Wise MD: Breast Cancer Flashcards
A 62-year-old Asian woman (gravida 3, para 1) comes to the physician’s office for a well-patient visit. She had a fibroadenoma removed at age 25. Menarche was at age 14 and menopause at age 52. She used oral contraceptive pills for 5 years prior to giving birth to her first child at age 32. The patient has no known medical problems and does not smoke cigarettes or drink alcohol.
Physical examination shows no abnormalities.
Which of the following is associated with the greatest increase in risk for breast cancer development in this patient?
a. Asian race
b. Menopause at age 52
c. Menarche at age 14
d. History of fibroadenoma
e. First birth at age 32
e. First birth at age 32
Late age of 1st full-term pregnancy after age 30 is a mild risk factor increasing the relative risk of breast cancer. While all women are at risk for breast cancer, there are a number of factors that increase a woman’s chance for developing breast cancer. There are some important disparities related to race and breast cancer risk. White women have the highest incidence of breast cancer, while African American women suffer the highest mortality. Asian women have a lower incidence of breast cancer than other races but they are less likely to follow screening guidelines.1 Reproductive history influences breast cancer risk. Early menarche (before the age of 12) and late menopause (after the age of 55) are associated with an increased risk of breast cancer because of a longer lifetime exposure to estrogen.2 Menarche at age 14 or menopause at age 52 would not be associated with an increased risk of breast cancer. Previous breast biopsies may influence a woman’s risk for breast cancer depending upon the pathology of the biopsy. Proliferative and atypical histology increase the risk of subsequent breast cancer.3 Fibroadenomas are the most common benign breast neoplasm and women with simple fibroadenomas have no increased risk of breast cancer.
A healthy 22-year-old woman comes to the physician for evaluation of mass in the left breast discovered during breast self examination. Menarche was at age 12. She has 1 child who was born when she was 20 years of age. She has no family history of breast or ovarian cancer. Except for an oral contraceptive, which she has used for 7 years, she takes no medications.
Physical examination discloses a 1-cm, rubbery, smooth, nontender mass in the upper outer quadrant of the left breast. There is no skin retraction or lymphadenopathy.
a. Fibroadenoma
b. Cyst
c. Galactocele
d. Abscess
e. Cancer
a. Fibroadenoma
A 52-year-old woman (gravida 3, para 1) comes to the physician after discovering a mass in the right breast during breast self examination. Menarche was at age 14. She gave birth to her first child at age 25. Her maternal aunt had breast cancer diagnosed at age 75. The patient’s only medication is hormone replacement, which she has taken for 5 years for severe perimenopausal symptoms.
Physical examination discloses a 1-cm, hard, irregular, nontender mass in the outer lower quadrant of the right breast. There is no skin retraction or axillary lymphadenopathy.
Which of the following is the most likely diagnosis?
a. Fibrocystic changes
b. Cancer
c. Abscess
d. Cyst
e. Fibroadenoma
b. Cancer
A 50-year-old woman comes to the physician after a diagnostic mammogram with ultrasound showed a suspicious mass in the upper outer quadrant of the left breast. Menarche was at age 11. She used oral contraceptive pills for 8 years before giving birth to her first child at age 32. Her mother had breast cancer diagnosed at age 55. There is no other family history of cancer.
On physical examination, the breasts are nontender with bilateral somewhat irregular, dense tissue but no discrete masses. There is no lymphadenopathy.
Which of the following is the most appropriate next step in management?
a. Lumpectomy
b. Incisional biopsy
c. Stereotactic core-needle biopsy
d. Excisional biopsy
e. Mastectomy
c. Stereotactic core-needle biopsy
The patient has a mammographic abnormality that requires biopsy. Image-guided core biopsy has virtually replaced open surgical biopsy in the management of breast abnormalities. Since the lesion was seen by ultrasound, it is the preferred imaging modality for biopsy. Microcalcifications are usually not visualized by ultrasound unless they are associated with a mass and therefore microcalcifications must be biopsied using mammographic guidance and a stereotactic table. The patient lies prone on the stereotactic table and her breast hangs through a hole in the table where a mammography unit localizes the area of concern. Some patients cannot tolerate lying prone on the stereotactic table and require needle-localized biopsy in an operating room. In addition, some lesions located near the nipple or chest wall may also not be amenable to image guided biopsy.1
Incisional biopsy involves removal of only part of a lesion or mass and it is usually performed when lesions are very large. Excisional biopsy implies removal of the entire lesion but it is requires a trip to the operating room and an incision on the patients breast so there are cost and cosmetic concerns. Lumpectomy and mastectomy are performed in patients with a tissue diagnosis of cancer.
A 56-year-old woman (gravida 1, para 1) comes to the physician after discovering a mass in the right breast during breast self examination. Menarche was at age 12. She gave birth to her only child at age 32. She has no family history of breast or ovarian cancer.
On physical examination, a 2-cm, hard, irregular, fixed mass is palpated in the lower outer quadrant of the right breast, with slight overlying skin dimpling and a 1.5-cm hard mass in the right axilla. Core-needle biopsy of the mass shows ductal carcinoma; fine-needle aspiration cytology of axillary nodes shows adenocarcinoma.
Which of the following is the best next step in management?
a. Endocrine therapy
b. Chemotherapy
c. Lumpectomy and sentinel node biopsy
d. Modified radical mastectomy
e. Radiation therapy
b. Chemotherapy
This patient has a T3N1M0 Stage IIIB or locally advanced breast cancer which is best treated with multimodal therapy and usually chemotherapy is administered first (i.e. neoadjuvant chemotherapy).1 The mass is fixed to the chest wall so radical surgery would be required if an operation were performed first. Administration of chemotherapy in a neoadjuvant (i.e. before surgery) fashion may shrink the tumor and may it mobile in relationship to the chest wall and thereby permit a less radical operation.
While endocrine therapy can be used to treat breast cancer, the treatment responses are not as rapid and therefore hormonal neoadjuvant therapy is usually limited to ER positive patients who can’t tolerate chemotherapy because of comorbidities.2
While radiation therapy will eventually be required in this patient to lessen the risk of local recurrence, it is usually delivered after chemotherapy and surgery. Lumpectomy and sentinel node biopsy is not indicated in this patient because the primary tumor is large and involves the chest wall and SLN biopsy is not indicated because an FNA of the axillary node was positive for tumor cells. Finally, modified radical mastectomy or removal of the breast and axillary contents would not be appropriate initially in this setting because the tumor is fixed to the chest wall. Modified radical mastectomy would be appropriate if the tumor responds favorably after neoadjuvant chemotherapy.
A previously healthy 48-year-old woman (gravida 3, para 2) comes to the physician after discovering a mass in the right breast during breast self examination. Menarche was at age 12. She gave birth to her first child at age 22. Her father’s sister had breast cancer diagnosed at age 35.
On physical examination, a 1-cm, hard, irregular mass is palpated in the outer lower quadrant of the right breast. There is no skin retraction or axillary lymphadenopathy. Core needle biopsy is performed, showing infiltrating ductal carcinoma, HER2/neu negative and estrogen and progesterone receptor positive.
Which of the following is the best next step in management?
a. Simple mastectomy
b. Chemotherapy
c. Radiation therapy
d. Endocrine therapy
e. Lumpectomy and sentinel node biopsy
e. Lumpectomy and sentinel node biopsy
The majority of women with early stage breast cancer can be treated with breast conservation.1 Therefore, in this patient, the next most appropriate step in management of the breast is lumpectomy while the axilla can be staged with SLN biopsy. Since the patients tumor is estrogen and progesterone receptor positive, the patient is a candidate for hormonal therapy after surgical treatment. Furthermore, the patient will require breast radiation after lumpectomy to reduce the risk of recurrence in the breast. Chemotherapy is not the next most appropriate step in this patient. Finally, the patient is a candidate for breast conservation and she does not require mastectomy.
A 58-year-old woman (gravida 3, para 3) comes to the physician after discovering a mass in the right breast during breast self examination. Menarche was at age 12. She gave birth to her first child at age 25. There is no family history of breast or ovarian cancer.
On physical examination, there is a 2-cm, hard, irregular mass in the outer lower quadrant of the right breast, with no skin retraction or axillary lymphadenopathy. The patient chooses to undergo simple mastectomy with sentinel node biopsy instead of breast-sparing therapy. Pathologic evaluation of the tissue specimen shows a 1.9-cm infiltrating ductal carcinoma with clean surgical margins. Two sentinel nodes show no evidence of malignancy. Immunohistochemistry testing shows the tumor is HER2/neu-negative and estrogen and progesterone receptor–negative.
Which of the following is the next best step in management?
a. Complete axillary dissection
b. Magnetic resonance imaging of the axilla
c. Endocrine therapy
d. Radiation therapy
e. Chemotherapy
e. Chemotherapy
Adjuvant therapy for breast cancer is treatment given after surgery when patients are at risk for recurrence. Surgery and radiation therapy are local treatments while chemotherapy and hormonal/endocrine therapy are systemic therapies that address potential micrometastatic disease. The indication for postoperative systemic treatment is determined by tumor size, histology, nodal status and the overall medical condition of the patient. Certain specific tumor characteristics predict response to specific types of systemic therapy. For example, ER positive patients benefit from hormonal therapy while HER2 positive patients benefit from Herceptin® (trastuzumab) which is a monoclonal antibody against the Her2/neu receptor.1
This patient would not benefit from an MRI of the axilla since the axilla was already staged by SLN biopsy. Furthermore, since the SLN was tumor-free there is no indication for axillary dissection. The tumor in this patient was also ER negative and therefore the patient would not benefit from endocrine therapy. Since the patient underwent mastectomy and the margins were clear there is no indication for postmastectomy radiation therapy.
An otherwise healthy 40-year-old woman is referred to a breast surgeon by her gynecologist because of a right breast mass she first noticed on self-examination 2 weeks ago. The mass was not present on physical examination 1 year ago. She has two children, ages 18 and 15 years. She takes a daily multivitamin and calcium supplement but no other medications, and she has no history of surgery. There is no family history of breast cancer in her family.
Physical examination is unremarkable except for a 1.5-cm firm, mobile, nontender, slightly irregular but well-defined mass in the right breast upper outer quadrant. No skin changes or dimpling are noted. There is no lymphadenopathy.
Mammography shows dense tissue but no suspicious lesions. An ultrasound of the right breast does not demostrate a cystic lesion.
Which of the following is the best next step in management?
a. Excisional biopsy
b. Wire localization biopsy
c. Incisional biopsy
d. Core-needle biopsy
e. Fine-needle aspiration biopsy
d. Core-needle biopsy
There are several methods available to clinicians to biopsy a breast abnormality.1 It is important to recognize that suspicious palpable masses must be biopsied even if they are not visible by breast imaging such as mammography or ultrasound. Some breast cancers are not visible by mammography or ultrasound. The optimal biopsy method provides an accurate diagnosis in the least invasive way. In this way, the surgeon can discuss options for treatment with the patient before going to the operating room. Biopsy techniques depend upon whether the lesion is palpable.
Fine-needle aspiration (FNA) biopsy involves aspirating cells by repetitive passes of a 21-gauge needle through a breast lesion. The procedure is well tolerated but has a relatively high false-negative rate such that a negative FNA requires another method of tissue acquisition such as core biopsy.
Wire-localization biopsy is performed for lesions that are not palpable but detected by breast imaging. For example, excision of suspicious microcalcifications is done by placing a wire near the calcifications using mammography. The surgeon then uses the wire as a guide to remove the area and a radiograph is done of the tissue removed with the wire to confirm removal of the microcalcifications (specimen mammogram). The procedure requires the patient go to the operating room and an incision on the breast, therefore it is not the optimal diagnostic procedure.
Core-needle biopsy provides a core of breast tissue as opposed to the cells provided by FNA, therefore, core biopsy offers a more definitive histologic diagnosis. Core biopsy can be done with image guidance to confirm passage of the core needle into the lesion. Core biopsy permits and accurate diagnosis and if positive for cancer, it allows a surgeon to discuss treatment options and plan for surgery before going to the operating room.
Excisional biopsy or surgical removal of a lesion is performed in certain situations. For example,
When core biopsy is not diagnostic or shows a lesion that may be associated with a cancer such as atypical hyperplasia or radial scar and excision of the entire lesion is indicated.
Incisional biopsy is rarely performed but involves removal of part of a lesion that is too big to be completely removed but the entire lesion.
An otherwise healthy 40-year-old woman is referred to a breast surgeon by her gynecologist because of a right breast mass she first noticed on self-examination 2 weeks ago. The mass was not present on physical examination 1 year ago. She has two children, ages 18 and 15 years. She takes a daily multivitamin and calcium supplement but no other medications, and she has no history of surgery. There is no family history of breast cancer in her family.
Physical examination is unremarkable except for a 1.5-cm firm, mobile, nontender, slightly irregular but well-defined mass in the right breast upper outer quadrant. No skin changes or dimpling are noted. There is no lymphadenopathy.
Mammography confirms the presence of the 1.5-cm lesion but shows no other abnormalities. Pathologic examination of a core needle biopsy specimen shows estrogen and progesterone receptor–negative, HER2/neu-negative infiltrating ductal carcinoma. Lumpectomy showed clear surgical margins, and sentinel nodes were negative for carcinoma.
Which of the following is the best next step in management?
a. Hormonal therapy
b. Axillary node dissection
c. Mastectomy
d. Observation
e. Chemotherapy followed by radiation.
e. Chemotherapy followed by radiation.
The next best steps in the management of a young woman with a T1cN0M0 breast cancer who undergoes breast conservation are chemotherapy and radiation. Although the patient’s SLN was tumor-free, she has a triple-negative breast cancer as defined by the absence of the estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2). Triple negative breast cancers tend to be more aggressive so this patient would benefit from adjuvant chemotherapy.1
Randomized clinical trials demonstrate equivalent outcomes for women treated with breast-conservation compared to mastectomy.2 A 40-year-old woman, treated with lumpectomy should receive radiation therapy to the breast to reduce the risk of tumor recurrence. Radiation therapy has traditionally been delivered by external beam to the whole breast over several weeks. Whole breast radiation therapy reduces the risk of recurrence by nearly half compared to lumpectomy alone. In highly select patients, however, alternative methods of delivering radiation include accelerated partial breast irradiation and intraoperative radiation.3 Accelerated partial breast irradiation is the delivery of radiation to the breast tissue near the lumpectomy site over a shorter period of time. Intraoperative radiation involves giving the entire dose of radiation in the operating room at the time of the lumpectomy.
Axillary lymph node dissection is not indicated in this patient because her SLN was tumor free. Observation is also not appropriate in this young woman because her risk of recurrence is high. Hormonal therapy is not indicated because her tumor was ER negative. Finally, mastectomy is not necessary because her lumpectomy showed tumor-free surgical margins.
