breast Flashcards
breast carcinoma
-Other than skin cancer, breast carcinoma is the most common cancer in the world
-There were nearly 300,000 cases of breast carcinoma diagnosed in the United States in 2022
-Approximately 43,000 of all patients with this diagnosis will die of their disease
-Approximately 12.5% of cisgender female patients will develop breast carcinoma in their lifetimes
-Men comprise about 1% of patients with breast carcinoma
-About 5-10% of breast carcinomas are related to gene mutations, most commonly BRCA 1 (72% lifetime risk) and BRCA 2 (69% lifetime risk)
-An individual’s risk is increased about 100% if a first degree relative has breast carcinoma
-Black individuals have the highest risk of death from breast carcinoma, in part due to a greater risk of triple negative breast carcinoma
-This type of carcinoma is named “triple negative” because these tumors do not contain receptors for estrogen or progestin, and they tend to not produce HER-2 proteins
factors affecting black pts with breast carcinoma
-genetic ancestry ->
-cancer dx, tx, and outcomes
-allostatic load stressors:
-social determinants of health
-structural inequity and inequality
-epigenetics
breast carcinoma
-Other than skin cancer, breast carcinoma is the most common cancer in the world
-There were nearly 300,000 cases of breast carcinoma diagnosed in the United States in 2022
-Approximately 43,000 of all patients with this diagnosis will die of their disease
-Approximately 12.5% of cisgender female patients will develop breast carcinoma in their lifetimes
-Men comprise about 1% of patients with breast carcinoma
-About 5-10% of breast carcinomas are related to gene mutations, most commonly BRCA 1 (72% lifetime risk) and BRCA 2 (69% lifetime risk)
-an individuals risk is increased about 100% if a first degree relative has breast carcinoma
-Black individuals have the highest risk of death from breast carcinoma, in part due to a greater risk of triple negative breast carcinoma
-this type of carcinoma is named triple negative bc these tumors do not contain receptors for estrogen or progestin, and they tend to not produce HER-2 proteins
factors affecting black individuals with breast carcinoma
-genetic ancestry->
-cancer dx, tx, and outcomes
-allostatic load stressors:
-social determination of health
-structural inequality and inequity
-epigenetics
non-modifiable vs modifiable RF for breast carcinoma
-NON-MODIFIABLE
-Growing older
-Having breast tissue
-Family history of breast carcinoma
-Genetic mutations
-Personal history of breast carcinoma
-Personal history of irradiation to thorax
-Personal history of breast biopsy with atypia
-Early menarche (<12 years of age)
-Late menopause (>55 years of age)
-MODIFIABLE:
-lack of breast feeding
-alc consumption
-sedentary lifestyle
-obesity
-first pregnancy after age 30
-nulliparity
genetic testing
-Should be offered to patients with breast carcinoma who also have a history of:
-Dx of breast carcinoma before age 50
-Bilateral breast carcinoma
-Triple negative breast carcinoma
-Family member with breast and ovarian carcinoma
-Family member with multiple members with breast carcinoma
-Family member with at least two primary BRCA-1 or BRCA-2 malignancies
-Family member with cisgender male breast carcinoma
-Family member with pancreatic or prostate carcinoma
-Being Ashkenazi Jewish
-Should be offered to anyone with a history of:
-Family history of gene mutation involving breast carcinoma
-Ovarian or pancreatic carcinoma in AFAB people and breast, pancreatic, or high grade or metastatic prostate carcinoma in AMAB people
-A family member with breast carcinoma before age 50
-Multiple family members with breast carcinoma
-An AMAB family member with breast carcinoma
MC site of breast carcinoma
-upper outer quad including tail of spence
-largest part of breast and where breast carcinoma is MC found
mammography
-1960s
-detection of 90% of breast cancers
-Has a false-negative rate of approximately 10%
-Uses a low dose of ionizing radiation
-mammo and US of the breast are reported using the breast imaging report and data system (BI-RADS)
-REMEMBER:
-mammography is a screening test
-tissue is the issue- bx is dx
-in order to render a dx of breast carcinoma pathological analysis of bx is required
screening mammo vs dx mammo
-SCREENING:
-performed in pt with:
-absence of any suspicion of breast cancer
-average risk of breast cancer
-DX:
-performed in pt with:
-hx of breast mass or other findings on clinical breast exam
-hx of abnormal screening mammo
-dx mammo takes longer and uses more radiation to take more detailed images
-top pic- normal
-bottom pic- spiculated masses
screening guidelines for ammo for average risk pts
role of clinical breast exam and breast self exam
-ACOG- performance of clinical breast exam after age 19
-ACS and USPSTF- do not recommend clinical breast exam
-ACOG, ACS and USPSTF do not recommend breast self exam
special circumstances
-In patients of increased risk (personal or family history of breast carcinoma, history of thoracic irradiation, genetic mutation, African ancestry, Ashkenazi Jewish ancestry, etc.), management must be individualized
-AMAB gender diverse patients who are age 50 or older on hormonal therapy for at least 5 years, who have a family history of breast carcinoma, or who are obese should be screened
-AFAB gender minority patients who do not have mastectomy as part of gender-affirming care should be screened
BI-RADS assess categories
reporting results to pts
-as per NY state law -> all pts having breast imaging must be sent their results in laypersons language within 7 days of having test
other imaging
-US may distinguish between solid and cystic lesions
-Ductogram may be performed in some institutions when there is spontaneous nipple discharge and mammography is inconclusive
-MRI of the breast may be helpful for screening in high risk patients
-Patients with dense breasts may have both mammography and ultrasound performed together, or may benefit from having MRI of the breasts performed
-The presence of dense breasts raises the risk of malignancy about sixfold
breast bx
-may be done for palpable lesiosn or for suspicious lesions found on screening mammo
-may often be done at same visit as mammo
-usually performed as core bx under local anesthesia
-may be performed as an open bx in operating room
non-malignant bx results
-Fibroadenoma of breast
-Well circumscribed, rubbery, mobile, nontender masses typically seen in younger patients
-May be observed or removed
-Lobular carcinoma in situ
-Atypical lobular hyperplasia
-Atypical ductal hyperplasia
-Phyllodes tumor
-Usually is benign but may become malignant
-These lesions often grow rapidly
-For all of the above, additional surveillance is required and must be individualized
invasion of breast carcinoma
-Malignant cells in the milk ducts are unable to metastasize and are noninvasive
-Those with the propensity to metastasize are invasive
-Locally advanced breast carcinoma has invaded into the axillary nodes but not beyond them
-Metastatic breast carcinoma has invaded beyond the axillary nodes
-Tends to metastasize to liver, brain, bones, lungs
S&S of breast carcinoma
-Painless, fixed, irregular mass
-Spontaneous non-milky nipple drainage
-Palpable, nontender lymph nodes
-Erythema of the breast that may involve the ipsilateral arm - inflammatory breast carcinoma
-Change in texture of the skin of the breast
-Peau d’orange
-Dimpling
-Retractions
-Nipple inversion
-Ulceration of the breast
-Pruritus of nipple
staging of breast carcinoma
-Based on a number of factors
-Tumor
-Nodes
-(Distant) metastasis
-Estrogen receptor status
-Progesterone receptor status
-Human epidermal growth factor 2 (HER 2 status)
-Grade
tumor
-Tx: primary tumor cannot be assessed
-T0: no evidence of primary tumor
-Tis: carcinoma in situ (ductal carcinoma in situ, or Paget disease of the breast with no associated tumor mass)
-T1: Tumor is no larger than 2 cm in diameter
-T2: Tumor is between 2-5 cm in diameter
-T3: Tumor is >5 cm in diameter
-T4: Tumor of any size growing into chest wall or skin, including inflammatory breast carcinoma
node dissection and risk of lymphedema
-In many surgical oncological cases, a large dissection must be performed to sample nodes for an accurate staging
-In the case of breast carcinoma, this can cause lymphedema of the upper extremity that can rarely lead to the need for amputation
-The sentinel node biopsy can preclude the need for dissection by the injection of a radioisotope with blue dye prior to surgery
-The sentinel node (the first node that takes up the isotope and dye) is removed when found via dye and gamma probe and is sent for frozen section
-If negative for malignancy, no further node dissection is indicated
-risk of lymphedema after axillary node dissection -> 15-25%
-risk of lymphedema after sentinel bx -> 0-7%
nodes
-Nx: nodes cannot be assessed
-N0: Malignancy has not spread to adjacent nodes
-N1: Malignancy has spread to 1-3 axillary nodes or is found via sentinel node biopsy in internal mammary nodes
-N2: Malignancy is found in at least 10 axillary nodes with at least one greater than 2 mm
-When an axillary node dissection is required, it involves 3 levels of nodes
-Level 1: tissue below the lower edge of pectoralis minor
-Level 2: tissue lying underneath pectoralis minor
-Level 3: tissue lying above the pectoralis minor
-After axillary node dissection, a patient cannot have any of the following performed in the ipsilateral upper extremity:
-Venipuncture
-Intravenous cannulization
-Blood pressure measurement
