Breast Flashcards
Margin for DCIS
2mm
What does radical mastectomy take?
Modified radical?
What and how much tissue/muscle, nodes?
Radical: total beast + pec major/minor muscles + lvl I/II/III nodes
Modified radical: total beast + fascia of pec major + lvl I/II nodes
What are the axillary node levels?
I: lateral to pec minor
II: under pec minor
III: medial to pec minor
Treatment for inflammatory breast CA
1) anthracyclin based neoadj chemo
2) modified radical mastectomy. SLN is contraindicated
3) chest wall radiation
Workup of palpable breast lesson for women <30 vs. >30?
<30: ultrasound first and then mammography if concerning features
> 30: mammography first then US + aspiration
Screening Breast MRI is only recommended for who? (4)
1) those with a BRCA mutation
2) a first-degree relative who is a BRCA carrier
3) a prior history of mantle irradiation
4) and a lifetime risk of breast cancer of at least 20 to 25% based on a careful family history
Evidence is not sufficient to recommend for or against annual breast MRI screening in women with a personal history of lobular carcinoma in situ or ductal carcinoma in situ
Margin forpatients with early-stage invasive breast cancer undergoing breast conservation therapy?
No ink on tumor. Because they’ll get radiation
ACOSOG Z0011 trial.
What the hell is it?
When do you do ALND?
randomized clinical trial comparing sentinel lymph node dissection (SLND) alone to SLND plus axillary lymph node dissection (ALND) in patients with cT1-2 N0 breast cancer found to have 1 or 2 positive sentinel lymph nodes.
Even though additional nodal disease was present in 27% of patients in the ALND arm of Z0011, there was no difference in rates of local recurrence, disease-free survival, or overall survival based on the performance of an ALND. The 5-year overall survival rates were 92.5% and 91.8% in the SLND-alone and ALND groups, respectively
Do ALND for
- inflammatory breast CA
- Pt undergoing mastectomy and if (+) SLN
- if the pt has palpable nodes then do ALND
- More than 2 (+) nodes
- extranodal extension
What to do with sentinel node when T2 cN1 undergoes neoadj chemo?
Do the SLN after the chemo.
Only clinical exam, no radiographic response needed
Surveillance schedule for BRCA(+) women if they don’t undergo prophylactic mastectomy
What % of cancers does mammography miss?
Annual mammography + MRI alternating every 6 months
Up to 15%
Breast cancer risk reduction by tamoxifen in BRCA1 vs BRCA2?
Reduction by 60% in BRCA2
no reduction in BRCA1
Lifetime risk of breast cancer in men with BRCA1?
Is prophylactic mastectomy recommended for men with BRCA1?
1.2%
Prophylactic mastectomy not recommended
Lifetime breast CA risk for nonBRCA men is ~0.1%
Screening guideline for pts with known LCIS?
When to do lumpectomy vs. Not for LCIS?
Radiation or not for LCIS after lumpectomy?
Yearly mammogram + yearly MRI in high risk pts
If LCIS is found incidentally on core needle biopsy then omit lumpectomy.
Suspicious mammogram + stereotactic biopsy -> LCIS -> lumpectomy
No radiation for LCIS because it’s a risk factor, not a cancer. DCIS you can radiate
Margin for phyllodes tumor?
Radiation? Survival benefit from radiation?
1cm
Only for tumors >2cm after breast conserving therapy OR tumor >10cm after mastectomy
Radiation improves local recurrence. No change in survival
Axillary Mass. Biopsy shows breast. Mammography is negative. Next step?
Treatment for patients diagnosed with occult breast cancer who have a negative preoperative breast MRI?
Breast MRI
Breast conservation (axillary lymphadenectomy alone) with whole breast radiation therapy is an option. significantly better overall survival compared with patients treated with modified radical mastectomy.
Tamoxifen vs. aromatase inhibitor in premenopausal vs postmenopausal? Raloxifene?
Side effects of tamoxifen?
How long do you treat hormonal therapy? Trastuzamab?
Tamoxifen for premenopausal
Aromatase inhibitor (anastrazole) for postmenopausal -> increased osteoporotic fractures, myalgias, arthralgia
Raloxifene: selective estrogen inhibitor. Postmenopausal. About 80% as effective as tomaxifen. Less side effects
Tamoxifen -> thromboembolic, uterine cancer
Hormonal therapy ~5 yrs. Trastuzamab: 1yr
What is the % risk of breast cancer in someone with ADH?
30% over 25 year period
1) Leading cause of cancer deaths in women?
2) What % of all women in the US will develop cancer in their lifetime? What % will develop breast CA?
3) White vs black women for breast CA incidence and mortality?
4) incidence of male breast CA?
1) #1: lung #2: breast
2) 38% of all women will get cancer. 12% will be breast
3) higher incidence in white female, higher mortality in black women. Higher triple negative in blacks
4) 1% of all breast CA males. 1 in 833 males get diagnosed with breast cancer in their lifetime ~0.1% risk
Breast CA risk factors:
- menarche when?
- menopause when?
- if no pregnancy, how much is the risk increased?
- first pregnancy at what age increases risk? Reduces?
- OCP’s?
Previous breast cancer increases your risk of another breast cancer by how much?
Hx of endometrial or ovarian cancer increases breast cancer risk by how much?
What % of women already diagnosed with breast CA have family history?
If you have a family history then how is your breast CA risk changed?
- Menarche before 12
- Delayed menopause after age 50. Think more estrogen -> more breast CA
- increased by 30%
- first preg after age 30 -> 2x risk. First preg before 18 -> reduces risk
- OCP’s may increase risk if prolonged use
Prev breast CA -> 5x higher risk
Endometrial/ovarian CA -> 2x higher risk
Only 20% has family history
If (+) FHx then 2-6x higher risk
For screening, mammography should start at what age?
Annual vs. biennial?
Start annually at 40
Biennial at age 50
Or 10 years earlier than the youngest first degree relative with breast cancer
Breast MRI finding. Type I vs. III enhancement?
Type I: slow and continued rise. 5% chance if malignancy
Type III: rapid initial rise followed by washout. 60-80% chance malignancy
Treatment for Paget’s disease of the breast
Mastectomy or lumpectomy + radiation
Removal of nipple
SLN
Who may not need RT after lumpectomy for invasive cancer?
Women >75, tumor <2cm, ER(+)
Molecular features of breast CA
- Luminal A
- Luminal B
- HER2
- Basal
- Luminal A: ER/PR(+), HER2(-), low KI67
- Luminal B: ER/PR(+), HER2(+), high Ki67
- HER2: ER/PR(-), HER2(+)
- Basal: triple (-)
Can you still do a lumpectomy with a (+) sentinel node?
Does mastectomy have a better cure rate compared to lumpectomy?
Yes. Can still do lumpectomy
Cure rate similar between mastectomy & lumpectomy. Therefore lumpectomy is a preferred treatment
First and best test for evaluating breast cancer in pregnancy?
can they get MRI?
can they get Radiation?
can they get Chemotherapy?
Do they have worse prognosis stage for stage?
Ultrasound
MRI Is contraindicated because gadolinium is teratogenic
Radiation is contraindicated
Pregnant pts can receive chemo
Same prognosis stage for stage
How many nodes to be considered adequate axillary dissection?
Minimum 10
Who gets radiation after MASTECTOMY?
- tumors > 5cm
- tumors invading chest wall or skin
- inflammatory breast CA
- Any extranodal invasion
- (+) surgical margin
BRCA 1 vs. 2
- male breast cancer?
- higher incidence of ovarian?
- which chromosomes?
- No other associated cancers
- autosomal dominant or recessive?
- male breast cancer? BRCA 2. BRCA 1 doesn’t have male breast CA
- higher incidence of ovarian? neither. BRCA 1: equal breast/ovarian. BRCA2: less ovarian
- which chromosomes? BRCA1: 17, BRCA2: 13
- No other associated cancers: BRCA 1
- autosomal doninant
TP53?
What syndrome?
What cancers?
Males vs females?
Li-Fraumeni
Breast, leukemia, brain, sarcomas
Male: up to 73% lifetime cancer risk
Female: 100% lifetime cancer risk (breast)
Cowden: PTEN (breast & thyroid)
BRCA2 men
What screening is recommended? Mammography?
Tamoxifen for chemoprevention?
Prostate cancer screening. Mammography only if dense breast or gynecomastia
Tamoxifen only for treatment, not for prevention