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 A 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
QUESTIONS 1 of 9 1 2 3 4 5 6 7 8 9 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI 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/LFemale: 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/mLFemale: 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/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative 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/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 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/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 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/minFemale: 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 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 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 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (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 Type & Select Correct Answer 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 Select Answer to see Preferred Response SUBMIT RESPONSE 4 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (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 Type & Select Correct Answer 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 Select Answer to see Preferred Response SUBMIT RESPONSE 3 You have 100% on this question. Just skip this one for now. Take This Question Anyway (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: A Type & Select Correct Answer 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 Select Answer to see Preferred Response SUBMIT RESPONSE 2