questions 10

Breast Cancer General

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Topic updated on 10/18/17 12:10am

Introduction
  • Most common cancer and second most common cause of death in adult women
    • 12% lifetime risk
  • BRCA1 and BRCA2 mutations are associated with multiple / early onset breast and ovarian cancer.
  • Incidence:
    • most common in the elderly
    • 50% of all breast cancer occur in woman over the age of 65
    • 20% among woman under 50
    • 2% in woman less than 30 
    • 75% have no risk factors
  • Risk factors include:
    • increasing age
    • breast cancer in first degree relatives or mother with breast cancer
    • low fiber, high fat diet
    • obesity
    • history of contralateral breast cancer
    • a history of endometrial cancer which is also a estrogen induced cancer
    • h/o radiation
    • increases # menstrual cycles or exposure to estrogen
      • nulliparity 
      • early menarche (<11 yo.)
      • late menopause (>50 yo.)
      • late first pregnancy (>30 yo)
  • Physical/anatomic risk factors include: (CHAFED LIPS)
    • C: cancer in breast
    • H: hyperplasia
    • A: atypical hyperplasia
    • F: female
    • E: elderly
    • D: DCIS
    • L: LCIS
    • I: inherited genes
    • P: papilloma
    • S: sclerosing adenitis
  • Prevention 
    • smoking cessation
    • alcohol cessation
    • exercise
    • breastfeeding
Presentation
  • Presents with:
    • asymptomatic
    • breast lump
    • nipple discharge 
      • especially bloody, unilateral
  • Most often presents in upper/outer quadrant
  • Physical Exam shows:
    • firm immobile, painless lump
    • some skin changes (redness, ulcerations, edema, nodularity)
      • skin retraction indicates involvement of Cooper's ligament
    • axillary lymohadenopathy in more advanced cases
    • breast skin edema with dimpling (peau d' orange)  is a finding with a poor prognosis
      • represents obstruction of the lymphatics cancer
Evaluation
  • Combination of the physical exam, mammography, and fine-needle aspiration is highly accurate
    • ultrasound is sometimes used to see if the mass is cystic  
  • Labs include
    • serum calcium level
    • alkaline phosphatase
    • check for estrogen and progesterone receptors
TMN Staging
  • Staging is done with the TNM system and imaging (CT/bone scan)
> 5cm
Stage IIB
Stage IIIA
Stage IIIA
Stage IV
2-5 cm
Stage IIA
Stage IIB
Stage IIIA
Stage IV
< 2cm
Stage I
Stage IIA
Stage IIIA
Stage IV
 
No nodes
Mobile axilalry nodes
Fixed axillary nodes
Distant mets (including ipsilateral supraclavicular nodes)


Types of Breast Cancer

Carcinoma in situ
LCIS LCIS 
DCIS DCIS 
DCIS Paget's Breast Disease 
Invasive carcinoma
DCIS Invasive Lobular Carcinoma 
DCIS Invasive Ductal Carcinoma 
DCIS Inflammatory Carcinoma 
DCIS Cystosarcoma Phyllodes 

Mammogram Screening
  • Highly effective screening tool except in young women
    • dense breast tissue in young woman interferes with specificity and sensitivity
    • most effective in postmenopausal patients because of less glandular breast
  • All women aged 50-74 should have mammograms every 1-2 years
    • controversial whether screening mammography should begin as early as age 40
  • Women with with first degree relatives with cancer should begin screening ten years before family member developed cancer
  • Women with breast implants should undergo the same screening schedule as women without implants


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Qbank (6 Questions)

TAG
(M3.ON.15) A 29-year-old woman decides to have a bilateral breast augmentation for cosmetic purposes. What is the breast cancer screening schedule for women with breast implants? Topic Review Topic

1. It follows the same screening schedule as women without breast implants.
2. It is implemented earlier because of a higher risk of breast cancer with breast implants.
3. It is implemented later because of a lower risk of breast cancer with breast implants.
4. The frequency of screening mammographies is increased.
5. The frequency of screening mammographies is decreased.

PREFERRED RESPONSE ▶
TAG
(M3.ON.38) A 27-year-old female presents to her OB/GYN with concern over a mass she felt in her left breast on a recent breast self-examination. She denies any nipple discharge and reports a negative family history of breast or other cancers. Physical examination confirms the presence of a firm, immobile lump in the superolateral quadrant of the left breast; there are no evident overlying skin changes and there is no notable axillary lymphadenopathy on palpation. An ultrasound is conducted and shows a complex cyst (Figure A). Which of the following is the most appropriate next step in management? Topic Review Topic
FIGURES: A          

1. No further work-up is needed; reassure the patient that the breast mass is benign
2. Repeat physical examination in 4 weeks
3. Mammography
4. Fine needle aspiration of the mass
5. Excisional biopsy

PREFERRED RESPONSE ▶
TAG
(M3.ON.95) Which one of the following patients requires further evaluation with a mammogram? Topic Review Topic

1. 28-year-old woman with pain and erythema in one breast associated with breastfeeding
2. 42-year-old woman with spontaneous discharge from one breast
3. 65-year-old woman with milky discharge from both breasts
4. 55-year-old woman with a negative mammogram last year
5. 40-year-old woman whose elderly (95-year-old) grandmother died of breast cancer

PREFERRED RESPONSE ▶
TAG
(M2.ON.10) A 50-year-old woman with a history of hypertension presents to her primary care physician for a routine visit. She has no personal history nor family history of breast cancer. When should this patient receive a screening mammogram? Topic Review Topic

1. When she turns 55-years-old, and every 1 year thereafter
2. This year, and every 1 to 2 year thereafter until the age of 75
3. This year, and every 1 to 2 years thereafter until the age of 85
4. This year, and every 5 years thereafter
5. Screening mammograms are no longer recommended in patients without a family history of breast cancer

PREFERRED RESPONSE ▶
TAG
(M2.ON.16) A 28-year-old female is concerned about a breast mass she discovered on self-exam. On inspection, the mass is rubbery and somewhat mobile. Ultrasound is performed with results shown below. What is the most accurate next step that would aid in making the correct diagnosis? Topic Review Topic
FIGURES: A          

1. Mammogram
2. Fine needle aspiration
3. Image-guided core biopsy
4. Begin empiric tamoxifen therapy
5. Have patient return following next period and assess for change in size

PREFERRED RESPONSE ▶
TAG
(M2.ON.17) A female patient presents to her primary care physician due to pain, changing skin texture, dimpling, and an inverted nipple areolar complex (Figure A). The doctor is immediately concerned that which of the following structures has been infiltrated by malignancy? Topic Review Topic
FIGURES: A          

1. Pectoralis major
2. Breast lobule
3. Suspensory Ligament
4. Rib
5. Extralobular duct

PREFERRED RESPONSE ▶
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