Breast Cancer Flashcards
How does breast cancer rank in cancer frequency and cancer death?
1st in frequency for females second in death
What fraction of women in the US will get breast cancer?
1/8
What breast cells give rise to the most breast cancer?
lobules and ducts
What is the main blood supply of the breast?
internal mammary (60%)
What is the primary site of lymph drainage?
axilla
What are the 3 anatomical levels of lymph, in reference to pec minor?
1- lateral
2- deep
3- medial
What are risks of breast cancer?
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
What is the GAIL MODEL
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?
What does GAIL MODEL calculate?
the 5 yr and life long risk of developing BRCA
What is considered high risk for the GAIL MODEL?
> 1.6%
The role of _________ could get a ________ % permanent reduction in lifetime risk
hormonal chemoprevention, 50
What types of breast cancer screenings are there?
self breast exam clinical breast exam screening mammogram US MRI
How often should you preform a self breast exam?
monthly
How much have self breast exams affected the reduction of BRCA deaths?
none
How often should you have a clinical breast exam?
every year
How often should you have a screening mammogram?
every 1-2 years, at 50 every year
Why would you have a breast US?
if you suspect a cystic lesion or the pt is very young; they have denser breast tissue
Why are mammograms not the best for younger females?
they have denser breast tissue and it may not be beneficial
When would you have an MRI to look at your breasts?
if you have BRCA 1&2
1st degree relative with BRCA
GAIL risk of >25%
RXT to chest
What is the most common initial mammogram presentation for women with BRCA?
abnormal
What percentage of mammograms have abnormal results?
5-10%
What is BRAIDS?
breast imaging and reporting data system
What are the BRAIDS categories?
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
Why do we use BRAIDS?
used to standardize breast cancer reporting
In an HPI we have to look at these criteria when looking into the pts Hx of breast masses:
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
What do we include in PMHx when getting a history of breast masses?
reproductive hx
PSHx
SHx
FHx
What are the different types of benign breast cancer or disease?
fibroadenoma cyst fibrocystic disease mastitis/abscess nipple discharge mastodynia
What is a fibroadenoma?
MCC breast mass in young women, firm, rubbery, smooth, mobile (hypoechoic mass on US)
What is a breast cyst treatment?
aspirate, if it does not completely disappear bx
What is fibrocystic disease?
breast pain, nipple discharge, masses, cyclical size change
What is mastitis/abscess?
usually associate with breast feeding, also associated with auto immune disease in non-lactating women
What is the most common pathogen of a mastitis/abscess?
S. aureus
What is mastodynia?
breast pain, rarely cancer
How do you treat mastodynia? What is the best treatment?
best: evening primrose oil (only one that has shown improvement)
others: danazol, OCPs and NSAIDS
What are types of benign tumors?
phyllodes tumor
What is a phyllodes tumor?
mimics a fibroadema, <5% metastasize, tend to occur locally
How do you treat a phyllodes tumor?
re-sect with 1 cm boarder
If findings from a US and clinical examination are consistent with a fibroademoma then what is the next course of action?
The lesion can be safely followed clinically with several sonograms, breast self exams or both
What is the first study preformed for nipple discharge?
mammography
What are the types of nipple discharge?
gray/green bloody clear yellow milky
What does a gray/green discharge signify?
duct actasisa
What does a bloody discharge signify?
intraductal papilloma
What does a clear discharge signify?
malignancy
What does a milky discharge signify?
prolactinoma
What is the discharge you should be the most concerned with?
yellow
What are the possible sites for ductal discharge?
unilateral or bilateral
What are the steps of a breast physical exam?
inspection
palpation
mass characterization
nodal levels?
What are you inspecting for in a breast exam?
asymmetry, skin changes (dimpling, rashes) nipples(discharge, retraction, inversion)
What position is the patient in during a breast exam?
upright sitting
What are you palpating in a breast physical exam?
regional LN, breast, nipple
What are the regional LN to the breast?
cervical supra/infraclavicular, axillary
What position is the patient in during the palpation portion of the breast physical exam?
supine, one arm raised
What are the mass characteristics to note?
size, shape, location, consistency and mobility
What mass characteristics are associated with a malignancy?
hard, immobile, fixed, irregular boarders
What are breast cancer symptoms?
- a change in how the breast feels
- a change in how the breast looks
- nipple discharge
What can change in how the breast feels?
thickening of the skin
nipple sensation
new discrete mass
What can change in how the breast looks? What are the different shapes?
abnormal shape
Peau d’orange
nipple inversion
What do you use to do a tissue diagnosis?
core needle biopsy, NOT FNA
use a US to guide, MR to guide
looking for receptor positivity (ER, PR, Her2Neu)
What type of biopsy do you do for non palpable lesions?
stereotactic biopsy for nonpalpable lesions
What must you correlate your imaging findings with?
pathological results
What are prgnostic/predictive factors for BRCA?
axillary LN status tumor size lymphatic/vascular invasion age histological grade histological subtype response to neoadjunctiva therapy ER/PR status Her2Neu gene amplification
What is Her2Neu overexpression associated with?
more aggressive tumor phenotype and worse prognostic
What tumors are more responsive to hormonal therapy?
hormone positive tumors because they have more indolent course
What are different types of breast cancer?
ductal
lobular
angiosarcoma
phyllodes
What is ductal breast cancer?
an inflammatory breast cancer, DCIS, that is invasive and is a locally advanced BRCA - neoadjuvant chemo
What is lobular cancer?
LCIS, invasive lobular
What is and angiosarcoma?
a vascular malignancy that is radiation induced
What is a phyllodes cancer?
mixed connective tissue and epithelium that does not metastasize to the LN
What should we keep in mind about LCIS?
it is not a malignant condition it is a marker for high risk malignancy
70% of pts with LCIS develop ductal carcinoma
What do patients with LCIS tend to develop?
multicentric or bilateral cancer disease
What are the essentials of tumor classification?
TNM
T- tumor (1-4 based on size)
N- nodes (1-3 based on involvement of axillary nodes)
M- metastasis (0=no, 1=yes)
What are the 5 yr survival rates associated with each tumor stage?
0- 92 1- 87 2- 75 3- 46 4- 13
What are the surgical resection options for breast cancer?
needle localized lumpectomy +/- sentinel biopsy
simple mastectomy +/- sentinel biopsy
modified radical mastectomy
radical mastectomy
What is approved for adjuvant therapy in pts treated with breast conserving therapy and radiation?
tamoxifen
What is a radical mastectomy?
mastectomy plus the axillary contents
INCLUDES PEC MUSCLES
not premed much today
What is a modified radical mastectomy?
mastectomy plus the axillary contents, not including pecs
takes all breast tissue out, muscle lays flat
What is the first node of drainage?
SLN sentinel lymph node
What is the significance of SLN?
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
What do you do if the SLN is positive?
preform a complete axillary dissection
Who should not have a BCT?
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
Who gets radiation thereapy?
all patients w/ breast conserving therapy who do not have contraindications
When do we use oncotype?
small tumors, ER+, node neg
calculates the likelihood of distant recurrance at 10 yrs after diagnosis
What is adjuvant online?
predicts 10 yr breast cancer outcome for pts w/ or w/out systemic therapy
valid for stage 1 and 2
What are the regimens?
adriamyon, cyclophosphamide
adriamyon, cyclophosphamide, taxol for more advanced tumors
duration is 6 weeks
When do you use hormone therapy?
for ER+, PR+ tumors
tamoxifen
anastrazole
herceptin
When do you use tamoxifen?
for pre-menopausal women
When do you use anastrazole?
for post-menopausal women
When do you use herceptin?
for Her2Neu pos. pts
What are the future directions of BRCA tx?
mammosite
intabeam
What are the requirements for mammosite?
- > 45 yo
- ductal or DCIS
- <3cm
- node neg.
- neg. margins
How long does mammosite take to treat?
5 days
What is intrabeams requirements?
> 45
DCIS
most frequently injured during breast surgery?
(book mentions medial pectoral nerve)
Major risk factors for Breast Cancer:
(PA CAN):
P = first pregnancy > 30 yo
A = age at menarche (=55 yo)
N = Nulliparity
What are some other risk factors for breast cancer?
Other: Age, HRT, Prior breast biopsies with atypical/lobular hyperplasia or LCIS
Abnormalities found in postmenopausal women are more likely to be related to what?
Abnormalities occurring in postmenopausal women such as pain, nipple d/c and masses are more likely to be related to malignancies.
Abnormalities found in women <30 are more likely to be related to what?
Abnormalities occurring in women < 30 yo are likely to be benign pathologies – fibrocystic changes, cysts and fibroadenomas.
Do no risk factors mean no breast cancer?
Many women who develop breast CA do not have risk factors
When do diagnostic problems w/ BRCA begin to arise in women?
Diagnostic problems most often arise in the intermediate group (aged 30 – 50 or menopause) – may be benign or malignant
What techniques are available for characterizing palpable lesions as a function of age?
(ie: Mammography, U/S and MRI)
Ductal carcinoma in situ (DCIS)
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
