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Heme/Onco > Breast cancer > Flashcards

Breast cancer Flashcards

1
Q

Intrinsic subtypes of breast cancer

What are the 4 types

A

Luminal A
Luminal B
Basal-like
HER2-positive

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2
Q

Breast cancer

Luminal A

A 
ER+ and/or PR +, HER2-:
Most common subtypes;
Less aggressive
Lower histological grade;
Good prognosis;
Hormone responsive
Associated with increasing age
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3
Q

Breast cancer

Luminal B

A

ER+ and/or PR+, HER2+
Similar to Luminal A
More frequently ER+/PR-;
Worse outcome than Luminal A

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4
Q

Breast cancer

Basal-like

A

Triple negative, cytokeratin 5/6 + and/or EGFR+
Aggressive subtype
High grade histology and high mitotic rate
Risk at younger age (age<4-)
More likely premenopausal African American women

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5
Q

Breast cancer

HER2+ (ER-)

A

Less common, highly aggressive subtype;
High grade histology;
Risk at young age <40 greater than luminal subtypes;
African American ethnicity may be a risk factor
Outcome improved with HER2

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6
Q

Breast cancer

Incidences orders by histology

A 
Infiltrating ductal carcinoma (75%)>
Lobular carcinoma in situ>
Infiltrating lubular carcinoma (<15%)>
Medullary carcinoma (5%)>
Mucinous carcinoma (<5%)>
Tubular carcinoma (1-2%)>
Papillary carcinoma (1-2%)>
Metaplastic breast canccer (<1%)>
Paget disease
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7
Q

Breast cancer
Prevention
What is the tool to estimate woman’s 5 year and liftetime breast cancer risk?

A

Gail Model Risk Assessment Tool

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8
Q

Breast cancer
Prevention
Who should receive breast cancer prophylaxis treatment?

A

GMRAT:
If 5 year breast cancer risk>=1.7% or
with Lobular carcinoma in situ

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9
Q

Breast cancer
Prevention
What should be given for prophylaxis treatment

A

Pre-menopausal:Tamoxifen;

Post-menopausal: Tamoxifen, raloxifene or exemestane

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10
Q

Breast cancer
Prevention
Screening if BRCA1/2 mutation positive

A

Breast cancer screening with MRI at age 25 and mammography at age of 30

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11
Q

Breast cancer
Prevention
Surgical prophylaxis for BRAC1/2 mutation positive

A

Prophylactic bilateral mastectomy (decrease by 90%);

Prophylatic bilateral salpingo-oophorectomy (decrease by 80%)

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12
Q

Breast cancer

Medication- Tamoxifen

A

SERM
Breast cancer risk reduction: 49%;
SE: Vasomotor; vascular events, endometrial and uterine cancer in postmenopausal women

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13
Q

Breast cancer
Medication- Tamoxifen
Contraindication

A

If with prior thromboembolic events

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14
Q

Breast cancer
Medication- Tamoxifen
Can it be used in premenopausal women?

A

Yes

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15
Q

Breast cancer

Medication- Raloxifene

A

SERM
Breast cancer risk reduction: less than tamoxifen
SE: vasomotor; vascular events

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16
Q

Breast cancer
Medication- Raloxifene
Contraindication

A

If with prior thromboembolic events

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17
Q

Breast cancer
Medication- Raloxifene
Can it be used in premenopausal women?

A

None, not studies;

unless part of a clinical trial

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18
Q

Breast cancer
Medication- Exemestane
Mechanism of action

A

Aromatase inhibitor: prevents conversion of androgen to estrogen
Breast cancer risk reduction: 65%

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19
Q

Breast cancer
Medication- Exemestane
Side effects:

A

Vasomotor symtpoms;
Arthralgia;
Headaches
Insomnia

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20
Q

Breast cancer
Medication- Exemestane
Can it be used in premenopausal women?

A

No. Not effective

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21
Q

Breast cancer
Medication- Exemestane
Will it cause other side effects?

A

At 3 year f/u, no increase in osteoporosis, factures, endometrial cancer, vascular events or cardiac disease

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22
Q

Breast cancer

Favorable prognosis of early stage breast cancer

A

Hormone receptor-positive cancer;
Small tumor size;
Low tumor grade;
Negative lymph nodes.

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23
Q

Breast cancer

When do you need images study to eval for metastasis in stage I and II breast cancer?

A 
Hormone receptor-negative cancer;
HER2 overexpression;
Large tumor size;
High tumor burden;
Positive lymph nodes;
Presence of extensive lymphovascular invasions.
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24
Q

Breast cancer
Ductal carcinoma in Situ (DCIS)
Treatment

A

Breast-conserving therapy;

Or Mastectomy

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25
Q

Breast cancer
Ductal carcinoma in Situ (DCIS)
Treatment-breast-conserving therapy

A

Lumpectomy + breast radiation

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26
Q

Breast cancer
Ductal carcinoma in Situ (DCIS)
Treatment
When to do sentinel lymph node biopsy?

A 
If microinvasion (<=1 mm foci of invasion);
of If mastectomy is done and found invasion
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27
Q

Breast cancer
Ductal carcinoma in Situ (DCIS)
DCIS and ER positive?

A

DCIS: 80% ER positive

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28
Q

Breast cancer
Ductal carcinoma in Situ (DCIS)
Treatment
Adjuvant therapy and mortality?

A

Tamoxifen does not affect mortality

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29
Q

Breast cancer
Ductal carcinoma in Situ (DCIS)
Treatment
Adjuvant therapy benefit:

A

Decrease the risk of local recurrence of both DCIS and invasive cancer by 20% and 25% and of contralateral breast cancer by 50%

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30
Q

Breast cancer
Invasive breast cancer
Treatment

A

Breast-conserving therapy AND mastectomy

31
Q

Breast cancer
Invasive breast cancer
When to do neoadjuvant therapy before surgery?

A

If tumor>5cm

32
Q

Breast cancer
Invasive breast cancer
Treatment
When to do axillary lymph node dissection?

A

If clinically involved lymph nodes or with 3 or more sentinel lymph nodes

33
Q

Breast cancer
Invasive breast cancer
When to do chest wall radiation after mastectomy?

A 
If
Tumor >5
Positive tumor margins
Skin or chest wall involvement
Inflammatory breast cancer
4 or more positive axillary lymph nodes
34
Q

Breast cancer
Invasive breast cancer
When to use breast-conserving therapy?

A

Tumors <=5 involving a single quadrant of the breast and clear margins after excision

35
Q

Breast cancer
Invasive breast cancer
When to use mastectomy?

A

Tumors involving the skin, chest wall or more than one quadrant of the breast and for inflammatory breast cancer

36
Q

Breast cancer
Adjuvant therapy
What is the goal of adjuvant therapy?

A

Eradicate occult microscopic foci of breat cancer to prevent or delay systemic recurrence for stage I-III breast cancer

37
Q

Breast cancer
Adjuvant therapy
Endocrine therapy

A

If ER positive:

Tamoxifen for 10 years shows benefit

38
Q

Breast cancer
Adjuvant therapy
Endocrine therapy–Premenopausal

A

Tamoxifen for 10 years;

Tamoxifen for 5 years and then araomatase inhibitor for 5 years once postmenopausal

39
Q

Breast cancer

Adjuvant therapy–Postmenopausal

A

2 years of tamoxifen therapy followed by 3-5 years of aromatase inhibitor;
Or 5 years of aromatase inhibitor

40
Q

Breast cancer
Adjuvant therapy
Aromatase inhibitors

A

Anastrazole
Letrozole
Exemestane

41
Q

Breast cancer
Adjuvant therapy
Chemotherapy- Who should receive?

A 
ER/PR negative;
HER2 positive;
High-grade tumor;
Extensive lymphovascular invasion;
Positive lymph nodes
42
Q

Breast cancer
Adjuvant therapy
Chemotherapy

A

2 or 3 agents:
Anthracyclines (Doxorubicin or epirubicin);
Cyclophosphamide
Taxanes (Paclitaxel or docetaxel)

43
Q

Breast cancer
Adjuvant therapy
Chemotherapy- SE

A

Anthrocyclines: cardiotoxicity
Cyclophosphamide: interstitial pneumonitis
Taxanes: mylelodysplasia and leukemia

44
Q

Breast cancer
Adjuvant therapy
Chemotherapy for HER2 positive patients?

A

If tumor >=0.5cm
And/Or positive lympoh nodes
–> ADD trastuzumab

45
Q

Breast cancer
Adjuvant therapy
Chemotherapy
Trastuzumab

A

Mortality benefit and decrease recurrence

Given for 1 year

46
Q

Breast cancer
Adjuvant therapy
Chemotherapy- Trastuzumab SE

A

Cardiotoxicity

High with anthrocyclines.

47
Q

Breast cancer
Adjuvant therapy
Chemotherapy- How to manage Trastuzumab SE

A

Baseline ECHO or Multigated acquisition scan and every 3 months during treatment

48
Q

Breast cancer
Locally advanced breast cancer
Definition?

A

Stage IIIA-IIIC

Tumor >5cm with lymph node involvement, skin or chest wall involvement, and/or extensive axillary lymph node involvement

49
Q

Breast cancer
Locally advanced breast cancer
Treatment

A

Neoadjuvant chemotherapy then surgery and the radiation

50
Q

Breast cancer
Inflammatory breast cancer
Feature

A

Aggressive, rapidly progressive;
High grade tumor
Hormone receptor negative
HER2 positive

51
Q

Breast cancer
Inflammatory breast cancer
Does it need images to evaluate for metastasis?

A

Yes

52
Q

Breast cancer
Inflammatory breast cancer
Treatment

A

Neoadjuvant cheomtherapy + surgery and then radiation

53
Q

Breast cancer
Inflammatory breast cancer
5 year survival?

A

Lowest, 40%

54
Q

Breast cancer
Follow up and survivorship
How often should be monitored?

A

Every 3-6 months in the first 2 years;
Every 5 months from year 2-5
Then annually

55
Q

Breast cancer
Follow up and survivorship
What images should be used to monitor?

A

Annual mammography

56
Q

Breast cancer
Follow up and survivorship
When to use MRI for monitoring?

A 
High risk (BRAC1/2 mutation);
Strong family history of breast cancer;
57
Q

Breast cancer
Follow up and survivorship
Do you do surveillance blood test and other imaging?

A

No. Not recommended.

58
Q

Breast cancer
Follow up and survivorship
Vasomotor symptoms treatment:

A

SSRI: escitalopram; or
SNRI: venlafaxine

59
Q

Breast cancer
Follow up and survivorship
If on tamoxifen, what should be avoided

A

CYP2D6 inhibitors:

Bupropion, fluoxetine and praxetine: can inhibit tamoxifen activation

60
Q

Breast cancer
Follow up and survivorship
Bone density monitoring.

A

Every 1-2 years

61
Q

Breast cancer
Follow up and survivorship
Arm mobility and lymphedema

A

Prompt referral to PT

62
Q

Breast cancer
Metastatic breast cancer
Management of metastatic lesions

A

Biopsy and test for hormone status and HER2 expression

63
Q

Breast cancer
Metastatic breast cancer
Treatment

A

Systemic treatment: mainstay;

Surgery and radiation: ancillary roles

64
Q

Breast cancer
Metastatic breast cancer
Hormone receptor positive: antiestrogen treatment

A

Aromatase inhibitors;
Tamoxifen;
Ovarina suppression in premenopausal women;
Fulvestrant (an estrogen receptor down-regulator)
Megestrol acetate
Estradiol
Combination of exemestene and the mTOR inhibitor (everolimus)

65
Q

Breast cancer
Metastatic breast cancer
Hormone receptor negative

A

Chemotherapy

66
Q

Breast cancer
Metastatic breast cancer
HER-2 positive

A

Trastuzumab plus antiestrogen therapy (if positive) or nonanthrocycline based chemotherapy

67
Q

Breast cancer
Metastatic breast cancer
If lytic bone metastases

A

Bisphosphonates

Denosumab

68
Q

Breast cancer
Metastatic breast cancer
Bispohosphonate SE

A

Fever, kidney injury, hypocalcemia and osteonecrosis of the jaw

69
Q

Breast cancer
Metastatic breast cancer
Denosumab mechanism

A

Monoclonal antibody against the receptor activator of nuclear factor kB ligant (RNAKL)

70
Q

Breast cancer
Metastatic breast cancer
Denusumab SE

A

Hypocalcemia

Osteonecrosis of the jaw

71
Q

Breast cancer
Metastatic breast cancer
If on Denosumab or Bisphosphonate?

A

Get baseline dental evaluation

Regular dental check while on treatment

72
Q

Paget disease of breast

Features

A
  1. aunilateral, erythematous, intensely pruritic, ulcerative lesion confined to the nipple and areola.
  2. Serous or serosanguineous discharge might occur
  3. Indicate underlying malignancy
  4. Require b/l mammography
73
Q

Paget disease of breast

Dx

A

Biopsy

Heme/Onco (19 decks)

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