Breast Flashcards
What’s in the differential for a benign palpable breast mass?
Fibrocystic change Fibroadenoma Intraductal papilloma Fat necrosis Abscess Galactocele
What’s in the differential for a malignant palpable breast mass?
DCIS Invasive ductal carcinoma Invasive lobular carcinoma Mucinous carcinoma Inflammatory carcinoma Phylloides tumor
What features on PE suggest breast cancer?
- Asymmetry, skin changes, nipple discharge (or crusting)
- Single dominant lesion that is hard, immobile and with irregular borders
- Look at lymph nodes: enlarged, firm, immobile and/or matted suggest mets
What are the most important risk factors for breast cancer?
- Female gender
- Increasing age
- Family history of premenopausal breast cancer
- All have increased lifetime exposure to estrogen
What are the 3 types of nipple discharge?
Lactation
Physiologic discharge
Pathologic discharge
What does physiologic discharge look like, and what usually causes it?
Clear, bilateral and multi ductal
- Post lactation, fluctuating hormone levels or nipple stimulation
What can cause pathologic nipple discharge?
Prolactinoma Hypothyroidism Cushing's Medications Papilloma: tumor of lining of breast duct
In what circumstances is nipple discharge likely to be cancer?
- Bloody, spontaneous, unilateral, uniductal discharge
- Associated with breast mass
- In women > 40
What are the fibrocystic changes and their associated increased risk of cancer?
Apocrine metaplasia: none
Ductal hyperplasia / Sclerosing adenosine: doubles risk of cancer
Atypical hyperplasia: highest risk
What is pathophys of “peau d’orange”? When is it seen?
Lymph drainage is compromised by tumor –> edema in inter follicular dermis –> dimples that look like orange peels
Seen in inflammatory breast cancer
What is pathophys of nipple retraction?
Breast tumor infiltrates suspensory ligaments (Cooper’s ligaments) and retracts the skin often around the nipples
What is the triple test for new breast mass?
PE
Imaging
Tissue sample
How does age of patient affect workup of a new palpable breast mass?
< 30: Ultrasound
> 30: mammogram plus ultrasound
How do we work-up a mass in a patient <30, after US, if it is a:
simple cyst
Painful/enlarging cyst
Solid mass?
Simple cyst: observe
Painful/enlarging cyst: aspirated and sent to cytology if bloody
Solid: do a core needle biopsy
Once a mass is identified in a woman > 30, what is the next step?
Core needle biopsy to exclude cancer
What metastatic workup is recommended after diagnosis of breast cancer?
None
- CXR
- LFTs
- alk phos, Ca to examine liver and bone function
- Otherwise, follow symptoms and only do bone scan, CT abdomen/chest/brain if suspicion for mets is high
How do we stage breast cancer?
Tumor
Nodes
Metastases
What surgical options are available for stage I and II breast cancer?
- Breast conserving therapy: lumpectomy + sentinel lymph node biopsy. Then radiation
- Simple mastectomy
What are the contraindications to breast conserving therapy?
- Primary tumors in 2+ quadrants
- Diffuse malignant appearing micro calcifications throughout breast
- Previous history of chest wall radiation
- Positive surgical margins despite repeat excision
- Early pregnancy (cannot give radiation)
Can nipple and breast skin be spared during simple mastectomy?
Yes
What is management for clinically advanced stage III breast cancer?
- Large tumor: simple mastectomy
- Lymph nodes enlarged: axillary lymph node dissection (ALND)
- Both: modified radical mastectomy: mastectomy + ALND
- Any skin invasion: chemo before surgery to shrink margins
What is considered stage III breast cancer?
- Tumors > 5c
- Tumors that invaded skin
- Presence of large matted clinically positive axillary lymph nodes
What is premise behind SLNB?
Hypothetical first node from which lymphatics of breast drain… if first ones are free of cancer, likely the rest are not, either.
How many sentinel nodes at a time usually?
2-4
What to do if during SLNB, no sentinel lymph node lights up?
Proceed to ALND: remove level I and II lymph nodes
When to perform axillary lymph node dissection?
- If >2 positive sentinel lymph nodes, or in patients who underwent mastectomy (because they don’t get radiation)
- Otherwise, can do radiation to axilla
What is the purpose of ALND?
Used for staging: not been shown to affect survival
What is the premise behind hormonal therapy?
- Decrease steroid hormone levels or antagonizing receptors that promote growth of cancer cells
- Usually adjuvant to prevent recurrence
What study must be done before trastuzumab?
Echocardiogram or MUGA to determine EF
Why are aromatase inhibitors only effective in post menopausal women?
E.g. anastrozole: Inhibit aromatase enzyme in fat tissue that make small amounts of estrogen in postmenopausal women: only work in people whose ovaries stopped producing estrogen
What are key hormonal therapies and mechanisms of action in breast cancer?
Tamoxifen/raloxifene/fulvestrant: blocks ER
Anastrozole: aromatase inhibitor
Trastuzumab: monoclonal Ab blocking HER-2 receptors
what are the key chemotherapeutics used for breast cancer and their mechanisms of action?
Doxorubicin: inhibit DNA/RNA synthesis by inhibiting topoisomerase II
Cyclophosphamide: promotes DNA damage: alkylates guanine bases
Methotrexate/5-FU: interfere with DNA synthesis
Paclitaxel: inhibits mitotic phase in cell cycle
Does everyone with breast cancer require chemo?
Most, except:
- Carcinoma in situ
- < 1cm with favorable tumor markers and negative SLNB
In breast cancer patients who do not get chemo, what test do they get and why?
Oncotype DX: look at molecular level cancer characteristics to predict chemo benefit and recurrence
What are options for breast reconstruction?
Immediate: autologous tissue flap with temporary tissue expander
Delayed: if patient requires post-op radiation
What nerves can be damaged during dissection of lymph nodes in breast cancer?
1 Long thoracic: winged scapula (serratus anterior)
2 Thoracodorsal: weak latissimus dorsi
3 Medial pectoral: weak internal rotation of humerus (pec minor and major)
4 Lateral pectoral: weak flexion, adduction and internal rotation of humerus (pec major)
What is the worst complication of lymph node dissection?
Lymphedema (more likely with ALND vs. SLNB)
What is the concern with lymphedema from ALND?
- Increased risk of infection
- Lymphangiosarcoma: poor prognosis even after limb amputation
What to do with a breast mass during pregnancy?
- Do not ignore!
- Patient can get chemo in second trimester
- In 3rd trimster, wait until after birth
- Never get radiation or hormones during pregnancy
What types of breast cancer do men typically get, and when?
65-70 years of age
Invasive ductal carcinoma
Should stage 4 breast cancer patient have a mastectomy?
Several studies that suggest mastectomy in select patients provides some survival benefit
What is most common cause of palpable breast mass?
Fibrocystic change
What’s the differential for abnormal mammogram without palpable breast mass?
Benign: Skin calcification Vascular calcification Eggshell calcification Suspicious: Amorphous calcification Coarse heterogeneous High probability malignancy: - Fine pleomorphic (BI-RADS 5) - Fine linear/linear branching
What are recommendations for breast cancer screening?
Age 40-44: Optional
45-54: annual screening mammography
55+: Annual or every 2 years
What are the risks of mammography?
- Radiation
- Detection of cancers that would not lead to symptoms
- Not always accurate
Why is mammography not useful in women < 30?
Denser breast tissue: make it harder to detect abnormal calcifications or masses
What is one quick feature to help differentiate between benign and malignant conditions on mammography?
Macrocalcifications: usually benign
Microcalcifications: more often breast cancer
What is presentation of DCIS vs. LCIS?
DCIS: incidental micro calcification: mammo
LCIS: incidental finding on histopath
What is location of DCIS vs. LCIS?
DCIS: Ducts
LCIS: lobules
What is pattern of DCIS vs. LCIS?
DCIS: Comedy with prominent necrosis in the center of the involved spaces
LCIS: solid
Is there axillary metastasis in DCIS vs. LCIS?
DCIS: 1-13%
LCIS: usually absent
What is the incidence of concurrent invasive carcinoma and risk of subsequent invasive carcinoma in DCIS vs. LCIS?
DCIS: Higher
LCIS: lower
What is treatment of DCIS?
Excision to negative margin, consider SLNB in select group
What is treatment of LCIS?
- If found on excisional biopsy: observation or tamoxifen
- If on core needle biopsy: rule out adjacent cancer
- High risk: offer prophylactic bilateral mastectomy
What does LCIS signify?
Marker for development of future invasive breast cancer, but not a precursor lesion!
How are mammograms used in staging breast lesions?
BIRADS: summarize reporting of mamographic findings to determine relative likelihood of benign or malignant diagnosis.
0: more imaging needed
1: Negative
2: Benign most likely (2% risk)
3: Probably benign: more follow-up
4: Suspicious abnormalities: biopsy (15-30% risk)
5: Highly suspicious: biopsy
6: Already proven to be malignant
What if stereotactic biopsy indicates DCIS?
BCS to avoid progression to invasive ductal cancer
What if stereotactic biopsy indicates LCIS?
Excisional biopsy to rule out any adjacent cancer. If path finds only LCIS: no further surgery.
What if stereotactic biopsy shows invasive ductal carcinoma?
Standard treatment:
- BCS with SLND + radiation
- Mastectomy with SLNB
Do DCIS cancers require SLNB?
- Usually no, but considered in some high risk patients with extensive microcacifications or palpable mass
- Also recommended if patient chooses mastectomy
Does mammography actually reduce mortality from breast cancer?
Recent study: no
Who could be considered a candidate for prophylactic bilateral mastectomy?
Patients with LCIS
Patients with family history of breast cancer
What is ACS guideline for clinical breast exams?
Every 3 years: Age 20-39
Annually after 40
What BIRADS scores get stereotactic biopsy?
4 or 5
