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Snapshot
  • A 46-year-old woman presents to her primary care physician after discovering a lump in her left breast. She denies any breast pain or nipple discharge. Physical exam reveals a 2 cm firm, fixed mass in the left breast in the upper outer quadrant with no axillary lymphadenopathy. 
Introduction
  • Overview
    • second most common cancer (after lung cancer)
    • most common cause of cancer-related death in adult women
      • 12% lifetime risk
  • Epidemiology
    • incidence
      • 260,000 cases per year
      • most common in the elderly
      • 50% of all breast cancer occurs in woman > 65 years of age
      • 20% among women < 50 years of age
      • 2% in women < 30 of age
    • risk factors
      • 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
      • prior radiation
      • increased number of menstrual cycles or exposure to estrogen
        • nulliparity 
        • early menarche (< 11 years of age)
        • late menopause (> 50 years of age)
        • late first pregnancy (> 30 years of age)
        • hormone replacement therapy
      • physical/anatomic risk factors include (CHAFED LIPS)
        • Cancer in breast
        • Hyperplasia
        • Atypical hyperplasia
        • Female
        • Elderly
        • DCIS
        • LCIS
        • Inherited genes
        • Papilloma
        • Sclerosing adenitis
    • prevention 
      • smoking cessation
      • alcohol cessation
      • exercise
      • breastfeeding
  • Genetics
    • BRCA1 and BRCA2 mutations associated with multiple/early onset breast and ovarian cancer
  • Prognosis
    • dependent on stage and type
      • triple negative (estrogen receptor (ER)/progesterone receptor (PR)-negative, HER2-neu-negative) has worse prognosis
    • 40,000 deaths per year
Classification
  • Benign breast tumors
    • intraductal papilloma 
      • bloody nipple discharge
  • Carcinoma in situ
    • LCIS 
      • not a premalignant lesion but considered a risk factor for breast cancer
    • DCIS 
      • a premalignancy
      • 50% develop into invasive ductal carcinoma
    • Paget disease 
      • breast itching, crusting, and scaling
      • > 80% associated with underlying breast cancer
      • spreads lymphatically
      • often transforms into invasive ductal carcinoma within 1 year
  • Invasive carcinoma
    • invasive lobular carcinoma 
    • invasive ductal carcinoma 
    • inflammatory carcinoma 
    • phylloides tumor 
      • 85-90% are benign
      • may grow aggressively and recur locally
Presentation
  • History
    • asymptomatic with recent screening mammography
    • felt a breast lump
  • Symptoms
    • asymptomatic
    • breast lump
    • nipple discharge
      • especially bloody, unilateral
  • Physical exam
    • firm immobile, painless lump
      • most often in upper/outer quadrant
    • skin changes (redness, ulcerations, edema, and nodularity)
      • skin retraction indicates involvement of Cooper ligament
    • axillary lymohadenopathy
      • more advanced cases
    • breast skin edema with dimpling (peau d'orange
      • represents obstruction of the lymphatics cancer
      • poorer prognosis
Imaging
  • Mammography  
    • indications
      • screening
        • less effective 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  
          • some recommend screening as early as age 40
          • if first-degree relative with cancer then begin screening ten years before family member developed cancer
        • screening for patients with breast implants is the same as general population  
      • diagnosis
        • first step in work-up
          • patients > 30 years of age
          • bloody nipple discharge
          • recurrent cyst
          • 10-15% of palpable cancers are not detected on mammography
      • findings
        • mass
        • calcifications
          • present in 60% of cancers
        • follow up with core needle biopsy
  • Magnetic resonance imaging (MRI)
    • indications
      • high risk women
        • prior radiation
        • BRCA gene mutation
    • findings
      • breast mass
  • Ultrasound
    • indications
      • patients < 30 years of age
      • cystic mass
        • follow up with fine needle aspiration
Tumor, Node, Metastasis (TNM) Staging
  • Staging is done with the TNM system and imaging (CT/bone scan)
  • Most important prognostic factor  
TNM Staging
Nodes None Mobile Axiliary Fixed Axiliary Distant Mets
Size        
> 5 cm
  • Stage IIB
  • Stage IIIA
  • Stage IIIA
  • Stage IV
2-5 cm
  • Stage IIA
  • Stage IIB
  • Stage IIIA
  • Stage IV
< 2 cm
  • Stage I
  • Stage IIA
  • Stage IIIA
  • Stage IV
 
Studies
  • Serum calcium level
    • may be elevated
  • Alkaline phosphatase
    • elevation may indicate metastasis
  • Hormone receptor tests
    • estrogen
    • progesterone
    • Her-2/neu
Differential
  • Benign breast mass
    • fibroadenoma
      • most common mass
      • especially common in younger women
    • fat necrosis injury
      • hardening of breast tisue secondary to injury to the breast
    • intraductal papilloma
      • bloody discharge
  • Other cancer
    • breast sarcoma
    • lymphoma
      • painless unilateral breast mass in an older woman 
Treatment
  • Medical
    • chemotherapy
      • indications
        • presence of metastases
        • neoadjuvant chemotherapy prior to surgery
        • target therapy for hormone receptor positive (ER and PR) and HER-2/neu oncogene
          • trastuzamab
            • adjuvant for HER-2/neu-positive cancer 
            • associated with reversible dilated cardiomyopathy  
    • endocrine therapy
      • indications
        • ER/PR receptor positive tumor
    • radiation
      • indications
        • induction therapy to reduce initial tumor burden prior to surgery 
        • following lumpectomy to destroy any residual tumor cells
  • Surgical
    • lumpectomy
      • indications
        • smaller tumors
        • patients with strong preference for breast conservation
      • followed by radiation therapy
    • mastectomy
      • indications
        • larger tumors
        • prior history of chest radiation
        • patients who desire mastectomy
      • risk of nerve injury
        • thoracodorsal nerve
          • causes weak adduction and internal rotation
        • long thoracic nerve
          • causes winged scapula
        • intercostobrachial nerve
          • most common nerve injured
          • causes reduced sensation to upper medial arm
Complications
  • Nerve damage during surgery
  • Cancer recurrence
  • Metastasis
  • Death

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(M3.ON.15.15) A 45-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 (which have been stable and without issue) but otherwise has not had any surgeries. She denies any family history of breast cancer. 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?

QID: 102614
1

BRCA genetic testing

0%

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Mammography

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3

No intervention indicated at this time

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4

Sentinel node biopsy

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5

Ultrasound

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M 12 E

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(M2.GN.15.15) 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?

QID: 103038
1

Alcohol cessation

40%

(2/5)

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Colonoscopy at age 60

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Colonoscopy now

40%

(2/5)

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Mammography at age 50

20%

(1/5)

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Mammography now

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(M3.ON.15.38) 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?

QID: 103329
FIGURES:
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Excisional biopsy

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Fine needle aspiration

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Mammography

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Reassurance

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Surgical excision

100%

(3/3)

M 11 E

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