Updated: 8/15/2019

Breast Cancer General

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Evidence
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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 

Treatment
  • Radiation
    • induction therapy can reduce the initial tumor burden prior to surgery 
  • Excision
  • Chemotherapy
  • Target therapy for hormone receptor positive (estrogen, progesterone) and HER-2/neu oncogene
    • e.g. trastuzumab as adjuvant for HER-2/neu oncogene positive 
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
    • screening for patients with breast implants is the same as general population  
  • 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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Questions (9)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.GN.15) A 35-year-old woman is presenting for a general wellness checkup. She is generally healthy and has no complaints. The patient does not smoke, drinks 1 alcoholic drink per day, and exercises 1 day per week. She recently had silicone breast implants placed 1 month ago. Her family history is notable for a heart attack in her mother and father at the age of 71 and 55 respectively. Her father had colon cancer at the age of 70. Her temperature is 99.0°F (37.2°C), blood pressure is 121/81 mmHg, pulse is 77/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam is unremarkable. Which of the following is the most appropriate initial step in management? Review Topic

QID: 103038
1

Alcohol cessation

50%

(2/4)

2

Colonoscopy at age 60

0%

(0/4)

3

Colonoscopy now

50%

(2/4)

4

Mammography at age 50

0%

(0/4)

5

Mammography now

0%

(0/4)

M2

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(M3.ON.15) A 49-year-old woman presents to her primary care physician for a general check up. She has not seen a primary care physician for the past 20 years but states she has been healthy during this time frame. She had breast implants placed when she was 29 years old but otherwise has not had any surgeries. She is concerned about her risk for breast cancer given her friend was recently diagnosed. Her temperature is 97.0°F (36.1°C), blood pressure is 114/64 mmHg, pulse is 70/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam is unremarkable. Which of the following is the most appropriate workup for breast cancer for this patient? Review Topic

QID: 102614
1

BRCA genetic testing

0%

(0/0)

2

Mammography

0%

(0/0)

3

No intervention indicated at this time

0%

(0/0)

4

Sentinel node biopsy

0%

(0/0)

5

Ultrasound

0%

(0/0)

M2

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(M3.ON.38) A 27-year-old woman presents to her primary care doctor with concern about a mass she felt in her left breast on a recent breast self-examination. She denies any nipple discharge and reports that her grandmother died of breast cancer at the age of 70. She is otherwise healthy, has a 5 pack-year smoking history, and drinks 3 to 4 alcoholic beverages daily. Her temperature is 99.0°F (37.2°C), blood pressure is 120/84 mmHg, pulse is 70/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical examination confirms the presence of a firm 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 performed as seen in Figure A. Which of the following is the most appropriate next step in management? Review Topic

QID: 103329
FIGURES:
1

Excisional biopsy

0%

(0/3)

2

Fine needle aspiration

0%

(0/3)

3

Mammography

0%

(0/3)

4

Reassurance

0%

(0/3)

5

Surgical excision

100%

(3/3)

M2

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