6. Breast lump/Screening Flashcards
1
Q
Identify the structures
A
2
Q
Name categories of causal conditions of breast lumps (3)
A
- Breast Cancer
- Invasive
- Non-invasive
- Non breast-specific Malignancy (found in breast tissue)
- Benign breast disease
- Infectious
- Non-infectious
3
Q
Name DDX of invasive breast cancer (6)
A
- Ductal
- Invasive ductal carcinoma
- Lobular
- Invasive lobular carcinoma
- Other
- Tubular
- Medullary
- Papillary
- Mucinous
4
Q
Name DDX of non-invasive breast cancer (2)
A
- Ductal
- Ductal carcinoma in situ
- Lobular
- Lobular carcinoma in situ
5
Q
Name DDX of Non breast-specific Malignancy (found in breast tissue) (2)
A
- Sarcoma
- Lymphoma
6
Q
Name infectious benign breast disease (4)
A
- Lactation related
- Lactational mastitis
- Breast abscess
- Not lactation- related
- Acute mastitis
- Subareolar abscess
7
Q
Name non-infectious benign breast disease (11)
A
- Fibro cystic changes (nodularity)
- Gross cyst
- Galato cele
- Fibro adenoma
- Fat necrosis
- Papilloma
- Duct ectasia
- Sclerosing adenosis
- Lipoma
- Neurofibroma
- Ductal/lobular hyperplasia
8
Q
Describe HX of breast cancer (5)
A
9
Q
Name risk factors for breast cancer (14)
A
- Age (>50)
- Female
- Prior Hx of breast or ovarian cancer
- Prior breast biopsy (regardless of pathology)
- Prior radiation therapy at site
- Family Hx of breast or ovarian cancer in 1st/2nd degree relatives
- Hx of prolonged hormone exposure
- Nulliparity
- First pregnancy > 30 y.o.
- Menarche < 12 y.o.
- Menopause > 55 y.o.
- HRT > 5yr
- Obesity
- Excessive alcohol intake
10
Q
Describe: Triple diagnosis
A
Refers to diagnosing palpable breast lumps, with concurrent use of:
- Physical exam
- Mammography
- Skilled Fine-needle aspiration biopsy (FNAB)
Very few breast cancers are missed using triple diagnosis.
11
Q
Describe characteristics of cancerous lesions (7)
A
- Location: Unilateral
- Number: Solitary
- Size: > 2 cm (A lesion that is < 2 cm or movable may still be cancerous.)
- Borders: Irregular
- Consistency: Firm/hard
- Mobility: Immovable (A lesion that is < 2 cm or movable may still be cancerous.)
- Changes with menses: No change
12
Q
Describe physical exam of breast lump (Figure)
A
13
Q
Describe this investigation of breast lump: Mammography
- Indications
- Use
A
- Indications: Any woman with a new/ concerning breast lump
- Use:
- Search for other lesions that are clinically occult
- Evaluate lump
14
Q
Name features suggesting malignancy in mammography (4)
A
- Increased density
- Irregular margins
- Spiculation
- Accompanying clustered irregular microcalcifications
15
Q
Describe this investigation of breast lump: U/S
- Indications
- Use
- Interpretation
A
- Indications: Any woman with a new/ concerning breast lump
- Use: Differentiate between simple or complex cystic or solid lumps
- Interpretation:
- Risk for cancer is low if lesion is a simple cyst
- Complex cystic or solid lumps require further investigation
16
Q
Describe this investigation of breast lump: Fine-needle aspiration biopsy (FNAB)
- Indications
- Use
- Interpretation
A
- Indications: Complex cyst or solid lump found on U/S
- Use: Collect samples for cytology
- Interpretation:
- Fluid obtained without blood unlikely to be cancer
- If fluid is bloody, send for cytology
- If no fluid, aspirate cells for cytology
17
Q
Describe this investigation of breast lump: Core needle biopsy
- Indications
- Use
- Interpretation
A
- Indications: Atypical or suspicious FNAB
- Use:
- Collect samples for histology
- Allows staining for ER, PR, and HER2/neu where indicated
- Interpretation: Can differentiate between atypical hyperplasia and ductal carcinoma in situ from invasive disease
18
Q
Describe this investigation of breast lump: MRI
- Indications
- Use
A
- Indications: Any women for whom mammogram and U/S results are inconclusive
- Use:
- Detection of breast lump
- Further characterization of mass detected on screening for breast cancer
19
Q
Name features suggesting malignancy in breast MRI (5)
A
- Increased density
- Irregular margins
- Spiculation
- Rim pattern of enhancement
- Washout of signal intensity
20
Q
Describe breast cancer screening: Mammography (± Clinical Exam) (3)
A
- 40–49 y.o.
- No evidence to include or exclude screening exam as it has not been consistently shown to reduce mortality
- 50–69y.o.: Every 1 – 2yr
- Positive family Hx in 1st degree relative
- Every 1–2 yr starting 10 yr before youngest age of presentation
21
Q
Describe breast cancer screening: Breast Self-Exam (1)
A
No clear evidence of benefit in reduction of breast cancer mortality
22
Q
Describe breast cancer screening: Genetic Testing for Breast Cancer 1 or 2 Gene (8)
A
- Ashkenazi Jewish women: Any 1st degree relative or two 2nd degree relatives from the same side of the family with breast cancer or ovarian cancer
-
All other women
- Patient age < 35 at diagnosis of breast cancer
- Patient or 1st degree relative with both breast cancer and ovarian cancer regardless of age at diagnosis
- Patient or 1st degree relative with bilateral breast cancer
- Patient with strong family Hx of breast cancer and/or ovarian cancer
- Two 1st degree relatives, one age < 50 at diagnosis or three 1st degree relatives regardless of age at diagnosis
- Combination of two or more 1st or 2nd degree relatives with ovarian cancer regardless of age at diagnosis
- Hx of breast cancer in male relative
23
Q
Describe : Clinical decision making of breast lump. (Figure)
A
24
Q
Describe the management of In Situ Breast Cancer (3)
A
- Lumpectomy Or
- Lumpectomy + radiotherapy* Or
- Mastectomy**
*Lumpectomy plus radiotherapy achieves the same survival benefit as mastectomy with in situ and stage I&IIdisease
**If patient undergoes mastectomy, radiation therapy is not required
25
Describe the management of T1 or T2 Breast Cancer
26
Describe the management of T3 Breast Cancer (4)
* Neoadjuvant chemotherapy followed by:
* Lumpectomy or mastectomy
* + Axillary Node Dissection AxND
* + Radiotherapy
27
Describe the management of T4 Breast Cancer (3)
* Neoadjuvant chemotherapy followed by: Mastectomy
* + Axillary Node Dissection
* + Radiotherap
28
Describe staging of breast cancer (3)
* Breast cancer staging requires removal of the primary tumor and ipsilateral axillary lymph node dissection.
* If tumors are **\> 5 cm** and axillary lymph nodes are positive, additional staging tests (chest x-ray, bone scan, CTAbdo) are required.
* Smaller tumors with negative axillary lymph nodes do not mandate additional staging tests unless symptoms of metastatic involvement are present.
29
In breast cancer, name indications for adjuvant therapy: Radiotherapy (3)
* After lumpectomy
* After mastectomy in stage IIIB disease
* With axillary node involvement
30
In breast cancer, name indications for adjuvant therapy: Hormonal (3)
* Almost all patients with tumor size \> 1 cm, ER/PR positive following surgery
* Premenopausal: tamoxifen, or ovarian ablation, or ovarian ablation and aromatase inhibitor (anastrozole, letrozole)
* Postmenopausal: tamoxifen, or aromatase inhibitor
31
In breast cancer, name indications for adjuvant therapy: Chemotherapy (4)
* Depends on tumor size, number of involved lymph nodes, and patient performance status
* Most patients with stage II or III disease
* Stage I disease with HER2/ neu positive tumor
* Trastuzumab (Herceptin) should be used in all HER2/ neu overexpressing tumors
32
Name Oncologic emergencies (not specific to breast cancer) (8)
* Metabolic
* Tumor lysis syndrome
* Hypercalcemia of malignancy
* Neurologic
* Strokes and seizures
* Mecanical
* Superior vena cava syndrome (SVCS)
* Spinal cord compression
* Treatment-Related
* Extravasation of chemotherapeutic drugs
* Neutropenic fever
* Hematology
* Disseminated Intravascular Coagulation (DIC) of malignancy
33
Describe: Tumor lysis syndrome (3)
* Triad of hyperuricemia, hyperkalemia, hyperphosphatemia
* Results from rapid release of intracellular contents of tumor cells into bloodstream
* Hyperkalemia is the most life-threatening problem
34
Describe: Hypercalcemia of malignancy (2)
* Disorder of calcium metabolism due to alterations in the pathways of calcium regulation involving PTH, calcitonin, and (1,25[OH]2 vitamin D)
* Patients are invariably dehydrated
35
Describe: Superior vena cava syndrome (SVCS) (2)
* Cough; dyspnea; dysphagia; swelling and discoloration of the neck, face, or upper extremities; and possibly vocal cord paralysis and Horner syndrome
* Results from an increase in central venous pressure caused by vena caval obstruction
36
Describe: Spinal cord compression (3)
* Sx include pain, weakness, sensory deficits, autonomic dysfunction
* Results from spinal cord being compressed by tumor
* Not immediately life threatening unless involving level C3 or above, but may lead to profound, permanent morbidity
37
Describe: Extravasation of chemotherapeutic drugs (2)
* Leakage of chemotherapeutic drugs into the skin, leading to pain, redness, swelling, and possibly necrosis
* Typically results from infusion therapy
38
Describe: Neutropenic fever (2)
* Neutrophil count \< 0.5 × 10(9)/L(500/mm3), or \< 1.0 × 10(9)/Land expected to decline below \< 0.5 soon
* Fever defined as single temperature of 38.3°C (101.0°F) or a temperature of 38.0°C (100.4°F) or higher lasting over 1 h
39
Describe: Disseminated Intravascular Coagulation (DIC) of malignancy (4)
* Hx of malignancy
* Clinical presentation of bleeding, thromboembolism, liver dysfunction, kidney failure, respiratory distress, or change in CNS exam
* Thrombocytopenia
* MAHA (microangiopathic hemolytic anemia) on blood smear
