8: Breast cancer

Question 0

Menstrual hx- risk factors

Answer 0

Early menarche: 55yrs

Question 1

Age- risk factor

Answer 1

3/4 of all breast cancers seen in pts >50yrs

Question 2

Pregnancy- risk factors

Answer 2

Late age at first pregnancy: >30yrs

Nulliparity: no pregnancy

Question 3

Obesity or Overweight- risk factors

Answer 3

• Adult weight gain of 20- 25kg
• Western pattern diet
• Sedentary lifestyle
• Regular, moderate consumption of alcohol

Question 4

Oral contraceptives & Hormone replacement therapy- risk factors

Answer 4

• Current users of OC-> risk goes down since discontinuance
• Post-menopausal HRT (esp. combination HRT [progesterone+estrogen])
• -Combination HRT is contraindicated in women with prior Hx of breast CA or a strong family Hx**

Question 5

mammary Paget’s disease- sx

Answer 5

-chronic, eczematous eruption of the nipple

Question 6

Inspections of the breast- 4 positions

Answer 6

• Arms at sides
• Arms over head
• Hands pressed against hips
• Leaning forward

Question 7

Palpation

Answer 7

Lateral portion of the breast
-roll onto the opposite hip
-hand on forehead but keeping the shoulders pressed against the bed or examining table
Medial portion of the breast
-lie with shoulders flat against the bed
-hand at neck and lifting elbow until is even with the shoulder

Question 8

Dx of mass

Answer 8

Best time: day 5-7 of menstrual cycle

• Palpation-> Aspiration/US-> Mammogram-> Biopsy
• palpable mass not visualized on ultrasound must be presumed to be solid

Question 9

Triple diagnosis

Answer 9

• palpation
• mammogram
• fine needle aspiration

Question 10

Breast self-exam (BSE)

Answer 10

Best time day 5-7 of menses

• Look at your breast in the mirror
• Repeat step 1 in different positions
• Examine your breasts lying down
• in the shower

Question 11

Clinical breast exam- screen

Answer 11

• by physican
• at least once per year after 40yrs women with risk factor
• at least every 3yrs for ages 20-39

Question 12

Screening mammography

Answer 12

-Recommend annual or biannual mammography to women past 40yrs

Question 13

Breast biopsy- non palpable lesions

Answer 13

-Ultrasound localization: used when mass is present
-Stereotactic localization: used when no mass is present (microcalcification)
Types of biopsy
-Fine needle aspiration biopsy (FNAB- low complication rate, less scarring, low cost)
-Core-needle biopsy & Open biopsy (permit analysis of breast tissue architecture, show if invasive cancer is present-> IMP for management)**
Surgical excision
-Needle (wire) localization biopsy

Question 14

Breast biopsy- palpable lesions

Answer 14

• FNA is nearly 100% accuracy

- -clinical, radiographic, and pathologic findings should be in concordance*

Question 15

Staging

Answer 15

-the single most IMP predictor of 10-20 year survival rates in breast CA is the number of axillary lymph nodes involved with metastatic disease

Question 16

Radical mastectomy

Answer 16

en bloc removal of all breast tissue, draining lymph nodes and pectoralis muscles

Question 17

Modified radical mastectomy

Answer 17

entire breast is removed, including the skin, areola and nipple, as well as most of the axillary lymph nodes

Question 18

Simple mastectomy

Answer 18

removes the breast tissue, nipple, areola and skin but not the uninvolved lymph nodes

Question 19

Lumpectomy

Answer 19

aka breast-conserving or breast-sparing

• Removal of tumor and some surrounding breast tissue
• lumpectomy + radiation: ROC for DCIS
• first rx option for early-stage breast CA

Question 20

Absolute contraindication for lumpectomy

Answer 20

• pregnancy
• prior irradiation to the breast
• 2 or more gross foci of CA in separate quadrants of the same breast
• mammographic findings suggests of diffuse areas or malignancy
• failure to obtain negative margins despite several surgical attempts
• collagen vascular disease

Question 21

Relative contraindications to lumpectomy

Answer 21

• tumors larger than 5cm
• small breasts
• fixation to chest wall or skin
• involvement of nipple or overlying skin

Question 22

SERMs

Answer 22

Tamoxifen
Raloxifene
-lobular carcinoma in situ is rx with SERM for 5yrs followed with careful annual mammography and semiannual physical exams

Question 23

Adjuvant therapy

Answer 23

Trastuzumab- Ab for HER-2

-with chemotherapy and hormonal therapy