Breast Cancer Flashcards
Risk factors for breast cancer
2 general categories
Specifics (9)
- 2 general risk factors are estrogen and DNA damage.
- More specifically: old age, female, endogenous estrogen exposure (early menarche, late menopause, few children), exogenous estrogen exposure (OCPs, HRT), prior radiation exposure (esp Hodgkin lymphoma), diet, exercise, obesity, alcohol, breast density.
2 genetic syndromes related to breast cancer
Associations
Risk reducing procedures
- BRCA 1 / 2 – lifetime risk of 40-85%. Associated w/ ovarian cancer. Enriched in Ashkenazi Jewish population.
- Li-Fraumeni (p53) – associated w/ leukemia / brain cancers
- Risk reducing procedures for these pxs include mastectomy, oophorectomy, or chemoprevention (tamoxifen)
Breast cancer presentation (7)
Nipple discharge, skin changes (erythema, dimpling, peau d’orange), breast asymmetry, axillary adenopathy, supraclavicular adenopathy. Most BC masses are NOT painful
Who should get mammograms?
Standard of care for women 50-75 y/o. Start at age 40 if risk factors are present.
2 non-cancerous breast tumors
- Fibroadenoma = benign tumor in stroma
* Papilloma = benign growth that can cause nipple discharge.
Where do most BC’s arise?
Terminal duct lobular units
Usual ductal hyperplasia
Proliferation of epithelial cells in the duct spaces. Polyclonal, benign, non-precursor.
Atypical ductal hyperplasia.
Intraductal epithelial proliferation w/ more monomorphic histology. Has genetic mutations. Early step toward BC.
Low-grade ductal carcinoma in situ (DCIS)
Treatment
Very monotonous epithelial cells. Monoclonal. Calcifications occur in ducts, which are picked up by mammography. Treat the same as cancer, w/ surgery + / - radiation or endocrine therapy.
Invasive carcinoma histology
Firm, gritty consistency w/ stellate configuration. Loss of normal arrangement of ducts / lobules. Increased glands and decreased stroma. Stromal desmoplastic response → stereotypic firmness. Grade depends on tubule formation, nuclear pleomorphism, and number of mitoses.
What does p63 stain for?
Myoepithelial cell nuclei
HER-2 / neu prognosis
Treating HER-2 / neu receptor cancer
Side effects
More aggressive
Trastuzumab (monoclonal Ab against the protein)
Side effects include reversible cardiomyopathy and rare pulmonary toxicity
Staging breast cancer
- Stage I: less than 2 cm, no lymph nodes / metastases
- Stage II: less than 5 cm, minimal involvement of LN’s or larger tumor w/o LN’s
- Stage III: any size w/ extensive involvement of skin, chest wall, or LN’s
- Stage IV: metastases. Incurable.
Halsted Model
Best way is to remove breast + all nearby structures w/ radical mastectomy (breast, pectoralis, and axillary nodes).
Fisher Model
At diagnosis, breast cancer is either disseminated or will never disseminate. LN’s are not an intermediate site for dissemination, but rather an indicator of whether cancer is already systemic. Removal of a tumor aids in local problems, but is not important for survival.
How does mastectomy compare to lumpectomy in terms of survival?
Equal
When is a sentinel node biopsy done?
What is recommended if the SLN biopsy is positive?
Done in pxs who do not have abnormal lymph nodes.
If positive, do full axillary dissection, removing 5-15 LNs
Indications for mastectomy (7)
Larger tumors, multiple cancers in the breast, prior hx of radiation, inflammatory breast cancer, desire to avoid radiation, minimize local recurrence, family hx w/ higher risk of 2nd cancer
When is radiation after mastectomy done? (4)
Only done if risk factors are present: large tumor, invasion of skin / muscle, 4+ lymph nodes, positive margins.
3 types of adjuvant chemo Side effects (4)
- Taxanes, cyclophosphamide, +/- anthracyclines.
* Side effects: allergic / infectious death, secondary leukemia, irreversible cardiomyopathy
2 types of adjuvant hormonal therapy
Side effects
- Aromatase inhibitors (only for postmenopausal women)
- Tamoxifen (daily for 5 years).
- Side effects - 2% venous thrombosis, 1% uterine cancer w/ tamoxifen, increased osteoporosis w/ aromatase inhibitor
Treating metastatic disease
Cornerstone of treatment is systemic therapy, but local therapies can reduce local sxs, such as radiation for painful mets, surgery / radiation for brain mets or impending fractures, pleurodesis for persistent pleural effusions.
Follow-up for breast cancer (3)
•Clinical breast exams, mammography, toxic effects of therapy
