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MD1 > Case 4: Doreen Cooperson > Flashcards

Case 4: Doreen Cooperson Flashcards

1
Q

DDx of Breast Masses (and distinguishing characteristics)

A
  • Fibroadenoma (premenopausal women)
  • Phyllodes tumor (leaf-like proliferation of glands, massive size)
  • Intraductal papilloma (blood nipple discharge)
  • Lipoma (soft, freely mobile)
  • Breast abscess (inflammation)
  • Fat necrosis (due to trauma/surgery)
  • Breast cancer (microcalcifications in mammograph)
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2
Q

Epidemiology of Breast Cancer

What is the most common type?

This is the ___ most common cancer in women

A
  • Invasive Ductal Carcinoma (75% of all breast cancer)
  • 2nd most common cancer
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3
Q

Risk Factors for Breast Cancer

A

Genetics (BRCA1, 2, HER2)

Age

Family History (affected age, closer relation)

Exposure to estrogen (early menarche, late menopause, late pregnancy, BCP, HRT)

Past history

Lifestyle (high fat, smoking, alcohol)

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4
Q

Staging of Cancer

Definition

Types

System used

A

Definition: standardized way for health care providers to summarize info about how far cancer has spread. Doesn’t change over time, even if cancer progresses (stays same as first diagnosis)

Types: Clinical (based on PE, biopsy, imaging) or Pathological** (based on surgery examination of mass/ lymph nodes; more helpful)

TNM staging I-IV

T=Tumor (size/spread)

N=Lymph node involvement

M=metastasis

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5
Q

Grading of Cancer

Definition

Scale system used

A

Representative of “aggressive potential” of tumor. Describes microscopic appearance of tumor cells/tissue

Grading scale: Nottingham Grading scale (each given a score of 1-3, combined score 3-9)

Tubule differentiation: amount of gland formation from tumor cells

Nuclear pleomorphism: “ugliness”, differences in size, shape, and coloration of nuclei

Mitotic count: Speed of division, count # of mitoses in 10 fields

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6
Q

Grade vs. Staging

A

Stage:

  • Macroscopic
  • Summarize how far cancer has spread
  • Types: Clinical vs. Pathologic
  • TNM (I-IV)= Tumor, Node, Metastasis

Grade:

  • Microscopic
  • “Aggressive potential” of tumor
  • Nottingham TNM (3-9)= Tubule differentiation, Nuclear pleomorphism, mitotic count
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7
Q

Types of surgery for breast cancer

Factors to consider for surgery

A

Mastectomy vs. lumpectomy

Factors: Type of cancer, Axillary lymph node involvement, Reconstruction timing, Disease control, Size/Location/# of tumors, Size of breast, Expected cosmetic result

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8
Q

Why would you use a mastectomy? A lumpectomy?

A

BOTH have IDENTICAL SURVIVAL RATES

Mastecomy (Removal of breast, pectoral muscles, and axillary lymph nodes). Used if tumor

  • >5cm
  • Lymphovascular invasion
  • Less expensive
  • BUT, worse quality of life due to disfigurement/mutilation

Lumpectomy (Breast conserving therapy, usually occurs with radiotherapy)

  • <5 cm
  • No skin/chest wall involvement
  • Anticipate good cosmetic outcome
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9
Q

What is radiation therapy?

A

High energy photons (X-rays or gamma rays) to shrink tumor/kill cancer cells

Usually used in conjuction with lumpectomy

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10
Q

What is neoadjuvant therapy?

How is this different from adjuvant therapy?

A

Chemotherapy or endocrine therapy done prior to tumor removal) to reduce tumor size, increasing surgical options (higher chance of breast conservation therapy)

Adjuvant therapy is started after primary therapy.

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11
Q

Tamoxifen

Family

Indications

MOA

Contraindications

A

Family: Selective Estrogen Receptor Modulator (SERM)

Indications: Primary hormonal treatment for ER + breast cancer (normally adjuvant therapy)

MOA: (ER antagonist in breast tissue)

  • Tamoxifen causes conformational change in estrogen receptor
  • Change in expression of estrogen-dependent genes
  • Induces re-expression of maspin (tumor-suppressor gene)
  • Binds to nuclear DNA to prolong the cell’s time in G2 phase, decreasing cell proliferation

Contraindications: Increased risk of DVT, PE, stroke

Known to cause uterine cancer/uterine malignancies

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12
Q

What is the normal role of estrogen?

A

Grow uterine lining

Circulate lipids/lipoproteins (combats increase in plasma cholesterol/LDL)

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13
Q

What are the main lymph nodes of the breast?

A
  • Axillary lymph nodes**
  • Parasternal lymph nodes
  • Abdominal lymphatics
  • Subareolar lymphatic plexus
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14
Q

Describe mammography

A

X-ray 2D imaging test

Craniocaudal, lateral, and mediolateral projections

78% sensitivity

Can’t use to diagnose, but can find microcalcifications

BI-RADS 0-6

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15
Q

Describe Tomosynthesis

A

Mobile X-ray source. Tube rotated around compressed breast and compiled into 3D image

Used to supplement/replace traditional mammography (more sensitive, lower anatomical noise); better for patients with dense breast

Longer to read, higher X-ray exposure

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16
Q

Describe ultrasonography

A

Sound energy created by piezoelectric crystals that are reflected back and translated into an image

Impendence: Measures resistance to sound wave propagation (this is why you need to use a gel)

17
Q

Describe a CT scan

A

Computed Tomography

Use X-rays to take a series of “sliced” images of body -> compiled into 3D image

Can see bones, organs, and tissue

May/may not have contrast dye

Increased radiation exposure

18
Q

Describe a PET scan

A

Positron Emissino Tomography

Radioactive tracer given via IV to observe physiological activity within body (higher metabolic activity absorbs more tracer - tumors, bowel, kidney). Positrons in tracer collide with body’s electrons. Images captured using camera that detect gamma ray emissions to form 3D image.

19
Q

What are the differences between FNA and CNB?

A

Fine Needle Aspiration

  • Needle attached to syringe, draw in cells/fluid from lump
  • 78% positive predictive value (PPV) for suspicious lesions
  • Better if patient is on anticoagulants, lesion close to chest wall
  • 5 minutes
  • Less expensive

Core Needle Biopsy

  • Hollow needle used to remove tissue (size of grain of rice)
  • 100% PPV for suspicious lesions
  • Better for diagnosing high risk lesions, distinguishing between benign vs. normal & invasive ductal vs. lobar, seeing calcifications
  • 36 hours
  • More expensive
20
Q

What is the significance of ER, PR, and HER2 in the prognosis/treatment of breast cancer

A

EGFR family, tyrosine kinase

Overexpression causes ligand-independent activation of HER2 kinase

Increased proliferation, resistance to proapoptotic stimuli, increased cell migration, upregulation of MMPs

21
Q

What are the stages of grief?

A
  1. Denial
  2. Anger
  3. Bargaining
  4. Depression
  5. Acceptance
22
Q

How can physicians support patients through grieving process?

A
  • Info/advice: answer any questions/provide resources
  • Body language: calm/confident, be at the same level
  • Honesty: think out loud, relate results to options
  • Speak in patient’s terms
  • Allow patient time to respond
  • Timeliness
23
Q

How to deliver bad news

A

SPIKES

  • S = Setting up: create environment, private, close ones, eye level, respect
  • P = Perception: does the pt understand their illness?
  • I = Invitation: ask if you can share info
  • K = Knowledge: provide info & allow for dialogue (diagnosis, plan of treatment, prognosis, support)
  • E = Emotion: stay emathetic
  • S = Strategy: listen, summarize, ask if patient has questions
24
Q

What is a hospice and its role?

Team?

Services?

A

Subset of palliative care (final phase) that is multidisciplinary, holistic, and non-curative (focused on care). Pt usually expected to live <6 months.

Team: physicians, nurses, social workers, counselors, volunteers, clergy

Services: Health care, equipment/supplies/meds, pain relief, therapy, counseling

MD1 (5 decks)

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