MALIGNANT Breast Disease Flashcards
1
Q
What is breast cancer
A
malignant proliferation of epithelial cells of the ducts or lolbules of the breast * hormone dependent cancer
2
Q
What is the epidemiology of breast cancer
A
- most common cancer in women = ~30% of all cancers - 2nd most common cause of death in women (lung Ca is first) - annual risk of developing br ca depends on AGE - 12% lifetime risk,
3
Q
Describe tha lobular/tubular anatomy of the breast
A
breast is composed of 12-20 tubuloalveolar lobes which terminate in lactiferous ducts which dilate to sinuses and drain into ampulla of nipple
4
Q
What are risk factors for breast cancer
A
Gender
Age
Genetics
Estrogen exposure
Diet
Radiation History,
Personal History, Familial
“GAGE the risk of breast cancer DR. HH”
5
Q
Descibe the patterns of inheritance of breast cancer
A
Sporadic -80% Familial -15% (= no AD penetrance - variable penetrance, complex interactions/mutations not yet understood) Hereditary 5-10% - defined mutations
6
Q
List known genetic mutations associated with breast cancer (7)
A
BRCA1 BRCA2
p53 - lifraumeni
PTEN - cowden’s disease
MSH2/MLH1 - muir-torre syndrome
ATM - ataxia - telangiectasia
STK11/LKB1 - peutz jeghers
7
Q
What is the relative % of hereditary breast cancer caused by the genetic mutations
A
BRCA1 - 45%
BRCA2- 35%
p53 Lifraumeni 1%
unknown 20%
All the rest, each 1%
8
Q
What is the BRCA gene
A
TSG with role in DNA repair AD inheritance
9
Q
What is the risk of cancer in patient with BRCA mutation
A
40-80% lifetime risk of breast cancer
20-80% lifetime risk of ovarian cancer
1/5 of women develop breast cancer before 40yo
10
Q
What is the BRCA1 mutation location and incidence
A
17q12-21
1/800
HIgher incidence (1/50) in ashkenazi jewish, netherlands, sweden, hungary, iceland
11
Q
What is the risk of breast cancer specifically for BRCA1?
A
40-80% lifetime risk of breast cancer (women)
*1-10 lifetime for men*
40% lifetime risk of ovarian cancer - can be delayed until after children b/c low risk
12
Q
What other cancers are associated with BRCA1?
A
BILATERAL breast cancer with high grade tumors
Colon
Ovarian
Prostate
13
Q
Where is the BRCA2 mutation
A
13q12.3
14
Q
What is the risk of breast and ovarian cancer specifically for BRCA2?
A
40-70% lifetime risk of breast cancer
20% risk of ovarian cancer
15
Q
What other cancers are associated with BRCA2?
A
BILATERAL breast
Colon
Ovarian
Prostate
pancreas, gastric, biliary, chole
melanoma, lymphoma
16
Q
What is cowden’s disease
A
Mutation of TSG PTEN, AD inheritance Lifetime risk of breast ca 25-50%
Pathognomonic features:
- tricholemmoma
- mucocutaneous papillomatosis (marker of gastric ca)
Major Diagnostic Criteria
- Breast Ca, endometrial Ca, thyroid Ca, cerebellar tumor
Minor Diagnostic criteria
- lipoma, fibroma, goiter, GI hamartoma, GU tumor
17
Q
What is Li Fraumeni disease
A
Mutation of TSg p53
AD inheritance
- 25fold icnrease cancer risk by age 50
Diagnostic criteria (all 3 must be met)
- sarcoma <45
- FDR with cancer <45
- FDR/SDR with cancer <45 or sarcoma anytime
Associated cancer
- Strong ass. Breast, soft tissue sarcoma, osteosarcoma, adrenal carcinoma, brain tumor
- Moderate: Phyllodes, Wilms
- Weak: leukemia, neuroblastoma
18
Q
What is ataxia-telangiectasia
A
Mutation of ATM
AR inheritance
Characterized by
- cerebellar ataxia
- telangiectasia (face)
associated Cancer
- Lymphoma, Brain, Gastric, Breast
19
Q
What is Peutz Jeghers syndrome
A
STK11 mutation = Hereditary intestinal polyposis syndrome
Characteristics
- Gi harmartomatous polyps
- melanocytic pigmentation of skin and mucous membrane
Associated cancer
- breast (55% <25yo)
- testicular, prostate
- colon
20
Q
What is Muir Torre
A
Mutation of MSH2/MLH - Variant of Lynch syndrome HNPCC
AD
Characterized by (need both)
- 1 sebaceous neuplasm (epithelioma, adenoma, carcinoma)
- visceral malignancy (usually breast, GI GU, endometrial)
21
Q
What are factors for increased estrogen exposure and risk of breast cancer
A
- Menarche <12yo
- Menopause >55yo
- First fullterm pregnancy >30yo
- Nulliparity
- Obesity
- Exogenous estrogen: HRT (estrogen+progesterone)
22
Q
What radiation exposure increases risk of breast cancer?
A
Radiation <30yo, not increased risk if >45
Highest risk b/w age 10-14
If li fraumeni, ATM - >high risk of developing new cancer w radiation exposure
23
Q
What dietary factors increase risk of breast cancer
A
high fat intake
Moderate alcohol intake (>2glassess/day in W, increases risk by 21%)
24
Q
What risk factors on breast history increase risk of breast cancer?
A
- IBC => annual 1% risk of contralateral IBC
- DCIS, LCIS => 5% per 10yrs risk of contralateral IBC
- FCD:
- proliferative with no atypia (RR 1.3-2)
- proliferative with atypia (ADH, ALH RR4-6)
- Any previous biopsy
25
What risk factors on Family history increase risk of breast cancer?
* FDR with IBC, RR 2.6
* multiple FRD with IBC, RR 4.5
* FDR with Dx\<40yo, RR 4.7
26
What are protective factors for preventing breast cancer
* Breast feeding
* Parity
* Exercise
* Low postmenopause BMI
* Oophrectomy \<35
27
What are the NCCN criteria for genetic counseling referral?
* 1 FDR with Dx of IBC\<50
* \>2FDR/SDR with Dx of IBC
* FDR/SDR with bilateral IBC
* Male relative with IBC
* FDR with Dx of Ovarian Ca
* Ashkenazi jewish heritage
28
What is the gail model used for and how is it applied
To determine the relative risk of breast cancer
If \>1.67% /5y risk of breast ca, recommend RRstrategies
Factors in model
* estrogen exposure
* family history
* personal history
29
What are risk reduction strategies for prevention of breast cancer development
SURGERY
* BPM - Drop risk by 90% in BRCA1/2 carrier. Not for LCIS
* BSO - Drop risk by 80% for ovarian Ca and 50% Breast cancer in BRCA1/2 carrier
PHARMACOLOGIC
\* for women with gail risk score\>1.7 and \>35yo , not enough evidence for BRCA or women\<35
* Tamoxifen: premenopausal, 5yrs of Tx, drop risk by 50% and 86% if ADH/ALH
* Need annual gyne check for endometrial ca
* Hold for elective surgery given risk of DVT
* Raloxifene: postmenopausal - equal to tamoxifen for IBC, but not for in situ cancer
LIFESTYLE
- limit alcohol intake
- diet
- exercise (weight control)
30
What are the recommended screening guidelines for breast cancer
Average risk Women 40-74 (Canadian recommendations)
Average risk defined as no personal Hx, family Hx (FDR), chest wall radiation, BRCA
* Mammogram q2-3yr if 50-74
* No routine Mammogram if 40-50
* Not recommended to routinely do MRI, CBE, self-breast exam
High Risk Women (Ontario breast screening program)
defined as BRCA+, FmHx of BRCA+ and no personal test, greater than 25% risk with risk calcultor, CW radiation \<30yo
* annual mammogram and MRI at age 30
31
What are signs/symtoms of breast cancer
* painless mass
* skin changes (peau d'orange, scaliness, erythema)
* Nipple changes (distortion, discharge, ulceration)
* Axillary lympadenopathy
* Systemic cahnges (weight loss, fever)
* often asymptomatic
32
How does a screening mamogram differ from a diagnositic mammogram?
Screening: MLO, CC
Diagnostic: MLO, CC +additional views w spot compression, 90degree lateral
33
What are findings on mammogram indicative of malignancy
* Mass with spiculated irregular border
* Microcalcifications
* DCIS: irregular, along ducts
* LCIS: Circular uniform in acini
* Fat necrosis: coarse calcification with lucent center
* Architecture distortion
* Interval change
Mass classified according to BIRADs score
34
WHat are findings on ultrasound
delineate b/w slid, cyst
35
What are findings on MRI
all IBC enhance with gadolium
36
How is biopsy chosen/performed
Percutanous Bx can be FNA or Core
FNA gives no architecture (cant tell if CIS or IBC)
Core - distinguished CIS from IBC
If mass palpable, U/S guided Bopsy.
If no mass, only Calcification:
* stereotactic percutaneous techniques
When negative perc BX, proceed to open Bx if
* ADH/ALH (may contain DCIS)
* discordance
* complex papilloma
* radial sclerosis
37
What is the metastatic work up and for what stage of breast cancer
Stage 3 - T3N1M0
Site of metastasis: regional LN, liver, Lung, Bone, Brain
Blood work - CBC LFT
Imaging - CXR, CT abdo
CT head, bone scan if symptomatic
38
How is breast cancer staged
T
Tx, is
T1 \<2cm
T2 2-5cm
T3 \>5cm
T4 extending into chest wall or skin
T1/2 clinically N0 (early stage)
T3/4 (LABC) \>N1 \* eligible for neoadjuvant chemo, will require radiation
N - Clinical (imaging or exam)
Nx, N0
N1 - ipsilateral ALN but movable
N2 - ipsilat ALN fixed OR IMLN without ALN
N3 - infra/supra clav OR IMLN and ALN
N pathologic
Nx,N0
N1- micromets in 1-3 LN
N2- micromets in 4-9LN or clincially detected IMLN
N3 - micromets \>10 or in supraclav or clinically detected IMLN with ALN
M
M1 - distant mets
39
Describe treatment according to cancer staging for breast cancer
1- Stage 0 (CIS)
2- Operable IBC (stage 1A - 3A - T3N1M0 only)
3- Non-operable IBC (3A {except T3N1M0}, 3B, 3C or if downstaged by systmic treatment)
4- Stage 4 (metastatic)
40
How is CIS distinguished from IBC
Invasion or not through basement membrance into stromal tissue
41
42
What is the hisotlogic grading of IBC and associated prognosis
Grading is based on 3 factors (scored each out of 3)
1. tubule formation
2. mitosis count
3. nuclear pleomorphism
Grade 1 - well diff = 5yrS 90%
GRade 2 - mod diff = 5yrS 75%
Grade 3 - poor diff = 5yrS 50%
Grade 4 - undiff
43
What features should be on synoptic report for IBC (9)
* Specimen receipt
* Procedure, Location/quadrant
* Tumor size
* Histologic type and grade
* margin status and distance from margin to tumor
* +/- DCIS
* +/- Peritumor LVI
* +/- microcalcifications
* LN status
44
What tumor markers are assessed if IBC
* ER/PR
* Her2/neu
* Plasma CEA, CA15.3, CA27.29 (monitor for metastatic disease)
* UPa, PAI-1 - if absent and no LN invasion, may not need chemot
45
What is LCIS, epidemiology, diagnosis, management
Def: neoplastic cells connfined to lobule
Epid: 4th decade, premenopausal
Risk of IBC:
* 1%/yr\*\*\*\*\*\*\*\*\*\*\*\*\*\*\* ipsi or contra
* marker of high risk of developing breast cancer
* higher risk if young or bilat
*
Dx
- non palpable, not easily visualized on mammogram, usually diagnosed by biopsy incidentally
Tx
- if core Bx Dx of LCIS, always open Bx+surgical excision
THEN- if surgical biopsy/excision is only LCIS, active surveillance with ammogram q1yr or RRS (BPM, tamoxifen premeno or raloxefine postmeno which is less toxic and less efficacious))
46
What are side effects of tamoxifen
* menopausal symptoms (hot flash, vaginal dryness, low libido)
* VTE (hold 3wks pre and post major surgery)
*Stopping tamoxifen peri-operatively for VTE risk reduction: A proposed management algorithm -* *Tasadooq Hussain Peter J. Kneeshaw - Int J Surg 2012*
47
What is DCIS, epidemiology, classification, diagnosis, management
Def: carcinoma within ductule structures but no penetration of ductule wall
Epid: 20% of breast cancer
Classification
* Comedo vs Non-comedo
* Comedo = necrosis = poor prognosis
* Non-comedo - all others (cribiform, papillary)
* High grade vs Low grade
Dx:
Mammogram
MRI - low specificity for DCIS, but high sensitivity
Tx - 3 options - differ in local recurrence but not survival
1- BCS + RTx (10%LR) - margin 1cm
2- BCS no Rtx (30% LR)
3- Mx (1% LR)
SLNBx if Mx selcted, high grace, comedo, multicentric
Tamoxifen if ER+
Follow-up
* Mammogram q1y
Prognosis
99% 5yS
Recurrence risk on ipsilateral side (not contralat as in LCIS)
48
What is tamoxifen, MOA, indications, side-effects
* Anti-estrogenic drug
* competitively blocks ER
INDICATIONS
- pharmacologic Risk reduction for IBC, CIS, AH in premenopausal W
- all patients with ER+ tumor should be offered tamoxifen for 5yrs, premenopausal women for 10yrs - reduces recurrence, DFS, OS (CCO 2014)
SIDEFFECTS
- increases risk of uterine sarcoma, endometrial Ca, venous thrombosis
49
List 4 high- , moderate- and low-risk factors for development of breast cancer
* High: female, age \> 65, BRCA1/2 gene +, previous breast biopsy of ADH/ALH
* Others: mammographically dense breasts, personal BC history
* Mod: 2x 1st degree relatives, high basal levels of estrogen/testosterone, high dose XRT to chest wall, high bone density
* Low:
* Endocrine RFs: late 1'st pregnancy/nulliparity, early menarche/late menopause, no breast feeding, recent use of OCP or HRT
* Modifiable RFs: smoking, obesity, excessive ETOH intake
* Non-modifiable RFs: Ashkenazi Jewish, 1x 1st degree relative, personal Hx of ovarian, endometrial, colon Ca
50
What is the BRCA gene? How does it influence your risk of developing breast cancer
* The BRCA gene is a tumour suppressor gene
* It is passed as an autosomal dominant gene and is highly penetrant (50% chance of inheriting gene & risk from a parent who is gene +)
* Women with BRCA 1 have 40-80% lifetime risk of developing breast cancer, and for BRCA 2 it is 40-70% (usual lifetime risk is 12%)
* Men with BRCA 1 have 1-2% increased lifetime risk and BRCA2 is 5-10% (usual lifetime risk is 0.1%)
51
what other cancers are associated w/ brca 1 and brca 2?
* BRCA1: breast, ovarian, fallopian tube, colon, prostate
* BRCA2: breast, ovarian, fallopian tube, colon, prostate, gastric, biliary, pancreatic, melanoma, lymphoma
52
List syndromes associated w/ development of breast cancer
CLAMP
* Cowden
* Li-Freumeni
* Ataxia-Telangectasia
* Muir-Torre
* Peutz-Jagers
53
List histologic types of Invasive breast Cancer (8)
1. Infiltrating Ductal (IDC) - 70% - worse prognosis
2. Invasive lobular (ILC) - 5%
3. Tubular - 10%
4. Medullary - 5%
5. Paget's Disease 1% - ass. with DCIS/IDC - hallmark is paget cells in epdiermis of nipple
6. Inflammatory -1% - very poor prognosis - presents as "cellulitis" = T4d - high risk LN/mets easly
7. Cystosarcoma phyllodes
8. Adenoid cysticCa, Apocrine CA
54
What are breast cancer screening guidelines in Canada?
* Screening guidelines are predominantly for average risk women age 50-74
* Set forth by the CTFPHC / CMAJ guideline
* no self-examination
* no routine breast clinical exam
* mammography q2-3 yrs
* no MRI
* For high risk patients, OBSP recommends screening starting at age 30+
* annual mammogram & MRI
* high risk by OBSP is:
* BRCA+ or FHx of BRCA (&declined testing)
* Risk calculator of lifetime risk \> 25%
* Chest wall rads at age \< 30
55
what is the difference between a screening and a diagnostic mammography?
* screening - 2 views - craniocaudal and mediolateral compression
* Diagnostic - 2 screening views plus 90' lateral and spot compression
56
What are Mx options and indications contraindications for types of Mx
Total Mx - removal of all +/- pec fascia
MRM = TMx + pec fascia + level 1/2 ALN
* Patey MRM - include level 33 +/- pec minor
RM = TMx + pec major,minor, ALN 1-3
SSM - subcutaneous removal of gland and NAC
* non RCT support SSM=outcomes to TMx for Stage 1/2, DCIS. T and N class determine prognosis, not Tx
NSM - subcutaneous removal of gland only
* for PM or select pt with DCIS/IDC
* Consensus paper support NSM
* tumor \<3cm, \>2cm from nipple
* no skin/pagets D
* clinically and SLNBx negative ALN
* frozen section from base of NAC intra-op negative
57
describe screening mammogrphy for patient wiht breast implants
* want screening views: craniocaudal and mediolateral compression plus
* EUKLAND views: isolate the implant from the breast tissue - the implant is pushed back and the breast is pulled forward
* subglandular implant decreases measurable tissue by 49%; decreases to 39% w Eukland views
* submuscular implant decreases measurable tissue by 29%; decreases to 9% w Eukland views
58
what findings on screening mammogram are suspicious for breast cancer
* microcalcifications
* architechtural distortion
* increased vascularity
* interval change
59
what is the gold standard way to diagnose breast cancer?
* history and physical exam (new lump) plus/minus finding on diagnostic mammogram/US
* vs finding on screening mammogram
* then core biopsy - TruCut
* image guided if non-palpable / surgeon preference
60
What are SLNBX or ALND
Goal - to treat local disease and prognosticate (guide adjuvant tx)
No increase in survival
ALND = Removal level 1&2. Level 3 if gross disease in level 2. Minimum 10LN required
SLNBX = identify LNs with most likely colonization from tumor - 92% will be in Axilla, 8% in IM. NPV 96%, PPV 100% with both dye and radioactive colloid
- Lymphazurin blue dye - 5cc injected at site mass/bx, massge 5min
- radioactive colloid - Te99-radioactvley labelled
Advantage of SLN over ALN
- reduced morbidity ( lymphedema 15Vs 5%, )
61
what is the clinical implication of ADH on core biopsy that prompts need for excisional biopsy/ lumpectomy
* 20% of ADH on core biopsy are upstaged to DCIS or IDC on final path review
62
what are clinically relevant staging concepts?
* early
* locally advanced
* non-operable
* "gray area"
* early = T1/2 & N-
* will not require PMRT
* LABC = T3/4 or clinically palpable N+ or matted/fixed LN
* bc will be considered for / require neoadjuvant chemo, and radiation (regardless of surgery type)
* "Grey area" = T1/2 & N1 (1-3LN or SLNB+) - grey area for PMRT
* non-operatable:
* some inflammatory BC, supraclavicular LN, axilla full of matted/fixed LN
* bc you only operative if you think you can achieve a negative margin
63
describe clinical staging for breast cancer
**T**
**N (clinical)**
**M**
Stage 1 = T1N0
Stage 2a = T1N1 or T2N0;
2b = T2N1 or T3N0
Stage 3a = T3N1, T1-3N2
3b = T4N0-2;
3c = any N3
Stage 4 = anything + M1
**T1**: \<2.0 cm
**T2**: 2.0→5.0cm
**T3**: \>5.0 cm
**T4**: *any* size with **extension to skin or CW**.
**N0**- no regional LN mets
**N1**- ipsilateral axillary LN
**N2**- matted ipsi ALN OR palpable IM LNs
**N3**- ipsi supra- or infraclavicular
**M0** – no mets
**M1** – distant
64
what features should be included and reviewed on a pathology report for breast cancer specimen?
* How the specimen was received (eg:number of pieces,fixative,orientation)
* The laterality, quadrant, type of procedure
* The measured size of the tumor
* Histological type and grade
* Coexistent ductal carcinoma in situ or an extensive intraductal component
* Peritumoral vascular or lymphatic invasion
* Gross or microscopic carcinoma at the margins of excision or distance from the margin
* Microcalcifications
* Lymph node status. Nodes + / Nodes taken; size of largest node; extra-capsular extension
65
What are indications/contraindications for RTx for IBC
VAriable per cancer center but
NOT required if
* post-Mx, negative LN AND tumor \<5cm AND margin\>1mm
INDICATED if
* Lumpectomy
* Mx with \>4+LN (and NCCN strongly recommend if 1-3+ - note pt wont be getting ALND if 1-2+
* Mx and tumor \>5cm
* Mx and tumor margin \<1mm
\* need to clarify ALND and Rtx when Mx and 1-2+
66
WHat are the options for RTx in breats cancer treatment
* Whole breast with boost - 50Gy in 2gy per fraction
* CW
* Regional nodal - 50Gy in 2Gy per fraction
67
What are options for adjuvant medical therapies for IBC
ENDOCRINE
* Tamoxifen
* 20mg daily, 5yr, started post-chemo if homorne responsive tumor
* reduce reucrrence by 40%, mortality by 30%
* SE: menopausal sx, VTE, endometrial ca, cataract
* CI: previous PE/DVT, stroke
* also offered for Risk reductio if gail model score\>1.7
* inhibited by SSRi fluoxetin, paroxetine only
* Aromatase Inhibitor
* anastrozole, letrozole
* survival adv if LN- and therapy after tamoxifen for [pstmenopausal W
* SE: POF in premenopausal, pathologic F# w drop in BMD
* Herceptin (trastuzamab)
* mAB for Her2/neu
* survival adv for Her2/neu+ independent of ER/PR
* SE: cardiac toxicity\*\*\*\*\*
68
what are subtypes of invasive breast cancer?
* ductal - worst prognosis, majority of invasive cancers (70-80%)
* lobular - 10%, increased risk of bilateral cancer
* tubular - 10-20% best prognosis, low mets
* Other breast cancer subtypes: medullary, inflammatory (poor prognosis), mucinous, papillary
* other: phyllodes, sarcoma, lymphoma
69
what is paget disease and why do we care?
* infiltrating adeno-Ca in nipple cells
* clinically can mimic melanoma
* care bc vast majority (\>95%) have underlying DCIS/IDC
70
what are absolute and relative contraindications to breast conserving surgery?
* absolute:
* think contra-indications to XRT
* **previous CW XRT, pregnant, lactating**
* Think inability to get clear surgical margins
* **diffuse microcalcifications, multi-focal disease**
* Relative
* think relative c/i to XRT:
* **connective tissue disease (scleroderma, lupus)**
* Think relative inability to get clear surgical margins
* **T \> 5cm; large tumour to breast ratio**
* Think risky to leave breast tissue
* **age \<35; pre-menopausal and BRCA+**
71
what are indications for NSM?
* Prophylactic mastectomy for high-risk patients
* Therapeutic mastectomy for DCIS/IDC when:
* Tumour size \< 3cm, Tumour to nipple distance \< 2cm, clinically negative LN, no skin involvement (no paget, no inflammatory etc)
* NCCN also considers other biologically favourable features: no LVI, grade I/II, HER2/neu -
* Other Considerations: no previous breast surgery/rads, small cup (? A-C) minimal ptosis (_\<_gr 1), non-smoker (related to survival of NAC)
72
What is the general treatment approach to patients with CLINICAL stage 1 or stage 2 invasive breast cancer?
* CLINICAL stage 1 or stage 2 breast cancer is by definition: tumour size \< 5cm and clinically node negative or ipsilateral mobile axiallary LN
* BCT - lumpectomy & post-op CW rads or simple mastectomy
* SLNB in all clinically LN-; ALND in all clinically LN+; completion LND in SNLB+
* add PMRT to CW and axilla if: T _\>_ 5cm; _\>_ 4LN involved; +ve margins
* PMRT controversial when: _\>_ 1-3LN, SLNB+
* chemo: T_\>_ 1cm; LN+ (consider oncotype Dx)
* endocrine therapy if ER/PR+ & T _\>_ 5mm or LN+
* Herceptin if Her2/Neu+ & T _\>_ 1cm or LN+
* CLINICAL STAGE III: T\>5cm or matted LN
* neoadjuvant chemo, mastectomy, PMRT (BCT in select cases) +/- ALND/endocrine/herceptin as indicated above
* CLINICALLY STAGE IV: consider debulking surgery, chemo/endocrine therapy, bisphosphonate if bone met +
73
What are chemotherapy options for IBC ttreatment
* CMF- cyclophosphamide, methotrexate, 5FU
* TAC - cyclophosphamide, DoceTaxel, doxorubicin,
74
What is your management of a Stage 1/2, 3A (T3N1M0) (operable with/out local-regional disease)
BCT + SLNB= Lump+Adj WBRtx +/- CWRtx
Or
Mx + SLNB
* LN-, T\<5cm, margin\>1mm = No Rtx
* LN-, T\>5cm OR margin \<1mm = CWRtx
* LN+ = CWRtx +/- Suprainfraclav
Clinically+ and +SLNBx =\>ALND
Clinically+ and -SLNBx =\>nothign further
Clinically - and SLNBx + with \>4LN+ =\>ALND
Adjuvant endocrine Tx + Herceptin if ER+and or PR+, + Her/neu+
Chemotherapy - stage 2 or T3N1M0
75
How do you do a SNLB?
1. Radioactive dye (Technetium-99) is injected pre-operatively in nuclear medicine
2. In the OR, blue dye (lymphazurin) is injected around the nipple intra-dermally
3. Once the mastectomy/lumpectomy is performed, access the axilla through the surgical site or new site
4. Use intra-operative lymphoscintography to measure the nodes captured by radiocolloid
5. Use vision to identify nodes captured by blue dye
6. remove ALL HOT nodes and ALL BLUE nodes
1. hot = nodes that register _\>_ 10% of "hottest" node
76
what will you counsel your patient regarding risk of lymphedema in ALND vs SLNB
* ALND - 10-40%
* SLND - 1-10%
77
why do you tell patients to hold tamoxifen for 2 weeks prior to DIEP?
* tamoxifen increases risk of VTE due to thrombogenic proteins produced during its metabolism in liver
* coupled with long surgery, this is done to reduce risk
78
what are the most common sites of distant mets for breast cancer?
lung
liver
bone
79
What is your management of a Stage 3A (except T3N1M0), stage3B, 3C (inoperable local-regional invasive disease)
Frist Chemotherapy (anthracycline +/- taxane)
Second, if responded
TMX, ALND, Radiation
Post-op, complete chemo and then endocrine tx
If no response, chemo and radaition
80
What is you management for stage4 metastatic disease
Combo of endocrine, chemo, bisphosphonates
81
What is managed of patient w local recurrence?
* Previous BCT =\> TMx ALND + chemo
* PRevious TMx +/- Rtx =\>surgical rsx + chemo +/- rad if not alreasy received
82
What is your post-op suveillance
mammogram q12m
If on tamoxifen, q12mth gyne exam
If on aromatase inh, BMD test q12m
83
WHat is the prognosis of breast cancer?
Nodal stage is best predictor of 5yrS
## Footnote
N 0- 80%
N 1-3 - 50%
N4-6 - 40%
N7-12 - 30%
N \>13% - 10%
Stage 1 - 4
95, 80, 40, \<5%
84
How does pregnancy affect breast cancer treatment?
Do surgical treatment without delay - Mx +/- ALND
Delay chemo until 2nd trimester
Delay Rtx + endrine Tx until post partum
If 1st trimester, cosnider abortion
85
WHat is ALCL
Anaplastic large cell lymphoma
## Footnote
= non-hodgkins T-cell lymphoma
Types: systemic, cutaneous, seroma associated
86
What are signs of ALCL
Late seroma
Mass adjacent to implant
Capsular contracture
87
What is the workup for ALCL and treatment
Imaging US/CT/MRI
U/S guided aspiration of seroma fluid for cytology -CD30, ALK markers
Capsule for histology
88
What do you recommend for surveillance to patients with implants
Same screening mammogram schedule
Eukland view (image displacement mammography views
89
What is done when IBC is identified in BBR pathology
Mx generally recommended - occurs \<3%
BBR reduces risks of IBC by 30% depending on amount removed
90
WHat is done wihen breast mass discovered intra-op in BBR?
1. Mark site with surgical clips
2. Intra-op consult iwth general surgery
3. Intra-op pathology with frozen sections
4. Removal of mass with 0.5cm gross margin if it does not compromised viability of dermoglandular pedicle
5. Oncology/gens urg consult post-op
91
What is you DDX of a breast mass
BENIGN
* Fibroadenoma (1.5-3x risk)
* AdenosisSclerosing (1.5-3x risk)
* Radial scar (3-5x risk)
* ADH/ALH (3- 5x risk)
* * Phyllodes (10% maignant)
* Intraductal papilloma
* Fibromatosis
MALIGNANT
* LCIS
* DCIS
* IC
*
OTHER
* Fat necrosis
* MAmmary duct ectasia
* granulomatous mastitis
92
Indications for open biopsy (lumpectomy) after a NEGATIVE core bx
* Discordance (imaging, path, clinical)
* ADH, ALH
* complex papilloma
* radial sclerosis
93
What is the % of ADH upstaged to DCIS from core to open bx
20%
94
