Breast Cancer Flashcards
14 Risk Factors
- Female
- Age > 30
- Caucasian
- Higher SE Status
- Nulliparous, first preg at older age or high parity (>4)
- Early menarche or late menopause (greater hormone exposure across lifetime)
- Family hx (first degree relatives)
- BRCA1/2 mutation
- Ductal or lobal hyperplasia w/ atypia
- LCIS
- Ionizing radiation
- High fat diet
- Alcohol or tobacco use
- Prior hx endometrial, colon or ovarian cancer
BRCA1/2
- Hallmarks - mult family members, breast and ovarian in same person, early age onset
- BRCA1 - chromo 17; greater risk ovarian cancer (removal recommended) and greater risk triple neg
- BRCA 2 - chromo 13; greater risk in men
- Both tumor suppressor genes; for DNA repair enzymes
- Accounts for 10% ovarian cancer & 3-5% breast cancer
- Lifetime risk = 60-85% if you are a carrier
- Founder Mutation - specific mutation found in specific populations - Ashkenazi Jews, French Canadians, Icelanders/Netherlands/Swedes
- What is considered a positive family hx (when actual genetic status is unknown)?
- Premenopausal, unilateral in mother or sister … 7% risk
- Postmenopausal, unilateral in mother or sister … 18% risk
- Premenopausal, bilateral in mother os sister … 51% risk
- Postmenopausal, bilateral in mother or sister … 25% risk
3 Step Dx
1- clinical
- peau d’orange (skin), retraction or indentation of nipple tissue, palpable mass, pain, nipple d/c
2- radiology
- Screen w/ mammography micro-calcifications
3- core biopsy
- Must make sure you biopsy the right spot so look for Ca on XRay first
What factors determine prognosis? What is the #1 prognostic factor?
- Lymph node status is #1 prognostic factor if no distant mets
- TMN Staging
- T- tumor (mainly size)
- N - none to 10+
- Histo type - mucinous, tubular, medullary
- Grade - Nottingham Grading
- Lymphovascular invasion
- ER/PR/Her2 status
- Race
Nottingham Grading
low - intermediate - high (ALL PATHOLOGY DEP)
- Amount of tubular formation (higher score - less differentiated tubules; cannot see donuts)
- Mitotic Count (higher # - higher score)
- Pleomorphism
How is Her2-neu staining used?
Membranous so expect to see staining around membrane
- 0 or 1+ - negative
- 2+ do FISH for further eval
- 3+ - positive
What is meant by inflammatory breast cancer?
- skin thickening if tumor invades lympho-vascular spaces in skin (plug lymphatics)
- named b/c looks similar to mastitis
- automatically stage IV
5 Categories of Gene Expression
1 - Luminal A - (most common) ER+/PR+ Low Ki67 - good prognosis
2 - Luminal B - ER+/PR+ High Ki67 - intermediate prognosis (Ki67 bad)
3 - Triple Negative (or basal like - basal/ p63 +) - poor prognosis
4- Normal Breast Like - triple negative and basal negative - intermediate prognosis
5 - HER2+ - poor prognosis (aggressive)
General Principles of Breast Cancer Management
- Breast conserving therapies followed by possible radiation and adjuvant chemotherapy has proven to be just as successful as radical mastectomy
- Sentinel Node Mapping - inject radioactive tracer and vital dye (methylene blue) into peri-areolar tissue; node that takes up dye is sentinel node (removed and sent for analysis); if mets to that node then do complete axillary dissection (instead of doing total axillary dissection no matter what)
- If advanced disease, may consider neo-adjuvant chem first
When might a total mastectomy still be used?
- Tumor size (> 5 cm)
- Medial lesions harder cosmetically
- Central location may require nipple reconstruction
- Inc tumor:breast ratio
- If many calcifications on mammography
- If BRCA mutation
- Mult lesions or mult quadrants
- If previous breast radiation
- In pregnancy (no radiation)
- If pos margins after surgery,
- Maybe if collagen vascular disease
- Large breast size may not be amendable to radiation
Adjuvant Medication Options
- Hormones (if ER+/PR+) - If premenopausal use tamoxifen, if postmenopausal use aromatase inhibitors (for 5 yrs)
- Chemotherapy - mult possible combinations
- Biologic agents
- Ex) Transtuzimab for HER2-neu +
