Red Book Early Stage Flashcards
What mutations are involved in breast cancer?
- Ataxia-telangiextasia
- BRCA1: 60-80% risk
- BRCA2: 50-60% risk
- Cowden
- Li-Fraumeni
What’s the most common location for breast cancer?
UOQ
Greatest volume of glandular elements
What are the common location for breast cancer
UOQ > Central > UIQ > LOQ > LIQ
What’re the anatomical margins of the breast?
- Overlaying pec major
- 2nd to 6th rib
- Sternum to anterior axillary fold
- Axillary tail of spencer extends into low axilla
What’re the location of IM nodes?
Along IM vessels
First three intercostal spaces
2-3 cm lateral to midline
2-3 cm deep
What % of tumors drain to IMN?
Medial: 30%
Lateral: 15%
What % of breast cancers are triple negative?
15%, and most commonly associated w/ BRCA mutations
What’re the common histologic types?
IDC: 80% ILC: 5-10% (less visible on mammo, more on MRI) Tubular Medullary Mucinous Colloid Papillary Cribriform
What’s extensive intraductal component (EIC)?
> 25% DCIS within invasive cancer
Which pt’s do we use Oncotype DX for?
LN -ve
ER +ve
Receiving tamoxifen
What does Oncotype DX tell us?
Benefit from chemotherapy in addition to hormonal therapy
What’re the Oncotype DX scores?
<18: Low risk
18-30: Intermediate risk
>30: High risk
What’re the rates of distant recurrence for different Oncotype DX groups?
Low: ~7%
Intermediate: ~14%
High: ~30%
What’re the 4 main intrinsic (molecular) subtypes of breast cancer?
Luminal A Luminal B Triple -ve HER2 enriched Normal-like
What defines Luminal A subtypes of breast cancer? What does Luminal A signify?
Hormone Receptor + (ER+ and/or PR+)
HER2-
Low Ki-67
Slow growing w/ the best prognosis
What defines Luminal B subtypes of breast cancer? What does Luminal B signify?
Hormone Receptor + (ER+ and/or PR+)
+/- HER2+
High Ki-67
Grow faster than Luminal A w/ worse prognosis
What defines HER2 enriched subtypes of breast cancer? What does HER2 enriched signify?
Hormone receptor -
HER2 +
Grow faster than luminal cancers w/ worse prognosis
What’s the SN/SP of mammogram?
> 90%
What’re the USPS recs for mammograms
40-49: No routine screening
50-72: Yearly mammograms
High-risk women: 10 yrs before dx of relative
No evidence for benefit/harm of clinical exam
Recommend against teaching self-exam
How’re breast cancers detected?
Mammogram 90%
Self-exam 10% (usually painless. Rarely (~5%) painful)
If a mass changes w/ menstrual cycles, what’s the likelihood of it being cancerous?
Low
What % of women have b/l cancers?
1-3%
What’s the risk of developing contralateral breast cancer after primary dx?
0.75% per year
What’s multifocal breast cancer?
2 or more foci in the same quadrant
What’s multi-centric breast cancer?
2 or more foci in di quadrants
OR
2 foci > 5 cm apart
NOT eligible for breast conservation
What’s BI-RADS?
Classification System
0: Incomplete. 1 % risk
1: -ve. <1% risk
2: Benign. <1% risk
3: Probably benign: <2% risk
4a: Low suspicion for malignancy. 2-10% risk > Bx
4b: Mod suspicion for malignany. 10-50% risk > Bx
4c: High suspicion for malignancy. 50-95% risk > Bx
5: Highly suggestive of malignancy. >95% risk > Bx
6: Bx proven malignancy
For which stages ca we skip systemic imaging for breast cancer pts?
Stage I-II w/o suspicious sx
What’re some suspicious sx/findings in a low stage breast cancer pt that would warrant systemic imaging?
Elevated LFTs
Elevated alk phos
What’re some suspicious findings on mammography?
Calcifications
Spiculated lesions
How does spot compression distinguish between benign vs. malignant lesions on mammography?
Benign (dense breast tissue) spreads out w/ compression.
Why do we do US w/ mammography?
Distinguish solid from cystic lesions, and evaluate nonpalpable masses identified on mammogram
What’re the different types of bx?
Core: Preferred
FNA: Cannot distinguish invasive cancer vs DCIS, or hormone/receptor status
Punch bx: For Paget’s disease/inflammatory breast cancer
What’re some poor prognostic factors associated w/ breast cancer?
LN +ve Young age ER/PR -ve HER +ve (in the absence of HER2 directed tx) High Grade LVSI + Basal-like subtype
What’s the T staging for breast cancer?
Tis: Carcinoma in situ
T1mic: <0.1 cm
T1a: 0.1-0.5 cm
T1b: 0.5-1 cm
T1c: 1-2 cm
T2: 2-5 cm
T3: > 5 cm
T4a: Extension into the chest wall (not pec major)
T4b: Extension into the skin
T4c: T4a + T4b
T4d: Inflammatory breast cancer
What’s the cN staging for breast cancer?
N0: No palpable LNs
N1: Mobile ipsilateral I/II Ax. LNs
N2a: Fixed/matted ipsilateral Ax LNs
N2b: Ipsilateral IM LNs w/o Ax LNs
N3a: Ipsilateral infraclavicular LNs
N3b: IM + Ax LNs
N3c: Ipsilateral Supraclav LNs
What’re the pN staging for breast cancer?
N0 (i-) -ve by IHC
N0 (i+) +ve by IHC
N0 (mol-) -ve by PCR
N0 (mol+) +ve by PCR
N1 (mi) >0.2 mm and/or >200 cells, but <2mm
N1 (a) 1-3 Ax LNs
N1 (b) IM +ve by pathology, -ve be exam
N1 (c) pN1a + pN1b
N2 (a) 4-9 axillary LNs
N2 (b) IM +ve pathologically and clinically, but -ve Ax LNs
N3 (a) >10 Ax LNs + or infraclav +
N3 (b) Pathologically and clinically +ve IM + +Ax LNs
N3 (c) Ipsilateral Supraclav LNs +ve
What’s the M staging for breast cancer?
M0 (i+) Circulating tumor cells in BM
M1 Distant Mets
What’s the treatment paradigm for low-risk breast caner?
MRM
BCT: Lumpectomy + RT
CHT: If desired, done either neoadjuvantly or adjuvantly
Endocrine: For hormone-receptor +ve cancers. Done after all other tx.
Therapies to prevent BCa or reduce risk of recurrence?
Tamoxifen: ER antagonist in Breast, ER agonist in endometrium. Reduces risk by 50%
Raloxifene: ER antagonist in breast and endometrium. Less thromboembolic effects than tamoxifen.
Vitamin D + Ca: May reduce risk in premenopausal women
Ppx mastectomy: Reduces risk by 90% in predisposed populations
No conclusive evidence from special dietary changes
What are the different types of mastectomies?
RM: Removes pec major + Level I/II/III LNs
MRM: Removal of Level I/II LNs +/- Pec minor. Preserves Pec major and Level III LNs
TM: Removal of breast tissue only
Skin-sparing M: Removal of breast + scar skin
Nipple-sparing M: Preservation of nipple-areolar complex
How many LNs are removed in ALND vs SLNBx?
Complete ALND: 20-22 LNs
Level I and II LND: ~15 LNs
SLNBx: Cariable
Which women typically receive CHT for early-stage breast cancer?
LN+ ER- HER2+ Young Age (unclear benefit in > 70 yrs) Multiple adverse features High Oncotype DX
Timing of CHT?
Typically, post-op
Neoadjuvant equivalent to adjuvant, but neo may allow for a less extensive surgery
Which CHT has an OS benefit for HER2+ pt’s? How much is the benefit?
Trastuzumab
OS benefit 1 yr
What’s the benefit of dose-dense (q2 wks) instead of standard regimens?
OS advantage for high-risk pt’s
Which pts benefit from hormone therapy?
All hormone-receptor +ve pts w/o contraindications
What’re the common hormone therapies? When are they used? What do they do?
All are typically given for 5 yrs
Tamoxifen: Decrease recurrence by 1/3 at 10 yrs, 1/2 subsequently. Carries risk of thromboembolic events (1%) and endometrial cancer.
Anastrozole: Prevents conversion of androgens to estrogen in peripheral tissue. Ineffective in premenopausal women. Less risk of thromboembolic events and endometrial cancer.
