Breast Cancer

Question 1

Risk factors for breast cancer
2 general categories
Specifics (9)

Answer 1

• 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.

Question 2

2 genetic syndromes related to breast cancer
Associations
Risk reducing procedures

Answer 2

• 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)

Question 3

Breast cancer presentation (7)

Answer 3

Nipple discharge, skin changes (erythema, dimpling, peau d’orange), breast asymmetry, axillary adenopathy, supraclavicular adenopathy. Most BC masses are NOT painful

Question 4

Who should get mammograms?

Answer 4

Standard of care for women 50-75 y/o. Start at age 40 if risk factors are present.

Question 5

2 non-cancerous breast tumors

Answer 5

• Fibroadenoma = benign tumor in stroma

* Papilloma = benign growth that can cause nipple discharge.

Question 6

Where do most BC’s arise?

Answer 6

Terminal duct lobular units

Question 7

Usual ductal hyperplasia

Answer 7

Proliferation of epithelial cells in the duct spaces. Polyclonal, benign, non-precursor.

Question 8

Atypical ductal hyperplasia.

Answer 8

Intraductal epithelial proliferation w/ more monomorphic histology. Has genetic mutations. Early step toward BC.

Question 9

Low-grade ductal carcinoma in situ (DCIS)

Treatment

Answer 9

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.

Question 10

Invasive carcinoma histology

Answer 10

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.

Question 11

What does p63 stain for?

Answer 11

Myoepithelial cell nuclei

Question 12

HER-2 / neu prognosis
Treating HER-2 / neu receptor cancer
Side effects

Answer 12

More aggressive
Trastuzumab (monoclonal Ab against the protein)
Side effects include reversible cardiomyopathy and rare pulmonary toxicity

Question 13

Staging breast cancer

Answer 13

• 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.

Question 14

Halsted Model

Answer 14

Best way is to remove breast + all nearby structures w/ radical mastectomy (breast, pectoralis, and axillary nodes).

Question 15

Fisher Model

Answer 15

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.

Question 16

How does mastectomy compare to lumpectomy in terms of survival?

Answer 16

Equal

Question 17

When is a sentinel node biopsy done?

What is recommended if the SLN biopsy is positive?

Answer 17

Done in pxs who do not have abnormal lymph nodes.

If positive, do full axillary dissection, removing 5-15 LNs

Question 18

Indications for mastectomy (7)

Answer 18

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

Question 19

When is radiation after mastectomy done? (4)

Answer 19

Only done if risk factors are present: large tumor, invasion of skin / muscle, 4+ lymph nodes, positive margins.

Question 20

3 types of adjuvant chemo
Side effects (4)

Answer 20

• Taxanes, cyclophosphamide, +/- anthracyclines.

* Side effects: allergic / infectious death, secondary leukemia, irreversible cardiomyopathy

Question 21

2 types of adjuvant hormonal therapy

Side effects

Answer 21

• 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

Question 22

Treating metastatic disease

Answer 22

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.

Question 23

Follow-up for breast cancer (3)

Answer 23

•Clinical breast exams, mammography, toxic effects of therapy