Breast Cancer Panel

Question 1

What are the two major risk factors for breast cancer?

Answer 1

exposure to estrogens (null parity, early menarche, oral estrogens, late menopaus, late age of first delivery, no breast feeding and obesity)

genetic mutation (either inherited through exposure), mutations increase with age

(being woman seriously increases risk)
OTHER: breast radiation e.g. for Hodgkins

Question 2

Name two germline mutations that put a person at higher risk for breast cancer.

Answer 2

BRCA 1 and 2

Li-Fraumeni

Question 3

What are important aspects of H&P to focus on when interviewing for breast cancer?

Answer 3

hx: pain, nipple discharge, skin changes, induration, duration

PE: nipple discharge, breast asymmetry, masses, skin changes (peau d’orange), axillary adenopathy, supraclavicular adenopathy

Question 4

What are the most common imaging options available?

Answer 4

mammogram (screening and diagnostic), ultrasound and MRI

masses or architectural distortion, (irregular, linear) calcifications on mammogram can be a big clue to continue investigation (possible DCIS)

Question 5

What findings on U/S suggest tumor?

Answer 5

irregular/ fuzzy boarder

(smooth boarders with hemogenous consistency- fibroadenoma)
(smooth boarders and dark center- cyst)
(mass growing into nipple is a papilloma)

Question 6

What biopsy options are available?

Answer 6

fine needle aspiration (sample of cells but does not preserve architecture - cannot determine if invasive) can be good to aspirate a suspected cyst (if any remains beware of cancer in addition)

core needle biopsy (big needle) can be radiology guided to sample calcification

excisional biopsy (more extensive sampling) can be used in case of weight restriction

Question 7

Contrast the normal and abnormal structure of breast tissue.

Answer 7

normal: glandular tissue within fibroduct structures; glandular tissue is lined by two cell layers (epithelium and myoepithelium)
abnormal: increased number of nuclei (proliferation, ductal hyperplasia) irregular lobules, sometimes sheets of cells, irregular architecture overall

(if still within the glands its not invasive)

Question 8

How would a pathologist test for genetic mutations in a tumor?

Answer 8

immunostain for markers like p53 or ER/PR

FISH testing for HER-2 NEU

Question 9

What nodes typically drain the breast?

Answer 9

supraclavicular, mammary and **auxillary nodes

Question 10

Summarize generally stage I- stage IV breast cancer.

Answer 10

stage I -small tumor
stage II- large tumor or small with LN
stage III- tumor invasion of skin, chest wall or large tumor + LN
stage IV- distant metastases (incurable)

Question 11

What are ways you may work up a patient for the potential of metastatic disease?

Answer 11

signs or symptoms of metastais
lab studies including CBC, liver function
chest imaging: CXR and CT scan
bone scan

(focus on likely places of metastasis: bone, liver and lung)

Question 12

Contrast the approaches for treatment of local v. systemic cancer.

Answer 12

surgery and radiotherapy can be used to address local disease

chemotherapy and endocrine therapy are used to address systemic disease

Question 13

What are the objectives in surgical treatment?

Answer 13

surgery acts as local source control by removing the primary tumor, allows for staging of the tumor, and allow for evaluation of the axilla

Question 14

What are the current surgical options for breast cancer?

Answer 14

mastectomy (more likely with large tumor)
breast conservation with radiation (lumpectomy)

both have similar overall survival with different rates of recurrence (having to go back for surgery)

Based on imaging characteristics, tumor characteristics and patient preferences

Question 15

What are the surgical management options regarding the axilla?

Answer 15

sentinel lymph node biopsy (preferable)

axillary lymph node dissection (usually level 1 and 2)

Question 16

When is radiation recommended as an adjunct therapy?

Answer 16

is standard of care for most women after lumpectomy (does not offer advantage for mortality)

if there are positive nodes it can make a difference in mortality and it can reduce the very high rate of recurrance

higher risk patients benefit most (those with positive surgical margins, large tumor size, 4+ positive nodes, 1-3 nodes positive only with other risk factors)

can be used for palliation (decrease pain and improve quality of life)

Question 17

What is the standard regimen for radiation therapy?

Answer 17

daily treatments for 6 weeks with the target including breast or chest wall +/- nearby nodes (axillary, supraclavicular, internal mammary)

Question 18

Describe the systemic model of cancer disease.

Answer 18

cancer is assumed to be a systemic disease and is either scattered at diagnosis or won’t metastasize

Question 19

What variables are important to consider when deciding whether adjuvant treatment is important for a patient.

Answer 19

age and co-morbidities
primary tumor size and grade, lymph nodes and ER status

usually hope that the intervention will help at lest 5/100, focus on absolute risk reduction, not relative risk

options include endocrine therapy or chemo therapy