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Surgery Clerkship > GYN Onc > Flashcards

GYN Onc Flashcards

1
Q

The most common cause of unilateral bloody breast discharge

A

Intraductal papilloma

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2
Q

The most common cause of unilateral serosanguinous breast discharge in the presence of a breast mass

A

Breast cancer

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3
Q

OCPs and breast cancer

A

OCPs do NOT increase risk for breast cancer. The dose of estrogen is not high enough. They are, in fact, probably protective since they shut down endogenous estrogen production.

HRT, on the other hand, is a risk factor for breast cancer.

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4
Q

Non-estrogen-related risk factors for breast cancer

A
  • Hx of chest radiation (classically for lymphoma)
  • Genes:
    • BRCA1 and 2
    • ATM (Ataxia telangiectasia)
    • p53 mutation
    • CHEK2 (checkpoint 2 kinase mutation)
    • PTEN
    • Cadherin 1
    • STK11 (Serine-threonine kinase 11)
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5
Q

Should you recommend self breast exams?

A

NO. Because women will find something, and it will require workup but it will not be breast cancer.

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6
Q

Should you do regular breast exams for your patients (primary care, GYN)?

A

NO

Evidence has not borne this out to be helpful. Rather, in the same way as self exams, it just dramatically increases workup of benign lesions and leads to unnecessary expense, unnecessary stress, and iatrogenicity.

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7
Q

Breast exams are out, ___ is in

A

Breast exams are out, mammogram is in

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8
Q

Best current recommendation for breast cancer screening

A

Age 40, q2 yrs for mammograms

This is the recommendation to follow right now.

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9
Q

When do you use MRI over mammogram for breast cancer screening?

A

When risk is VERY high.

BRCA patients, BRCA-negative patients with strong family history, patients w/ history of chest irradiation

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10
Q

Breast cancer diagnosis

A
  • 1st step: Mammogram
    • May arrive at this __ ways:
      • Screening mammogram > 30 years
      • Diagnostic mammogram in the setting of suspected breast cancer outside of screening
      • Breast mass (not cyst) on US < 30
      • Bloody FNA on < 30 cyst by US
      • Recurrence of cyst on < 30 by US
  • 2nd step: Core needle biopsy (OR excisional if you know it is cancer)
    • Necessary for confirmation of diagnosis and for pathological diagnosis
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11
Q

Breast mass algorithm

A
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12
Q

Importance of age to breast cancer screening

A
  • Prior to age 30, breast tissue is too firm for mammogram to be useful. Ultrasound is a better test in these patients.
  • BUT, we wait 1-2 cycles first to see if the mass goes away, since it is highly unlikely to have breast cancer in this population
  • Wait 1-2 cycles, then ultrasound if < 30
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13
Q

Possible findings on breast ultrasound for a woman with a breast mass < 30

A
  • Mass: Probably fibroadenoma, possibly breast cancer. Need core needle biopsy.
  • Cyst:
    • Blood: Probably breast cancer
    • Pus: Probably an abscess
    • Fluid: Probably a benign cyst
  • Fibrocystic pattern: Fibrocystic change. Must repeat US on next early follicular phase (cycle day 3)
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14
Q

Standard breast cancer chemotherapy

A
  • Doxarubicin
  • Cyclophosphamide
  • Paclitaxel
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15
Q

CHF caused by __ for breast cancer therapy is irreversible, while CHF caused by __ for breast cancer therapy is reversible.

A

CHF caused by anthracyclines for breast cancer therapy is irreversible, while CHF caused by trastuzumab for breast cancer therapy is reversible.

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16
Q

Prognostication for breast cancer receptors

A
  • PR+: good prognosis
  • ER+: good prognosis
  • HER2/Neu+: poor prognosis
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17
Q

Targeting HER2/neu

A

Trastuzumab

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18
Q

Targeting ER/PR

A

If premenopausal: SERM

If postmenopausal: Aromatase inhibitor

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19
Q

BRCA prophylactic measures

A
  • Prophylactic mastectomy and BLSO
  • Otherwise, MRI and mammogram every year to screen
20
Q

Adjuvant chemotherapy

A

Chemotherapy after surgical resection

21
Q

Neoadjuvant chemotherapy

A

Chemotherapy first to reduce tumor size, then surgery

22
Q

“Triple test” for breast cancer

A
  • Clinical exam
  • Imaging
  • Pathology
    • All three must be negative in order to rule breast cancer out
23
Q

If imaging and clinical exam of a breast mass are concerning, but biopsy findings are benign. . .

A

. . . excisional biopsy is still warranted in order to avoid the possibility of sampling error

24
Q

Prognostication for inflammatory breast cancer

A

Lymph node involvement is common

Most cases will require neoadjuvant therapy followed by surgery and radiation

25
Q

If you’re gonna give an aromatase inhibitor, you also need to give. . .

A

. . . a bisphosphonate

26
Q

PARP inhibitors are particularly effective in the treatment of . . .

A

. . . breast cancers with DNA repair gene mutations

BRCA1, BRCA2, TNBCs, basal-type cancers

27
Q

Treatment of breast cancer metastases

A

As a general rule, radiation and surgery are unlikely to be curative

Playing w/ chemotherapeutics is the best option at this stage

28
Q

Aromatase inhibitors vs SERMs for ER/PR+ breast cancer

A

Aromatase inhibitors do work better for those who are eligible

If SERMs fail, it may be time to switch to AIs

29
Q

If a breast FNA detects malignant cells, the next step is . . .

A

Core needle biopsy

30
Q

If a patient has inconclusive results on mammogram due to breast tissue that is too dense, the next thing to do is. . .

A

. . . MRI

Suprisingly, not ultrasound. This is because the patient is older than 30 (since they were screened w/ mammogram)

31
Q

In whom does the American Cancer Society recommend using MRI for screening for breast cancer?

A

Those with a “high risk” profile, defined as >20% lifetime risk

32
Q

BIRADS categories of mammogram reading

A
  • BIRADS 4 is subdivided into:
    • 4A: Low suspicion of malignancy
    • 4B: Moderate suspicion of malignancy
    • 4C: High suspicion of malignancy
33
Q

Patient’s core needle biopsy is read by pathology as atypical ductal hyperplasia. What is the next step?

A

Excisional biopsy

25-35% of patients with ADH also have ductal carcinoma in situ (DCIS)

34
Q

Indications for breast MRI as annual breast cancer screening test

A
  • Known BRCA mutation or untested first-degree relative of someone with known BRCA mutation
  • Known Li-Fraumeni syndrome (p53 mut) or untested first-degree relative of someone with known Li-Fraumeni
  • History of prior chest wall irradiation
  • Estimated lifetime breast cancer risk > 20%
35
Q

Interpretation of LCIS vs DCIS on core needle biopsy

A

DCIS: Likely indicates either a precursor stage of cancer or invasive cancer elsewhere in the breast – warrants excisional biopsy.

LCIS: Indicative of an increased risk of future breast cancer moreso than it is itself a precursor stage of invasive cancer. Managed with SERM prophylaxis and q6-12 month imaging.

36
Q

Prophylactic mastectomy

A

A reasonable treatment option for those at very high risk – for example, those with BRCA1 mutations

However, all options should be discussed first. This is not reasonable for an individual of average risk.

37
Q

Workup for suspected intraductal papilloma

A
  • Start with bilateral mammogram and/or ultrasound
    • If positive for suspicious lesion, core needle biopsy
    • If negative, perform doctography
      • If ductography is positive for suspicious lesion, core needle biopsy
38
Q

Ductal ectasia etiology and risk factors

A
  • Etiology: Loss of elastin in the duct wall as a result of chronic inflammation
  • Risk factors: Ductal ectasia only occurs in smokers
39
Q

Treatment for ductal ectasia and intraductal papilloma

A

Ductectomy

40
Q

If a patient has a breast mass/symptoms, your workup order is ___.

If they have are just being screened, you would only do ___.

A

If a patient has a breast mass/symptoms, your workup order is MRI AND ultrasound AND biopsy if indicated

If they have are just being screened, you would only do mammogram OR ultrasound.

41
Q

Past what BIRADs score do you consider biopsy?

A

BIRADS 3: Odds are low (2-3%), but may consider

BIRADS 4 or above: You should biopsy

42
Q

Why is core needle biopsy SO much better for breast cancer evaluation than FNA?

A

FNA is just cytology – you can’t stain to evaluate for ER/PR/HER2

43
Q

90% of breast cancers arise from ____

A

90% of breast cancers arise from TDLUs (terminal ductal lubular units)

44
Q

Axillary node levels

A
45
Q

In individuals of Ashkenazi ancestry, we evaluate for BRCA mutation in.

A

. . . anyone with breast cancer, even without family history

The prevalence in this population is already 1/40, so if they are already presenting with breast cancer the odds are quite high

46
Q

If a symptomatic breast cyst has no malignant features and is present in a young woman. . .

A

. . . you aspirate it, but don’t need to send the aspirate for cytology

Surgery Clerkship (42 decks)

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