Breast cancer Flashcards
Anatomic border for breast LND
Pectoralis minor
Clinical risks for breast cancer
Thoracic RT (highest risk - 50x), first birth after 35 y/o, HRT, early menarche, late menopause, nulliparity
Pathologic risks for breast cancer
Lobular CIS, atypical ductal or lobular hyperplasia, proliferative disease without atypia (fibroadenoma with complexity, hyperplasia, sclerosing adenosis, intraductal papilloma)
Genetic risks for breast cancer
BRCA, family hx
Factors protective against breast cancer
Breastfeeding at least one year, menopause before 40 y/o
ACOG screening guidelines
Annual mammogram starting at age 40 y/o
Factors that make mammogram less sensitive and specific
Young age, dense breast tissue
Mammographic signs of malignancy
Clusters of calcifications, radiodense mass, parenchymal distortion, skin thickening or edema
BIRADS 0
Need further imaging
BIRADS 1-2
Routine screening
BIRADS 3
<2% risk of cancer, plan mammogram q6 mos for 1-2 yrs and bilateral mammogram yearly for 3 yrs
BIRADS 4-5
Biopsy
BIRADS 6
Known malignancy
BRCA, type of genes
Cancer suppressor genes
How many breast cancers are associated with BRCA?
5%
Lifetime breast cancer risk with BRCA
50-85%
How many genetic-associated breast cancers are associated with BRCA?
40-50%
Factors indicative of genetic causes
Dx <40 y/o, Ashkenazi Jewish, family history, bilateral breast cancer, adnexal or peritoneal high-grade or serous cancer
Surveillance for BRCA carriers or those with hx of thoracic radiation
Start at 25 y/o
BSE monthly, CBE twice yearly, mammogram annually, breast MRI alternating with mammogram
Risk-reducing surgery for BRCA carriers
Prophylactic mastectomy, risk-reducing BSO, risk-reducing BS
Use for breast ultrasound
Differentiate between cystic and solid mass, no sensitive so not a screening tool, good for eval of known mass
Use for breast MRI
If other modalities result in less adequate conclusions (highly sensitive but not specific)
Downsides of FNA for diagnosis
10-15% non-diagnostic rate, complications of hematoma or infection
Triple test (CBE, breast imaging, FNA) efficacy
99-100% if all concordant
Core needle biopsy efficacy
85-100% sensitivity and specificity, provides tissue for diagnosis
Needle localized excisional breast biopsy efficacy
Diagnostic, needle directly in lesion then excised; imaging confirms removal
Multiple cystic masses, fluctuate with menses, bilateral, tender, possible nipple discharge
Fibrocystic breast disease
How common is fibrocystic breast disease?
50% of women
Mobile, nontender, firm, solitary mass, benign
Fibroadenoma
Most common breast tumor in women 20-35 y/o
Fibroadenoma
Management of mastalgia
Bra, d/c hormonal therapies like OCPs, avoid cigarettes / caffeine / stress, NSAIDs
Vit E and evening primrose do not have enough evidence
Risks of tamoxifen, bromocriptine, danazol, and GnRH outweight benefits
Most common cause of bloody discharge
Intraductal papilloma (others are ductal ectasia or cancer)
Causes of physiologic discharge
Idiopathic, breast stimulation, OCPs, hypothyroidism, pituitary tumores, hyperprolactinemia, dopamin inhibitors (ie antipsychtics)
Paget’s disease of the breast presentation
Eczematoid lesion in nipple/areola complex
Associations to Paget’s disease of the breast
DCIS, infiltrating ductal carcinoma
Who gets ductal carcinoma in situ (DCIS)?
Postmenopausal
Likelihood of DCIS progression to cancer
30-50%
Treatment for DCIS
Most reasonable wide excision alone (can consider mastectomy, radiation)
Who gets lobular carcinoma in situ (LCIS)?
40-50 y/o (<10% postmenopausal)
Likelihood of breast cancer after LCIS?
25% (can be either breast, is a risk factor not a precursor)
Treatment for LCIS
Most commonly cautious observation, can do prophylactic mastectomy in high-risk patient
Most common location for early-detected breast cancer
Upper, outer quadrant
Anatomic location of breast cancer
Most commonly terminal duct lobular unit
Most common histology of breast cancer
70% invasive ductal carcinoma
Indian filing of cells
Invasive lobular carcinoma
Molecular assessments of breast cancer
Hormone receptor status, Her2neu overexpression (oncogene protein), Her2gene amplification
When to do SLN biopsy
Early breast cancer with nonpalpable lymph nodes (otherwise biopsy the palpable ones)
Surgery for breast cancer
Lumpectomy + radiation (used to be radical mastectomy)
Who needs adjuvant chemotherapy for breast cancer?
Women with >10% risk of systemic disease
Tamoxifen drug type and actions
SERM, blocks ER in breast and stimulates in endometrium
Drugs with tamoxifen interaction
Antidepressants (inhibit P450 2D6 enzymes and make tamoxifen less effective) except Effexor or Lexapro
Raloxifene drug type and actions
SERM, blocks ER in breast and endometrium
Indication for raloxifene
Prevention of breast cancer in postmenopausal women (NOT adjuvant therapy)
Indication for aromatase inhibitors in breast cancer
Postmenopausal women with ER pos
Aromatase inhibitors compared to Tamoxifen
Increased osteoporosis and bone fracture, decreased endometrial cancer, decreased VTE risk, decreased hot flashes
How long can aromatase inhibitor be used?
5 years (usually Tamoxifen for 5 yrs then AI for 5 yrs)
What are aromatase inhibitor names?
Anastrozole, letrozole, exemastane
Use for trastuzumab (Herceptin)
Overexpression of Her2neu antigen, amplification of Her2 gene
When to give trastuzumab
With or after chemo, but not with doxorubicin (increased CHF risk)
Most important prognostic factor for breast cancer
Axillary lymph node status
Other prognostic factors
Tumor size, histologic rage, ER/PR status, Her2neu overexpression