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Repro > Breasts and Cancer > Flashcards

Breasts and Cancer Flashcards

1
Q

Top 3 chief complaints of breast health

A

Breast tenderness
Breast mass or lump
Nipple discharge

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2
Q

Orange peel sign

A

D/t retraction of suspensory ligaments > signs of lymphatic invasion

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3
Q

Vertical strip method of palpation

A

While supine, use three middle fingers and apply three levels of pressure in a circular motion; Follow and up and down pattern

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4
Q

Physical findings of breast cancer

A
  • Irregular in contour
  • firm to hard consistency
  • not well delineated from surrounding tissue
  • nontender
  • dimpling
  • retraction
  • fixation
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5
Q

Breasts during pregnancy

A
  • ducts increase in size and number
  • vascular engorgement
  • increase in glandular tissue and vascularization
  • tissue becomes softer and looser (firmer later on)
  • lactation preparation (SD of ribs, vertebra, clavicles may interfere with success)
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6
Q

Breasts post-menopausal

A

glandular tissue atrophies, fatty replacement of parenchyma

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7
Q

Multiple ducts nipple discharge usually….

A

Hormonal

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8
Q

Isolated ducts nipple discharge usually…

A

Local (intraductal papilloma - bloody; mammary duct ectasia - purulent)

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9
Q

Meds that increase prolactin

A

BCP, Digoxin, antipsychotics, diuretics, steroids

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10
Q

Breast pain

A

Mastalgia

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11
Q

Breast cancer risk factors

A

Early menarche, late menopause, age, gender, personal or family hx of breast cancer, nulliparity, late age first birth, hormone therapy, proliferative breast disease, alcohol, etc.

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12
Q

Key principles of spirituality

A
  1. Religion and spirituality are important to many of your patients
  2. When you explore the role of religion and spirituality in patients’ lives, this is usually helpful to them
  3. When patients make meaning of their medical condition in religious terms, this may have positive as well as negative consequences for their well being
  4. Clarifying patients’ religious interpretation of their suffering may help you offer additional support and/ or referral to an expert
  5. Strive to avoid imposing your religious/ spiritual beliefs on your patients, as this is a professional boundary violation
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13
Q

1 imaging of breast

A

Mammography

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14
Q

Secondary imaging of breast

A

Ultrasound

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15
Q

Problem-solving or special study imaging of breast

A

MRI

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16
Q

In what scenario would you might have to use ultrasound or MRI FIRST instead of mammography?

A

Dense breast tissue

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17
Q

ACS guidelines for screening

A
  • Yearly mammograns starting at age 40 and continuing as long as the woman is in good health
  • CBE ~every 3 years for women in their 20s and 30s and every year for women 40+
  • Women at high risk (>20%) should get an MRI and mammogram every year
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18
Q

BIRADS

A 
0 - needs assitional assessment
1 - NML - no further action
2 - benign - no further action
3 - probably benign - 6 month f/u
4 - suspicious - biopsy most of the time
5 - malignant - biopsy
6 - known malignancy
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19
Q

Two categories of mammograms

A

Screening - no breast complaints, following guidelines

Diagnostic - pt either has symptoms or palpable mass OR abnormal finding on screening mammogram

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20
Q

What is important about screening mammograms?

A
  • CC and MLO views
  • comparison of previous exam CRUCIAL (may look awful on exam, but if it’s been there for a while with no change > changes next steps)
  • CAD improves accuracy
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21
Q

What should you look out for on mammograms?

A
  • Symmetry/Asymmetry**
  • Nodule margins-regular vs irregular**
  • Irregular clustered microcalcification**
  • Interval nodule development or growth
  • Skin thickening or nipple retraction (peau d’orange)
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22
Q

Computer Assisted Diagnosis (CAD)

A
  • Improve accuracy
  • Useful in detecting subtle calcifications
  • can identify potential abnormalities, but often over calls masses
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23
Q

Signs of cystic lesion on ultrasound

A

Through transmission, no shadowing, no signs of vascular flow, well-defined border

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24
Q

Signs of solid lesion on ultrasound

A

No through transmission, shadowing, irregular border, complex

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25
Q

What should be done with signs of a solid lesion on ultrasound?

A

Biopsy

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26
Q

On mammogram, what are bad signs indicative of a necessary biopsy?

A

Dense mass, spiculations, calcifications (sometimes)

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27
Q

What imaging modality is commonly used for biopsy?

A

Ultrasound

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28
Q

When would a biopsy be done?

A

Palpable mass and/or abnormal mammogram

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29
Q

Stereotactic biopsy

A
  • Used for non-palpable mass
  • Guided by imaging (usually ultrasound or mammogram)
  • Local anesthetic, needle biopsy, bandaid surgery
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30
Q

Why are clips usually places post-Stereotactic biopsy?

A

For the radiologist to find again and for physicians to know there was a surgery there in future follow-ups

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31
Q

TNM staging

A

T - size of primary tumor
N - involvement of lymph nodes
M - presence of distant metastasis

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32
Q

T class

A 
Tx - cannot evaluate
Ts - CA in situ; intraductal CA or lobar CA, Paget's of nipple w/o tumor
T1 - tumor <2 cm
T2 - tumor 2-5
T3 - >5
T4 - extends to chest wall or skin
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33
Q

N class

A

Nx - cannot assess
N0 - no regional node mets
N1 - mets to ipsilateral axillary nodes, moveable
N2 - mets to ipsilateral axillary nodes, fixed
N3 - mets to ipsilateral internal mammary nodes or beyond

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34
Q

M class

A

Mx - cannot asses
M0 - no distant mets
M1 - distant mets (including ipsilateral supreclavicular nodes)

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35
Q

What is the most important prognostic variable?

A

Presence or absence of clinical lymph nodes

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36
Q

Sentinel lymph node biopsy (SLN)

A
  • For pts with clinically negative (non-palpable) lymph nodes, a less morbid method of staging
  • Consistently identify the migration of tumor cells
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37
Q

Axillary lymph node dissection (ALND)

A
  • Benefit on axilllary recurrence and survival & prognostic value
  • Anatomic disruption may cause lymphedema, nerve injury, shoulder dysfunction
  • If there is palpable abnormal lymph nodes these may be biopsied more simply
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38
Q

What are other prognostic indicators of poor prognosis?

A
  • Large primary tumor
  • Negative ER and PR
  • high grade
  • high proliferative rate
  • certain histologic subtypes
  • over-expression of certain oncogenes (esp. HER2)
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39
Q

Metastatic work-up

A
  • Blood tests (esp. compare to THEIR normal)
  • Chest X-ray
  • bone scan
  • If indicated, CT of brain, abdomen
  • PET scan for full body
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40
Q

General treatment categories

A
  • Surgery
  • Radiation
  • Chemo
  • Hormone
  • Biologic
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41
Q

What is TARGIT?

A

single-dose targeted intraoperative radiotherapy

42
Q

Goals of surgery

A

Remove cancer fully and stage surgically the extent of the disease locoregionally

43
Q

Lumpectomy benefits

A
  • breast is preserved
  • quicker recovery period with the more limited surgery
  • cosmetically generally good
44
Q

Lumpectomy disadvantages

A

-Have to get radiation (6-7 weeks)

45
Q

Mastectomy benefits

A
  • one surgery
  • usual recovery period of 1 week
  • usually no radiation is needed, although this is being reevaluated
46
Q

Mastectomy disadvantages

A
  • long recovery in some women
  • emotional/sexual implications of loss of breast
  • cosmetically less acceptable for some
47
Q

Simple mastectomy

A

Removes all breast tissue

48
Q

Modified radical mastectomy (MRM)

A

Removes all breast tissue and contents of axilla

49
Q

Radical mastectomy

A

Removes breast, axilla, pec major and minor

50
Q

Goal of radiation

A

Targets cells in its path so DNA is destroyed

51
Q

Side effects of chemo

A

-fatigue, nausea, diarrhea, hair loss, weight loss, depression, suppression of the body’s immune system (usually temporary); “chemo brain”

52
Q

Complications of chemotherapy

A

Infection, bleeding, secondary cancers (leukemia)

53
Q

SERMs

A

Selective estrogen receptor modulators (Tamoxifen and raloxifene)

54
Q

Tamoxifen characteristics

A
  • Typically administer for five years after surgery
  • It is not a primary/sole treatment
  • Also has use prophylactically to prevent first and second breast cancers
  • May use both pre- and post- menopause
  • Serious risk of endometrial cancer, thrombotic events (do not use if h/o PE, DVT)
55
Q

Raloxifene characteristics

A
  • As effective in prophylaxis of invasive breast cancer
  • fewer uterine side effects
  • Bone benedits
56
Q

SERDs (selective estrogen receptor downregulators)

A

Fulvestrant

57
Q

Aromatase inhibitors

A
  • Prevent the production of estradiol by blocking enzyme aromatase
  • For post-menopausal women with estrogen receptor positive breast cancers
  • Given as first-line post-tx prophylaxis OR after SERM tx
58
Q

Examples of aromatase inhibitors

A
  • Arimedex (anastrazole)
  • Aromasin (exemestane)
  • Femara (letrozole)
  • Fadozole (third generation)
59
Q

How can you tell if a cancer is estrogen/progesterone related or stimulated by estrogen/progesterone

A

Immunostaining

60
Q

What drug blocks estrogen from binding ER by acting as an antagonist?

A

Tamoxifen

61
Q

What drugs prevent estrogen production in the first place?

A

Aromatase inhibitors

62
Q

Herceptin (trastuzumab)

A
  • Now for early and late stage tx

- Ab targets HER2 protein

63
Q

Avastin (bevacizumab)

A
  • Used in tx of metastatic disease

- Binds a substance required for growth of new blood vesels in tumor

64
Q

Tykerb (lapatinib)

A
  • To tx advanced cancer, usually with chemo
  • Disrupts HER2/neu protein and interferes with growth signal on the tumor
  • Often used when herceptin becomes ineffective
65
Q

Adjuvant therapy

A

Medical treatment using endocrine therapy, chemo, and/or biologic therapy

66
Q

Neoadjuvant therapy

A

treatment before surgery with goal of inducing tumor response/shrinkage, possibly enabling breast conserving surgery; also provides information on response if the pt should have a recurrence

67
Q

Recurrence risk

A
  • Related to extent of disease; tumor size & nodes
  • May recur 20-40 years after dx
  • Lowest risk with tumor size < 1cm and no nodes
  • Tools to calculate specific risk range based on genetics and tumor characterisitcs—therapy guide
68
Q

Risk of second primary malignancy

A
  • 7-8% overall occurrence in contralateral breast
  • Breast cancer risk lowered by tamoxifen use
  • Slight increased risk of colon & ovarian cancer
69
Q

Survivors’ risk of complications with tx

A
  • Secondary malignancy - endometrial cancer with Tamoxifen, sarcoma of chest wall/UE (rare)
  • Ovarian failure/menopause - with adjuvant cytotoxic agent, SERMs
  • Lymphedema
  • Cardiovascular toxicities
  • Brachial plexopathies
  • Venous & arterial thrombosis
  • “Chemo brain”
70
Q

F/U for survivors

A

-History and physical
(q 3 months x 3 years, q 6-12 months x 2 yrs, then yearly)
-Mammography yearly
-Self breast /scar exam monthly
-Pelvic exam yearly
-Chest film/ bone scan when clinically indicated
-Blood counts/ chemistries when indicated

71
Q

Luminal A cancer subtypes

A
  • ER+ and/or PR+, HER2-, low Ki67 index
  • most common, low grade and proliferation, good prognosis, low relapse
  • endocrine therapy +/- chemo
72
Q

Luminal B cancer subtypes

A
  • ER+ and/or PR+, HER2+ or HER2-, high Ki67 index
  • higher proliferation and worse prognosis compared to A
  • endocrine therapy +/- chemo, +/- HER2 (if HER2 present)
73
Q

HER2+ cancer subtype

A
  • HER2+, ER/PR-
  • aggressive, poor prognosis
  • HER2 targeted therapy +/- chemo
74
Q

Triple negative cancer subtype

A
  • HER2/ER/PR-
  • aggressive, high metastasis, poor prognosis
  • chemo
75
Q

Estrogen sources

A

Estradiol, estriol, estrone

76
Q

Estrogen main functions

A

Development of sex organs, maintenance of secondary sex characteristics, metabolic effects

77
Q

Progesterone main functions

A

Regulates luteal phase, regulates implantation, maintains early pregnancy, lobular-alveolar development in preparation of milk secretion

78
Q

Mifepristone

A

For abortion

79
Q

Ulipristal

A

For emergency contraception

80
Q

What type of receptors are the ER and PR?

A

Nuclear/intracellular

81
Q

HER2

A

Human epidermal growth factor receptor 2

82
Q

What kind of receptor is HER?

A

Tyrosine kinase

83
Q

What does increased HER2 activity and expression do?

A
  • Enhances metastatic potential and inhibits apoptosis

- Associated with disease aggression/progression and increased resistance to endocrine therapy and chemo

84
Q

HER2 signaling pathways

A
  • RAS>Raf>MEK>MAPK

- PI3K>AKT>mTOR

85
Q

HER2 targeted therapy drug

A

Trastuzumab > Herceptin

86
Q

Trastuzumab MOA

A
  • Humanized monoclonal Ab to HER2 receptor
  • Targets extracellular domain of the HER2 transmembrane tyrosine kinase receptor
  • Binds to and blocks HER2 receptor activity
  • internalizes and degrades HER2, stimulates apoptosis, cell cycle arrest, inhibits tumorigenic signaling pathways
87
Q

Side effects of trastuzumab

A

Increased risk of cardiotoxicity

88
Q

No chemo if…

A

Low risk of recurrence > lymph node negative, small tumor (T1)

89
Q

When would chemo always be used as adjuvant therapy?

A

Triple negative

90
Q

Characteristics of high risk recurrence

A

High tumor grade, large tumor size (> 2 cm), positive lymph

91
Q

Oncotype Dx characteristics

A

PCR, 21 genes, prognostic and predictive

92
Q

MammaPrint characteristics

A

Microarray, 70 genes, only prognostic

93
Q

Oncotype Dx

A
  • Gene expression pattern translated into quantitative recurrence score (low, intermediate, or high risk)
  • Used to estimate risk of recurrence (prognostic) and likely benefit of chemo after breast cancer surgery (predictive)
  • Suggested for decision of adjuvant chemo in ER+, node- breast cancer pt
94
Q

MammaPrint

A
  • Expression of the selected genes defines prognostic classification of patients (low risk or high risk)
  • NOT for decisions on adjuvant therapy
  • Approved as prognostic assay for node - pt younger than 61 with tumor smaller than 5 cm
95
Q

Sanger sequencing

A
  • First generation sequencing
  • determination of base sequences in nucleic acids
  • Chain-terminating nucleotides lack a 3’-OH group, causing DNA polymerase to stop extension of DNA when a modified (fluorescently or radioactively labeled) ddNTP is incorporated and detected
96
Q

Next generation sequencing (NGS)

A

Uses array-based sequencing which combines the techniques developed in Sanger method to process a very large of reactions in parallel (much quicker and cheaper)

97
Q

Three steps of NGS

A
  1. Library preparation: libraries are created using random fragmented DNA, followed by ligation with custom adaptors (e.g., short, synthetic dsDNA) which enable the sequence to bind its complementary counterpart.
  2. Amplification: library is amplified using clonal amplification methods and PCR
  3. Sequencing: DNA is sequenced using different methods (e.g. pyrosequencing)
98
Q

Application of NGS

A
  • Study whole genome
  • Sequence RNA
  • Study epigenetic changes
  • In cancer, identify gene mutations
99
Q

Cre-LoxP system

A
  • Site specific recombinase technology for controlling gene expression
  • Enzyme Cre can recognize loxP DNA sequences and the orientation of the loxP sites determines how the targeted gene will be modified (same direction = excised/deleted)
100
Q

CRISPR-Cas9

A
  • Consists of synthetic gRNA that detects the specific sequence in the genome and Cas9 binds gRNA and cleaves DNA at target site > cell DNA repair machinery fill the gap through non-homologous end joining (NHEJ - direct ligation without template)
  • Used for knock-out or knock-in genes, gene therapy

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