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Medicine II: Surgery > Breast Cancer > Flashcards

Breast Cancer Flashcards

1
Q

How does breast cancer rank in cancer frequency and cancer death?

A

1st in frequency for females second in death

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2
Q

What fraction of women in the US will get breast cancer?

A

1/8

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3
Q

What breast cells give rise to the most breast cancer?

A

lobules and ducts

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4
Q

What is the main blood supply of the breast?

A

internal mammary (60%)

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5
Q

What is the primary site of lymph drainage?

A

axilla

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6
Q

What are the 3 anatomical levels of lymph, in reference to pec minor?

A

1- lateral
2- deep
3- medial

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7
Q

What are risks of breast cancer?

A 
sex
age
personal hx with BRCA
Fhx
breast changes
gene changes
reproductive and menstrual hx
race
xrt to chest wall
DES exposure
breast density
postmenopausal obesity
lack of physical activity
EtOH consumption
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8
Q

What is the GAIL MODEL

A

used to determine the risk of BRCA; develops lifetime risk factors

does pt have hx of BRCA or DCIS/LCIS?
age?
age at menarche?
age at 1st child birth?
how many 1st deg relatives have had BRCA?
has pt had breast biopsy? if so how many?
atypical hyperplasia found?
ehtnicity?
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9
Q

What does GAIL MODEL calculate?

A

the 5 yr and life long risk of developing BRCA

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10
Q

What is considered high risk for the GAIL MODEL?

A

> 1.6%

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11
Q

The role of _________ could get a ________ % permanent reduction in lifetime risk

A

hormonal chemoprevention, 50

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12
Q

What types of breast cancer screenings are there?

A 
self breast exam
clinical breast exam
screening mammogram
US
MRI
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13
Q

How often should you preform a self breast exam?

A

monthly

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14
Q

How much have self breast exams affected the reduction of BRCA deaths?

A

none

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15
Q

How often should you have a clinical breast exam?

A

every year

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16
Q

How often should you have a screening mammogram?

A

every 1-2 years, at 50 every year

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17
Q

Why would you have a breast US?

A

if you suspect a cystic lesion or the pt is very young; they have denser breast tissue

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18
Q

Why are mammograms not the best for younger females?

A

they have denser breast tissue and it may not be beneficial

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19
Q

When would you have an MRI to look at your breasts?

A

if you have BRCA 1&2
1st degree relative with BRCA
GAIL risk of >25%
RXT to chest

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20
Q

What is the most common initial mammogram presentation for women with BRCA?

A

abnormal

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21
Q

What percentage of mammograms have abnormal results?

A

5-10%

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22
Q

What is BRAIDS?

A

breast imaging and reporting data system

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23
Q

What are the BRAIDS categories?

A 
0- incomplete
1- negative finding
2- benign finding
3- probably benign finding, 6 mo follow up
4- suspicious abnormality
5- highly suggestive of malignancy
6- known biopsy proven malignancy
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24
Q

Why do we use BRAIDS?

A

used to standardize breast cancer reporting

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25
Q

In an HPI we have to look at these criteria when looking into the pts Hx of breast masses:

A 
location of mass
how it was identified
how long has it been present
nipple changes- discharge(unilateral or B/L, nipple inversion?, #of ducts involved, color, spontaneity)
new or persistent skin changes?
changes in size or tenderness?
do symptoms vary with menstrual cycle?
hx of other breast complaints
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26
Q

What do we include in PMHx when getting a history of breast masses?

A

reproductive hx
PSHx
SHx
FHx

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27
Q

What are the different types of benign breast cancer or disease?

A 
fibroadenoma
cyst
fibrocystic disease
mastitis/abscess
nipple discharge
mastodynia
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28
Q

What is a fibroadenoma?

A

MCC breast mass in young women, firm, rubbery, smooth, mobile (hypoechoic mass on US)

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29
Q

What is a breast cyst treatment?

A

aspirate, if it does not completely disappear bx

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30
Q

What is fibrocystic disease?

A

breast pain, nipple discharge, masses, cyclical size change

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31
Q

What is mastitis/abscess?

A

usually associate with breast feeding, also associated with auto immune disease in non-lactating women

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32
Q

What is the most common pathogen of a mastitis/abscess?

A

S. aureus

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33
Q

What is mastodynia?

A

breast pain, rarely cancer

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34
Q

How do you treat mastodynia? What is the best treatment?

A

best: evening primrose oil (only one that has shown improvement)
others: danazol, OCPs and NSAIDS

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35
Q

What are types of benign tumors?

A

phyllodes tumor

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36
Q

What is a phyllodes tumor?

A

mimics a fibroadema, <5% metastasize, tend to occur locally

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37
Q

How do you treat a phyllodes tumor?

A

re-sect with 1 cm boarder

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38
Q

If findings from a US and clinical examination are consistent with a fibroademoma then what is the next course of action?

A

The lesion can be safely followed clinically with several sonograms, breast self exams or both

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39
Q

What is the first study preformed for nipple discharge?

A

mammography

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40
Q

What are the types of nipple discharge?

A 
gray/green
bloody
clear
yellow
milky
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41
Q

What does a gray/green discharge signify?

A

duct actasisa

42
Q

What does a bloody discharge signify?

A

intraductal papilloma

43
Q

What does a clear discharge signify?

A

malignancy

44
Q

What does a milky discharge signify?

A

prolactinoma

45
Q

What is the discharge you should be the most concerned with?

A

yellow

46
Q

What are the possible sites for ductal discharge?

A

unilateral or bilateral

47
Q

What are the steps of a breast physical exam?

A

inspection
palpation
mass characterization
nodal levels?

48
Q

What are you inspecting for in a breast exam?

A

asymmetry, skin changes (dimpling, rashes) nipples(discharge, retraction, inversion)

49
Q

What position is the patient in during a breast exam?

A

upright sitting

50
Q

What are you palpating in a breast physical exam?

A

regional LN, breast, nipple

51
Q

What are the regional LN to the breast?

A

cervical supra/infraclavicular, axillary

52
Q

What position is the patient in during the palpation portion of the breast physical exam?

A

supine, one arm raised

53
Q

What are the mass characteristics to note?

A

size, shape, location, consistency and mobility

54
Q

What mass characteristics are associated with a malignancy?

A

hard, immobile, fixed, irregular boarders

55
Q

What are breast cancer symptoms?

A
  • a change in how the breast feels
  • a change in how the breast looks
  • nipple discharge
56
Q

What can change in how the breast feels?

A

thickening of the skin
nipple sensation
new discrete mass

57
Q

What can change in how the breast looks? What are the different shapes?

A

abnormal shape
Peau d’orange
nipple inversion

58
Q

What do you use to do a tissue diagnosis?

A

core needle biopsy, NOT FNA
use a US to guide, MR to guide

looking for receptor positivity (ER, PR, Her2Neu)

59
Q

What type of biopsy do you do for non palpable lesions?

A

stereotactic biopsy for nonpalpable lesions

60
Q

What must you correlate your imaging findings with?

A

pathological results

61
Q

What are prgnostic/predictive factors for BRCA?

A 
axillary LN status
tumor size
lymphatic/vascular invasion
age
histological grade
histological subtype
response to neoadjunctiva therapy
ER/PR status
Her2Neu gene amplification
62
Q

What is Her2Neu overexpression associated with?

A

more aggressive tumor phenotype and worse prognostic

63
Q

What tumors are more responsive to hormonal therapy?

A

hormone positive tumors because they have more indolent course

64
Q

What are different types of breast cancer?

A

ductal
lobular
angiosarcoma
phyllodes

65
Q

What is ductal breast cancer?

A

an inflammatory breast cancer, DCIS, that is invasive and is a locally advanced BRCA - neoadjuvant chemo

66
Q

What is lobular cancer?

A

LCIS, invasive lobular

67
Q

What is and angiosarcoma?

A

a vascular malignancy that is radiation induced

68
Q

What is a phyllodes cancer?

A

mixed connective tissue and epithelium that does not metastasize to the LN

69
Q

What should we keep in mind about LCIS?

A

it is not a malignant condition it is a marker for high risk malignancy
70% of pts with LCIS develop ductal carcinoma

70
Q

What do patients with LCIS tend to develop?

A

multicentric or bilateral cancer disease

71
Q

What are the essentials of tumor classification?

A

TNM
T- tumor (1-4 based on size)
N- nodes (1-3 based on involvement of axillary nodes)
M- metastasis (0=no, 1=yes)

72
Q

What are the 5 yr survival rates associated with each tumor stage?

A 
0- 92
1- 87
2- 75
3- 46
4- 13
73
Q

What are the surgical resection options for breast cancer?

A

needle localized lumpectomy +/- sentinel biopsy
simple mastectomy +/- sentinel biopsy
modified radical mastectomy
radical mastectomy

74
Q

What is approved for adjuvant therapy in pts treated with breast conserving therapy and radiation?

A

tamoxifen

75
Q

What is a radical mastectomy?

A

mastectomy plus the axillary contents
INCLUDES PEC MUSCLES
not premed much today

76
Q

What is a modified radical mastectomy?

A

mastectomy plus the axillary contents, not including pecs

takes all breast tissue out, muscle lays flat

77
Q

What is the first node of drainage?

A

SLN sentinel lymph node

78
Q

What is the significance of SLN?

A

important for axillary staging
if it is neg it can be presumed the rest is negative
it is detected w/radioactive tracer and/or blue dye
allowing close histological examination of a single node

79
Q

What do you do if the SLN is positive?

A

preform a complete axillary dissection

80
Q

Who should not have a BCT?

A 
pts who wish to have a mastectomy
inflammatory BRCA
multicentric disease
contraindications to XRT: previous radiation, pregnancy, collagen vascular disease
no ascess to radiation therapy center
very small mass in a small breast
81
Q

Who gets radiation thereapy?

A

all patients w/ breast conserving therapy who do not have contraindications

82
Q

When do we use oncotype?

A

small tumors, ER+, node neg

calculates the likelihood of distant recurrance at 10 yrs after diagnosis

83
Q

What is adjuvant online?

A

predicts 10 yr breast cancer outcome for pts w/ or w/out systemic therapy
valid for stage 1 and 2

84
Q

What are the regimens?

A

adriamyon, cyclophosphamide
adriamyon, cyclophosphamide, taxol for more advanced tumors

duration is 6 weeks

85
Q

When do you use hormone therapy?

A

for ER+, PR+ tumors
tamoxifen
anastrazole
herceptin

86
Q

When do you use tamoxifen?

A

for pre-menopausal women

87
Q

When do you use anastrazole?

A

for post-menopausal women

88
Q

When do you use herceptin?

A

for Her2Neu pos. pts

89
Q

What are the future directions of BRCA tx?

A

mammosite

intabeam

90
Q

What are the requirements for mammosite?

A
  • > 45 yo
  • ductal or DCIS
  • <3cm
  • node neg.
  • neg. margins
91
Q

How long does mammosite take to treat?

A

5 days

92
Q

What is intrabeams requirements?

A

> 45

DCIS

93
Q

most frequently injured during breast surgery?

A

(book mentions medial pectoral nerve)

94
Q

Major risk factors for Breast Cancer:

A

(PA CAN):
P = first pregnancy > 30 yo
A = age at menarche (=55 yo)
N = Nulliparity

95
Q

What are some other risk factors for breast cancer?

A

Other: Age, HRT, Prior breast biopsies with atypical/lobular hyperplasia or LCIS

96
Q

Abnormalities found in postmenopausal women are more likely to be related to what?

A

Abnormalities occurring in postmenopausal women such as pain, nipple d/c and masses are more likely to be related to malignancies.

97
Q

Abnormalities found in women <30 are more likely to be related to what?

A

Abnormalities occurring in women < 30 yo are likely to be benign pathologies – fibrocystic changes, cysts and fibroadenomas.

98
Q

Do no risk factors mean no breast cancer?

A

Many women who develop breast CA do not have risk factors

99
Q

When do diagnostic problems w/ BRCA begin to arise in women?

A

Diagnostic problems most often arise in the intermediate group (aged 30 – 50 or menopause) – may be benign or malignant

100
Q

What techniques are available for characterizing palpable lesions as a function of age?

A

(ie: Mammography, U/S and MRI)

101
Q

Ductal carcinoma in situ (DCIS)

A

pre-invasive form of ductal cancer (if not treated may develop invasive cancer in 30-50% of patients over 10 years)
Typical appearance involve microcalcifications

Medicine II: Surgery (14 decks)

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