Casefiles 4: breast cancer Flashcards
the “triple test” to rule out breast cancer
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
Once the biopsy confirms cancer, the patient should have staging work-up that includes ?
bilateral mammography ± breast MRI, chest x-ray, chest and abdominal CT, or positron emission-CT (PET-CT)
what offers the same survival as a mastectomy?
a partial mastectomy with radiation therapy
Breast Cancer AJCC Staging
http://casefiles.mhmedical.com.mwu.idm.oclc.org/ViewLarge.aspx?figid=140647759&gbosContainerID=92&gbosid=246074
FNA can identify malignant cells but cannot definitively differentiate ?
useful for ?
in situ cancers from invasive cancers
cytologic assessment of axillary lymph nodes
core needle biopsies can be done under what imaging guidance ?
mammographic guidance (stereotactic biopsy), MRI guidance, ultrasound guidance, or without image guidance (palpation alone)
BIRADS Breast Imaging Reporting and Data Systems
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
BCT: breast-conserving treatment
partial mastectomy (also known as segmental mastectomy or lumpectomy) should receive whole breast irradiation following surgery or local radiation treatment with intraoperative radiation therapy
what is an aggressive form of breast cancer that occurs more frequently in younger women of African-American descent?
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
neoadjuvant systemic therapy typically given to what disease type and involves what?
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)
benefites to neoadjuvant therapy
(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.
Individuals with ? have significantly increased risk of developing MBC (male breast cancer)
Klinefelter’s syndrome (XXY) and BRCA2 mutations
an estimated 40% of MBCs are associated with BRCA2 mutations
TNBC
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.
antiestrogen therapy for breast cancer
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
monoclonal antibody targeting the extracellular portion of HER2 receptor
worry about what side effect?
trastuzumab
cardiotoxicity
cardiac-toxic chemotherapeutic agents such as doxorubicin (Adriamicin) should be avoided in patients with HER2-neu (+) tumors
biologic treatments targeting DNA repair
particularly effective in the treatment of breast cancers with DNA-repair-gene mutations such as ?
Poly(ADP-ribose) polymerases (PARPs) inhibitors: monoclonal antibodies that target tumors with PARP mutations
BRCA1, BRCA2, TNBCs, and basal-type cancers.
nearly all women with invasive breast cancers of what size are now given some form of systemic therapy
more than 1 cm
The initial workup for a dominant breast mass should involve ?
tissue analysis and bilateral mammography to assess the lesion and look for other occult abnormalities
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 ?
ALND to address the axillary lymph node involvement
What is more sensitive for the detection of breast cancers in women with dense breast tissue?
Breast MRI
raloxifene was found to be associated with significantly lower risk of ? than tamoxifen
venous thromboembolic events and uterine cancers and uterine hyperplasia than tamoxifen
Benign breast histology not associated with an increased risk for breast cancer
Adenosis, apocrine metaplasia, cysts, ductal ectasia, fibroadenoma, fibrosis, mild hyperplasia, mastitis, squamous metaplasia
breast cancer risk increased 1.5- to 2.0-fold
Moderate or severe ductal hyperplasia, papillomatosis
breast cancer risk increased 5-fold
Atypical ductal hyperplasia
breast cancer risk increased 10-fold
Lobular carcinoma in situ
Atypical ductal hyperplasia with family history of breast cancer
benign vs malignant cyst characteristics
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.
imaging that can be used to characterize cystic and solid lesions
breast US
BRCA1 and BRCA2 mutations
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
Women with BRCA1 mutations have a ? lifetime risk of developing breast cancers and ? risk of developing ovarian cancers
55% to 60%
35% to 40%
Invasive Lobular Carcinoma
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
Atypical Ductal Hyperplasia (ADH)
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
LCIS
Lobular Carcinoma in Situ
In some patients, LCIS is an actual precursor to invasive lobular carcinoma.
ACS vs USPSTF mammogram screening guidelines
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
Gail model
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
MRI has been recommended as an adjunct to screening mammography for patients with ?
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).
screening ductal lavage
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.
screening guidelines if family history or genetic predisposition (mutations of BRCA1 or BRCA2)
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.
screening guidelines for LCIS
Annual mammogram and physical examination every 6-12 mo; consider risk-reduction strategies.
Mammography in young women under 30 years of age tends to be less sensitive because of ?
increased breast density and fibrocystic changes
Women with BRCA2 mutations have a ? lifetime risk of developing breast cancers and ? risk of developing ovarian cancers
45%
11% to 17%
Men with BRCA2 mutations are at risk of developing ?
breast cancers, prostate cancers, melanomas, and pancreatic cancers
BRCA1, BRCA2, and P53 mutations are associated with familial breast cancer syndromes and follow an ? inheritance pattern
autosomal dominant
most appropriate tx option for ADH discovered on breast biopsy
needle localization excisional biopsy of that area of the breast
ADH is often found adjacent to DCIS
what condition is often associated with elevated prolactin levels and can predispose to having galactorrhea or a form of physiologic “milky” nipple discharge
hypothyroidism
A 43-year-old premenopausal, nonlactating woman presents with unilateral nipple discharge that is serosanguineous, think ?
workup with ?
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)
duct ectasia
only occurs in who?
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
radiographic study of the duct that is obtained with the injection of contrast material into the duct
ductography
Tumors along the duct walls will appear as filling defects or irregularities.
introduction of a small-diameter flexible endoscope into the suspicious duct(s) to visualize and obtain cytologic assessment of the duct and ductal contents
ductoscopy
Surgical treatment for intraductal masses identified during the work-up of pathologic nipple discharges can consist of ?
partial duct excision or complete central duct excision
physiologic vs pathologic nipple discharge
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
medications that can cause nipple discharge
Antihypertensive medications, phenothiazines, antidepressants, and antipsychotic medications
Medications that block the secretion of dopamine can cause galactorrhea.)
