Breast Cancer Flashcards
Whats the most important lymphatic drainage in the breast?
Axillary lymph nodes
What is the general clinical presentation of breast cancer?
- breast lump
- nipple discharge
- breast pain
- change in nipple or areola
- change in breast size
- inflammatory symptoms
- abnormal mammogram with no symptoms
if a woman is younger than 40 and complaining of breast pain, what method of diagnosis should be done?
ultrasound
What is the difference between a high risk lesion and a premalignant lesions?
high risk: could develop cancer anywhere
premalignant: if untreated could turn into a malignancy in the same place
What are the high risk lesions?
PEARL
- Papillary lesions
- Expertise discordance (puts patient at high risk)
- Atypical hyperplasia
- Radial scar/complex sclerosing lesions
- Lobular carcinoma in situ (LCIS)
How do we manage a high risk lesion?
- Excision
- Risk reduction (stop OCPs for example)
- Surveillance
What are the risk factors for breast cancer?
- increasing age
- female
- obesity in post-menopausal women
- reproductive factors
- early menarche
- late menopause
- nulliparous
- older age of first pregnancy
- history of breast cancer
- genetic predisposition: BRCA, Li-Fraumeni (P53)
- family history in first degree relatives
- exogenous hormone use (OCP, HRT)
- high risk breast lesions
- previous breast biopsy (due to abnormal breast tissue discovered in the past)
- lifestyle (alcohol, smoking, no sleep)
- exposure to ionizing radiation of the chest at young age (younger than 30)
What are the most common Li-Fraumeni (P53) associated cancer types?
leukemia osteosarcoma brain breast adrenals
what are the protective factors against breast cancer?
- breast-feeding
- parity
- physical activity
- ovarian ablasion before 35 years
What are the specific clinical presentations of breast cancer?
- palpable mass: nontender, firm, irregular, immobile
- nipple discharge: serous or bloody
- nipple retraction
- excoriation of nipple: Paget’s disease
- axillary lymphadenopathy
- skin changes (dimpling, tethering, edema, peau d’orange)
- metastasis: lungs, bone, brain, liver
- suspicious lesion on imaging or biopsy
What workup should be done in case of breast complaint?
LABS IMAGING - bilateral mammogram - bilateral ultrasound - MRI if indicated - PET scan if indicated - Biopsy (FNA axilla, core biopsy, excisional biopsy) METASTATIC WORKUP - if early -> CXR, liver ultrasound - if advanced or high risk -> CT chest abdomen & pelvis, Bone scan
What are the histological types of breast cancer?
Carcinoma in situ -DCIS -LCIS Invasive (ductal) carcinoma NOS (most common) Invasive lobular carcinoma Paget's disease
Which type of cancer is usually bilateral and multicentric?
Invasive lobular carcinoma
DO MRI
How do we treat DCIS & LCIS?
DCIS - like cancer (mastectomy or BCT SLNB if high risk features) - hormonal therapy if ER+ LCIS - excision - risk reduction
What is Paget’s disease?
- Malignant cells that invade the nipple epidermis
- erythema & mild eczematous reaction that ulcerates
- it has a rapid progression
(could be associated with DCIS or invasive carcinoma)
What is the most rapidly lethal cancer of the breast?
Inflammatory breast cancer
What do we consider as early breast cancer?
Stage I and IIA (T <5cm, N-) or (T<2cm with <3LNs)
How do we diagnose and manage Paget’s?
Diagnose: scrape cytology, punch biopsy
Manage: excision of NAC if limited disease or mastectomy
When do we use aromatase inhibitors?
in post menopausal women (to block androgen conversion into estrogen)
What’s the difference between DCIS & LCIS?
DCIS LCIS
- 50-60 yr - 40-50 yr
- mass, pain, discharge - none
- microcalcifications - none
- 35% multicentric - 60-80% multicentric
- 10-20% bilateral - 50-70% bilateral
- invasive ductal - invasive ductal or lobular
Breast Conservative Therapy vs Modified Radical Mastectomy indications?
- patients wish, comorbidities, cosmesis
- ratio of tumor to breast size
- fixation/tethering
- multi centricity
- surgical margins
- contraindications to radiotherapy after BCT
How do we manage inflammatory breast cancer?
Full metastatic workup
Neoadjuvant chemotherapy ASAP
What is the DD of inflammatory breast cancer?
MASTITIS
what is the TNM staging?
TIS -> DCIS N1 = 1 - 3 positive regional nodes
T1mi: < or = 0.1 N2 = 4 - 9 positive regional nodes
T2: > 2 - 5cm N3 = > 10 positive regional lymph nodes
T3: > 5cm infraclavicular nodes
T4: invades chest wall or skin supraclavicular nodes
positive axillary & internal mammary nodes
When can’t we do a breast conservative surgery?
if there are ANY contraindications to radiotherapy
- pregnancy
- homozygous ATM mutation
- prior RT
- active CT disease (SLE, scleroderma)
- genetic predisposition for breast cancer
When do we use hormonal/endocrine therapy?
ER+ PR+ tumors
What are the contradictions to radiotherapy?
- pregnancy
- homozygous ATM mutation
- prior radiation therapy
- active connective tissue disease
- genetic predisposition for breast cancer
What hormonal therapy should be used on premenopausal women?
Selective ER modulator (SERM)
What complication could happen post-op due to axillary lymph node dissection?
Lymphedema
What are the different complications of hormonal therapy?
Selective ER modulator (SERM) Tamoxifen
- menopausal symptoms
- endometrial hyperplasia or malignancy
- thromboembolism
Aromatase Inhibitors (AI) Letrozole & Anastrozole
- Osteoporosis
- arthralgia
Herceptin
- heart toxicity
What is the only modality of screening for average risk women?
- Mammogram every 1 - 2 years (40 - 69 year olds)
- no screening in 70-74 years but every 2-3 years if needed
When do we stop screening?
- life-expectancy < 5 - 7 years
- no further management possible due to age or comorbidities
What are the risk factors for breast cancer in men?
- prolonged heat exposure
- previous chest wall radiation
- family history of breast cancer
- BRCA2 mutation
- relative hyperestrogenicity (testicular abnormalities, exogenous estrogen, obesity, liver disease, Klinefelter’s syndrome)
What is the clinical picture of inflammatory breast cancer?
- diffuse induration
- erythemia
- warmth
- edema
- peau d’orange
- +/- palpable mass
- axillary lymphadenopathy
What stage is considered advanced breast cancer, and how should it be treated?
Stage IIB & III (T > 5cm, extensive LN) & INFLAMMATORY BREAST DISEASE
TREATMENT
- neoadjuvant chemotherapy
- breast conservative surgery OR modified radical mastectomy
- MRM for IBD
What stage is considered metastatic breast cancer, and how should it be treated?
Stage IV (M+)
TREATMENT
- chemotherapy
- radiotherapy
- Herceptin if HER2+
- Endocrine therapy if ET+
- mets-specific treatment
What are the complications of radiotherapy?
- breast edema
- breast fibrosis
- fat necrosis
- radiation pneumonitis
- pulmonary fibrosis
- radiation osteonecrosis, rib fractures
- radiation induced malignancy
What screening should be done for increased risk women?
Strong family history of breast cancer or BRCA
- start screening at 30 years or 10 years younger than index patients age (but not before 25 years)
Lifetime risk of breast cancer >20%
- start screening at 30 years
History of chest radiotherapy between 10 - 30 years
- start screening 8 years after end of radiotherapy (but not before 25 years)
High risk lesion
- every year since diagnosis regardless of age
What is the most common breast cancer in men and how should it be managed?
- ductal carcinoma (no lobules in men)
- evaluate by ultrasound & biopsy/excision
- same management as in women
