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Surgery M4 part 1 > Breast Cancer > Flashcards

Breast Cancer Flashcards

1
Q

Whats the most important lymphatic drainage in the breast?

A

Axillary lymph nodes

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2
Q

What is the general clinical presentation of breast cancer?

A
  • breast lump
  • nipple discharge
  • breast pain
  • change in nipple or areola
  • change in breast size
  • inflammatory symptoms
  • abnormal mammogram with no symptoms
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3
Q

if a woman is younger than 40 and complaining of breast pain, what method of diagnosis should be done?

A

ultrasound

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4
Q

What is the difference between a high risk lesion and a premalignant lesions?

A

high risk: could develop cancer anywhere

premalignant: if untreated could turn into a malignancy in the same place

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5
Q

What are the high risk lesions?

A

PEARL

  • Papillary lesions
  • Expertise discordance (puts patient at high risk)
  • Atypical hyperplasia
  • Radial scar/complex sclerosing lesions
  • Lobular carcinoma in situ (LCIS)
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6
Q

How do we manage a high risk lesion?

A
  • Excision
  • Risk reduction (stop OCPs for example)
  • Surveillance
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7
Q

What are the risk factors for breast cancer?

A
  • 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)
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8
Q

What are the most common Li-Fraumeni (P53) associated cancer types?

A 
leukemia 
osteosarcoma 
brain
breast 
adrenals
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9
Q

what are the protective factors against breast cancer?

A
  • breast-feeding
  • parity
  • physical activity
  • ovarian ablasion before 35 years
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10
Q

What are the specific clinical presentations of breast cancer?

A
  • 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
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11
Q

What workup should be done in case of breast complaint?

A 
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
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12
Q

What are the histological types of breast cancer?

A 
Carcinoma in situ
 -DCIS
 -LCIS
Invasive (ductal) carcinoma NOS (most common)
Invasive lobular carcinoma 
Paget's disease
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13
Q

Which type of cancer is usually bilateral and multicentric?

A

Invasive lobular carcinoma

DO MRI

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14
Q

How do we treat DCIS & LCIS?

A 
DCIS
- like cancer (mastectomy or BCT SLNB if high risk features)
- hormonal therapy if ER+ 
LCIS
- excision 
- risk reduction
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15
Q

What is Paget’s disease?

A
  • 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)
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16
Q

What is the most rapidly lethal cancer of the breast?

A

Inflammatory breast cancer

17
Q

What do we consider as early breast cancer?

A

Stage I and IIA (T <5cm, N-) or (T<2cm with <3LNs)

18
Q

How do we diagnose and manage Paget’s?

A

Diagnose: scrape cytology, punch biopsy
Manage: excision of NAC if limited disease or mastectomy

19
Q

When do we use aromatase inhibitors?

A

in post menopausal women (to block androgen conversion into estrogen)

20
Q

What’s the difference between DCIS & LCIS?

A

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
21
Q

Breast Conservative Therapy vs Modified Radical Mastectomy indications?

A
  • patients wish, comorbidities, cosmesis
  • ratio of tumor to breast size
  • fixation/tethering
  • multi centricity
  • surgical margins
  • contraindications to radiotherapy after BCT
22
Q

How do we manage inflammatory breast cancer?

A

Full metastatic workup

Neoadjuvant chemotherapy ASAP

23
Q

What is the DD of inflammatory breast cancer?

A

MASTITIS

24
Q

what is the TNM staging?

A

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

25
Q

When can’t we do a breast conservative surgery?

A

if there are ANY contraindications to radiotherapy

  • pregnancy
  • homozygous ATM mutation
  • prior RT
  • active CT disease (SLE, scleroderma)
  • genetic predisposition for breast cancer
26
Q

When do we use hormonal/endocrine therapy?

A

ER+ PR+ tumors

27
Q

What are the contradictions to radiotherapy?

A
  • pregnancy
  • homozygous ATM mutation
  • prior radiation therapy
  • active connective tissue disease
  • genetic predisposition for breast cancer
28
Q

What hormonal therapy should be used on premenopausal women?

A

Selective ER modulator (SERM)

29
Q

What complication could happen post-op due to axillary lymph node dissection?

A

Lymphedema

30
Q

What are the different complications of hormonal therapy?

A

Selective ER modulator (SERM) Tamoxifen

  • menopausal symptoms
  • endometrial hyperplasia or malignancy
  • thromboembolism

Aromatase Inhibitors (AI) Letrozole & Anastrozole

  • Osteoporosis
  • arthralgia

Herceptin
- heart toxicity

31
Q

What is the only modality of screening for average risk women?

A
  • Mammogram every 1 - 2 years (40 - 69 year olds)

- no screening in 70-74 years but every 2-3 years if needed

32
Q

When do we stop screening?

A
  • life-expectancy < 5 - 7 years

- no further management possible due to age or comorbidities

33
Q

What are the risk factors for breast cancer in men?

A
  • 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)
34
Q

What is the clinical picture of inflammatory breast cancer?

A
  • diffuse induration
  • erythemia
  • warmth
  • edema
  • peau d’orange
  • +/- palpable mass
  • axillary lymphadenopathy
35
Q

What stage is considered advanced breast cancer, and how should it be treated?

A

Stage IIB & III (T > 5cm, extensive LN) & INFLAMMATORY BREAST DISEASE

TREATMENT

  • neoadjuvant chemotherapy
  • breast conservative surgery OR modified radical mastectomy
  • MRM for IBD
36
Q

What stage is considered metastatic breast cancer, and how should it be treated?

A

Stage IV (M+)

TREATMENT

  • chemotherapy
  • radiotherapy
  • Herceptin if HER2+
  • Endocrine therapy if ET+
  • mets-specific treatment
37
Q

What are the complications of radiotherapy?

A
  • breast edema
  • breast fibrosis
  • fat necrosis
  • radiation pneumonitis
  • pulmonary fibrosis
  • radiation osteonecrosis, rib fractures
  • radiation induced malignancy
38
Q

What screening should be done for increased risk women?

A

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

39
Q

What is the most common breast cancer in men and how should it be managed?

A
  • ductal carcinoma (no lobules in men)
  • evaluate by ultrasound & biopsy/excision
  • same management as in women

Surgery M4 part 1 (47 decks)

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