exam 3 - breast cancer Flashcards
(40 cards)
breast carcinoma
-Other than skin cancer, breast carcinoma is the most common cancer in the world
-There were nearly 300,000 cases of breast carcinoma diagnosed in the United States in 2022
-Approximately 43,000 of all patients with this diagnosis will die of their disease
-Approximately 12.5% of cisgender female patients will develop breast carcinoma in their lifetimes
-Men comprise about 1% of patients with breast carcinoma
-About 5-10% of breast carcinomas are related to gene mutations, most commonly BRCA 1 (72% lifetime risk) and BRCA 2 (69% lifetime risk)
-An individual’s risk is increased about 100% if a first degree relative has breast carcinoma
factors affecting black pts with breast carcinoma
-Genetic ancestry ->
-Cancer dx, tx, and outcomes
-Allostatic load stressors:
-Social determinants of health
-Structural inequity and inequality
-Epigenetics
-Black individuals have the highest risk of death from breast carcinoma, in part due to a greater risk of triple negative breast carcinoma
-This type of carcinoma is named “triple negative” because these tumors do not contain receptors for estrogen or progestin, and they tend to not produce HER-2 proteins
non-modifiable vs modifiable RF for breast carcinoma
-NON-MODIFIABLE
-Growing older
-Having breast tissue
-Family history of breast carcinoma
-Genetic mutations
-Personal history of breast carcinoma
-Personal history of irradiation to thorax
-Personal history of breast biopsy with atypia
-Early menarche (<12 years of age)
-Late menopause (>55 years of age)
-MODIFIABLE:
-Lack of breast feeding
-Alcohol consumption
-Sedentary lifestyle
-Obesity
-First pregnancy after age 30
-Nulliparity
genetic testing
Should be offered to patients with breast carcinoma who also have a history of:
-Dx of breast carcinoma before age 50
-Bilateral breast carcinoma
-Triple negative breast carcinoma
-Family member with breast and ovarian carcinoma
-Family member with multiple members with breast carcinoma
-Family member with at least two primary BRCA-1 or BRCA-2 malignancies
-Family member with cisgender male breast carcinoma
-Family member with pancreatic or prostate carcinoma
-Being Ashkenazi Jewish
Should be offered to anyone with a history of:
-Family history of gene mutation involving breast carcinoma
-Ovarian or pancreatic carcinoma in AFAB people and breast, pancreatic, or high grade or metastatic prostate carcinoma in AMAB people
-A family member with breast carcinoma before age 50
-Multiple family members with breast carcinoma
-An AMAB family member with breast carcinoma
Offer if:
Breast CA <50
Bilateral CA
Triple negative CA
Male relative w/ breast CA
Ashkenazi Jewish ancestry
Family history of BRCA-associated cancers
MC site of breast carcinoma
-Upper outer quadrant including tail of Spence
-Largest part of breast and where breast carcinoma is most commonly found
mammography
-1960s
-Detection of 90% of breast cancers
-Has a false-negative rate of approximately 10%
-Uses a low dose of ionizing radiation
-Mammo and US of the breast are reported using the breast imaging report and data system (BI-RADS)
-REMEMBER:
-Mammography is a screening test
-Tissue is the issue—biopsy is diagnostic
-In order to render a dx of breast carcinoma, pathological analysis of biopsy is required
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 ammo for average risk pts
prof recommends annual screen
role of clinical breast exam and breast self exam
-ACOG: performance of clinical breast exam after age 19
-ACS and USPSTF: do not recommend clinical breast exam
-ACOG, ACS and USPSTF do not recommend breast self exam
special circumstances
-In patients of increased risk (personal or family history of breast carcinoma, history of thoracic irradiation, genetic mutation, African ancestry, Ashkenazi Jewish ancestry, etc.), management must be individualized
-AMAB gender diverse patients age ≥50 on hormonal therapy ≥5 years, with family hx or obesity, should be screened
-AFAB gender minority patients without mastectomy as part of gender-affirming care should be screened
BI-RADS assess categories
reporting results to pts
-As per NY state law:
-All pts having breast imaging must be sent their results in layperson’s language within 7 days of the test
other imaging
-Ultrasound may distinguish between solid and cystic lesions
-Ductogram may be performed for spontaneous nipple discharge when mammography is inconclusive
-MRI of the breast may be helpful for screening high-risk patients
-Patients with dense breasts may benefit from both mammography and US or MRI
-Dense breasts raise risk of malignancy about sixfold
breast biopsy
-May be done for palpable lesions or for suspicious lesions found on screening mammogram
-May often be done at same visit as mammogram
-Usually performed as core biopsy under local anesthesia
-May be performed as an open biopsy in operating room
non-malignant biopsy results
-Fibroadenoma of breast:
-Well-circumscribed, rubbery, mobile, nontender masses, typically in younger patients
-May be observed or removed
-Lobular carcinoma in situ
-Atypical lobular hyperplasia
-Atypical ductal hyperplasia
-Phyllodes tumor:
-Usually benign but may become malignant
-Often grow rapidly
-All require individualized additional surveillance
invasion of breast carcinoma
-Malignant cells in milk ducts are noninvasive and cannot metastasize
-Invasive types can metastasize
-Locally advanced breast carcinoma: invades axillary nodes but not beyond
-Metastatic breast carcinoma: invades beyond axillary nodes
-Common metastasis sites: liver, brain, bones, lungs
S&S of breast carcinoma
-Painless, fixed, irregular mass
-Spontaneous non-milky nipple drainage
-Palpable, nontender lymph nodes
-Erythema involving breast or ipsilateral arm—consider inflammatory breast carcinoma
-Skin texture changes
-Peau d’orange
-Dimpling or retractions
-Nipple inversion
-Ulceration
-Pruritus of nipple
staging of breast carcinoma
-Based on several factors:
-Tumor
-Nodes
-(Distant) metastasis
-Estrogen receptor status
-Progesterone receptor status
-HER2 status
-Grade
tumor
-Tx: primary tumor cannot be assessed
-T0: no evidence of primary tumor
-Tis: carcinoma in situ (ductal or Paget’s without mass)
-T1: ≤2 cm
-T2: 2–5 cm
-T3: >5 cm
-T4: Any size with chest wall or skin involvement (e.g., inflammatory)
node dissection and risk of lymphedema
-Node dissection done for staging in some cases
-Can cause lymphedema of the upper extremity * Swelling of the arm due to lymphatic fluid accumulation
-Sentinel node (First node(s) cancer drains to) biopsy may prevent need for full dissection:
-Involves dye and gamma probe
-If negative → no further node dissection
Risk of lymphedema:
-Axillary dissection: 15–25%
-Sentinel node biopsy: 0–7%
- Prefer SLNB over full ALND when possible
After axillary dissection, avoid:
-Venipuncture
-IV cannulization
-Blood pressure in ipsilateral arm
nodes
-Nx: cannot be assessed
-N0: no nodal spread
-N1: 1–3 axillary or sentinel node involvement
-N2: ≥10 axillary nodes, at least one >2 mm
-Axillary node levels:
-Level 1: below pectoralis minor
-Level 2: under pectoralis minor
-Level 3: above pectoralis minor
metastasis
-M0: no distant metastasis
-M1: metastasis identified via imaging or biopsy
-Most common sites:
-Lung
-Liver
-Bone
-Brain
estrogen and progesterone receptor status
-Most tumors are hormone receptor positive
-These can be treated with medications that block hormone access
-Hormone receptor negative tumors are not eligible for such therapy
HER2 (Human epidermal growth factor receptor 2)
-Protein promoting tumor growth
-Associated with more aggressive tumors
-Managed with monoclonal antibody: trastuzumab (Herceptin)
