Breast Cancer Flashcards
1
Q
3 major structure of the breast
A
skin
sub Q
breast tissue
2
Q
what is breast tissue made up of?
A
parenchyma and stroma
3
Q
how many collecting milk duct open to a nipple?
A
5-10
4
Q
what tissue envelop the breast?
A
fascial tissues
5
Q
what is an important barrier to prevent invasion of breast cancer into the chest wall
A
pectoral fascia
6
Q
what is the suspensory system w/ the breast
A
Cooper’s ligaments
7
Q
where does most of the blood supply for the breast come from?
A
internal mammary (internal thoracic)
8
Q
what is the lympathic drainage for the breast?
A
97% axillary
3% internal mammary chain
9
Q
what muscles are found under the breast?
A
Pectoralis major
pectoralis minor
serratus anterior (lateral)
latissimus dorsi (anterior border can be seen)
10
Q
what nerves innervate the pecs
A
medial and lacteral pectoral nerves (not at risk usually w/ masectomy)
11
Q
what motor nerves run through the axilla?
A
lateral thoracic (serratus anterior) thoracodorsal (lat dorsi)
12
Q
what is the sensory cutaneous nerve that runs through the axilla?
A
intercostal-brachial cutaneous nerve
13
Q
what are the 2 main risk factors for breast cancer?
A
female
advancing age
14
Q
what reproductive factors are risks for breast cancer development?
A
late age at 1st full term pregnancy (>30)
early menarche (55)
no full term pregnancy, never breast fed
15
Q
what majority of genetic breast cancer is accounted for by what genes?
A
BRCA1/2 (only 5-10% of breast cancers)
tested by buccal or blood
16
Q
what model is used to determine risk of breast cancer by combining reproductive factors and family history.
A
Gail model
17
Q
lifetime risk for someone w/ a BRCA mutations?
A
50-90%
18
Q
surveillance for BRCA positive patients
A
exam (2x a year) mammo (once a women is 30) U/S MRI q 6 months mammo and MRI alternate every 6 months
19
Q
prevention options for BRCA positive patients
A
bilateral prophylactic mastectomy
BSO
tamoxifen
20
Q
there is a slightly increased risk of what other cancers with a BRCA mutation?
A
ovarian cancer
pancreatic cancer
melanoma
prostate cancer
21
Q
why are mammograms controversial in younger women?
A
less effective because tissue in breast is still pretty dense
22
Q
who are clinical breast exams possibly more effective in?
A
younger patients
23
Q
when should a women between ages of 50-74 have mammograms?
A
every 2 years (according to task force)
24
Q
what does a screening mammogram include?
A
CC= cranio-caudal
MLO- mediolateraloblique (chest wall and tail of Spence)
25
what is in a diagnostic mammography
evaluation of physical exam or screening mammo finding
| give the tech the authority to get more views
26
If there is a mass what do you want
US and mammogram
27
what type mammography seems to be more sensitive for dense breasts?
digital mammography (now becoming the norm)
28
what is 3D mammography (doesn't have clear indications, not covered by insurance)
tomosynthesis
29
on mammorgaphy how do densities show up?
white
30
on mammography how does fat show up?
gray
31
microcalcifications on mamorgraphy are concerning for what?
DCIS
32
what is a BI-RADs ( breast imaging-reporting and data systems) 0
needs further eval
33
what is a BI-RADs 1
negative
34
what is a BI-RADs 5
highly suggestive of malignancy
35
what is a BI-RADs 6
known biopsy proven malignancy
36
is a breast mass w/ a negative mammography the end of the workup?
No- send to surgeon for consideration of biopsy
37
What is the "triad of error" for delayed dx of breast cancer
young age (<45)
negative mammogram
self-discovered breast mass
38
what should you order anytime you are ordering a diagnostic mammograms. good for a specific area you want to investigate
US
39
what is involved in inspection for a clinical breast exam?
Upright with arms relaxed, arms raised, pectoralis muscles contracted (hands on hips)
Skin for edema, lesions, retraction, dimpling
Nipple areolar complex for retraction or discharge
40
what is involved in palpation for a clinical breast exam?
Upright and supine, examine breasts and LN basins
Have a systematic routine
Use finger pads in small circular motion and palpate at varying depths
Cover the entire breast, from clavicle to beyond inframammary crease, and from sternum through axilla
41
what will a fine needle aspiration give you?
nothing about invasion
| only a few cells
42
this has become the usual way that malignancy is diagnosed
| Often done by radiologists under image guidance
core needle biopsy
43
removal of the entire palpable or imaged abnormality
excisional biopsy
44
common cause of breast pain, often cyclic
| "lump bumpy breasts" can change w/ hormone changes
fibrocystic condition
45
fluid filled cyst can become large and painful
breast cyst
46
common in young women
| Round/oval, solid mass
fibroadenoma
47
Tx for fibroadenoma
May be observed, excised, or cryoablated
48
subtype of fibroadenoma that needs to be excised w/ clear margins. diagnosable on core biopsy
Phyllodes tumor
49
management for breast pain
decrease caffeine
vit E
evening primrose oil
(rule out breast pathology first)
50
3 drugs that are avaliable for breast pain, but ADRs limit use
danocrine
tamoxifen
bromocriptine
51
breast infections in non-lactating women are usually seen in who?
smokers
52
what must you r/o w/ a breast infection?
inflammatory breast CA
53
when are breast infections common?
during lactation
54
management for breast infection during lactation
Management include emptying breast (nurse or pump), antibiotics, and drainage if there is an abscess
It is safe to continue to feed the infant…
55
what are concerning signs on PE?
fixed to chest wall or skin
dimpling, nipple retraction or retraction of skin
edema (peau d'organe)
56
how will microcalcifications appear on mammography
linear, branching, clustered
| concerning for DCIS (but often related to fibrocystic changes)
57
what is a piculated mass concerning for?
invasive cancer
58
What are concerning finding son US?
irregular, solid mass
taller than wide
shadowing
vascularity
59
what is usually used to get a tissue sample for breast cancer
core needle bx
| will tell if DCIS or invasive, ductal or lobular, grade, ER/PR and Her2neu status
60
what is a MRI helpful for in diagnosis of breast cancer
to evaluate remaining breast tissue, axillary and internal mammary nodes, lungs, bony structures of chest, upper liver
MRI is very sensitive and often leads to “second look” ultrasound to evaluate enhancing lesions seen on MR
61
what is normally the first consultation for a person w/ breast cancer?
surgery
62
radiation usually occurs after what?
lumpectomy (this radiation is pretty well tolerated)
63
if a patient doesn't want radiation what should they do
be more aggressive in surgical options
64
what does the decision to have chemo depend on?
biology of tumor and staging
65
what are the main goals for surgery for breast cancer
clear margins
| stage tumors
66
when is axillary node dissection done?
if more than 2 SLN positive but moving toward less, so now no AND is less than 3 (as long as they get radiation therapy)
67
when is radiation necessary w/ a mastectomy
tumor is >5 cm
| margins positive or LN positive (>4 LN)
68
do breast conserving therapy and mastectomy have the same survival rate?
yes but slightly higher local recurrence rate w/ lumpectomy
69
contradincations to breast conservation therapy
tumors in 2 or more separate quadrants of diffuse microcalcifications or inflammatory breast CA
hx or previous radiation to chest/ breast
pregnancy
inability to get clear margins
active autoimmune diseases (especially SLE or scleroderma)
70
reasons for doing a masectomy
fear of local recurrence
unable or unwilling to do radiation
"just take it off"
71
how often is radiation treatment
5 days / week for 6 weeks
72
side effects of radiation
fatigue, skin changes, low risk of cardiac or pulmonary effects
73
– Requires placement of a balloon catheter into the lumpectomy cavity and twice daily radiation for 5 days
Not currently the standard of care
mammosite
74
what do most patients do for breast cancer?
lumpectomy and SLN biopsy
leaves 2 separate incision (mass and sentinel node)
fairly rapid recovery
75
with nonpalpable tumors how will they be localized?
with a wire "needle loc" by radiology
76
is helpful to place the incision and guide tumor resection
intraoperative U/S
77
risks of lumpectomy and SLN bx
fluid collection (common)
arm numbness (paresthesias on back of upper arm)
arm wekaness
lymphedema
78
what is a TRAM falp?
transverse recto abdominal myocutaneous flap
take this muscle and tunnel it under to recreate a breast
this does disrupt the core abdominal muscles
79
what is a DIEP flap?
deep inferior epigastric perforators
| microvascular anastamosis- needs ICU
80
is all the breast tissue removed w/ a mastecomy
no, but some remains on flaps to preserve blood supply of the skin
81
what type chemo is usually done w/ breast cancer
adjuvant chemo
| after primary tx w/ surgery to reduce risk
82
Treatment given in pre-op setting may shrink the tumor
Provides evidence of whether the chemo will works
May shrink large or fixed tumors to allow clearance of margins and makes BCT more feasible
neo-adjuvant therapy
83
what is the usual order of treatment
surgery
chemo (if indicated)
radiation
hormonal blockade
84
when is neo-adjuvant chemo always done?
inflammatory breast cancer
85
what are hormone blockade drugs?
tamoxifen- estrogen receptor blocker
| aromatase inhibitors- block production of estrogen
86
who are aromatase inhibitors only used in
only for post menopausal women
87
who usually gets chemo?
premenopausal and high risk tumors
ER negative
ER, PR, and her2 negative (triple negative) tumors
88
what determines risk of recurrence based on specific genetic information of the tumor specimen
Helpful in women for whom benefit of chemo is unclear (small ER positive tumors with limited LN involvement) will stratify their risk
oncotype DX
89
risks from tamoxifen?
uterine cancer, blood clots
| ADR- hot flashes
90
benefits of tamoxifen
increased bone density and lower cholesterol
| prevents 1 our of 3 deaths from breast cancer
91
what type cancer does tamoxifen help with?
ER positive tumors
92
what other surgery can lower breast cancer risk?
ovarian ablation
93
what will often shift shifts pre- and peri-menopausal women into menopause
chemo (thought to aid to some of the survival benefit)
94
what are aromatase inhibitors
Anastrozole (arimidex), Letrozole (femara), and exemestane (aromasin)
95
what is an antibody to the oncogene (her2-neu)
trastuzumab (herceptin)
96
what do you combine trastuzumab with?
chemo
97
what are ADRs w/ herceptin?
increased risk of heart failure
| pts get MUGA scans to monitor
