GYN Onc Flashcards
The most common cause of unilateral bloody breast discharge
Intraductal papilloma
The most common cause of unilateral serosanguinous breast discharge in the presence of a breast mass
Breast cancer
OCPs and breast cancer
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.
Non-estrogen-related risk factors for breast cancer
- 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)
Should you recommend self breast exams?
NO. Because women will find something, and it will require workup but it will not be breast cancer.
Should you do regular breast exams for your patients (primary care, GYN)?
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.
Breast exams are out, ___ is in
Breast exams are out, mammogram is in
Best current recommendation for breast cancer screening
Age 40, q2 yrs for mammograms
This is the recommendation to follow right now.
When do you use MRI over mammogram for breast cancer screening?
When risk is VERY high.
BRCA patients, BRCA-negative patients with strong family history, patients w/ history of chest irradiation
Breast cancer diagnosis
-
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
- May arrive at this __ ways:
-
2nd step: Core needle biopsy (OR excisional if you know it is cancer)
- Necessary for confirmation of diagnosis and for pathological diagnosis
Breast mass algorithm
Importance of age to breast cancer screening
- 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
Possible findings on breast ultrasound for a woman with a breast mass < 30
- 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)
Standard breast cancer chemotherapy
- Doxarubicin
- Cyclophosphamide
- Paclitaxel
CHF caused by __ for breast cancer therapy is irreversible, while CHF caused by __ for breast cancer therapy is reversible.
CHF caused by anthracyclines for breast cancer therapy is irreversible, while CHF caused by trastuzumab for breast cancer therapy is reversible.
Prognostication for breast cancer receptors
- PR+: good prognosis
- ER+: good prognosis
- HER2/Neu+: poor prognosis
Targeting HER2/neu
Trastuzumab
Targeting ER/PR
If premenopausal: SERM
If postmenopausal: Aromatase inhibitor
BRCA prophylactic measures
- Prophylactic mastectomy and BLSO
- Otherwise, MRI and mammogram every year to screen
Adjuvant chemotherapy
Chemotherapy after surgical resection
Neoadjuvant chemotherapy
Chemotherapy first to reduce tumor size, then surgery
“Triple test” for breast cancer
- Clinical exam
- Imaging
-
Pathology
- All three must be negative in order to rule breast cancer out
If imaging and clinical exam of a breast mass are concerning, but biopsy findings are benign. . .
. . . excisional biopsy is still warranted in order to avoid the possibility of sampling error
Prognostication for inflammatory breast cancer
Lymph node involvement is common
Most cases will require neoadjuvant therapy followed by surgery and radiation
If you’re gonna give an aromatase inhibitor, you also need to give. . .
. . . a bisphosphonate
PARP inhibitors are particularly effective in the treatment of . . .
. . . breast cancers with DNA repair gene mutations
BRCA1, BRCA2, TNBCs, basal-type cancers
Treatment of breast cancer metastases
As a general rule, radiation and surgery are unlikely to be curative
Playing w/ chemotherapeutics is the best option at this stage
Aromatase inhibitors vs SERMs for ER/PR+ breast cancer
Aromatase inhibitors do work better for those who are eligible
If SERMs fail, it may be time to switch to AIs
If a breast FNA detects malignant cells, the next step is . . .
Core needle biopsy
If a patient has inconclusive results on mammogram due to breast tissue that is too dense, the next thing to do is. . .
. . . MRI
Suprisingly, not ultrasound. This is because the patient is older than 30 (since they were screened w/ mammogram)
In whom does the American Cancer Society recommend using MRI for screening for breast cancer?
Those with a “high risk” profile, defined as >20% lifetime risk
BIRADS categories of mammogram reading
- BIRADS 4 is subdivided into:
- 4A: Low suspicion of malignancy
- 4B: Moderate suspicion of malignancy
- 4C: High suspicion of malignancy
Patient’s core needle biopsy is read by pathology as atypical ductal hyperplasia. What is the next step?
Excisional biopsy
25-35% of patients with ADH also have ductal carcinoma in situ (DCIS)
Indications for breast MRI as annual breast cancer screening test
- 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%
Interpretation of LCIS vs DCIS on core needle biopsy
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.
Prophylactic mastectomy
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.
Workup for suspected intraductal papilloma
- 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
Ductal ectasia etiology and risk factors
- Etiology: Loss of elastin in the duct wall as a result of chronic inflammation
- Risk factors: Ductal ectasia only occurs in smokers
Treatment for ductal ectasia and intraductal papilloma
Ductectomy
If a patient has a breast mass/symptoms, your workup order is ___.
If they have are just being screened, you would only do ___.
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.
Past what BIRADs score do you consider biopsy?
BIRADS 3: Odds are low (2-3%), but may consider
BIRADS 4 or above: You should biopsy
Why is core needle biopsy SO much better for breast cancer evaluation than FNA?
FNA is just cytology – you can’t stain to evaluate for ER/PR/HER2
90% of breast cancers arise from ____
90% of breast cancers arise from TDLUs (terminal ductal lubular units)
Axillary node levels
In individuals of Ashkenazi ancestry, we evaluate for BRCA mutation in.
. . . 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
If a symptomatic breast cyst has no malignant features and is present in a young woman. . .
. . . you aspirate it, but don’t need to send the aspirate for cytology
