5/6 Breast Malignancy Flashcards
I only made FCs off the notes
what hormonal risk factors increase risk of breast cancer?
being F
early menarche/late menopause risk (previous lectures say that is due to increased periods of estrogen exposure)
what are important risk factors of breast cancer?
******AGE***** Family Hx Prior dx of BCa Prior bx with atypical hyperplasia or carcinoma in situ Ionizing radiation
what are indicators of possible breast malignancy? 4
new, non-painful hard fixed irregular mass
dimpling
nipple retraction
bloody nipple discharge
T/F A negative mammogram in a person with a breast mass is an indication that person probably doesn’t have BCa
FALSE. A negative mammogram cannot be the sole reason the evaluation of a breast mass is concluded
Of the breast malignancies, how many are carcinoma? sarcoma?
carcinoma = 99% sarcoma = 1%
What are two greatest predictors (prognosis) of 10yr survival of breast cancer?
size (+tumor grade)
nodal status
What is the primary “local” therapy in the treatment of non-metastatic invasive BCa?
Who is this most suitable for?
What is a late complications of this therapy?
lumpectomy + XRT
suitable for women w/ NEWLY diagnosed BCa with a resectable breast mass W/O evidence of metastatic spread beyond the regional LN
Complications
- pain/numbness in breast, chest wall, axilla
- arm swelling/lymphedema (esp if dissection was on the L side)
- restricted arm mobility
- infection
Why is XRT impt in the primary local therapy regimen?
to reduce the incidence of in-breast recurrence of BCa
What happens if there is local recurrence of breast cancer after the primary local therapy was performed?
mastectomy
Lumpectomy is contraindicated in who?
women w/
- really large tumors
- extensive multifocal disease
- where radiation is also contraindicated
how is the decision btwn mastectomy and lumpectomy decided on?
personal choice
T/F The dx of BCa is a medical emergency and action must be taken immediately
False. It is not so time should be taken to evaluate the options to reach a well-reasoned decision
What 3 different kinds of systemic adjuvant therapy? Why is it used? Who is it typically used for?
3 categories (more in detail later)
- endocrine Rx
- chemotherapy
- Antibody (targeted) therapy
used to reduce risk of later metastatic or local recurrence
women w/ invasive BCa since their risk of systemic recurrence is high
What is neoadjuvant chemotherapy and when is it typically done?
chemoRx or hormonal Rx that is administered BEFORE the surgical removal of the tumor
done when the tumor is very large (or involves skin)
What is the role of endocrine therapy in its use as an adjuvant therapy for BCa?
options for pre- and post-menopausal women?
interferes w/ production or function of E in women whose cancer express E or P receptors
pre-menopausal: tamoxifen, ovarian ablation or LHRH agonist
post-menopausal: same as above, or aromatase inhibitors
What is tamoxifen?
Indications?
ADR?
Contraindications?
SERM
breast: anti-estrogenic
bone, uterus: estrogenic
Indications: ER+ breast cancer treatment and prevention
ADRs
increase risk of uterine or endometrial cancers, hot flashes, thromboembolic events, decreased bone mineral density in premenopausal women**
Contraindications: hypersensitivity to tamoxifen, warfarin therapy, venous thromboembolic disorders**
What is the role of chemotherapy in its use as an adjuvant therapy for BCa? examples?
Complications?
prevents cells from dividing by inhibiting various steps that produce metabolites impt for cell division
Cytoxan, Adriamycin, 5FU
What is an example of antibody (targeted) therapy in the adjuvant therapy for BCa?
Indications?
ADR?
Herceptin “Trastuzumab” - mAb aganist HER2 (cerbB2), a tyrosine kinase receptor, and mediates antibody-dependent cellular toxicity by inhibiting proliferation of cells
indications: HER-2 (+) breast cancer and gastric cancer
ADRs: Cardiotoxicity “HEARTceptin damages the heart”
Adjuvant therapy reduces risk of later recurrences of BCa. How does it affect menopause sx?
MAKES IT WORSE
difference of a prognostic factor vs a predictive factor? example of each?
prognostic: molecular + histologic features that influence the final outcome, regardless of treatment. (ex: HER2 status)
predictive: tumor characteristics that predict responsiveness to specific therapies (ex: ER or HER2 status are responsive to tamoxifen and herceptin, respectively)
HER2 status is both a prognostic factor and a predictive factor for Herceptin
Women w/ a hx of BCa are at increased risk of what?
As a result of this, they should do this…
What should they not do?
contralateral BCa
annual mammography and clinical physical exam
NOTE: in the absence of any signs or sx of metastatic recurrence, periodic CT, bone scans, and blood tests are NOT indicated
What always precedes the initiation of systemic therapy?
evaluation of the common sites of metastasis (staging)
What constitutes a typical staging work-up for breast cancer?
bone scan
CT of chest/back/pelvis
labs/LFTs
typical staging work-up for breast cancer involves bone scan, CT of chest/back/pelvis, and labs/LFTs. When is an Xray done and why?
when the bone scan indicates metastatic involvement of the weight-bearing bones of the legs
Done to evaluate the degree of cortical destruction
What should you do if a BCa patient shows more than >50% loss of the cortex in the shaft of the femur due to metastasis?
prophylactic XRT +/- surgical stabilization due to a high risk of pathologic fracture
T/F metastatic breast cancer is incurable
True (with RARE exceptions)
Tumor markers for breast cancer?
What are these markers generally used for?
CEA
CA27-29
CA15-3
clinical use: follow a response to therapy, esp. when the patient has a metz disease that is difficult to quantify on clinical exam
Why is the expression of erbB2 receptor relevant to therapy decisions?
erbB2 is aka HER2/neu
b/c these respond to antibody-targeted therapy (trastuzumab or pertuzumab)
Why is the expression of ER receptor relevant to therapy decisions?
b/c these respond to endocrine therapy (tamoxifen or aromatase inhibitors)
Patients w/ metastatic disease to the bone should be treated with…?
What is the purpose of these treatments?
bisphosphonate (zoledronic acid) or
inhibitors of RANK-L (denosumab)
reduce the incidence of:
- bone pain
- hypercalcemia
- pathologic fractures
MoA of zoledronic acid??
bisphosphonate - pyrophosphate analog that bind hydroxyapatite and inhibit osteoclast-mediated bone resorption
MoA of denosumab??
blocks interaction of RANK ligand with its receptor on osteoclast
When do you stop treatment? 4
- complete remission
- side effects outweigh the benefit
- tumor progression occurs
- multi-drug resistance
T/F lobular carcinoma in situ (LCIS) is a premalignant lesion (ie destined to progress to invasive lobular cancer)
False. it is a marker of increased risk of subsequent invasive cancer of either histology (lobular or ductal)
Management of patients with LCIS?
- intensive follow-up (mammogram + clinical breast exam)
- chemoprevention (ie tamoxifen)
T/F ductal carcinoma in situ (DCIS) is a premalignant lesion (ie destined to progress to invasive lobular cancer)
True. it can undergo malignant progression to an invasive cancer.
Management of patients with DCIS?
lumpectomy + XRT
Why is post-lumectomy XRT a critical part of the management of DCIS, but still remains an evolving issue?
because it significantly reduces both invasive + non-invasive tumors but it does NOT affect survival rates….
