Breast Cancer & Treatment

Question 1

fibroadenoma - review

Answer 1

*BENIGN breast disease
*usually found in women from teens to early 40s
*estrogen-sensitive: commonly grow during pregnancy & fluctuate in size throughout menstrual cycle
*rounded in outline and easily movable
*about 10% will disappear per each year followed

Question 2

breast cyst - review

Answer 2

*found in women, usually in their 40’s
*fine needle aspiration or ultrasound for diagnosis
*prerequisites for a successful cyst aspiration:
-non-bloody fluid is obtained
-lump disappears
-reexamination 6 weeks later shows no mass
*BENIGN

Question 3

fibrocystic changes - review

Answer 3

*fibroadenosis & micro-cysts in fibrocystic change
*found in women age 20-40
*disappears after menopause
*usually diffuse and ill-defined
*usually cyclic with menses
*painful and prominent before menses
*resolves with menses
*BENIGN

Question 4

Phyllodes tumor - review

Answer 4

*a fibroepithelial tumor of unpredictable behavior
*tend to be benign but can have a malignant phyllodes tumor
*most common in women ages 40-50

Question 5

intraductal papilloma - review

Answer 5

*small growth in duct
*cause spontaneous bloody nipple discharge
*single papillomas without atypia carry a 3-fold risk factor and carry a 4-fold risk factor when there is atypical hyperplasia in the papilloma

Question 6

lobular carcinoma in situ (LCIS) - overview

Answer 6

*an incidental biopsy diagnosis
*a “marker” indicating increased risk for breast cancer
*8-10x risk factor or about a 1% per year risk for invasive carcinoma in the same or opposite breast
*treatment may be a lumpectomy +/- chemoprevention

Question 7

atypical ductal hyperplasia - overview

Answer 7

*atypical lesion
*associated with a 13% subsequent development of breast cancer (4-5x risk factor)
*need to rule out an associated breast cancer
*if diagnosed on a core needle biopsy, need to perform lumpectomy to rule out DCIS

Question 8

ductal carcinoma in situ (DCIS) - overview

Answer 8

*diagnosed with increasing frequency due to mammography
*risk for subsequent development of invasive cancer in the breast
*stage 0 or early-stage breast cancer

Question 9

ductal carcinoma in situ (DCIS) - treatment

Answer 9

*because “in situ,” does NOT travel to the lymph nodes
*treatment = lumpectomy + radiotherapy, or mastectomy if DCIS is extensive
*DCIS can become invasive breast cancer

Question 10

Paget’s Disease of the breast - overview

Answer 10

*eczematoid lesion of the nipple caused by malignant cells
*cells arise from the ducts and invade the surrounding nipple epithelium
*nonpalpable Paget’s is usually due to DCIS
*palpable mass usually indicates invasive ductal carcinoma

Question 11

work-up of a patient with a breast complaint

Answer 11

*detailed history of chief complaint
*review of prior breast problems
*review of breast cancer risk factors
*review of general medical history
*careful physical examination
*appropriate imaging studies

Question 12

evaluation of a discrete palpable breast mass

Answer 12

*evaluate contour, texture, borders
*assess axillary nodes, skin, nipples
*distinguish solid from cystic by aspiration or ultrasound
*mammogram in women over 30 to look for synchronous, non-palpable lesions

Question 13

evaluation of a solid breast mass

Answer 13

*all solid masses require a tissue diagnosis
1. fine needle aspiration (FNA) - sample obtained via a 23 gauge needle
2. core needle biopsy - tissue obtained via a 14+ gauge needle
3. open biopsy as clinical situation dictates

Question 14

mammography - overview

Answer 14

*appropriate in evaluating a breast problem in any women over 30
*recommendation = screening mammography to start at age 40 and annually thereafter
*diagnostic mammogram:
-any palpable mass, abnormal mammogram, history of cancer
-family history of breast cancer: 10 years less than the age at which a first-degree relative (mother, daughter, sister) was diagnosed with breast cancer

Question 15

breast tomosynthesis - overview

Answer 15

*a method of imaging the breast in three dimensions (3D)
*image slices are 1 mm thick
*image slices high resolution (like mammograms)
*benefits:
-tissue superimposition hides pathologies in 2D
-tissue superimposition mimics pathologies in 2D

Question 16

role of ultrasound in evaluation of breast mass

Answer 16

*main use is to distinguish solid from cystic lesions
*ultrasound is NOT a screening tool or a substitute for mammography
*useful for palpable masses
*can identify benign and malignant lesions
*can be used for image-guided biopsies

Question 17

role of MRI in evaluation of breast mass

Answer 17

*MRI utilizes magnetic fields to produce cross-sectional images of tissues
*has the ability to image in 3D
*provides good physiologic and morphologic information
*contrast-enhanced MRI with gadolinium has a high sensitivity for detecting breast cancer (can detect smaller tumors than mammograms)
*specificity using MRI for tumors is variable
*costs 15x more than mammogram

Question 18

workup for an abnormal screening mammogram

Answer 18

*obtain tissue diagnosis if suspicious via stereotactic core biopsy or open surgical biopsy with needle localization if non-palpable

Question 19

breast cancer - risk factors

Answer 19

*increasing age
*positive family history / risk gene mutations
*prior breast cancer
*LCIS, atypical ductal hyperplasia
*estrogen exposure
*lifestyle: diet, weight gain
*radiation exposure (eg. Hodgkin’s disease)

Question 20

breast cancer - genetic factors

Answer 20

1. BRCA1 and BRCA2 mutations:
   -linked to the familial form of breast cancer
   -higher risk of developing breast & ovarian cancer
2. Li-Fraumeni syndrome (p53 mutations):
   -autosomal dominant
   -higher risk of developing breast cancer, ovarian cancer, osteosarcoma, liposarcoma, leukemia, gastric cancer, uterine cancer, brain tumors

*genetic counseling and genetic testing should be considered for families who may carry a hereditary form of cancer

Question 21

breast cancer - epidemiology

Answer 21

*1 in 8 American women affected
*sporadic breast cancer: 70-80% of cases
*familial breast cancer: 15-20%
*hereditary breast cancer: 5-10%

Question 22

genetic testing recommendations for breast cancer

Answer 22

*women with breast cancer diagnosed at 45 yo or younger
*women with breast cancer in close relatives if diagnosed age 50 or less
*women with breast cancers in close relatives diagnosed at any age
*male breast cancer
*triple negative breast cancer diagnosed < 60 yo
*family history of ovarian cancer + breast cancer, pancreatic cancer, prostate cancer, AJ heritage

Question 23

breast cancer - overview

Answer 23

*may be associated with skin fixation, dimpling, or nipple retraction
*most common types of invasive carcinoma:
-ductal
-lobular
-medullary

Question 24

classifications of breast cancer

Answer 24

*breast cancer is a heterogeneous disease
*classification combines morphology + molecular markers
*estrogen-receptor (ER), HER2, and grade help classify most breast cancers

Question 25

estrogen receptor-positive breast cancer

Answer 25

*cell proliferation is controlled by estrogen & inhibited by tamoxifen

Question 26

estrogen receptor-negative breast cancer

Answer 26

*cell proliferation is NOT controlled by estrogen and NOT inhibited by tamoxifen
*unknown what causes proliferation of breast cancer

Question 27

HER2 positive breast cancer

Answer 27

*HER2 is member of the EGFR receptor family with tyrosine kinase activity
*HER2 overexpression leads to increased signaling (increased cell proliferation, increased cell migration, resistance to apoptosis)
*trastuzumab (Herceptin) directly blocks the HER2 receptor

Question 28

surgical treatment of breast cancer: lumpectomy

Answer 28

*surgeon must establish that the tissue removed in the operation has margins clear of cancer (indicating that the cancer has been completely excised)
*if the tissue removed does not have clear margins, then further operations to remove more tissue may be necessary

Question 29

surgical treatment of breast cancer: mastectomy

Answer 29

*an option for large tumors, positive family history, patient preference
*can perform skin-sparing or nipple-sparing mastectomy with immediate breast reconstruction on good candidates

Question 30

surgical treatment of breast cancer: sentinel lymph node biopsy

Answer 30

*lymph ducts of the breast usually drain to one lymph node first, before draining through the rest of the lymph nodes underneath the arm
*that first lymph node = the sentinel lymph node
*identification of the sentinel lymph node:
1. radioactive dye (technetium-labeled sulfur colloid) that can be measure by a hand-held probe
2. blue dye (isosulfan blue) that stains the lymph tissue a bright blue so it can be seen

Question 31

treatment of breast cancer: AFTER surgery

Answer 31

*chemotherapy for premenopausal, some postmenopausal, and all node + patients
*patients with estrogen receptor-negative tumors require chemotherapy
*most useful systemic therapy include: doxorubicin + cyclophosphamide, and/or taxane
*trastuzumab and/or pertuzumab used for HER2+

Question 32

treatment of breast cancer: antiestrogen therapy

Answer 32

*used in estrogen-positive tumors
*tamoxifen or aromatase inhibitors (postmenopausal women only)

Question 33

treatment of breast cancer: radiation therapy

Answer 33

*all patients who had a lumpectomy require radiation
*mastectomy if 4+ lymph nodes are involved with cancer, or if a large breast cancer
*not indicated for metastatic disease

Question 34

breast cancer - prognosis

Answer 34

*STAGE is the single most important prognostic factor in breast cancer
*presence of estrogen and progesterone receptors in the cancer cell is another important prognostic factor
*HER2/Neu status has also been described as a prognostic factor; HER2+ pts receive trastuzumab