • Multicentric disease
  • Previous chest radiation
  • Diffuse malignant microcalcifications
  • Inability to achieve clear margins
  • Large tumor:breast ratio
  • Pregnancy (1st/2nd trimester, radiation contraindicated)
  • Connective tissue disease (scleroderma, lupus)
  • Patient preference for mastectomy

PYQ (NEET PG 2020): "A 45-year-old woman has a 2 cm lump in breast. What is the preferred surgical option?" - Breast conserving surgery + radiotherapy (if eligible).

Sentinel Lymph Node Biopsy (SLNB):

• Used for clinically node-negative patients
• Technique: Technetium-99m labeled sulfur colloid + blue dye (patent blue / methylene blue) injected around tumor
• Identifies first draining node (sentinel node)
• If sentinel node negative → no axillary clearance needed
• If sentinel node positive → axillary lymph node dissection (ALND)

PYQ: "Which dye is used for SLNB?" Answer: Patent blue dye / Isosulfan blue (or Methylene blue) + Technetium-99m colloid

7.2 Systemic Therapy

Chemotherapy:

• Neoadjuvant: given BEFORE surgery (downstage tumor, assess response)
• Adjuvant: given AFTER surgery
• Regimens: AC-T (Adriamycin + Cyclophosphamide → Taxane); CMF (older)

Hormone Therapy:

• For ER+ / PR+ tumors
• Premenopausal: Tamoxifen (SERM - blocks ER) for 5-10 years; also consider ovarian suppression
• Postmenopausal: Aromatase inhibitors (Anastrozole, Letrozole, Exemestane) - superior to tamoxifen in postmenopausal

Mnemonic: "Pre-T, Post-AI" - Premenopausal = Tamoxifen; Postmenopausal = Aromatase Inhibitor

• Endometrial cancer risk (↑4x)
• Thromboembolism
• Hot flashes, vaginal dryness
• Bone protective in postmenopausal

Anti-HER2 Therapy:

• For HER2+++ tumors
• Trastuzumab (Herceptin): monoclonal antibody; given with chemotherapy
• Complication: Cardiotoxicity (cardiomyopathy) - monitor ECHO
• Pertuzumab: used with trastuzumab in metastatic HER2+ disease

CDK4/6 Inhibitors:

• Palbociclib, Ribociclib, Abemaciclib - for HR+/HER2- advanced disease
• Combined with aromatase inhibitor

PARP Inhibitors:

• Olaparib, Talazoparib - for BRCA1/2 mutant HER2-negative advanced breast cancer

7.3 Radiotherapy

• Mandatory after BCS (reduces local recurrence by ~75%)
• Also given after mastectomy when: ≥4 positive axillary nodes, tumor >5 cm, positive margins
• Targets: breast/chest wall ± regional nodes
• Side effects: radiation dermatitis, fatigue, pneumonitis, rib fractures, secondary malignancy

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SECTION 8 - SPECIAL SITUATIONS

8.1 Breast Cancer in Pregnancy

• Most common cancer in pregnancy (after cervical cancer)
• Majority are IDC, usually ER-negative
• Mammography: safe in pregnancy (shielded); USG preferred
• FNAC/CNB: safe
• Surgery: safe in all trimesters; MRM preferred
• Chemotherapy: safe after 1st trimester (AC regimen)
• Radiation: CONTRAINDICATED in pregnancy
• Termination does NOT improve prognosis
• Prognosis: worse stage-for-stage than non-pregnant (delayed diagnosis)

PYQ (NEET PG): "Breast cancer diagnosed at 26 weeks. What is contraindicated?" Answer: Radiotherapy (contraindicated throughout pregnancy).

8.2 Male Breast Cancer

• Rare, ~1% of all breast cancers
• Associated with: BRCA2 mutations, Klinefelter syndrome, exogenous estrogen, cirrhosis
• Mostly IDC; ER/PR positive in most
• Presents late (no awareness, less breast tissue)
• Treatment: MRM + tamoxifen

8.3 Locally Advanced Breast Cancer (LABC)

• Stage IIIA, IIIB, IIIC
• T4 disease or N2/N3
• Approach: Neoadjuvant chemotherapy FIRST → surgery → radiation
• Inflammatory breast cancer is LABC by definition

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SECTION 9 - NIPPLE DISCHARGE - DIFFERENTIAL DIAGNOSIS

NIPPLE DISCHARGE GUIDE

COLOR/TYPE              MOST LIKELY CAUSE
Milky (bilateral)    →  Galactorrhea (prolactinoma, drugs, hypothyroidism)
Clear / serous       →  Fibrocystic disease
Green / brown        →  Duct ectasia
BLOODY (unilateral)  →  DUCT PAPILLOMA (most common)
                     →  Carcinoma (if >40 years)
Purulent             →  Breast abscess/mastitis

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SECTION 10 - COMPARISON TABLE (HIGH-YIELD)

Fibroadenoma vs Fibroadenosis vs Phyllodes

DCIS vs LCIS

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SECTION 11 - MNEMONICS MASTER LIST

KEY MNEMONICS FOR BREAST

1. ANDI: Aberrations of Normal Development and Involution
   (all benign breast disease)

2. Risk factors: "FARM BEL HORMONES" (see Section 4.2)

3. Triple Assessment: Clinical + Imaging + Tissue = C.I.T.

4. Surgery types (historical order):
   "Halsted → Patey → Auchincloss → BCS"
   (More radical → Less radical → Conservation)
   
   Halsted = Radical (pec major + minor removed)
   Patey = MRM (pec minor removed, pec major kept)
   Auchincloss = MRM variant (pec minor kept)
   
5. Axillary node levels = "I Love III" 
   (I = Lateral, II = Behind/posterior, III = Medial to pec minor)

6. Cooper's ligament infiltration → peau d'orange
   Mnemonic: "COPPER makes ORANGE juice"

7. Hormone therapy:
   "Pre-T, Post-AI"
   Premenopausal → Tamoxifen
   Postmenopausal → Aromatase Inhibitor

8. Most common breast lump by age:
   <25 yrs: Fibroadenoma
   25-45 yrs: Fibroadenosis (ANDI/fibrocystic)
   >45 yrs: Carcinoma

9. SLNB agents: "Tech + Blue makes True" 
   Technetium-99m + Blue dye → Sentinel node identification

10. T4d = Inflammatory cancer = "FOURTH D-isaster"
    (Diffuse, Dermal lymphatic obstruction, Do chemo first)

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SECTION 12 - PREVIOUS YEAR QUESTIONS (PYQ) BANK

NEET PG Previous Year Questions - Breast

• A) T4a
• B) T4b
• C) T4c
• D) T4d ✅

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• A) Breast carcinoma
• B) Intraductal papilloma ✅
• C) Duct ectasia
• D) Fibrocystic disease

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• A) Mammography
• B) Ultrasonography ✅
• C) MRI
• D) FNAC

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• A) Tamoxifen
• B) Raloxifene
• C) Anastrozole ✅
• D) Medroxyprogesterone

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• A) It is a true carcinoma in situ
• B) Wide excision with clear margins is essential
• C) It is a risk indicator for bilateral breast cancer ✅
• D) It presents as a mammographic mass

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• A) Simple excision
• B) FNAC and follow-up
• C) Wide local excision with 2 cm clear margin ✅
• D) Modified radical mastectomy

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• A) Methylene blue only
• B) Indocyanine green only
• C) Patent blue dye + Technetium-99m colloid ✅
• D) Congo red

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• A) Fibroadenoma
• B) Fibrocystic disease
• C) Underlying breast carcinoma (DCIS or invasive) ✅
• D) Eczema

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• A) Brain
• B) Liver
• C) Bone ✅
• D) Adrenal

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• A) Luminal A
• B) HER2 enriched
• C) Triple negative (basal-like) ✅
• D) Luminal B

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• A) Age >60 years
• B) Multicentric disease ✅
• C) ER negative tumor
• D) Axillary node positive disease

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• A) Tumor size
• B) Histological grade
• C) Axillary lymph node status ✅
• D) ER receptor status

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INICET Specific High-Yield Questions

• Removes: Breast + skin + pectoralis major + pectoralis minor + axillary LN (Level I, II, III)
• Historically described in 1894
• Now largely replaced by MRM

• Cystic hygroma - NO (neck)
• Galactocele - if lactating
• Seroma / hematoma - post-surgery
• Breast cyst - most likely in 35-50 age group (transillumination = fluid-filled)

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SECTION 13 - FLOWCHARTS

Flowchart 1: Approach to Breast Lump

BREAST LUMP
      |
      ├── Age? 
      |      ├── <25 yrs → Likely FIBROADENOMA
      |      ├── 25-45 yrs → FIBROADENOSIS or FA
      |      └── >45 yrs → CARCINOMA until proven otherwise
      |
      ├── Characteristics?
      |      ├── Mobile, smooth, regular → FA (USG to confirm)
      |      ├── Tender, multiple/bilateral → Fibroadenosis
      |      └── Hard, irregular, fixed → CARCINOMA
      |
      └── TRIPLE ASSESSMENT
             |
             ├── Clinical examination
             ├── USG (<35) / Mammography (>35)
             └── FNAC / Core biopsy
                    |
                    ├── Benign concordant → Follow-up / excise if indicated
                    └── Malignant / discordant → Further workup & treatment

Flowchart 2: Treatment of Breast Cancer

CONFIRMED BREAST CANCER
         |
         ├── Staging (Clinical + CT Chest/Abdomen + Bone scan)
         |
         ├── Is it LABC/Inflammatory?
         |      YES → Neoadjuvant chemo first → Then surgery
         |      NO → Primary surgery
         |
         ├── Surgery decision
         |      ├── BCS eligible? → WLE + SLNB + Radiation
         |      └── BCS not eligible → MRM + ALND
         |
         └── Adjuvant therapy
                ├── ER/PR+ → Tamoxifen (premenop) / AI (postmenop)
                ├── HER2+ → Trastuzumab × 12 months
                ├── High risk → Chemotherapy (AC-T or CMF)
                └── Radiation → After BCS; after MRM if ≥4 nodes+

Flowchart 3: Nipple Discharge Workup

NIPPLE DISCHARGE
      |
      ├── Bilateral + milky → Prolactin level → Prolactinoma?
      |
      ├── Unilateral + serous/clear → USG + mammogram
      |
      ├── Unilateral + BLOODY
      |      ├── <40 yrs → Likely DUCT PAPILLOMA → Microdochectomy
      |      └── >40 yrs → Carcinoma must be excluded → Triple assessment
      |
      └── Purulent → Mastitis/abscess → Culture + treat

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SECTION 14 - PROFESSOR'S LAST MINUTE HIGH-YIELD POINTS

"These are the points that come in exams almost every year. Tattoo them on your brain."

1. Most common breast lump overall: Fibroadenosis (fibrocystic disease)
2. Most common in <25 years: Fibroadenoma
3. Most common cause of bloodstained discharge: Intraductal papilloma
4. Most common cancer in women: Breast cancer
5. Most common site of breast cancer: Upper outer quadrant (UOQ) - why? Maximum breast tissue there
6. Most common histological type: IDC-NST (Invasive Ductal Carcinoma, No Special Type)
7. Best prognosis carcinoma type: Tubular carcinoma
8. Most important prognostic factor: Axillary lymph node status
9. T4d = Inflammatory carcinoma - treat with chemo first, not surgery
10. LCIS = bilateral risk marker, NOT a true carcinoma - no clear margins needed
11. Paget's disease = always has underlying carcinoma
12. MRI breast indication = women with BRCA mutations / dense breast / implants / equivocal mammogram
13. Cooper ligaments → peau d'orange (infiltration by cancer)
14. Post-mastectomy radiation when: ≥4 nodes positive, T3/T4, positive margins
15. Tamoxifen complication: Endometrial cancer - do annual pelvic exam
16. Trastuzumab complication: Cardiotoxicity - monitor LVEF (echo)
17. HER2 scoring:
    • 0 or 1+ = negative
    • 2+ = equivocal → FISH/ISH testing
    • 3+ = positive → trastuzumab eligible
18. Chemoprevention for high-risk women: Tamoxifen (pre/postmenopausal) or Raloxifene (postmenopausal only)
19. Sentinel node = first axillary node to receive drainage from tumor
20. Male breast cancer → BRCA2 > BRCA1 association

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1. Anatomy - Cooper's ligaments, TDLU, lymph nodes with a textbook anatomy diagram
2. ANDI framework - the conceptual backbone of benign breast disease
3. Benign conditions - Fibroadenoma, Phyllodes, Cysts, Abscess, Duct ectasia, Papilloma, Mastalgia with clinical pearls
4. Breast cancer - Epidemiology, risk factors (FARM BEL HORMONES mnemonic), pathology, molecular subtypes, full TNM staging
5. Triple Assessment - BI-RADS table, USG vs mammography, FNAC vs CNB
6. Treatment - All surgical options (Halsted vs Patey vs BCS), SLNB technique, chemo, hormone therapy, anti-HER2
7. Special situations - Pregnancy, male breast cancer, LABC
8. 15 PYQs with full explanations (NEET PG 2018-2025, INICET, AIIMS)
9. 3 clinical flowcharts - Breast lump, treatment pathway, nipple discharge
10. 20 last-minute high-yield points
11. 10 memory mnemonics