breast Flashcards
(40 cards)
breast carcinoma
-Other than skin -> breast is MC ca
-12.5% of female pts
-5-10% - gene mutations -> BRCA 1 (72% lifetime risk) and BRCA 2 (69% lifetime risk)
-risk is increased 100% if 1st degree relative has breast carcinoma
-Black pts highest risk of death -> greater risk of triple negative breast ca
(no receptors for estrogen or progestin, no HER-2 proteins)
factors affecting black individuals with breast carcinoma
-genetic ancestry->
-cancer dx, tx, and outcomes
-allostatic load stressors:
-social determination of health
-structural inequality and inequity
-epigenetics
non-modifiable vs modifiable RF for breast carcinoma
-NON-MODIFIABLE:
-Age
-Having breast tissue
-Family hx
-Genetic mutations
-Personal hx of breast ca
-Personal hx of irradiation to thorax
-Personal hx of breast bx with atypia
-Early menarche (<12yo)
-Late menopause (>55yo)
-MODIFIABLE:
-lack of breast feeding
-alc
-sedentary lifestyle
-obesity
-1st pregnancy >30yo
-nulliparity
genetic testing
-offered to pts with BREAST CA + HX OF:
-Dx <50yo
-B/L breast ca
-Triple negative breast ca
-Family member with breast and ovarian carcinoma
-Family member with multiple members with breast ca
-Family member with at least 2 primary BRCA-1 or BRCA-2 malignancies
-Family member with male breast carcinoma
-!Family member with pancreatic or prostate carcinoma
-Being Ashkenazi Jewish
-Should be offered to ANYONE with a hx of:
-Family hx of gene mutation involving breast ca
-Ovarian or pancreatic ca in females
-breast, pancreatic, or metastatic prostate ca in males
-family member with breast ca < 50yo
-Multiple family members with breast ca
-male family member with breast ca
MC site of breast carcinoma
-upper outer quad including tail of spence
-largest part of breast and where breast carcinoma is MC found
mammography
-1960s
-detection of 90% of breast cancers
-false-negative rate of approx 10%
-low dose of ionizing radiation
-mammo and US -> breast imaging report and data system (BI-RADS)
-REMEMBER:
-mammo is a screening test
-tissue is the issue- bx is dx
screening mammo vs dx mammo
-SCREENING:
-performed in pt with:
-absence of any suspicion of breast cancer
-average risk of breast cancer
-DX:
-performed in pt with:
-hx of breast mass or other findings on clinical breast exam
-hx of abnormal screening mammo
-dx mammo takes longer and uses more radiation to take more detailed images
-top pic- normal
-bottom pic- spiculated masses
screening guidelines for mamo for average risk pts
role of clinical breast exam and breast self exam
-ACOG- after 19yo
-ACS and USPSTF- NONE
-ACOG, ACS and USPSTF do not recommend breast self exam
special circumstances
-In patients of increased risk (personal or family hx, hx of thoracic irradiation, genetic mutation, African ancestry, Ashkenazi Jewish ancestry, etc.) -> management must be individualized
-trans females who are >50yo on hormonal therapy for at least 5yrs, who have family hx or are obese -> should be screened
-trans men who do not have mastectomy -> should be screened
BI-RADS assess categories
reporting results to pts
-as per NY state law ->must send results in laypersons language w/i 7 days of test
other imaging
-US- distinguish between solid and cystic lesions
-Ductogram - spontaneous nipple discharge and mammography is inconclusive
-MRI - helpful for screening in high risk pts
-dense breasts -> mammo + US performed together, or MRI
-dense breasts -> inc risk of malignancy 6x
breast bx
-for palpable lesions
-suspicious lesions found on mammo
-often done at same visit as mammo
-usually, core bx under local anesthesia (large needle)
-can do open bx in OR
non-malignant bx results
-Fibroadenoma:
-Well circumscribed, rubbery, mobile, nontender masses typically seen in younger pts
-observed or remove
-Lobular carcinoma in situ
-Atypical lobular hyperplasia
-Atypical ductal hyperplasia
-Phyllodes tumor
-Usually is benign but may become malignant
-These lesions often grow rapidly
-For all of the above, additional surveillance is required and must be individualized
invasion of breast carcinoma
-Malignant cells in the milk ducts are unable to metastasize and are noninvasive
-if it can metastasize -> its invasive
-Locally advanced breast ca has invaded into axillary nodes but not beyond them
-Metastatic breast ca has invaded beyond the axillary nodes
-Tends to metastasize to liver, brain, bones, lungs
S&S of breast carcinoma
-Painless, fixed, irregular mass
-Spontaneous non-milky nipple drainage
-Palpable, nontender lymph nodes
-Erythema of breast that may involve ipsilateral arm -> inflammatory breast carcinoma
-Change in texture:
-Peau d’orange
-Dimpling
-Retractions
-Nipple inversion
-Ulceration of the breast
-Pruritus of nipple
staging of breast carcinoma
-Based on a number of factors
-Tumor
-Nodes
-(Distant) metastasis
-Estrogen receptor status
-Progesterone receptor status
-Human epidermal growth factor 2 (HER 2 status)
-Grade
tumor
-Tx: primary tumor cannot be assessed
-T0: no evidence of primary tumor
-Tis: carcinoma in situ (ductal carcinoma in situ, or Paget disease of the breast with no associated tumor mass)
-T1: Tumor is no larger than 2 cm in diameter
-T2: Tumor is between 2-5 cm in diameter
-T3: Tumor is >5 cm in diameter
-T4: Tumor of any size growing into chest wall or skin, including inflammatory breast carcinoma
node dissection and risk of lymphedema
-lymphedema of upper extremity (15-25% after dissection; 0-7% after sentinel bx)
-rarely lead to need for amputation
-sentinel node bx can avoid need for dissection
-injection of radioisotope with blue dye prior to surgery
-sentinel node (1st node that takes up isotope and dye) is removed when found via dye and gamma probe and is sent for frozen section
-If neg for malignancy -> no further node dissection is indicated
-After axillary node dissection following in ipsilateral UE is CI:
-Venipuncture
-IV cannulization
-BP measurement
nodes
-Nx: nodes cannot be assessed
-N0: Malignancy has not spread to adjacent nodes
-N1: Malignancy has spread to 1-3 axillary nodes or is found via sentinel node biopsy in internal mammary nodes
-N2: Malignancy is found in at least 10 axillary nodes with at least one greater than 2 mm
-When an axillary node dissection is required, it involves 3 levels of nodes
-Level 1: tissue below the lower edge of pectoralis minor
-Level 2: tissue lying underneath pectoralis minor
-Level 3: tissue lying above the pectoralis minor
-After axillary node dissection, a patient cannot have any of the following performed in the ipsilateral upper extremity:
-Venipuncture
-Intravenous cannulization
-Blood pressure measurement
metastasis
-M0: no distant metastasis is identified by imaging or physical exam
-M1: distant metastasis is identified by imaging or physical exam, and/or a biopsy demonstrates distant metastasis
-MC sites of metastatic breast carcinoma:
-Lung
-Liver
-Bone
-Brain
estrogen and progesterone receptor status
-Most have both estrogen and progesterone receptors
-certain meds can be used to block access to these hormones, restricting growth
Human epidermal growth factor receptor 2 (HER 2)
-A protein that promotes tumor growth
-Assoc with more aggressive tumors
-May be managed with monoclonal antibody such as trastuzumab (Herceptin)
