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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

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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,
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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

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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”

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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

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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

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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%

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8
Q

What is the BRCA gene

A

TSG with role in DNA repair AD inheritance

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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

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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

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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

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12
Q

What other cancers are associated with BRCA1?

A

BILATERAL breast cancer with high grade tumors

Colon

Ovarian

Prostate

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13
Q

Where is the BRCA2 mutation

A

13q12.3

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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

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15
Q

What other cancers are associated with BRCA2?

A

BILATERAL breast

Colon

Ovarian

Prostate

pancreas, gastric, biliary, chole

melanoma, lymphoma

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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
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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
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18
Q

What is ataxia-telangiectasia

A

Mutation of ATM

AR inheritance

Characterized by

  • cerebellar ataxia
  • telangiectasia (face)

associated Cancer

  • Lymphoma, Brain, Gastric, Breast
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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
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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)
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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)
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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

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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%)

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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
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25
Q

What risk factors on Family history increase risk of breast cancer?

A
  • FDR with IBC, RR 2.6
  • multiple FRD with IBC, RR 4.5
  • FDR with Dx<40yo, RR 4.7
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26
Q

What are protective factors for preventing breast cancer

A
  • Breast feeding
  • Parity
  • Exercise
  • Low postmenopause BMI
  • Oophrectomy <35
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27
Q

What are the NCCN criteria for genetic counseling referral?

A
  • 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
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28
Q

What is the gail model used for and how is it applied

A

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
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29
Q

What are risk reduction strategies for prevention of breast cancer development

A

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)
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30
Q

What are the recommended screening guidelines for breast cancer

A

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
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31
Q

What are signs/symtoms of breast cancer

A
  • painless mass
  • skin changes (peau d’orange, scaliness, erythema)
  • Nipple changes (distortion, discharge, ulceration)
  • Axillary lympadenopathy
  • Systemic cahnges (weight loss, fever)
  • often asymptomatic
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32
Q

How does a screening mamogram differ from a diagnositic mammogram?

A

Screening: MLO, CC

Diagnostic: MLO, CC +additional views w spot compression, 90degree lateral

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33
Q

What are findings on mammogram indicative of malignancy

A
  • 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

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34
Q

WHat are findings on ultrasound

A

delineate b/w slid, cyst

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35
Q

What are findings on MRI

A

all IBC enhance with gadolium

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36
Q

How is biopsy chosen/performed

A

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
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37
Q

What is the metastatic work up and for what stage of breast cancer

A

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

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38
Q

How is breast cancer staged

A

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
Q

Describe treatment according to cancer staging for breast cancer

A

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
Q

How is CIS distinguished from IBC

A

Invasion or not through basement membrance into stromal tissue

41
Q
A
42
Q

What is the hisotlogic grading of IBC and associated prognosis

A

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
Q

What features should be on synoptic report for IBC (9)

A
  • 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
Q

What tumor markers are assessed if IBC

A
  • 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
Q

What is LCIS, epidemiology, diagnosis, management

A

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
Q

What are side effects of tamoxifen

A
  • 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
Q

What is DCIS, epidemiology, classification, diagnosis, management

A

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
Q

What is tamoxifen, MOA, indications, side-effects

A
  • 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
Q

List 4 high- , moderate- and low-risk factors for development of breast cancer

A
  • 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
Q

What is the BRCA gene? How does it influence your risk of developing breast cancer

A
  • 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
Q

what other cancers are associated w/ brca 1 and brca 2?

A
  • BRCA1: breast, ovarian, fallopian tube, colon, prostate
  • BRCA2: breast, ovarian, fallopian tube, colon, prostate, gastric, biliary, pancreatic, melanoma, lymphoma
52
Q

List syndromes associated w/ development of breast cancer

A

CLAMP

  • Cowden
  • Li-Freumeni
  • Ataxia-Telangectasia
  • Muir-Torre
  • Peutz-Jagers
53
Q

List histologic types of Invasive breast Cancer (8)

A
  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
Q

What are breast cancer screening guidelines in Canada?

A
  • 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
Q

what is the difference between a screening and a diagnostic mammography?

A
  • screening - 2 views - craniocaudal and mediolateral compression
  • Diagnostic - 2 screening views plus 90’ lateral and spot compression
56
Q

What are Mx options and indications contraindications for types of Mx

A

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
Q

describe screening mammogrphy for patient wiht breast implants

A
  • 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
Q

what findings on screening mammogram are suspicious for breast cancer

A
  • microcalcifications
  • architechtural distortion
  • increased vascularity
  • interval change
59
Q

what is the gold standard way to diagnose breast cancer?

A
  • 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
Q

What are SLNBX or ALND

A

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
Q

what is the clinical implication of ADH on core biopsy that prompts need for excisional biopsy/ lumpectomy

A
  • 20% of ADH on core biopsy are upstaged to DCIS or IDC on final path review
62
Q

what are clinically relevant staging concepts?

  • early
  • locally advanced
  • non-operable
  • “gray area”
A
  • 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
Q

describe clinical staging for breast cancer

A

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
Q

what features should be included and reviewed on a pathology report for breast cancer specimen?

A
  • 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
Q

What are indications/contraindications for RTx for IBC

A

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
Q

WHat are the options for RTx in breats cancer treatment

A
  • Whole breast with boost - 50Gy in 2gy per fraction
  • CW
  • Regional nodal - 50Gy in 2Gy per fraction
67
Q

What are options for adjuvant medical therapies for IBC

A

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
Q

what are subtypes of invasive breast cancer?

A
  • 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
Q

what is paget disease and why do we care?

A
  • infiltrating adeno-Ca in nipple cells
  • clinically can mimic melanoma
  • care bc vast majority (>95%) have underlying DCIS/IDC
70
Q

what are absolute and relative contraindications to breast conserving surgery?

A
  • 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
Q

what are indications for NSM?

A
  • 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
Q

What is the general treatment approach to patients with CLINICAL stage 1 or stage 2 invasive breast cancer?

A
  • 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
Q

What are chemotherapy options for IBC ttreatment

A
  • CMF- cyclophosphamide, methotrexate, 5FU
  • TAC - cyclophosphamide, DoceTaxel, doxorubicin,
74
Q

What is your management of a Stage 1/2, 3A (T3N1M0) (operable with/out local-regional disease)

A

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
Q

How do you do a SNLB?

A
  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
Q

what will you counsel your patient regarding risk of lymphedema in ALND vs SLNB

A
  • ALND - 10-40%
  • SLND - 1-10%
77
Q

why do you tell patients to hold tamoxifen for 2 weeks prior to DIEP?

A
  • 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
Q

what are the most common sites of distant mets for breast cancer?

A

lung

liver

bone

79
Q

What is your management of a Stage 3A (except T3N1M0), stage3B, 3C (inoperable local-regional invasive disease)

A

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
Q

What is you management for stage4 metastatic disease

A

Combo of endocrine, chemo, bisphosphonates

81
Q

What is managed of patient w local recurrence?

A
  • Previous BCT => TMx ALND + chemo
  • PRevious TMx +/- Rtx =>surgical rsx + chemo +/- rad if not alreasy received
82
Q

What is your post-op suveillance

A

mammogram q12m

If on tamoxifen, q12mth gyne exam

If on aromatase inh, BMD test q12m

83
Q

WHat is the prognosis of breast cancer?

A

Nodal stage is best predictor of 5yrS

N 0- 80%

N 1-3 - 50%

N4-6 - 40%

N7-12 - 30%

N >13% - 10%

Stage 1 - 4

95, 80, 40, <5%

84
Q

How does pregnancy affect breast cancer treatment?

A

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
Q

WHat is ALCL

A

Anaplastic large cell lymphoma

= non-hodgkins T-cell lymphoma

Types: systemic, cutaneous, seroma associated

86
Q

What are signs of ALCL

A

Late seroma

Mass adjacent to implant

Capsular contracture

87
Q

What is the workup for ALCL and treatment

A

Imaging US/CT/MRI

U/S guided aspiration of seroma fluid for cytology -CD30, ALK markers

Capsule for histology

88
Q

What do you recommend for surveillance to patients with implants

A

Same screening mammogram schedule

Eukland view (image displacement mammography views

89
Q

What is done when IBC is identified in BBR pathology

A

Mx generally recommended - occurs <3%

BBR reduces risks of IBC by 30% depending on amount removed

90
Q

WHat is done wihen breast mass discovered intra-op in BBR?

A
  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
Q

What is you DDX of a breast mass

A

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
Q

Indications for open biopsy (lumpectomy) after a NEGATIVE core bx

A
  • Discordance (imaging, path, clinical)
  • ADH, ALH
  • complex papilloma
  • radial sclerosis
93
Q

What is the % of ADH upstaged to DCIS from core to open bx

A

20%

94
Q
A

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