breast Flashcards
polythelia
accessory nipple; can occur anywhere along the milk line from axilla to inguinal region
polythelia
accessory nipple; can occur anywhere along the milk line from axilla to inguinal region
polymastia
accessory breast tissue; mostly occurs in the axilla
amastia
congenital absence of the breast
amazia
lack of breast tissue development with perseverance of the nipple
what does inc hormonal production by the ovary at puberty cause
ductal budding and initial formation of acini; proliferations of the terminal ducts lined w secretory cells for milk production
what effects do estrogen and progesterone have
full maturation of the ductal and lobular components of the breast
gynecomastia
enlarged breasts may be asym and tender secondary to a physiologic excess of plasma estradiol relative to plasma testosterone; age 20 male
what should be considered for a solid mass in a postmenopausal woman
cancer until proven otherwise
risk of hormone replacement therapy
inc risk of breast cancer; esp estrogen plus progestin
major risk factors for breast cancer
females, inc age, fhx, proliferative pathology with atypic on bx (atypical ductal or lobular hyperplasia)
what familial cancer syndromes are assoc w greater risk of breast cancer
Li-Fraumeni and Cowden’s
what genes are assoc with breast cancer
BRCA 1 long arm of chromosome 17 and BRCA 2 long arm of chromosome 13
guidelines on referral for genetic counseling
Individuals from a family with a known BRCA1 or BRCA2 mutation;Personal history of breast cancer with one of the following:
- Diagnosed at or before age 45
- Diagnosed at or before age 50 with one or more close family relatives diagnosed with breast cancer or ovarian cancer at or before 50a
- Diagnosed at or before age 50 with two or more synchronous primary breast cancers
- Diagnosed at any age and two or more close family relatives with breast or ovarian cancera
- Two or more close family relatives with breast or ovarian cancera
- Personal history of ovarian cancer
- Close male relative with breast cancer
- High-risk ethnic background (i.e., Ashkenazi Jewish)
- Personal history of male breast cancer
- Close family member with one or more of the above criteria
what two drugs showed a reduction in incidence of breast cancer for high risk pt
tamoxifen and raloxifene
what two surgeries lowers the risk of developing breast cancer
mastectomy and salpino-oophorectomy
what is the best palpating method that has the lowest incidence of missed abnormalities
vertical strip
spontaneous nipple discharge
discharge on clothing in the absence of breast stimulation; in contrast, elicited discharge is noted after the nipple or breast is squeezed, or after vigorous mammography; only spontaneous discharge requires evaluation.
what type of discharge is more likely a result from an underlying malignancy
unilateral bloody single duct spontaneous discharge especially if there is an assoc mass
mc cause of unilateral spontaneous bloody nipple discharge
benign papilloma
what is the foundation of breast cancer screening
annual mammogram
American Cancer Society Guidelines for Breast Cancer Screening
Yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health.
Women should know how their breasts normally feel and report any breast change promptly to their health care providers. BSE is an option for women starting in their twenties.
Women at high risk (>20% lifetime risk) should get an MRI and a mammogram every year. Women at moderately increased risk (15%–20% lifetime risk) should talk with their doctors about the benefits and limitations of adding MRI screening to their yearly mammogram. Yearly MRI screening is not recommended for women whose lifetime risk of breast cancer is
what are the two views of a mammography
craniocaudal (CC) and median lateral oblique (MLO)
Breast imaging reporting and data system classification score for need for additional studies or interval follow up
0 (add imx eval) 1(negative) 2 (benign finding) 3 (probably benign, short interval f/u) 4 (suspicious abn, bx) 5 (highly sugg malig, approp action)
additional dx views
tissue compression and magnification
2 technological advances for imaging
computer assisted detection (CAD) software and digital mammography
what is a imaging adjunct to mammography
us- good at characterizing a mammography density or palpable mass as cystic or solid, and in guiding core needle bx
benign sonographic features of masses on us include
well demarcated borders, posterior enhancement, absence of internal echoes (characteristic of cysts)
what features are suspicious for malignancy on us
poorly demarcated borders, posterior shadowing, heterogeneous internal echoes, and a taller than wide orientation that invades across tissue planes
what does an mdi use to produce breast images w improved resolution of soft tissues
fat, water, and iv gadolinium contrast in magnetic fields
what imaging test is appropriate in women who carry deleterious BRCA1/2 mutation, or who by fhx and other risk factors
mri- if lesion is detected can do an mri directed bx
what is the definitive dx of breast lesions
microscopic examination of tissue by either cytology (individual cells obtained by fine needle aspiration) or histology (samples of tissue obtained by core needle or surgical bx)
which tissue sampling gives a rapid dx of suspected malignancy
cytology
what do histologic specimens provide
invasive vs in situ carcinoma, type of cancer, expression of estrogen/progesterone/HER2/neu
difference between bx of palpable lesion and one detected radiologically
palpable can be needle bx directly; radiologic must be under guidance
bx of mass lesions
us guidance
bx microcalcifications and subtle abnorm
stereotactic localization in mammography suite
triple test to say lesion is benign
concordance between clinical exam, radiographic appearance, and pathology
what is the needle bx results are discordant
excisional bx guided by localizing wire placed under radiological guidance is necessary
why shouldn’t an open excisional bx without a prior needle bx be done
possible positive margins, cosmetically unfavorable incision placement, need to go back to the operating room for lymph node staging
when should a pt be reeval if pe and imaging show typical areas of fibroglandular tissue without discrete mass
6-12weeks
what do all pt who have a discrete persistent mass require
tissue dx
dx test for age
us
dx test for age >30 w palpable breast mass
mammogram and us
palpable breast mass that is cystic on imaging and asymptomatic simple
re examine 2-3months
palpable breast mass that is cystic on imaging and symptomatic or complex
aspirate and if no residual mass then 2-6m f/u; if there is a residual mass then bx
palpable breast mass that is solid on imaging
fna or core bx: non dx (action depends on clinical correlation), benign, malignancy (definitive therapy)
what is a common experience a few days preceding menses
mild, cyclic b/l breast tenderness and swelling; rarely prompts medical consultation
in the absence of any physical or radiological abnormality what is the next step
reassurance and follow up exam in a few months
what is thought to be the underlying cause of mastalgia
hormonal stimulation of glandular breast tissue
what is recommended to be stopped in postmenopausal women w breast pain
HRT
therapeutic measures for breast pain/tenderness
compressive elastic style bra (sport or minimizer bra), dec caffeine consumption, non steroidal anti inflammatory analgesics, evening primrose oil capsules
what androgen analogue is effective in relieving breast pain and tenderness and when is it used
danazol and used only after failure of prev measures because of adverse effects such as deepening the voice and hirsutism
fibroadenoma
very common benign tumor of the breast usually occurring in young women
typical pe findings of fibroadenoma
1-3cm in size and palpated as a freely movable, discrete, firm round mass in the breast
histologically what are fibroadenomas composed of
fibrous stromal tissue and tissue clefts lined w normal epithelium
what establishes dx of fibroadenomas
fns or core bx
tx of fibroadenomas
tx rapid growing fibroadenomas during pregnancy
due to hormonal stimulation and tx is excision
tx giant fibroadenoma
core needle bx prior to excision to distinguish the relatively rare phyllodes tumor
phyllodes tumor
usually a benign tumor of the stromal elements requiring wide margins of resection to prevent local recurrence
mc cause of breast mass in women in 4/5th decade of life
cyst
how do cysts present
solitary or multiple, firm, mobile, slightly tender masses often with less defined borders
what fluctuates w menstrual cycle and cysts
size and degree of tenderness
imaging of cysts
mammography will detect nonpalpable cysts; us in simple cyst as well demarcated hypo echoic mass w posterior enhancement of transmission
does the us finding of a cyst require bx
no
tx cyst
aspiration on large symptomatic cyst; fluid may be straw colored or greenish and no cytologic analysis needed
us appearance of complex cyst and tx
shows internal echoes or an assoc solid component; mammography and core needle bx needed prior to excision
mc cause of nipple discharge
duct ectasia- nonneoplastic condition characterized by multiple dilated ducts in subareolar space
eval of nipple discharge
apply to occult blood test paper and further evaluation performed when blood is present
what nipple discharge is considered pathological
persistent, spontaneous discharge from a single duct and bloody discharge
intraductal papilloma
local proliferation of ductal epithelial cells that typically presents in women in their 4/5th decade of life
what is important to be done to evaluate for malignancy w nipple discharge
mammography
tx nipple discharge in the absence of clinical or radiological evidence of malignancy
duct excision through a circumareolar incision allows definitive histological dx and eliminates discharge
breast that is warm, edematous and erythematous represents ddx revolves around
infx process
what is mastitis mc assoc w
lactation
what may occur in nonlacting women who smoke
recurrent retroareolar abscess may occur w chronic inflammation and fistula formation between the skin and the duct
pe findings of breast w erythema
erythema spreading in lymphangitic pattern from areola toward the axilla, skin thickening w accentuation of the pores (peau d’orange), lymphadenopathy, overall breast enlargement and heaviness, mass that may be fluctuant
difference of pain w malignancy and abscess
malig has no pain while abscess is very tender
dx imaging with erythematic breast
mammography and us; mri is no mass is demonstrated
what will us show w erythema breast
drainable fluid collections
tx breast abscess
repeated aspiration combined w abx may allow resolution of the abscess without open drainage
tx of chronic retroareolar inflammation and mammary duct fistula
abx then excision of subareolar ducts including fistula tract
what is mastitis in lactating women usually caused by
staphylococci or streptococci
what abx used for abscess
dicloxacillin or clindamycin
earliest sign of breast cancer
abnormality on a mammogram
what happens as breast cancers grow
produce palpable mass that is often hard and irregular
signs of breast cancer
thickening, swelling, skin irritation, dimpling
nipple changes due to breast cancer
scaliness, dryness, ulceration, retraction, discharge
preinvasive form of ductal cancer
ductal cancer in situ (DCIS); intraductal carcinoma
typical appearance of DCIS on mammography
microcalcifications; rarely a mass on pe or mammography
histologic types od DCIS
solid, cribiform, micropapillary, comedo type
classification of DCIS
based on nuclear grades 1-3 with 1 being most favorable
what constitutes approx 80% of invasive breast cancers
infiltrating ductal carcinoma
higher incidence of mulicentricity in same breast and by its presence in contralateral breast; difficult to detect
infiltrating lobular carcinoma
higher incidence of mulicentricity in same breast and by its presence in contralateral breast; difficult to detect
infiltrating lobular carcinoma
polymastia
accessory breast tissue; mostly occurs in the axilla
amastia
congenital absence of the breast
amazia
lack of breast tissue development with perseverance of the nipple
what does inc hormonal production by the ovary at puberty cause
ductal budding and initial formation of acini; proliferations of the terminal ducts lined w secretory cells for milk production
what effects do estrogen and progesterone have
full maturation of the ductal and lobular components of the breast
gynecomastia
enlarged breasts may be asym and tender secondary to a physiologic excess of plasma estradiol relative to plasma testosterone; age 20 male
what should be considered for a solid mass in a postmenopausal woman
cancer until proven otherwise
risk of hormone replacement therapy
inc risk of breast cancer; esp estrogen plus progestin
major risk factors for breast cancer
females, inc age, fhx, proliferative pathology with atypic on bx (atypical ductal or lobular hyperplasia)
what familial cancer syndromes are assoc w greater risk of breast cancer
Li-Fraumeni and Cowden’s
what genes are assoc with breast cancer
BRCA 1 long arm of chromosome 17 and BRCA 2 long arm of chromosome 13
guidelines on referral for genetic counseling
Individuals from a family with a known BRCA1 or BRCA2 mutation;Personal history of breast cancer with one of the following:
- Diagnosed at or before age 45
- Diagnosed at or before age 50 with one or more close family relatives diagnosed with breast cancer or ovarian cancer at or before 50a
- Diagnosed at or before age 50 with two or more synchronous primary breast cancers
- Diagnosed at any age and two or more close family relatives with breast or ovarian cancera
- Two or more close family relatives with breast or ovarian cancera
- Personal history of ovarian cancer
- Close male relative with breast cancer
- High-risk ethnic background (i.e., Ashkenazi Jewish)
- Personal history of male breast cancer
- Close family member with one or more of the above criteria
what two drugs showed a reduction in incidence of breast cancer for high risk pt
tamoxifen and raloxifene
what two surgeries lowers the risk of developing breast cancer
mastectomy and salpino-oophorectomy
what is the best palpating method that has the lowest incidence of missed abnormalities
vertical strip
spontaneous nipple discharge
discharge on clothing in the absence of breast stimulation; in contrast, elicited discharge is noted after the nipple or breast is squeezed, or after vigorous mammography; only spontaneous discharge requires evaluation.
what type of discharge is more likely a result from an underlying malignancy
unilateral bloody single duct spontaneous discharge especially if there is an assoc mass
mc cause of unilateral spontaneous bloody nipple discharge
benign papilloma
what is the foundation of breast cancer screening
annual mammogram
American Cancer Society Guidelines for Breast Cancer Screening
Yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health.
Women should know how their breasts normally feel and report any breast change promptly to their health care providers. BSE is an option for women starting in their twenties.
Women at high risk (>20% lifetime risk) should get an MRI and a mammogram every year. Women at moderately increased risk (15%–20% lifetime risk) should talk with their doctors about the benefits and limitations of adding MRI screening to their yearly mammogram. Yearly MRI screening is not recommended for women whose lifetime risk of breast cancer is
what are the two views of a mammography
craniocaudal (CC) and median lateral oblique (MLO)
Breast imaging reporting and data system classification score for need for additional studies or interval follow up
0 (add imx eval) 1(negative) 2 (benign finding) 3 (probably benign, short interval f/u) 4 (suspicious abn, bx) 5 (highly sugg malig, approp action)
additional dx views
tissue compression and magnification
2 technological advances for imaging
computer assisted detection (CAD) software and digital mammography
what is a imaging adjunct to mammography
us- good at characterizing a mammography density or palpable mass as cystic or solid, and in guiding core needle bx
benign sonographic features of masses on us include
well demarcated borders, posterior enhancement, absence of internal echoes (characteristic of cysts)
what features are suspicious for malignancy on us
poorly demarcated borders, posterior shadowing, heterogeneous internal echoes, and a taller than wide orientation that invades across tissue planes
what does an mdi use to produce breast images w improved resolution of soft tissues
fat, water, and iv gadolinium contrast in magnetic fields
what imaging test is appropriate in women who carry deleterious BRCA1/2 mutation, or who by fhx and other risk factors
mri- if lesion is detected can do an mri directed bx
what is the definitive dx of breast lesions
microscopic examination of tissue by either cytology (individual cells obtained by fine needle aspiration) or histology (samples of tissue obtained by core needle or surgical bx)
which tissue sampling gives a rapid dx of suspected malignancy
cytology
what do histologic specimens provide
invasive vs in situ carcinoma, type of cancer, expression of estrogen/progesterone/HER2/neu
difference between bx of palpable lesion and one detected radiologically
palpable can be needle bx directly; radiologic must be under guidance
bx of mass lesions
us guidance
bx microcalcifications and subtle abnorm
stereotactic localization in mammography suite
triple test to say lesion is benign
concordance between clinical exam, radiographic appearance, and pathology
what is the needle bx results are discordant
excisional bx guided by localizing wire placed under radiological guidance is necessary
why shouldn’t an open excisional bx without a prior needle bx be done
possible positive margins, cosmetically unfavorable incision placement, need to go back to the operating room for lymph node staging
when should a pt be reeval if pe and imaging show typical areas of fibroglandular tissue without discrete mass
6-12weeks
what do all pt who have a discrete persistent mass require
tissue dx
dx test for age
us
dx test for age >30 w palpable breast mass
mammogram and us
palpable breast mass that is cystic on imaging and asymptomatic simple
re examine 2-3months
palpable breast mass that is cystic on imaging and symptomatic or complex
aspirate and if no residual mass then 2-6m f/u; if there is a residual mass then bx
palpable breast mass that is solid on imaging
fna or core bx: non dx (action depends on clinical correlation), benign, malignancy (definitive therapy)
what is a common experience a few days preceding menses
mild, cyclic b/l breast tenderness and swelling; rarely prompts medical consultation
in the absence of any physical or radiological abnormality what is the next step
reassurance and follow up exam in a few months
what is thought to be the underlying cause of mastalgia
hormonal stimulation of glandular breast tissue
what is recommended to be stopped in postmenopausal women w breast pain
HRT
therapeutic measures for breast pain/tenderness
compressive elastic style bra (sport or minimizer bra), dec caffeine consumption, non steroidal anti inflammatory analgesics, evening primrose oil capsules
what androgen analogue is effective in relieving breast pain and tenderness and when is it used
danazol and used only after failure of prev measures because of adverse effects such as deepening the voice and hirsutism
fibroadenoma
very common benign tumor of the breast usually occurring in young women
typical pe findings of fibroadenoma
1-3cm in size and palpated as a freely movable, discrete, firm round mass in the breast
histologically what are fibroadenomas composed of
fibrous stromal tissue and tissue clefts lined w normal epithelium
what establishes dx of fibroadenomas
fns or core bx
tx of fibroadenomas
tx rapid growing fibroadenomas during pregnancy
due to hormonal stimulation and tx is excision
tx giant fibroadenoma
core needle bx prior to excision to distinguish the relatively rare phyllodes tumor
phyllodes tumor
usually a benign tumor of the stromal elements requiring wide margins of resection to prevent local recurrence
mc cause of breast mass in women in 4/5th decade of life
cyst
how do cysts present
solitary or multiple, firm, mobile, slightly tender masses often with less defined borders
what fluctuates w menstrual cycle and cysts
size and degree of tenderness
imaging of cysts
mammography will detect nonpalpable cysts; us in simple cyst as well demarcated hypo echoic mass w posterior enhancement of transmission
does the us finding of a cyst require bx
no
tx cyst
aspiration on large symptomatic cyst; fluid may be straw colored or greenish and no cytologic analysis needed
us appearance of complex cyst and tx
shows internal echoes or an assoc solid component; mammography and core needle bx needed prior to excision
mc cause of nipple discharge
duct ectasia- nonneoplastic condition characterized by multiple dilated ducts in subareolar space
eval of nipple discharge
apply to occult blood test paper and further evaluation performed when blood is present
what nipple discharge is considered pathological
persistent, spontaneous discharge from a single duct and bloody discharge
intraductal papilloma
local proliferation of ductal epithelial cells that typically presents in women in their 4/5th decade of life
what is important to be done to evaluate for malignancy w nipple discharge
mammography
tx nipple discharge in the absence of clinical or radiological evidence of malignancy
duct excision through a circumareolar incision allows definitive histological dx and eliminates discharge
breast that is warm, edematous and erythematous represents ddx revolves around
infx process
what is mastitis mc assoc w
lactation
what may occur in nonlacting women who smoke
recurrent retroareolar abscess may occur w chronic inflammation and fistula formation between the skin and the duct
pe findings of breast w erythema
erythema spreading in lymphangitic pattern from areola toward the axilla, skin thickening w accentuation of the pores (peau d’orange), lymphadenopathy, overall breast enlargement and heaviness, mass that may be fluctuant
difference of pain w malignancy and abscess
malig has no pain while abscess is very tender
dx imaging with erythematic breast
mammography and us; mri is no mass is demonstrated
what will us show w erythema breast
drainable fluid collections
tx breast abscess
repeated aspiration combined w abx may allow resolution of the abscess without open drainage
tx of chronic retroareolar inflammation and mammary duct fistula
abx then excision of subareolar ducts including fistula tract
what is mastitis in lactating women usually caused by
staphylococci or streptococci
what abx used for abscess
dicloxacillin or clindamycin
earliest sign of breast cancer
abnormality on a mammogram
what happens as breast cancers grow
produce palpable mass that is often hard and irregular
signs of breast cancer
thickening, swelling, skin irritation, dimpling
nipple changes due to breast cancer
scaliness, dryness, ulceration, retraction, discharge
preinvasive form of ductal cancer
ductal cancer in situ (DCIS); intraductal carcinoma
typical appearance of DCIS on mammography
microcalcifications; rarely a mass on pe or mammography
histologic types od DCIS
solid, cribiform, micropapillary, comedo type
classification of DCIS
based on nuclear grades 1-3 with 1 being most favorable
what constitutes approx 80% of invasive breast cancers
infiltrating ductal carcinoma
firm irregular mass on pe
infiltrating ductal carcinoma
higher incidence of mulicentricity in same breast and by its presence in contralateral breast; difficult to detect
infiltrating lobular carcinoma
forms small tubules, randomly arranged, each lined by a single uniform row of cells; tends to occur in slightly younger patients
tubular carcinoma
form of ductal carcinoma
extensive tumor invasion by small lymphocytes; tends to be rapidly growing and large and assoc w DCIS; less commonly metastasizes to regional lymph nodes
medullary carcinoma
clumps and strands of epithelial cells in pools of mucoid material; grows slowly and occurs more often in older women
colloid or mucinous carcinoma
what type of carcinoma is hard to differentiate histologically from intraductal papilloma (benign lesion)
true papillary carcinoma
presents with skin edema (peau d’orange) and erythema; skin edema is secondary to dermal lymphatics congested w malignant cells
inflammatory carcinoma
poor prognosis
what malignancies rarely occur in the breast
sarcomas, lymphomas, leukemia
cutaneous nipple abnormality, which may be moist and exudative, dry and scaly, erosive or just thickened area; +/- itching, burning, or sticking pain in the nipple; over times spreads from the duct orifice
Paget’s ds of the nipple
(dermis is infiltrated by Paget’s cells, which are of ductal origin, large and pale, with large nuclei, prominent nucleoli, and abundant cytoplasm
mc areas of breast cancer metastasis
bone, lung, liver, brain
TNM staging system for breast cancer
Primary tumor (T): tis (carcinoma in situ), t1 (5cm), t4 (any size with extension to chest wall or skin)
Lymph Nodes (N): no( no nodes), n1 (1-3 axillary nodes), n2 (4-9 axillary nodes), n3 (>10 axillary)
M0= no distant metastasis
M1= distant metastasis
stage 0 of breast cancer using tnm scale
tis, no, mo
stage 1 of breast cancer using tnm scale
t1, no, mo
stage 2a of breast cancer using tnm scale
(to, n1, mo), (t1,n1,mo), (t2,no,mo)
stage 2b of breast cancer using tnm scale
(t2,n1,mo) (t3,no,mo)
stage 3a of breast cancer using tnm scale
t0-3 with n2 (one t3 can be w n1) with mo
stage 3b of breast cancer using tnm scale
t4 with n0-2, mo
stage 3c of breast cancer using tnm scale
any t, n3,mo
stage 4 of breast cancer using tnm scale
any t, any n, m1
what tests are needed before surgery when the pt’s risk for metazoic ds is low (
chest radiograph and cbc
more adv need chest and abd ct plus bone scans
what is the single most important factor in determining ds free and overall survival
axillary lymph node status; then tumor size and estrogen receptor status
what does f/u for breast cancer pts include
b/l mammogram 6m after completion of radiation therapy following lumpectomy and yearly thereafter
what should be performed annually after mastectomy
contralateral breast mammogram
pe f/u breast cancer
every 3-6m for 3 yrs then annually
local tx of breast cancer
surgery and radiation
systemic tx of breast cancer
iv and oral medicines
what size tumor is lumpectomy feasible
lumpectomy, wide excision, segmental, and partial mastectomy
excision of malignancy w circumferential margin of microscopically normal tissue
simple or total mastectomy
removes entire breast w pectoralis major fascia
modified radical mastectomy
simple mastectomy w axillary dissection
indications for mastectomy
dermal lymphatic involvement, diffuse or multiple tumors, unwillingnes or inability to undergo radiation therapy, cosmetically unacceptable
what should be discussed with all pt undergoing mastectomy
breast reconstruction using prosthetic implants or autologous tissue
what has become the standard of care for early breast cancer
sentinel node bx
what allows surgeon to id the first lymph node that receives drainage from the breast
radioactive colloid and or blue dye in quadrant of tumor
what are absolute contraindications to radiation therapy
pregnancy and previous radiation to same field
relative contraindications to radiation therapy
prev radiation to same general area, underlying pulmonary ds or cardiomyopathy, significant vasculitis, inability to lie flat
when should omitting radiation be considered
at least 70yo, single cancer
whole breast external beam radiation
take few min and given 5d/wk for a period of at least 4-6wks, usually w a boost to the tumor bed
partial breast irradiation
local area of the lumpectomy is radiated more intensively w external beams, radioactive material in a balloon, or radioactive seeds
selective estrogen receptor modulators (SERMs)
-tamoxifen; act as estrogen receptor antagonists in breast tissue and as estrogen agonists in bone
what are SERMs used to tx
estrogen receptor positive (ER+) tumors, dec incidence of contralateral breast cancer and dec recurrence
aromatase inhibitors (AIs)
letrozole, anastrozole, exemestane; dec circulating estrogen levels in postmenopausal women
indications for chemotherapy
node positive ds or tumors >1cm in greatest diameter
most commonly used chemo regimen
anthracycline, a taxane (paclitaxel and docetaxel), and possibly an alkylating agent
cytotoxic chemo
chemical agents that kill cells; never given as a single agent
what improves survival in pts w HER 2 positive tumors
trastuzumab
tx of operable breast cancer in men
mastectomy
what is the tx for recurrence of local tumor after lumpectomy
mastectomy
tx for recurrence of tumor after mastectomy
excision and radiation
what are brain metastases tx w
radiation
tx bony metastases
radiation and surgical fixation; bisphosphonates give bone strength
common side effects of tamoxifen
fatigue, night sweats, hot flashes, fluid retention, vaginitis, thrombocytopenia
side effects AIs
osteoporosis, fractures, muscle and join pains, hot flashes
se chemo
n,v, bone marrow suppression, stomatitis, alopecia
se trastuzumab
usually mild but may include significant cardiac or pulmonary toxicity as well as fever, nausea, vomiting, diarrhea, weakness, headache, anemia, neutropenia, tumor pain, cough, dyspnea, and infusion reactions. Combining trastuzumab with chemotherapy increases cardiac risk.
A 35-year-old woman comes to clinic because of right breast pain for the past 3 months. The pain Is cyclical in nature. Her mother and two maternal aunts were all diagnosed with breast cancer In their 30s. There are no abnormal findings on exam and a recent diagnostic mammogram and ultrasound are normal. Which of the following would be the most appropriate option for management?
high risk screening and genetic counseling
A 35-year-old woman comes to clinic because of a 2-month history of thickening In the upper outer quadrant of her left breast. The patient’s mother had breast cancer at age 48. Physical examination shows a slight retraction of the skin in the upper outer quadrant when the patient is upright. The breast tissue In that quadrant is rather firm, with the Impression of a poorly demarcated thickening. A mammogram also shows dense tissue with no distinct mass or suspicious microcalcifications. What Is the next step In the evaluation?
Ultrasound Is an adjunct to mammography that is useful to characterize palpable masses; ultrasound of the palpable area may give the most useful information at this time. The radiographic finding Is discordant with suspicious clinical presentation; further diagnostic workup is required. Excislonal biopsy without prior attempted needle biopsy can lead to suboptimal management of a breast cancer. Stereotactic biopsy can only be performed on a lesion demonstrated by mammography. A breast abscess Is exquisitely tender and demonstrable by ultrasonography. Section: Evaluation of the patient with breast mass.
A 51 -year-old woman comes to clinic because of a mass In the left breast for 2 weeks. She has no previous history of breast problems. Her last menstrual period was 1 week ago, menarche was at age 12 and she had her first child at age 30. She has no history of any major medical Illness. Her paternal aunt had breast cancer at age 75. On physical examination, she has a 1 -cm mass in the upper outer quadrant of the left breast. The mass is firm and freely movable with Indistinct borders. There is minimal tenderness and skin dimpling over the mass. There is no nipple discharge and no axillary lymphadenopathy. The mammogram and breast ultrasound are normal. A biopsy shows cancer. Which of the following Is the most likely histologic type of cancer causing these findings?
Infiltrating lobular often presents as described In this patient. Inflammatory breast cancer will have red edematous skin. Infiltrating ductal carcinoma will be hard with irregular borders and will usually be seen on mammogram and ultrasound. Lobular carcinoma in situ does not usually present as a mass. It is usually found incidentally when excising other breast pathology. Paget’s disease Involves the nipple.
A 45-year-old woman is seen in clinic because of skin nodules on the upper portion of the breast and over the clavicle. One year ago, she underwent lumpectomy and sentinel node biopsy for Stage HA invasive ductal carcinoma, ER+, PR-, and HER-2/neu-. She then received a full course of whole-breast radiation with a boost to the tumor bed. After four cycles of cytotoxic chemotherapy, she was started on tamoxifen by her oncologist. Physical exam shows several clusters of firm nodules In the skin over the clavicle and along the upper portion of the left breast. Biopsy of one of these nodules shows metastatic breast cancer. What is the best treatment now?
Cytotoxic chemotherapy should be started as soon as possible. An aromatase inhibitor Is not Indicated. The patient has already failed hormonal treatment, as her cancer has advanced while she was taking tamoxifen. This is not a single skin nodule but rather several clusters extending beyond the breast. Mastectomy is a local treatment and may be considered, including excision of the entire area of Involved skin and possible skin graft, if she responds to systemic treatment (cytotoxic chemotherapy). The breast has already been radiated once and should not be radiated again. Trastuzumab is only effective in HER2/neu-positlve breast cancers; it is a monoclonal antibody that binds selectively to the Her-2 protein, a regulator of cell growth. This patient is HER-2/neu negative.
A 52-year-old woman comes to clinic because of a bloody nipple discharge. She has noticed spontaneous bloody nipple discharge from her left breast every 2 to 3 days for the last month. She has no pain and takes no medications. Menarche was at age 12. She has four children and was 22 years old when her first child was born. There Is no family history of breast cancer. There are no palpable breast masses, but a small amount of bloody discharge can be expressed from the upper Inner quadrant of the left nipple. A mammogram done earlier today was read as normal. What Is the most Important next step in her evaluation?
-duct excision
MRI Is not useful in the evaluation of nipple discharge. Ductography will not avoid the need for duct excision. Cytology has been shown to be unhelpful In the workup and diagnosis of nipple discharge. A significant percentage of patients with nipple discharge have no mammographic abnormalities.
