BREAST Flashcards
The greatest benefit of radiation therapy in breast cancer
is seen in patients with
axillary node metastasis
large tumors
When offered post operatively, radiation can reduce the risk of local recurrence by 66%
Some studies have shown up to a 9% increase in survival when radiation was used with tamoxifen
Only 1-2% of patients develop a secondary malignancy attributable to the radiation treatment, usually after at least 10 years
Indications for xrt in breast cancer
ALWAYS lumpectomy
After mastectomy: Tumors >5cm (T3) Skin or chest wall involvement (T4) Tumor had + margins - really needs excision of margin? Inflammatory cancer
Nodes:
Extracapsular extension
Fixed axillary nodes (N2) > 4 positive axillary nodes
Indications for chemo in breast cancer
NEOadjuvant: T > 5cm Positive nodes Inflammatory breast cancer Triple negative breast cancer Trying to shrink tumor for lumpectomy Possible stratagy for pregnant waiting delivery
ADJUVANT
Tumor:
ANY tumor > 1cm! (CAREFUL don’t mix this up with xrt that is used for tumor greater than 5cm..)
Oncotype Dx especially for node -, ER + tumors
Recurrence
Nodes:
ANY positive nodes
Mets
Chemo agents
TAC Docetaxel (Taxotere) Doxorubicin (Adriamycin) cyclophosphamide AC ->T TC (heart problems) AC
papillomas
Solitary intraductal papillomas are true polyps of epithelium-lined breast ducts.
Solitary papillomas are most often located close to the areola but may be present in peripheral locations.
Most papillomas are less than 1 cm but can grow to as large as 4 or 5 cm.
Papillomas are NOT associated with an increased risk for breast cancer.
Papillomas are often accompanied by bloody nipple discharge. Less frequently, they are discovered as a palpable mass under the areola or as a density lesion on a mammogram.
Treatment is duct excision through a circumareolar incision.
Phyllodes tumors
are rare neoplasms defined by epithelial and stromal overgrowth.
Upwards of 50% have malignant potential based upon the cellular atypia, mitotic
activity, and stromal overgrowth! (CAREFUL this seems high)
Although the majority resemble fibroadenomas, the risk of malignancy warrants
surgical excision as the standard of care
Even though radiation therapy has proven to be beneficial in reducing local recurrence, there is no role for chemotherapy in the treatment of phyllodes tumors
Calcified rim lesion on mammography is consistent with
oil cyst (fat necrosis of breast tissue)
radiologic diagnosis can be made.
no bx need even if palp
histology consistent with oil syst
fat necrosis reveal lymphocytes, histiocytes, fat necrosis, and saponification.
Occult breast cancer presents with axillary adenopathy and NO evidence of the primary breast lesion work up
First, biopsy of the axillary adenopathy
If adenocarcinoma is detected the most likely source is the ipsilateral breast.
Next, imaging studies including mammogram AND MRI! to search for the primary lesion.
If negative, do NOT do whole body imaging as the next step as the likelihood of a primary breast lesion is nearly 100%.
Occult breast cancer presents with axillary adenopathy and NO evidence of the primary breast lesion tx
In the setting of negative mammogram and MRI with axillary node adenocarcinoma, treatment should consist of
axillary lymph node dissection,
chemo
AND endocrine therapy (even though you do not know hormone status)!!!
then whole breast RADIATION to the breast.
Historically, mastectomy was the treatment for these patients but has proven to be unnecessary.
Injections of radioactively labeled colloid have demonstrated that about what percent drains into the axilla versus the internal mammary nodes
97% of the lymphatic flow from the breast drains directly into the axillary lymph nodes, with the remaining 3% draining into the internal mammary nodes.
The axillary space is bordered by
the axillary vein superiorly,
the latissimus dorsi laterally,
the serratus anterior medially.
pectoralis major lies anterior to the axillary space,
subscapularis comprises its posterior wall.
histologic findings that require an excisional biopsy include
Atypical ductal hyperplasia!
lobular carcinoma in situ,
radial scar,
papillary lesion.
Sentinel lymph node biopsy (SLNB) is indicated for
almost all INVASIVE breast cancer with a negative axillary nodal exam
A positive nodal exam warrants an axillary dissection.
Sentinel lymph node biopsy (SLNB) is contraindicated for
contraindicated in inflammatory breast cancer because the results are inaccurate.
Relative contraindications include: increased size of tumor, multi- centricity, or previous surgery that may have disrupted the lymphatic drainage, such as breast augmentation - THIS IS RELATIVE
Previous excisional biopsy is not a contraindication to SLNB
SLNB is not usually performed for in situ disease because the tumor cells have not
breached the basement membrane
Extremity Soft tissue mass work up
MRI
Tissue via :
CNB for
hard, fixed to underlying structures, immobile,
more than 5 cm in size,
or
deep in location (subfascial or intramuscular)
It usually
provides adequate tissue to make the diagnosis and it is less invasive than open biopsy.
Excisional biopsy ONLY if CORE NEEDLE BX FAILED and is LESS THAN 3 cm
Incisional biopsy ONLY if CORE NEEDLE BX FAILED and is 3 cm of LARGER
Atypical ductal hyperplasia is a proliferative lesion with atypia and is associated with a relative risk of
4-5 of being diagnosed with breast in 10-20 years.
Benign histologies associated with no relative risks of developing breast cancer are:
Nonproliferative (no increase in risk): cyst, ductal ectasia, fibroadenoma, mastitis, fibrosis, squamous or apocrine metaplasia, mild hyperplasia
Benign histologies associated relative risks of developing breast cancer are:
Proliferative without atypia (RR 1.5-2.0): complex fibroadenoma, papilloma, sclerosing adenoma, moderate or severe hyperplasia
Proliferative with atypia (RR 4.0-5.0):
atypical lobular hyperplasia,
atypical ductal hyperplasia
Gail et al. These include
model to allow calculation of risk for an individual woman by
age,
age at menarche,
age at first live birth,
number of first-degree relatives with breast cancer,
number of prior breast biopsies,
whether or not any of the biopsies showed atypical hyperplasia.
This model calculates risk over a defined time interval, allows comparison with age-specific incidence figures, and predicts risk accurately in groups of women undergoing annual mammographic screening.
It is a useful tool for counseling women who are concerned about their level of risk.
Age at menopause is not one of the elements of Gail model.
The typical histologic finding with inflammatory breast cancer is
dermal lymphatic
invasion of tumor
Proliferation of mixed connective tissue is found with
cystosarcoma phyllodes
Lipid-laden macrophages are seen with
fat necrosis
Enlarged nucleoli are typical of
Paget’s disease
Indian filling on histology is seen with
LCIS
Lactational infections are thought to arise from
entry of bacteria through the nipple into the duct system
Staphylococcus aureus
Lactational infections Treatment requires
antibiotics
frequent emptying of the breast
TRUE abscesses require surgical drainage because they are generally multiloculated
The highest incidence of lactational breast infection occurs in what time period
first 12 weeks of the postpartum period.
Breastfeeding from the INFECTED side is thought to be safe for a healthy infant
although infants should be monitored for the development of infection
Most common presentation of women with breast cancer
ASX!
diagnosis is usually made after an abnormality has been identified on a screening mammogram.
most common presentation and dx of blood Nipple discharge
premenopausal women.
benign in approximately 95% of women.
The most common cause of pathologic discharge identified in surgical specimens is a solitary papilloma.
Mastodynia is most commonly due to
hormonal changes in the breast that cause glandular tenderness.
Cyclic mastodynia is usually due to what and what is treatment
fibrocystic disease
treated with oral contraceptives or NSAIDs.
Non-cyclic pain in women over 30 years
studied with mammography.
Mastodynia is an uncommon symptom of breast cancer, but needs to be investigated in certain circumstances.
Women with mastodynia and a palpable mass
further studied to rule out malignancy.
most common presentaiton of breast cancer in pregnancy
A palpable mass is the most common presentation and patients often diagnosed with more advanced tumors and involved lymph nodes because of delayed diagnosis.
The density of the breast tissue may limit the usefulness of mammography, but pregnancy is not a contraindication for mammography.
Ultrasound often identifies a suspicious mass.
Management of breast cancer in pregancy
Partial mastectomy can be performed during ANY trimester if radiotherapy can delayed until after delivery.
Mastectomy is an option during ANY trimester.
Sentinel lymph node biopsy can be performed with radioactive tracers, but vital dyes should be avoided because they are teratogenic.
Chemotherapy can be given during the second and third trimesters, but there is still a 2% risk of fetal malformation. NO methotrexate
Trastuzumab and hormone therapies are contraindicated during pregnancy.
Women should not breastfeed if they are undergoing chemotherapy or hormone therapy
adverse rxn methylene blue
skin necrotic abscess
adverse rxn to isosulfan blue
anyphylaxis
Atypical ductal hyperplasia
is a benign, proliferative lesion with atypia. ‘
Although atypical ductal hyperplasia is a benign lesion it is associated with a relative risk of developing breast cancer of 4.0-5.0.
Also in 18-50% of cases of atypical ductal hyperplasia there is a concurrent associated cancer, which is invasive in about one third of those cases.
A finding of atypical ductal hyperplasia on core needle biopsy should be managed how
excisional biopsy!
to evaluate whether or not cancer is associated with the lesion;
this is done essentially to rule out sampling error of core needle biopsy.
If the lesion is removed and there is not associated cancer:
then no further treatment is necessary.
If cancer is identified:
then treatment is based on the pathological diagnosis of the excisional biopsy.
benign breast lesions that are indications for excisional biopsy include:
atypical ductal hyperplasia atypical lobular hyperplasia radial scar, columnar cell hyperplasia with atypia, papillary lesion, lack of concordance between appearance of mammographic lesion and pathologic histology nondiagnostic specimen LCIS DCIS
why is Chemotherapy is
administered in a neoadjuvant setting to treat Inflammatory breast cancer
Chemotherapy is administered in a neoadjuvant setting to treat possible micrometastases without delay.
management of Inflammatory breast cancer
Mastectomy
is associated with a trend in increased survival compared to breast conserving therapy.
require axillary lymph dissection of levels I and II
Lymph nodes are so regularly involved in cases of inflammatory breast cancer that they are presumed involved at diagnosis and therefore patients with inflammatory breast cancer.
Sentinel lymph biopsy is contraindicated.
post-operative radiotherapy for inflammatory breast cancer
There is little data on the benefit of, but in general it is considered part of the management to maximize locoregional control.
Anastrozole
aromatase inhibitor
prevents peripheral conversion of androgens to estrogen and is
used in postmenopausal women and women without ovaries.
Chemotherapy should be administered pre-operatively to immediately address possible micrometastatic disease.
hormone therapy based on receptor status
The diagnosis of inflammatory breast cancer is made by
clinical exam
The breast is typically erythematous and edematous.
Skin dimpling, or peau d’orange lymphedema, is the classic finding on exam.
There is not usually a palpable breast mass associated with inflammatory breast cancer!
Biopsy can be used to confirm the diagnosis, but a negative result does not rule out the disease
Sclerosing adenosis
frequently listed as one of the component lesions of fibrocystic disease;
common and has no malignant potential.
How is the axilla treated in male breast cancer compared to female breast cancer
Indications for the evaluation and management of axillary lymph nodes are the same in men as in women.
clinically negative axillary lymph nodes should undergo sentinel lymph node biopsy.
If the biopsied lymph node(s) does not contain cancer then the biopsy is sufficient to stage the axilla.
If the biopsied lymph node(s) contains cancer then a level I and II axillary lymph node dissection is indicated (possible exception is 1-2 nodes positive and tumor less than 5 cm, pt getting xrt, negative margin.. )
ACOSOG Z0011 Inclusion criteria and Exclusion criteria
Inclusion criteria Invasive breast cancer 5 cm or less (T1 or T2) No palpable lymphadenopathy 1-2 SLN containing metastases Lumpectomy with negative margins Received XRT***
Exclusion criteria 3 or more positive SLNs Matted nodes Gross extranodal disease Received NEOadjuvant hormonal or chemotherapy
ACOSOG Z0011 Suggests
Suggests
Pts with T1/T2 cancer, no palpable adenopathy, undergoing lumpectomy + XRT with 1-2 + SLN may not need ALND to affect survival
Interpret with caution..
Radiation fields were applied
Apply correctly..
Not for 3 or more SLN positive
Not for extranodal disease
NOT for MASTECTOMIES
