NMS Breast Flashcards
Breast cancer treatment for Stage 0, I, II?
Stage 0-I with small <1 cm tumors: lumpectomy, axillary sampling, radiation, hormonal treatment if ER+
Stage I with larger 1-2 cm tumors: lumpectomy, sentinel node biopsy, radiation, hormonal treatment + chemo if ER+ and premenopausal
Stage II: lumpectomy, sentinel node biopsy, radiation, hormonal treatment + chemo if ER+ and premenopausal
+ option for radical mastectomy
Breast Cancer treatment for Stage III, IV?
Stage III: must get preop chemo and MRI for surgical planning (usually modified radical mastectomy) + further chemo and radiation
Stage IV: chemo + palliative radiation + surgery if painful/infected
Breast Cancer staging/metastatic workup
CBC, LFT, alk phos, Ca, Tbili, CT chest + liver, bone scan, renal function
When to get MRI?
Surgical planning of advanced breast ca, poor renal function (cant do CT with contrast), evidence of spinal/brain mets (steroids, cord decompression, radiation, surgery if possible)
What drugs can cause gynecomastia?
Diuretics, estrogens, INH, marijuana, digoxin, alcohol
Important risk factors for breast ca?
Prev hx (in self), fam hx (premenopausal), older age, ovarian or endometrial ca hx, older first full-term pregnancy, oopherectomy (check this), obesity, rich North American, hx fibrocystic dz, single, urban, white, early menarche and late menopause
Screening recommendations for breast ca
Disclaimer: breast exams are not recommended anymore I don’t think
Non high risk: monthly self exams at 20, professional breast exams 20-39 2 2 years, yearly after 40, mammograms q 1-2 years at 30-40, yearly after 40
False negative rate of mammograms
7-20%
BIRADS 0-5 definitions
0: needs additional eval
1: normal
2: benign, recommend routine screening
3: prob benign, recommend 6 month followup
4: suspicious, recommend bx
5: highly suggestive of malignancy
Difference between screening and diagnostic mammography
- screening cranio-caudal and mediolateral oblique views
- diagnostic can do magnification mammography; diagnostic is cranio-caudal + mediolateral oblique views PLUS mediolateral and lateromedial
Types of calcifications on mammogram that are suspicious of malignancy
Pleomorphic, heterogeneous, fine/linear/branching
2 entities that look like DCIS histopathologically but have higher cancer risk
- sclerosing adenosis
2. atypical ductal hyperplasia
Treatment for fibrocystic disease
elimination of caffeine, vitamin E supplement, cyst aspiration, f/u in 3 months
What could a 14 cm mass in a young woman be
cystosarcoma phyllodes: large, occasional ulceration of skin.
excise with generous margins
Most common cause of bloody discharge and treatment
intraductal papilloma: mammography + ductogram + excision
Prognostic indicators in breast cancer
histologic type: IDC (invasive ductal ca), ILC (invasive lobular ca), inflammatory ca
worse than
tubular, papillary, mucinous, or Paget’s
ER+ better; progesterone (?), aneuploidy worse prognosis
Ki-67+ (higher S phase fraction or mitotic index) = worse prognosis
Her-2 Neu+ (human epidermal growth factor receptor) = worse prognosis and shorter relapse time
younger at dx tend to do worse
What does inflammatory carcinoma of breast look like
ulcerated, edema of breast, peau d’orange, retraction of skin
What does retraction of skin overlying the mass mean?
suggests invasion of breast support structures and lymphatics
worse prognosis!
what do you do when fluid cysts recur
excise cyst to rule out cancer.
prognosis depends on pathology
what does it mean when mass is fixed to deeper tissues
invasion to tissue outside breast = worse prognosis
significance of lymph node palpable in supraclavicular area
= distant metastasis
M1=stage IV
unresectable and incurable
arm edema means: ?
obstruction of axillary lymphatics = worse prognosis
What to do with crusty lesion in nipple?
- biopsy nipple lesion and subareolar mass to rule out Paget’s disease
- if Paget’s + and confined to nipple then excision of nipple areolar complex or primary radiotherapy
- if underlying DCIS: excision and radiotherapy
Surgical principles in mgmt of breast ca
what does it mean if you have >10 LN involved
- establish diagnose
- completely eradicate primary tumor
- regional nodes or distant mets?
- wide excision + radiation good for localized tumor with clear margins
- mastectomy usually for larger/multicentric tumors
- removal of axillary LNs are for staging, not treatment
- decrease in survival correlates with increase in # of LNs involved;
poor prognosis: >10 LNs = 10-year survival of 14% - systemic adjuvant treatment in breast ca with axillary node involvement decreases risk of recurrence by 30%
Blood supply to breast
arterial: internal mammary (thoracic) and lateral thoracic
venous: axillary and internal mammary vein
Lymphatic drainage of breast? divisions?
axillary LN chain
Level I: lateral to pec minor
Level II: posterior to pec minor
Level III: medial to pec minor
Radical mastectomy
removal of: breasts, skin, pec major and minor, axillary LNs
only for tumors that extend into the muscle!
Modified radical mastectomy
spares pec major!
removes breasts, skin, pec minor, axillary LNs
Auchincloss modification of radical mastectomy
spares pec minor!
removes breasts, skin, axillary LNs
Patey modification
transection of pec minor and dissection of level III nodes (medial to pec minor)
Simple mastectomy
removal of breast, nipple-areolar complex, skin.
usually for LCIS and DCIS
When to radiate after mastectomy
- tumors > 5 cm that involve margin of resection or invade pec fascia or muscle
- axillary radiation when > 4 LN involved
- radiation of internal mammary nodes if apparent on sentinel node imaging
- supraclavicular nodes if extranodal extension into axillary fat
Limits of dissection for mastectomy
clavicle, lat(issimus dorsi?), costal margin, lateral border sternum
Lumpectomy? Segmental mastectomy?
For 4 nodes are positive or positive extracapsular invasion
Note: radiation after lumpectomy greatly reduces chance of local recurrence
Does lumpectomy with radiation affect survival rates
not compared to modified radical mastectomy in stages I and II
What measurements do you need for staging
tumor size, LN bx, histology
What is standard method for LN bx
remove nodes at levels I (lateral to pec minor) and II (posterior to pec minor)
How do you do a sentinel LN bx
- inject dye or radiotracer around primary tumor
- wait for dye or tracer to reach node
- take it out and perform histo/path
If sentinel node negative for tumor, what are chances that other nodes are negative?
> 90%
Most physicians dont advocate modified radical mastectomies for tumors less than what?
<2 cm
Does radiation increase survival
no, only decreases local recurrence
Contraindications to radiation treatment
- prior radiation to chest or breasts
- connective tissue disease
- positive margins
- extensive DCIS (often seen as diffuse microcalcifications)
also: pregnancy
4 methods of breast reconstruction
1) TRAM (transverse rectus abdominus myocutaneous) flap
2) lat (issimus doris?) flap
3) DIEP (deep inferior epigastric perforator)
4) free flap
Flaps not as successful in which patients
obese and smokers
Contraindications for mastectomies
- primary lesions involving chest wall
- extensive local or regional dz
- stage III or IV cancer
Mgmt of stage 0 and I BC with <1 cm tumors (no nodes)
lumpectomy + axillary sampling + radiation + hormonal tx if ER+ (Aromatase inhibitor for postmenopausal, Tamoxifen for premenopausal)
At what stage of BC do you check for mets
Stage I
What is in the workup for mets
- CXR for lung and bone mets;
- liver enzymes for liver mets–> abdominal CT if liver -enzymes or bilirubin or alk phos abnormal
- bone scan and/or head CT if bone pain or neuro complaints,
Mgmt of stage I br ca with larger (1-2 cm) tumor and no nodes
lumpectomy + axillary sampling + radiation + hormonal tx if ER+ and chemo only if premenopausal
Mgmt stage II br ca
lumpectomy + axillary sampling + radiation + hormonal tx if ER+ and chemo if node positive or premenopausal without node negative (table 11-8, p. 342)
Chemo is poorly tolerate in what population?
elderly
Who responds better to chemo
premenopausal patients
Who responds better to hormonal treatment
postmenopausal
Follow-up surveillance protocol for Stage I and II
- see dr. 2x/yr
- annual CXR + LFTs
- if lumpectomy, mammogram that breast q6 mo for 2 years then annually
- if mastectomy. mammogram the other breast (how frequently?)
After mastectomy what are chances of Ca developing in remaining breast
15%
Stage I, 5-year
93%
Stage II, 5-year survival
72%
Mgmt Stage III Breast Ca
1) consult onc for neoadjuvant chemo (before surg)
2) surg
Mgmt stage IV breast ca
1) palliative radiation and chemo
2) surg only reserved for local control of primary tumor (painful or infected)
Imaging modality to plan for surg
MRI
Stage III 5 yr survival
41%
Stage IV 5 yr survival
18%
Breast mass with cellulitis and edema =
Inflammatory carcinoma
Tx for inflammatory carcinoma
- staging workup: CBC, liver enzymes, alk phos, Ca, Tbili, CT chest, bone scan, CT liver with contrast or MRI w/gadolinium if poor renal function
- chemo
- modified radical mastectomy
- adjuvant chemo
- hormonal tx for ER+
- radiation for chest and regional LN basins
What should you do if you have pathological fracture from cancer
Due to bony mets, control the cancer locally with radiation and orthopedic repair, radiation shouldn’t interfere with fracture union
If after dx breast ca you get neuro sx like decreased sensation or motor function, what do you do
MRI, steroids, cord decompression, radiation
If after dx of breast ca you get new seizures, what do you do
CT/MRI to dx brain mets, immediate steroids to decrease ICP, surgery or irradiation
Coma/confusion with hx of breast ca could be what
acute hypercalcemia due to bony mets or PTH-related peptide release (usually breast ca or lung cancer)
Abx for mastitis?
dicloxacillin/cefalexin (usually S.aureus or coag neg staph)
If a mastitis doesn’t heal with abx, what are we worried about
inflammatory ca
Mgmt of breast ca in pregnancy
Stage I and II mastectomy or lumpectomy with radiation after birth is safe.
Lumpectomy discouraged in early pregnancy bc of need for radiation.
Stage III and IV: rapid radiation and chemo, may need to abort
Is ER or prog status reliable during pregnancy
No
What do you do for breast mass in a man
mammogram to diff gynecomastia from cancer, mastectomy, and radiation
when do men usually present with breast ca
after 60; tend to present at later stage
What can cause gynecomastia
diuretics (spironolactone), estrogens, INH, weed, dig, etoh
Most common sites of metastasis
lungs, liver, bone, brain, ovaries
what cancers predisposed by BRCA1 mutation (2)
breast and ovarian
screening recommendations for breast cancer (based on level of risk)
NORMAL RISK: q1y mammo with clinical exam starting at age 40; HIGH RISK: q1y mammo with q6m exam starting at age 30
what study should follow finding of microcalcifications on mammogram
MAGNIFICATION mammogram –> stereotactic vs. open biopsy depending on low vs. high suspicion (open bx allows excision)
tx for DCIS
if unifocal: lumpectomy;
if multifocal: simple mastectomy
when to combine radiation with mastectomy
NEVER; no need for radiation if breast has been resected
implications and tx of LCIS
LCIS is an incidental finding on breast bx that is an INDICATOR, NOT PRECURSOR of malignancy –> no role for resection, only for close surveillance (q6m exam/mammo)
workup of simple cyst in breast
aspiration –> if resolves, NTD; if bloody or persistent, need cytology –> excision
characteristics and workup of fibrocystic dz
often multiple, bilateral, fluctuates with menstrual cycle;
TREATMENT: cyst aspiration –> 3mo f/u –> bx/excision if persistent
characteristics and tx of fibroadenoma
most common lesion in young females (<25 y); benign; TREATMENT: multiple, including excision, bx, or observation (if small)
characteristics and tx of phyllodes tumor
LARGE, BULKY mass –> excision
mgmt of bloody nipple discharge
suggests intraductal papilloma; need surgical bx +/- excision
mgmt of clear, non-milky nipple discharge from multiple ducts
likely fibrocystic dz –> observation
how does age affect breast cancer prognosis
younger women do worse :(
what types of skin changes cant be seen with breast cancer (3)
ALL ARE BAD
- ULCERS: suggest inflammatory carcinoma;
- PEAU D’ORANGE/EDEMA: suggests lymphatic involvement
- SKIN/NIPPLE RETRACTION: suggests invasion of support structures
what does eczematoid lesion of nipple suggest? what is mgmt
Paget’s dz of nipple, almost always a/w underlying malignancy –> mammo/PE –> mastectomy + staging if mass, bx nipple if not
when to do lumpectomy/simple mastectomy vs. modified radical mastectomy
depends on size of solitary tumor.
if 5 cm, need to do modified radical mastectomy
how to tx metastatic breast cancer
stages III and IV –> palliative chemo/rads/surg + hormonal tx
how does menopause change adjuvant treatment for breast cancer
premenopausal: chemo;
postmenopausal: hormonal
how to deal with local recurrence following breast surgery
if 1st surgery was mastectomy, do local excision; if 1st surgery was lumpectomy, do mastectomy
what do you suspect in pt with h/o breast cancer who presents with coma
hypercalcemia
tx for mastitis
warm compresses, antibiotics (for staph and strep)
tx of breast abscess
surgical drainage (incision and drainage), NOT needle drainage
