Breast cancer clinical Flashcards
what is the Triple test for clinically benign dominant or discrete solid mass? What about if its suspicious
Benign PE (rubbery, mobile, smooth), imaging (US mammography), and biopsy (core + histology) then feel confident
Suspicious- imaging, biopsy, and excision
What is the appropriate imaging for a palpable breast mass that is BIRADS 0-6?
0 Incomplete
1- Normal: US and mammography likely fibrocystic change
2- Benign solid or cyst: US dx cyst and aspirate. Solid depends could FNA, excision
3-Probably benign solid/complex US- Solid: radiology f/u, FNA or core, Excision. Complex: f/u
4-suspicious-biopsy, referral (risk varies widely)
5-highly suspicious- 95% malignancy, biopsy and surgical referral
6-Known malignancy- Follow up imaging
When is a eval on a breast warranted? What kind of eval is warranted?
a. low risk woman at age 40
b. persistent self-identified mass you can’t feel
c. 35 y/o woman whose grandmother had breast cancer
d. milky nipple discharge post partum
b. even if you can’t feel it
US breast and possible mammography or FNA depending on age and risk factors. Don’t attribute a lump to fibrocystic change without evidence obtained via US 30.
How might you work up a nodularity with a discrete mass?
US FNA solid
cyst aspirate
How accurate are FNA, and Core needle biopsies and when are they warranted?
FNA 75%
Core 95%
warranted when imaging and PE can’t provide an answer for whether a mass is benign.
staging for breast cancer is defined how?
TNM
T size in situ 5 cm
N LN involvement by number: 0. 1-3, 4-10, >10
M mets (not good)
How does one reduce the local recurrence rate of breast cancer following surgery? Why bother if you have clear margins?
Can’t detect micro metastasis
Normal staging studies do not mean no micro mets
Radiation decrease local recurrence from 40-10%
Hormonal therapy
Chemotherapy
How does adjuvant treatment based on factors unrelated to tumor biology hold up against the Oncotype Dx?
These other factors can lead to over or under treatment as compared to the Oncotype dx which is a 21 gene assay that is a better predictor of outcome than other surrogate markers such as age, size etc unrelated to tumor biology.
What are some high risk features of woman that should be screened for breast cancer
First degree relative with breast cancer
BRCA 1, 2 or HER2/neu mutations
Radiation exposure
When is MRI imaging usually indicated for breasts in cancer diagnosis?
Its often used to determine the extent of the cancer; it does have an increased mastectomy rate. Not a first choice imaging modality. Increased benign biopsy rate and risks over diagnosis and treatment.
What is the best corse of action for a small cancer that can be completely removed and followed up with radiation?
a. lumpectomy
b. mastectomy
c. neoadjuvant chemotherapy with tamoxifen
d. core needle biopsy
lumpectomy b/c its survival rate is equal to mastectomy so less is better. Also, an MRI is probably not indicated as it will likely detect additional cancer foci which are the target of adjuvant therapy and likely don’t warrant a mastectomy.
The oncotype Dx and its benefits are best for what age and cancer recurrent risk categories/
high risk-28% reduction in recurrence; more young patients with high risk cancers
Which CAM would likely be least beneficial for a patient?
a. yoga
b. weight loss
c. decreased ETOH consumption
d. vitamin C
d. Vit C
The other items have some data to support their efficacy
How should you approach screening in the following groups? Average risk, high risk, and young women?
Avg: baseline mammogram 40y/o
High: screen 10 prior to age of cancer diagnosis in first degree relative. Annual mammogram and CBE every 6 months
Young: Breast awareness as monthly exams just generate more benign biopsies with no increase detection
How do you investigate a 29y/o with a subjective breast complaint vs a 33 y/o?
30 US and diagnostic mammogram
Which of the following combinations is accurate as a diagnostic findings a mammogram can detect, next to a dx a mammogram can’t detect?
a. Mass and lump
b. calcifications and mass
c. cyst and lump
d. calcifications and cyst
d. mammogram is the only reliable test for this calcification but is unable to diagnose a cyst
US fluid vs cyst
What is an MRI good for in breast exams and how does it work to discriminate its findings?
Benign vs malignant, additional cancers,
contrast and morphology
When do you use the BIRADS classification?
For US mammography, and not for just a palpable mass
You’re smoking hot patient has new implants and is concerned about the mammogram crushing them like melons. Will this happen and what can you see with fake boobs?
Probably won’t burst
They are placed retropectorally so they don’t interfere with mammography. If these have been placed post mastectomy they wouldn’t need mammography.
Which patient is likely going to get an MRI
a. one receiving neoadjuvant therapy for high grade DCIS
b. one post lumpectomy
c. Patient with prior negative FNA and core biopsy
d. pagent disease
a. neoadjuvant therapy for high grade DCIS though there is insufficient evidence to recommend for or against this
When is an annual MRI screen indicated?
BRCA muations
first degree relative of BRCA carrier but untested
Lifetime risk 20-25% defined by BRCAPRO
Radiation exposure
MRI is usually an adjunct to, not a replacement for, mammography
Whenever possible in breast cancer detection ______ should be done rather than ________ to get a dx
needle biopsy rather than surgical removal
FNA, and Core biopsy require what type of analysis and is how accurate?
FNA cytology 75%
Core histology 95%
What does concordance mean when used in conjunction with PE imaging and biopsy in the detection of breast cancer?
Does the biopsy makes sense based on imaging and exam
What are some high risk lesions associated with breast cancer and how should they be dealt with?
LCIS, atypia usually suggest 10-30% of the time that cancer is present and that the biopsy simply missed the site of cancer, so take it out.
