Internal Med- Oncology Flashcards
How will a Pt with Breast cancer most likely present?
Asymptomatic lesion on women on screening mammography or by the palpation of a mass by the patient or a physician. When breast cancer presents as a palpable mass, it is hard to the touch. It may also be associated with retraction of the nipple because ligaments in the breast will withdraw and pull the nipple inward.
What is the best initial test for Breast cancer?
What is the most accurate?
Biopsy is the best initial test.
Open biopsy is the most accurate.
What are the types of biopsies that can be done when suspecting Breast cancer and what are their advantages or disadvantages?
- Fine needle aspiration (FNA): FNA is usually the best initial biopsy. However, because FNA is a small sample, the disadvantages are a false negative rate of 10%. You cannot test for estrogen or progesterone receptors or HER 2/neu on an FNA.
- Core needle biopsy: This is a larger sample of the breast. It is more deforming, but you can test for estrogen receptors (ER), progesterone receptors (PR), and HER 2/neu. Difficulties include greater deformity with the procedure and the possibility that the needle will miss the lesion.
- Open biopsy: The “most accurate diagnostic test,” open biopsy allows for frozen section to be done while the patient is in the operating room followed by immediate resection of cancer followed by sentinel node biopsy.
When is Mammography indicated for screen of breast cancer in the general population?
Starting at the age of 50.
A woman finds a hard, nontender breast mass on self-examination. There is no alteration of the mass with menstruation. She is scheduled to undergo a FNA biopsy.
Which of the following is most likely to benefit the patient?
a. Mammography.
b. BRCA testing.
c. Ultrasound.
d. Bone scan.
e. PET scan.
*A.
If breast biopsy is going to be performed, what is the point in doing a screening test like mammography? The answer is: 5% to 10% of patients have bilateral disease. In addition, there is a huge difference in the management of the patient if there is a single lesion or multiple lesions within the same breast. BRCA testing confirms an extra risk of cancer compared to the general population, but will add nothing to a patient who must already undergo biopsy. Ultrasound is useful in evaluating whether masses that are equivocal by clinical examination are cystic or solid. Bone scan is used after a diagnosis of breast cancer is made to exclude occult metastases. PET scan helps determine the content of abnormal masses within the body or enlarged nodes without biopsy. However, PET scan does not eliminate the need to establish an initial diagnosis with biopsy. MRI is used in young women with dense breasts.
When is Ultrasound appropriate when suspecting breast cancer?
if the lesion:
- Is painful
- Varies in size or pain with menstruation
- Clinically indeterminant mass lesions. It tells cysts versus solid lesions.
When is a PET Scan the next best step?
When we need to determine the content of abnormal lymph nodes that are not easily accessible to biopsy. Cancer increases uptake on PET scan.
An 80-year-old woman with biopsy-proven breast cancer has no nodes with cancer in the axilla. The primary lesion is small and the woman may not need adjuvant chemotherapy. Chest CT shows an abnormal hilar lymph node.
What is the most appropriate next step?
In this case, PET scan is useful to exclude a metastasis and the need for additional chemotherapy. Also, lymph nodes that are not easily accessible to biopsy.
What is the significance of BRCA?
-BRCA is definitely associated with an increased risk of breast cancer, particularly within families.
-BRCA is associated with ovarian cancer and pancreatic cancer.
When Positive,
patients can opt for bilateral mastectomy.
What is Sentinel Lymph Node Biopsy and what is it’s significance?
The first node identified near the operative field of a definitively identified breast cancer is the sentinel node. Contrast or dye is placed into the operative field and the first node identified that it travels to is the sentinel node.
Sentinel node biopsy is done routinely in all patients at the time of lumpectomy or mastectomy.
A negative sentinel node eliminates the need for axillary lymph node dissection.
Which Pt’s get tested for Estrogen and Progesterone Receptors?
How do the results of the testing aid us?
Estrogen receptor (ER) and progesterone receptor (PR) testing is routine for all patients with or suspected of breast cancer. Hormone manipulation therapy is done if either test is positive.
What are some of the surgical ways of dealing with breast cancer and how are they different from each other in terms of efficacy?
- Lumpectomy with radiation
- Modified radical
mastectomy
Lumpectomy with radiation is equal in efficacy to modified radical mastectomy but much less deforming. The addition of radiation to lumpectomy is not a small issue. Radiation at the site of the cancer is indispensable in preventing recurrences at the breast.
*Radical mastectomy is always the wrong answer.
When is Lumpectomy contraindicated?
if the cancer is multifocal or radiation is contraindicated in the Pt.
Which group of breast cancer Pt’s get Hormonal Manipulation therapy?
All Estrogen receptor (ER) or Progesterone receptor positive patients should receive Tamoxifen or Aromatase inhibitors. Aromatase inhibitors are generally for postmenopausal women. Tamoxifen is better in premenopausal patients.
What is the most common side effect for a breast cancer Pt on Tamoxifen?
Tamoxifen gives endometrial cancer and clots (tamoxifen is a selective ER modifier)
What is the most common side effect for a breast cancer Pt on an Aromatase inhibitor?
Aromatase inhibitors give osteoporosis (aromatase inhibitors inhibit estrogen effect everywhere, even the good effects, like on bone density)
Which is more effective Tamoxifen or Aromatase inhibitors?
Aromatase inhibitors seem to have a slight superiority in efficacy. If both are among the answer choices, aromatase inhibitors are the answer to the “most likely to benefit the patient” question.
Which group of breast cancer Pt’s should be tested for Her 2/neu receptors?
What is the significance of this test?
All breast cancers should be tested for Her 2/neu. This is an abnormal estrogen receptor.
Those who are positive should receive anti-Her 2/neu antibodies known as Trastuzumab. Trastuzumab decreases the risk of recurrent disease and increase survival.
What is the significance of Adjuvant chemotherapy and when is it indicted in breast cancer?
Adjuvant means an additional therapy to clean up presumed microscopic cancer cells too small in amount to be detected.
Indicated when;
-Lesions are larger than 1 cm
-Positive axillary lymph nodes are found
When is breast cancer prophylaxis indicated?
Which drug is used?
When multiple first-degree relatives have breast cancer.
Tamoxifen / Raloxifene
How does Prostate cancer present?
It presents with obstructive symptoms on voiding similar to benign prostatic hypertrophy or a palpable lesion on examination. Most prostate cancers are asymptomatic.
What is the best initial test when suspecting Prostate cancer?
What is the most accurate test?
Biopsy is the best initial test and the most accurate test.
