Casefiles 4: breast cancer

Question 1

the “triple test” to rule out breast cancer

Answer 1

clinical evaluation (history and physical examination)
imaging (mammography, ultrasound, and/or breast MRI)
pathology (cytology or histology)
Negative triple-test confirmation is required before breast cancer can be definitively ruled out

Question 2

Once the biopsy confirms cancer, the patient should have staging work-up that includes ?

Answer 2

bilateral mammography ± breast MRI, chest x-ray, chest and abdominal CT, or positron emission-CT (PET-CT)

Question 3

what offers the same survival as a mastectomy?

Answer 3

a partial mastectomy with radiation therapy

Question 4

Breast Cancer AJCC Staging

Answer 4

http://casefiles.mhmedical.com.mwu.idm.oclc.org/ViewLarge.aspx?figid=140647759&gbosContainerID=92&gbosid=246074

Question 5

FNA can identify malignant cells but cannot definitively differentiate ?
useful for ?

Answer 5

in situ cancers from invasive cancers

cytologic assessment of axillary lymph nodes

Question 6

core needle biopsies can be done under what imaging guidance ?

Answer 6

mammographic guidance (stereotactic biopsy), MRI guidance, ultrasound guidance, or without image guidance (palpation alone)

Question 7

BIRADS Breast Imaging Reporting and Data Systems

Answer 7

he standard reporting system originally developed for mammography (now MRI and US as well) results reporting and is based on the likelihood of a lesion being malignant

Question 8

BCT: breast-conserving treatment

Answer 8

partial mastectomy (also known as segmental mastectomy or lumpectomy) 
should receive whole breast irradiation following surgery or local radiation treatment with intraoperative radiation therapy

Question 9

what is an aggressive form of breast cancer that occurs more frequently in younger women of African-American descent?

Answer 9

inflammatory breast cancer (IBC)

• presentation often rapid and dramatic with erythema and swelling of the breast occurring over a period of weeks to months
• peau d’orange (orange peel-like)
• treated with neoadjuvant chemotherapy followed by surgery and radiation therapy
• poor prognosis

Question 10

neoadjuvant systemic therapy typically given to what disease type and involves what?

Answer 10

Most commonly implemented in patients presenting with locally advanced disease
-involves systemic therapy (chemotherapy, biologic therapy, or hormonal therapy) is given prior to surgical treatment (locoregional Rx)

Question 11

benefites to neoadjuvant therapy

Answer 11

(1) It improved success of breast-conserving treatment, especially for women presenting with cancers with unfavorable tumor size to breast size ratios. (2) Leaving the tumors in place provides clinicians with opportunities to modify systemic treatment regimens when favorable clinical responses are not produced by the initial treatments. (3) Neoadjuvant approach gives clinicians the opportunity to identify complete pathologic responses (cPR) in patients following systemic therapy, and patients who exhibit cPR have a much better prognosis in comparison to patients who do not achieve cPR.

Question 12

Individuals with ? have significantly increased risk of developing MBC (male breast cancer)

Answer 12

Klinefelter’s syndrome (XXY) and BRCA2 mutations

an estimated 40% of MBCs are associated with BRCA2 mutations

Question 13

TNBC

Answer 13

triple receptor negative breast cancer: ER (–), PR (–), and Her2 (–)
10% to 15% of all female breast cancers
premenopausal women of African-American descent
often chemosensitive,
experience early (less than 3 years) visceral metastases and poorer survival in comparison to women with non-TNBCs.

Question 14

antiestrogen therapy for breast cancer

Answer 14

tamoxifen: pre-or post-menopausal women and men with ER/PR (+) breast cancers, may cause uterine cancer
aromatase inhibitors: more effective but only for postmenopausal women, bisphosphonate isBreast MRI is more sensitive for the detection of breast cancers in women with dense breast tissue.

often given with AIs to minimize bone mineral losses and reduce osseous metastasis

Question 15

monoclonal antibody targeting the extracellular portion of HER2 receptor
worry about what side effect?

Answer 15

trastuzumab
cardiotoxicity
cardiac-toxic chemotherapeutic agents such as doxorubicin (Adriamicin) should be avoided in patients with HER2-neu (+) tumors

Question 16

biologic treatments targeting DNA repair

particularly effective in the treatment of breast cancers with DNA-repair-gene mutations such as ?

Answer 16

Poly(ADP-ribose) polymerases (PARPs) inhibitors: monoclonal antibodies that target tumors with PARP mutations

BRCA1, BRCA2, TNBCs, and basal-type cancers.

Question 17

nearly all women with invasive breast cancers of what size are now given some form of systemic therapy

Answer 17

more than 1 cm

Question 18

The initial workup for a dominant breast mass should involve ?

Answer 18

tissue analysis and bilateral mammography to assess the lesion and look for other occult abnormalities

Question 19

Patients with small invasive breast cancers (T1 or T2) and occult axillary lymph node metastasis involving two or fewer lymph nodes demonstrated by SLNB, who are undergoing partial mastectomy with whole breast radiation therapy do not need ?

Answer 19

ALND to address the axillary lymph node involvement

Question 20

What is more sensitive for the detection of breast cancers in women with dense breast tissue?

Answer 20

Breast MRI

Question 21

raloxifene was found to be associated with significantly lower risk of ? than tamoxifen

Answer 21

venous thromboembolic events and uterine cancers and uterine hyperplasia than tamoxifen

Question 22

Benign breast histology not associated with an increased risk for breast cancer

Answer 22

Adenosis, apocrine metaplasia, cysts, ductal ectasia, fibroadenoma, fibrosis, mild hyperplasia, mastitis, squamous metaplasia

Question 23

breast cancer risk increased 1.5- to 2.0-fold

Answer 23

Moderate or severe ductal hyperplasia, papillomatosis

Question 24

breast cancer risk increased 5-fold

Answer 24

Atypical ductal hyperplasia

Question 25

breast cancer risk increased 10-fold

Answer 25

Lobular carcinoma in situ

Atypical ductal hyperplasia with family history of breast cancer

Question 26

benign vs malignant cyst characteristics

Answer 26

cysts without solid components or septations are more likely benign, and solid lesions are more likely cancers when they are irregularly shaped, taller-than-wide, and hypoechoeic.

Question 27

imaging that can be used to characterize cystic and solid lesions

Answer 27

breast US

Question 28

BRCA1 and BRCA2 mutations

Answer 28

tumor suppressor genes responsible for DNA repairs
Only 5% to 10% of patients with breast cancers have BRCA mutations, and BRCA mutations account for 20% to 25% of the hereditary breast cancers
higher in Ashkenazi Jewish population
associated with early-onset breast cancers, ovarian cancers, and fallopian tube cancers, rostate cancers, melanomas, and pancreatic cancers

Question 29

Women with BRCA1 mutations have a ? lifetime risk of developing breast cancers and ? risk of developing ovarian cancers

Answer 29

55% to 60%

35% to 40%

Question 30

Invasive Lobular Carcinoma

Answer 30

only 10% to 15% of all breast cancers
asymmetric focal thickening rather than dominant breast masses
often negative on mammogram, detection is based on PE, MRI, and US

Question 31

Atypical Ductal Hyperplasia (ADH)

Answer 31

some believe that this histology pattern is along the progression to DCIS and invasive carcinoma
if identified by core biopsy, an excisional biopsy of the area should be obtained

Question 32

LCIS

Answer 32

Lobular Carcinoma in Situ

In some patients, LCIS is an actual precursor to invasive lobular carcinoma.

Question 33

ACS vs USPSTF mammogram screening guidelines

Answer 33

The ACS recommends annual screening mammography beginning at age 40, optional SBE and annual CBE
the USPSTF 2009 guidelines recommend initiation of screening mammography at age 50 with repeat examinations every 2 years, recommends against SBE, insufficient evidence for CBE

Question 34

Gail model

Answer 34

used to tabulate 5-year and lifetime risks of breast cancer based on patient age, age of menarche, age of first live birth, number of first-degree relatives with breast cancer, number of previous benign biopsies, atypical hyperplasia on previous biopsy, and patient race

Question 35

MRI has been recommended as an adjunct to screening mammography for patients with ?

Answer 35

BRCA mutations, untested first-degree relatives of patients with BRCA mutations, patients with lifetime cancer risk greater than 20% to 25%, patients with prior chest wall radiation, and patients and first-degree relatives with the Li–Fraumeni syndrome (p53 mutations).

Question 36

screening ductal lavage

Answer 36

aspiration of the nipple–areolar complex to induce nipple discharge. The effluent produced is analyzed by cytology.
-may help identify patients with early lesions who may benefit from more aggressive screening strategies, including ductography, ductoscopy, or MRI.

Question 37

screening guidelines if family history or genetic predisposition (mutations of BRCA1 or BRCA2)

Answer 37

Annual mammogram and physical examination every 6 mo starting at age 25 or 5-10 y prior to the earliest familial case. Breast MRI starting at age 30 and consider risk-reduction strategies.

Question 38

screening guidelines for LCIS

Answer 38

Annual mammogram and physical examination every 6-12 mo; consider risk-reduction strategies.

Question 39

Mammography in young women under 30 years of age tends to be less sensitive because of ?

Answer 39

increased breast density and fibrocystic changes

Question 40

Women with BRCA2 mutations have a ? lifetime risk of developing breast cancers and ? risk of developing ovarian cancers

Answer 40

45%

11% to 17%

Question 41

Men with BRCA2 mutations are at risk of developing ?

Answer 41

breast cancers, prostate cancers, melanomas, and pancreatic cancers

Question 42

BRCA1, BRCA2, and P53 mutations are associated with familial breast cancer syndromes and follow an ? inheritance pattern

Answer 42

autosomal dominant

Question 43

most appropriate tx option for ADH discovered on breast biopsy

Answer 43

needle localization excisional biopsy of that area of the breast
ADH is often found adjacent to DCIS

Question 44

what condition is often associated with elevated prolactin levels and can predispose to having galactorrhea or a form of physiologic “milky” nipple discharge

Answer 44

hypothyroidism

Question 45

A 43-year-old premenopausal, nonlactating woman presents with unilateral nipple discharge that is serosanguineous, think ?
workup with ?

Answer 45

intraductal papilloma (benign)

bilateral mammography to evaluate for potential breast lesions and US to evaluate the retroareolar thickening. A ductogram or biopsy should be considered.
NOT cytology of fluid
Treatment consists of removal of the involved duct(s)

Question 46

duct ectasia

only occurs in who?

Answer 46

duct dilatations that occur as the result of elastin loss in the duct walls, only occurs in smokers, may occur following chronic inflammation of the duct wall, discharges are often purulent appearing. Treatment of the condition involves identification of the involved duct(s), followed by duct excision

Question 47

radiographic study of the duct that is obtained with the injection of contrast material into the duct

Answer 47

ductography

Tumors along the duct walls will appear as filling defects or irregularities.

Question 48

introduction of a small-diameter flexible endoscope into the suspicious duct(s) to visualize and obtain cytologic assessment of the duct and ductal contents

Answer 48

ductoscopy

Question 49

Surgical treatment for intraductal masses identified during the work-up of pathologic nipple discharges can consist of ?

Answer 49

partial duct excision or complete central duct excision

Question 50

physiologic vs pathologic nipple discharge

Answer 50

physiologic: bilateral, involving multiple ducts, nonspontaneous, and appears clear or milky
pathologic: serous, serosanguineous, purulent, or bloody, spontaneous, can be only one nipple and often from a single duct

Question 51

medications that can cause nipple discharge

Answer 51

Antihypertensive medications, phenothiazines, antidepressants, and antipsychotic medications
Medications that block the secretion of dopamine can cause galactorrhea.)