Case 4: Doreen Cooperson Flashcards
(24 cards)
DDx of Breast Masses (and distinguishing characteristics)
- Fibroadenoma (premenopausal women)
- Phyllodes tumor (leaf-like proliferation of glands, massive size)
- Intraductal papilloma (blood nipple discharge)
- Lipoma (soft, freely mobile)
- Breast abscess (inflammation)
- Fat necrosis (due to trauma/surgery)
- Breast cancer (microcalcifications in mammograph)
Epidemiology of Breast Cancer
What is the most common type?
This is the ___ most common cancer in women
- Invasive Ductal Carcinoma (75% of all breast cancer)
- 2nd most common cancer
Risk Factors for Breast Cancer
Genetics (BRCA1, 2, HER2)
Age
Family History (affected age, closer relation)
Exposure to estrogen (early menarche, late menopause, late pregnancy, BCP, HRT)
Past history
Lifestyle (high fat, smoking, alcohol)
Staging of Cancer
Definition
Types
System used
Definition: standardized way for health care providers to summarize info about how far cancer has spread. Doesn’t change over time, even if cancer progresses (stays same as first diagnosis)
Types: Clinical (based on PE, biopsy, imaging) or Pathological** (based on surgery examination of mass/ lymph nodes; more helpful)
TNM staging I-IV
T=Tumor (size/spread)
N=Lymph node involvement
M=metastasis
Grading of Cancer
Definition
Scale system used
Representative of “aggressive potential” of tumor. Describes microscopic appearance of tumor cells/tissue
Grading scale: Nottingham Grading scale (each given a score of 1-3, combined score 3-9)
Tubule differentiation: amount of gland formation from tumor cells
Nuclear pleomorphism: “ugliness”, differences in size, shape, and coloration of nuclei
Mitotic count: Speed of division, count # of mitoses in 10 fields
Grade vs. Staging
Stage:
- Macroscopic
- Summarize how far cancer has spread
- Types: Clinical vs. Pathologic
- TNM (I-IV)= Tumor, Node, Metastasis
Grade:
- Microscopic
- “Aggressive potential” of tumor
- Nottingham TNM (3-9)= Tubule differentiation, Nuclear pleomorphism, mitotic count
Types of surgery for breast cancer
Factors to consider for surgery
Mastectomy vs. lumpectomy
Factors: Type of cancer, Axillary lymph node involvement, Reconstruction timing, Disease control, Size/Location/# of tumors, Size of breast, Expected cosmetic result
Why would you use a mastectomy? A lumpectomy?
BOTH have IDENTICAL SURVIVAL RATES
Mastecomy (Removal of breast, pectoral muscles, and axillary lymph nodes). Used if tumor
- >5cm
- Lymphovascular invasion
- Less expensive
- BUT, worse quality of life due to disfigurement/mutilation
Lumpectomy (Breast conserving therapy, usually occurs with radiotherapy)
- <5 cm
- No skin/chest wall involvement
- Anticipate good cosmetic outcome
What is radiation therapy?
High energy photons (X-rays or gamma rays) to shrink tumor/kill cancer cells
Usually used in conjuction with lumpectomy
What is neoadjuvant therapy?
How is this different from adjuvant therapy?
Chemotherapy or endocrine therapy done prior to tumor removal) to reduce tumor size, increasing surgical options (higher chance of breast conservation therapy)
Adjuvant therapy is started after primary therapy.
Tamoxifen
Family
Indications
MOA
Contraindications
Family: Selective Estrogen Receptor Modulator (SERM)
Indications: Primary hormonal treatment for ER + breast cancer (normally adjuvant therapy)
MOA: (ER antagonist in breast tissue)
- Tamoxifen causes conformational change in estrogen receptor
- Change in expression of estrogen-dependent genes
- Induces re-expression of maspin (tumor-suppressor gene)
- Binds to nuclear DNA to prolong the cell’s time in G2 phase, decreasing cell proliferation
Contraindications: Increased risk of DVT, PE, stroke
Known to cause uterine cancer/uterine malignancies
What is the normal role of estrogen?
Grow uterine lining
Circulate lipids/lipoproteins (combats increase in plasma cholesterol/LDL)
What are the main lymph nodes of the breast?
- Axillary lymph nodes**
- Parasternal lymph nodes
- Abdominal lymphatics
- Subareolar lymphatic plexus
Describe mammography
X-ray 2D imaging test
Craniocaudal, lateral, and mediolateral projections
78% sensitivity
Can’t use to diagnose, but can find microcalcifications
BI-RADS 0-6
Describe Tomosynthesis
Mobile X-ray source. Tube rotated around compressed breast and compiled into 3D image
Used to supplement/replace traditional mammography (more sensitive, lower anatomical noise); better for patients with dense breast
Longer to read, higher X-ray exposure
Describe ultrasonography
Sound energy created by piezoelectric crystals that are reflected back and translated into an image
Impendence: Measures resistance to sound wave propagation (this is why you need to use a gel)
Describe a CT scan
Computed Tomography
Use X-rays to take a series of “sliced” images of body -> compiled into 3D image
Can see bones, organs, and tissue
May/may not have contrast dye
Increased radiation exposure
Describe a PET scan
Positron Emissino Tomography
Radioactive tracer given via IV to observe physiological activity within body (higher metabolic activity absorbs more tracer - tumors, bowel, kidney). Positrons in tracer collide with body’s electrons. Images captured using camera that detect gamma ray emissions to form 3D image.
What are the differences between FNA and CNB?
Fine Needle Aspiration
- Needle attached to syringe, draw in cells/fluid from lump
- 78% positive predictive value (PPV) for suspicious lesions
- Better if patient is on anticoagulants, lesion close to chest wall
- 5 minutes
- Less expensive
Core Needle Biopsy
- Hollow needle used to remove tissue (size of grain of rice)
- 100% PPV for suspicious lesions
- Better for diagnosing high risk lesions, distinguishing between benign vs. normal & invasive ductal vs. lobar, seeing calcifications
- 36 hours
- More expensive
What is the significance of ER, PR, and HER2 in the prognosis/treatment of breast cancer
EGFR family, tyrosine kinase
Overexpression causes ligand-independent activation of HER2 kinase
Increased proliferation, resistance to proapoptotic stimuli, increased cell migration, upregulation of MMPs
What are the stages of grief?
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
How can physicians support patients through grieving process?
- Info/advice: answer any questions/provide resources
- Body language: calm/confident, be at the same level
- Honesty: think out loud, relate results to options
- Speak in patient’s terms
- Allow patient time to respond
- Timeliness
How to deliver bad news
SPIKES
- S = Setting up: create environment, private, close ones, eye level, respect
- P = Perception: does the pt understand their illness?
- I = Invitation: ask if you can share info
- K = Knowledge: provide info & allow for dialogue (diagnosis, plan of treatment, prognosis, support)
- E = Emotion: stay emathetic
- S = Strategy: listen, summarize, ask if patient has questions
What is a hospice and its role?
Team?
Services?
Subset of palliative care (final phase) that is multidisciplinary, holistic, and non-curative (focused on care). Pt usually expected to live <6 months.
Team: physicians, nurses, social workers, counselors, volunteers, clergy
Services: Health care, equipment/supplies/meds, pain relief, therapy, counseling
