Breast cancer Flashcards
What is lobular carcinoma in situ?
incidental ddx
- incr risk breast cancer
- tx: surgical excision if diagnosed by needle biopsy. Can use tamoxifen to decrease risk breast cancer
What is ductal carcinoma in situ?
cancer cells fill portions of mammary ductal system WITHOUT invading beyond duct’s basement membrane
- Stage 0 breast cancer
- imaging: pleomorphic, linear, branching calcifications
- Morphologic types: cribriform, solid, micropapillary, comedo.
- classified by morphologic type, presence of comedonecrosis and nuclear grade. Grade=most predictive of cancer/dz/recurrence
- Tx: wide excision or mastectomy. if breast conservation, radiation.
What is Paget Disease?
type of DCIS - focal rash of nipple.
- ductal carcinoma cells migrate to nipple and induce skin breakdown.
- high risk underlying DCIS (2/3) and invasive cancer (1/3).
- Tx: wide excision.
Strategies for managing breast cancer risk?
- Lifestyle modification/weight loss
- screening w/ MRI
- Chemoprevention w/ SERM or aromatase inhibitor (tamoxifen if >35, raloxifene if post-menopausal)
- Prophylactic surgery
What are genetic syndromes associated with increased breast cancer risk?
BRCA1/2
Li-Fraumeni (p53)
Cowden (PTEN)
Peutz-Jegher (STK11)
Hereditary diffuse gastric cancer (CHD1), ATM
What are most common forms of invasive breast cancer?
1st: Infiltrating ductal carcinoma (80%)
2nd: Infiltrating lobular carcinoma (15%)
Others: phyllodes tumor, sarcoma, lymphoma
What is workup of invasive breast cancer?
mets sites: bone then lung/liver/brain. Need CBC, LFTs, CT, bone scan, PET.
What is treatment of invasive breast cancer?
Surgery
Radiation, adjuvant chemo (doxorubicin, cyclophosphamide, cis/carboplatin to replace doxorubicin if use cardiotoxic trastuzumab)
What are hormonal therapies for breast cancer?
ER-positive tumors:
Tamixofen: pre/post menopausal. SE: menopausal sx, inca risk VTE/endometrial cancer.
Anastrazole/Letrozole: incr risk bone loss (need bone mineral density testing) + bisphosphonates (Zoledronic acid).
What are non-proliferative breast lesions?
- Simple cysts=most common
- cysts w/ apocrine metaplasia
-mild hyperplasia (usual type) - papillary apocrine change
Cysts seen in ⅓ of women ages 35-50. Simple cysts (no septations or mural thickening) always benign and no aspiration unless bothersome
What are proliferative breast lesions without atypia?
- fibroadenoma
- intraductal papilloma
- moderate/florid hyperplasia
- epithelial hyperplasia
- sclerosing adenosis
- complex sclerosing scar
What is a fibroadenoma?
most common cause breast masses in adolescents/young women.
- Firm, well-circumscribed mobile mass. Look like cysts on exam
Giant fibroadenoma (>10cm) unusual variant of fibroadenomas, account for 4%. Enlarging masses that distort breasts.
What is sclerosing adenosis?
type of proliferative breast lesion.
- increased #/size of glandular components within lobular units. small/mod incr risk of breast cancer
What is an intraductal papilloma?
Type of proliferative breast lesion.
- tumors in lactiferous duct, centrally located near duct opening/solitary or multiple/peripherally located. Solitary ones can present as nipple discharge (bloody, serous, clear). In ages 30-50, typically small
What are proliferative lesions WITH atypia?
- atypical ductal hyperplasia
- atypical lobular hyperplasia
Management: surgical excision. DCIS or invasive cancer detected at tiem of excision in 15% of cases. Then get an annual mammogram and breast exam q6-12 months. Risk reduction w/ tamoxifen (pre/post menopausal), raloxifene, aromatase inhibitors (post menopausal).
What is atypical lobular hyperplasia?
incidental finding on mammography histologic evaluation. substuntially incr risk of invasive cancer in affected and contralateral breast
What is a tubular adenoma?
benign proliferators breast lesion
- glandular cells w/ minimal stromal elements. Can present as breast mass and solid on US.
What is a phyllodes tumor?
uncommon fibroepithelial tumors (only 0.4%) can be benign to propensity for recurrence to sarcoma. Median age is 40, single enlarging breast mass.
- Ddx: imaging, need excisional biopsy bc look like fibroadenoma or benign tumor but can invade locally and cause distant mets.
What is lobular carcinoma in situ?
incidental at time of breast biopsy. NOT precursor lesion for breast cancer like DCIS. incr risk for future cancer 10-20% chance of developing DCIS or invasive cancer in 15 years.
Risk reduction w/ tamoxifen (pre/post menopausal), raloxifene, aroatase inhibitors (post menopausal).
What is management of nipple discharge?
Benign: bilateral, milky/green, multidouctal
If unilateral, uniductal, spontaneous, higher risk of malignancy
If <30, get US. If birads 1-3, duct excision
If >30, get mammogram + US. If birads 4-5, tissue biopsy
What is tamoxifen?
SERM: anti-estrogen effect on breast, pro-estrogen effect on bone and endometrium. Prevents osteoporosis in post-menopausal.
- incr risk endometrial hyperplasia and VTE (decreases antithrombin 3). most common side effect=hot flushes.
Teratogenic, no pregnancy!
post-menopausal sx increases: hot flushes, vaginal dryness, decreased libido, thin vaginal discharge
pre-menopausal: menorrhagia and ovarian cysts 2/2 ovarian stimulator.
if 5 year risk breast cancer >1.7%, use tamoxifen
reduces breast cancer in BRCA2 by 60% (higher prevalence of ER-positive breast cancer with brca2 than brca1).
What are aromatase inhibitors?
indicated ONLY in postmenopausal (unlike tamoxifen). side effects=joint and muscle pain, hair thinning. Incr risk fractures. incr in disease free survival!! (Better than tamoxifen).
How is Tamoxifen used?
in BRCA2 carriers, can reduce risk of breast cancer by 62%
- BRCA2 more likely to be ER positive
- reduces risk by 50%! use for 5 years only.
BRCA1 carriers are at risk for which other cancers?
pancreatic
ovarian
- NOT brain or melanoma (melanoma only in BRCA2!!)
- assoc w/ triple neg (ER/PR/Her 2 neu) vs. BRCA2 assoc w/ ER/PR pos.
-BRCA1/2 are tumor suppressor genes, do homologous recombination that repairs double stranded DNA breaks
What is the lifetime risk of breast cancer?
12%
facts about breast cancer
Ashkenazi Jews: 1 in 40 will have BRCA
Protective factors: LESS estrogen so late menarche, early menopause, breastfeeding, young age at 1st pregnancy
- RRSO reduces risk of developing breast cancer by 50%. roughly 4% of RRSO specimens will have occult malignancies.
management: age 25, annual breast MRI. age 30: annual breast MRI + mammogram
