Week 8 Breast Malignacies Flashcards
WHat is the MC cancer in women?
Breast Cancer
Breast cancer increases the risk for?
endometrial cancer
and vice versa.
The mass in Breast Cancer is most often detected by?
patient on self-breast examinatio
The majority of patients with breast cancer are diagnosed as a result of?
abnormal mammogra
What are the RF for Breast Cancer?
A. Increasing age
B. BRCA1 or BRCA2 gene
C. FH of gynecologic malignancies
D. First-degree relative with breast cancer – esp if premenopausal or bilateral or found in 2+ relatives – 15-20%
E. Personal history of breast cancer
F. Exposure to ionizing radiation, esp before age 30
What are associated factors with Breast Cancer?
Nulliparity First pregnancy after 30 yo Early menarche (before 12 yo) Late menopause (after 50 yo) Significant alcohol use
What is involved in the prevention Breast Cancer?
Early pregnancy Prolonged lactation Chemical or surgical sterilization Exercise Low-fat diet
WHat are the types of invasive breast cancer?
Invasive ductal (NOS) Medullary Colloid (mucinous) Tubular Papillary Invasive lobular
All invasive lobular, and 2/3 of ductal carcinomas are?
estrogen-receptor positive
What is inflammatory breast carcinoma?
aggressive form of breast cancer
diffuse/brawny/edema
erysipeloid border
without an
underlying palpable mass
What is Paget Disease?
ductal carcinoma
1% of breast cancers
How does Paget Disease present?
eczematous lesion
red/scaling/crusty patch on the nipple, areola, and surrounding skin
Does not respond to steroids
Unilateral or bilateral
mass is palpable in about 50% of patients with Paget’s disease
Pregnancy-associated breast cancer is defined as
breast cancer that is
- diagnosed during pregnancy
- in the first postpartum year
- anytime during lactation
What is the minimal treatment of choice for Breast cancer in pregnancy?
modified radical mastectomy
Most women with breast cancer diagnosed during pregnancy or lactation will be candidates for?
systemic chemotherapy
Noninvasive cancers lack the ?
ability to spread
What is special about Lobular carcinoma in situ?
lacks the ability to spread
associated with development of invasive ductal cancer in 25–30% of cases within 15 years
Ductal carcinoma in situ
Age - 50s
Mammogram - Clustered microcalcifications
Diagnosis - Needle or excisional biopsy
Treatment - Surgical excision
Lobular carcinoma in situ
Age - 40s
Mammogram - Not seen on mammogram
Diagnosis - Incidentally on biopsy for other condition
Treatment - Local excision
What is critical to managing patients with initial, recurrent, and metastatic disease?
the presence or absence of estrogen and/or progesterone receptors in the nucleus of tumor cells
Both estrogen receptors (ERs) and progesterone receptors (PRs) are?
nuclear hormone receptors
The responsiveness of breast cancer to hormonal therapy is determined by?
tumor expression of the ER and/or PR
ER/PR-negative tumors are unlikely to benefit from?
endocrine therapy and would be better treated with systemic chemotherapy
ER-positive tumors are more likely to metastasize to?
bone
soft tissue
genital organs
ER-negative tumors are more likely to spread to?
liver
lung
brain
Clinical manifestations of Breast cancer?
single nontender firm irregular immobile
Breast pain is rarely a symptom of breast cancer
In reguards to Breast cancer 45% occur in the _____ outer quadrant; 25% occur _____ the nipple an areola.
upper
under
What are Later symptoms of Breast cancer?
skin or nipple retraction axillary lymphadenopathy breast enlargement redness edema brawny induration peau d'orange pain fixation of mass to skin or chest wall
What are Late symptoms of Breast cancer?
ulceration
supraclavicular lymphadenopathy
edema of arm
bone/lung/liver/brain or other distant metastases
What is the diagnosis of Breast cancer?
Clinical breast exam
Monthly self-breast examination
Mammogram imaging modality of choice
What is recommended in patients >20yo in regards to Breast cancer?
Monthly self-breast examination 5 days after menses
What is important to note about a mammogram?
used to detect early lesions
breast imaging modality of choice
consistently found to decrease mortality
Mammogram Screening Recommendations?
A. Yearly starting at 40 years of age and continuing for as long as a woman is in good health
B. 40-49, every 1-2 years, then annually
C. Biennial screening mammography 50 and 74 years
D. Insufficient evidence to assess the additional benefits and harms in women 75 years or older
Clinical Breast Exams (CBE) Recommendations?
A. 40 yo annually
C. Insufficient evidence >40 years or older (USPSTF, 2009)
MRI Screening Recommendations?
Women at high risk:
A. Known BRCA mutation or untested but have a first-degree relative with a BRCA mutation
B. Greater than 20% lifetime risk based primarily on family history
C. Prior mantle radiation
MRI in addition to mammogram every year
If fine-needle aspiration is negative what should be done?
excisional biopsy should be done
Biopsy specimen should undergo?
histologic
estrogen receptor
progesterone receptor
What are findings suggestive of carcinoma?
Spiculated mass
Asymmetric local fibrosis
Microcalcifications with a linear, branched pattern
What are sensitive, but increased radiation and false-positive results?
CT scans
What is good for staging and metastatic evaluation, esp bone mets?
PET scans
What labs are used in diagnosis of Breast cancer?
CBC Chemistry panel with LFTs Beta- hCG (reproductive patients) Estrogen receptor (ER) assay Oncotype DX test
What could be noted in LFTs?
elevated alk phos or LFTs for liver mets
hypercalcemia in advanced cases of mets
What is special about an Oncotype DX test?
is used to help determine need for chemotherapy for women with stage I or hormone receptor-positive cancer.
looks at 21 genes in tumor to determine the likelihood of the cancer recurring or spreading
What should occur before treatment begins?
staging
All oncologic treatment may be classified as?
curative or palliative
When is Palliative treatment indicated?
stage IV disease
previously treated patients who develop distant metastases or unresectable local recurrence
When is Curative treatment indicated?
stage I
stage IIA
stage IIB cancer
considered with locally advanced disease (IIIB)
What are included in medical treatment options?
chemotherapy and hormone (anti-estrogen) therapy
What are medical treatment options used to control?
micrometastases
When are medical treatment options indicated?
lymph node–positive patients
high-risk lymph node– negative patients
What is included in chemotherapy treatment?
Polychemotherapy (≥2 agents)
3–6 months or 4–6 cycles
Anthracyclines taxanes cyclophosphamide methotrexate 5-fluorouracil (CMF)
When is chemotherapy considered as standard of care for patients?
ER-negative tumors who are candidates for adjuvant systemic therapy because of adverse prognostic indicators..
tumor size >1 cm
positive lymph nodes high-grade disease
What is included in hormone treatment?
Tamoxifen x 5 years
used with estrogen receptor-positive dz and postmenopausal women
What are patients at an increased risk for when using tamoxifen?
endometrial cancer
DVTs
hot flashes
How do Aromatase inhibitors (AI) work?
work by blocking the conversion of testosterone to estradiol, and androstenedione to estrogen, both in the adrenal cortex and in peripheral tissue, including breast cancers themselves
What are the Aromatase inhibitors (AI)?
anastrozole
letrozole
What is special to note about Aromatase inhibitors (AI)?
as effective or more than tamoxifen in postmenopausal women with early-stage, invasive breast cancer
Increased disease-free survival, time to recurrence, and the incidence of contralateral breast cancer
When are Aromatase inhibitors (AI) NOT used and why?
premenopausal patients because of paradoxical estrogen feedback on the hypothalamus
Aromatase inhibitors (AI) when compared to tamoxifen have an increased risk of?
musculoskeletal disorders
osteoporosis
cardiac events
Aromatase inhibitors (AI) when compared to tamoxifen have an decreased risk of?
endometrial cancer
venous thromboembolic events
hot flashes
What surgical option is preferred with early-stage cancer?
wide local excision or lumpectomy with sentinel node biopsy
What is involved with wide local excision or lumpectomy with sentinel node biopsy?
breast-conserving treatment option
used if tumor less than 4 cm and tumor not fixed to underlying tissue
Postoperative radiation
What is removed in Simple mastectomy?
breast tissue
nipple-areolar complex
skin
no axillary node dissection
What is removed in Modified radical mastectomy?
breast tissue nipple-areolar complex skin pectoralis fascia axillary lymph nodes
What is removed in Radical mastectomy?
breast tissue nipple-areolar complex skin axillary lymph nodes pectoralis major pectoralis minor
Goals of close breast cancer follow-up are?
detect recurrences
detect second primaries after treatment in the ipsilateral breast
detect new cancers in the contralateral breast
What are recommendations for post-treatment in Breast cancer?
A. PE every 4 months for first 2 years
then every 6 months until year 5
then annually
B. Mammogram annually for all patients and no less than 6 months after the completion of radiation therapy.
C. patients who received irradiation => yearly CXR
D. Routine labs: for pts on chemo
Patients on tamoxifen should have what follow up recommendations?
annual pelvic exam
report any irregular vaginal bleeding
Patients on AIs should have what follow up recommendations?
periodic bone density studies
lipid panels to assess their cardiovascular risk factors
_____ is predominant and paramount in predicting outcome.
stage
Patients with ______ estrogen and progesterone receptor have a more favorable prognosis
positive
Modified and simple or partial mastectomies have equivalent survival rates when followed by?
XRT
What histologies are generally believed to have a more favorable prognosis?
colloid (mucinous) medullary papillary adenoid cystic tubular
What is important to note about Stage IV (disseminated disease)?
incurable by surgery
goals of care shift from..
cure to palliation
symptom control
improved quality of life
What should be reserved for patients in order to control their symptoms and minimize the risk of complications in Stage IV (disseminated disease)?
Local therapy
- palliative XRT
- surgery
When is Surgery an option?
A. patients with a good performance status
B. minimal organ involvement
C. prolonged disease-free interval
D. slow disease growth
E. if complete resection of the tumor or metastasis is reasonable
When is Palliative XRT an option?
A. valuable for certain bone or soft tissue metastases to control pain or avoid pathologic fracture
B. isolated bony metastasis
C. chest wall recurrences.
Hormonal manipulation is usually more successful in?
postmenopausal women
For premenopausal woman with advanced breast canceris what is the treatment of choice in HRT?
tamoxifen
**Also use GnRH agonists
– suppress FSH and LH
can combine with tamoxifen or AIs
For postmenopausal patients, what are the initial therapy of choice in HRT?
AIs and tamoxifen
What does a favorable response to initial hormonal therapy with tamoxifen is predictive of?
future responses to hormonal maneuvers
When should cytotoxic drugs be considered for the treatment of metastatic breast cancer?
(1) if visceral metastases are present (especially brain or pulmonary lymph node spread)
(2) if hormonal treatment is unsuccessful or the disease has progressed after an initial response to hormonal manipulation
(3) if the tumor is ER and PR negative
What are the single most useful agents in the treatment of hormone-refractory metastatic breast cancer?
taxanes
Combination chemotherapy using multiple agents can be used which?
decreased risk of drug resistance
cumulative toxicity is decreased
What is the most common site of metastatic disease at initial presentation and at the time of breast cancer recurrence?
bone
What can bisphosphonate therapy help?
- diminish pain
- decrease the rate of skeletal events
- decrease complications related to the bone metastases
How is bisphosonate therapy given?
- Administer with other palliative treatments
2. IV every 3–4 weeks and continued indefinitely
Regular dental exams, labs for creatinine and renal function, calcium and vitamin D levels, are recommended due to the risk of?
osteonecrosis of the jaw
renal insufficiency
hypocalcemia
