Download Oncology for Step 3

By James K. Rustad, M.D.
Copyright © 2010 All Rights Reserved.
Lecture Outline
 Lung Cancer
 Colon Cancer
 Pancreatic Cancer
 Renal Cell Carcinoma
 Bladder Cancer
 Men’s Health: Prostate and Testicular Cancer
 Women’s Health: Ovarian, Endometrial, and Cervical
Cancer
 Breast Cancer
Lung Cancer
 Leading cause of cancer death
 Adenocarcinoma: most common lung cancer;
peripheral location; bronchoalveolar type is associated
with multiple nodules, bilateral lung infiltrates, and
metastases late in the course.
 Squamous cell: Presents centrally
 Large cell/neuroendocrine carcinomas: Least
common
 Small cell lung cancer (SCLC): Cigarette exposure.
Usually centrally located and always presumed to be
disseminated at time of diagnosis. Tx: Chemo
Symptoms/Exam
 Cough, Hemoptysis, weight loss, or postobstructive pneumonia.
 Pancoast’s syndrome (apical tumor): Shoulder pain, Horner’s
syndrome (ptosis, miosis, anhidrosis), lower brachial plexopathy.
Treatment: Surgical removal and radiation.
 Superior vena cava syndrome: swelling of the face and arm
(most often right side), AMS, headache, visual symptoms.
 Hoarseness: Vocal cord paralysis from entrapment of recurrent
laryngeal nerve (more often left).
 Hypercalcemia: (most often seen with squamous cell
carcinoma). Treatment includes fluids, calcitonin,
bisphosphonates.
 Hyponatremia/SIADH: (Small cell).
 Trousseau’s syndrome: hypercoagulable state (Adenocarcinoma).
Symptoms/Exam continued
 Lambert-Eaton: (Small Cell)
progressive weakness usually
doesn’t involve respiratory
muscles/facial muscles. In
patients with affected ocular and
respiratory muscles,
involvement not as severe as
myasthenia gravis. In contrast to
MG, symptoms of LEMS tend to
be worse in AM, improve w/
exercise and nerve stimulation.
Proximal parts of the legs and
arms predominantly affected.
Autonomic symptoms (dry
mouth, impotence). Reflexes
usually reduced or absent.
Diagnosis
 Chest CT: nodules that
double in size in one year
usually malignant.
 Bronchoscopy or sputum
cytology to diagnose
centrally located cancers.
 Staging: Chest and
abdominal CT, bone
scan, and CT (or MRI) of
head.
Treatment
 Non-small cell lung cancer
(NSCLC): potentially curable
with resection of localized
disease (early stage disease, I
and II); only modestly
responsive to chemo.
 Locally or regionally
advanced disease
(supraclavicular or
mediastinal
lymphadenopathy or chest
wall/pleura/pericardium
invasion): chemo/radiation,
not surgery.
 Distant mets: Palliative care.
 For SCLC: Chemo
Case Scenario
 76 yo M with SOB,
cough, blood-streaked
sputum. Progressive
malaise, weight and
appetite loss for 6
months. 40 pack-year
smoking history.
 Physical Exam: Afebrile,
VSS. Chest: Barrelshaped with
gynecomastia. Lungs:
decreased breath
sounds, rales, wheezing,
dullness on percussion
in L upper lung. Ext:
Finger clubbing, dark
pruritic rash on both
forearms.
Differential Diagnosis?
 DDX: Lung cancer,
lymphoma, sarcoidosis, TB.
 Initial office workup: CBC
with decreased hemoglobin,
CMP (LFTs with increased
transaminases), ABG,
increased ESR, CXR shows
infiltrate and nodules in
upper left lobe.
 Sputum cytology shows
Adenocarcinoma, sputum
culture, CT chest with L
upper lobe mass.
 Continuing management:
 PFT’s
 Oncology, Surgery, Dietary




consult
Bronchoscopy with biopsy
CT abdomen/pelvis and CT
head
Antiemetic medication
Follow-up: TOB/EtOH
cessation, patient/family
counseling, follow up 3-4
weeks with CXR and CBC.
Colon Cancer Screening
 Average Risk individual greater than or equal to 50:
 Annual fecal occult blood X 3 and Flex Sig q5 years.
 Colonoscopy at 50 then q10 years.
 If patient not suitable for colonoscopy: Barium Enema
q 5-10 years, CT or Spiral CT or virtual Colonoscopy.
Colon Cancer Screening (continued)
One family member
with colon cancer > 55
One family member
with colon cancer < 55
or two or more family
members
One family member
with Adenomatous
polyp < age 60
Screening at 10 years
earlier than relative’s age
of diagnosis or at 40:
FOBT (annual) and
sigmoidoscopy (q 5years).
Screening at 10 years
earlier than relative’s age
of diagnosis or at 40 with
colonoscopy (q 10 years).
Screen at 10 years earlier
than relative’s age of
diagnosis or at 40.
Colorectal Polyps: follow-up
 Adenoma: > 1 cm, villous, high grade Dysplasia, > 2 polyps

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


> surveillance q 3 yr (Colonoscopy).
Adenoma: < 1 cm, tubular, three year follow up of above
clinical setting is negative > surveillance q 5 years
(Colonoscopy).
Hyperplastic Polyp: Benign tumor: do normal follow up.
Colorectal Malignant Polyp: Follow up.
If malignant polyp completely removed, margins are clear,
no vascular or lymphatic invasion: First follow up in 3
months then every 3 years (Colonoscopy)
Malignant Polyp: margins not clear, ill differentiated,
vascular or lymphatic invasion: Colectomy.
Staging and Treatment
 Stages I and II = DUKES A
and B. Tumor without
nodal involvement.
Resection and regional
lymph node dissection.
 Stage III (DUKES C).
Bowel wall/nodal
involvement. Add
Flurouracil and Leucoverin
for 6 months.
 Stage IV disease (DUKES
D): Distant mets. Add
irinotecan to (F and L).
Poor prognosis.
Post-op follow up
 Physical exam, FOBT,
LFT, CEA q 3-6 months
for 3-5 years.
 Colonoscopy 6-12
months for 3 years.
 Change in clinical
picture, abnormal LFT
and/or increasing CEA:
Abdominal CT and CXR.
Clinical Case
 68 yo male presents with blood in stool.
 Office work up:
 CBC (decreased hematocrit, increased RDW, decreased
MCV, decreased MCHC), CMP, TSH, Stool for ova and
parasites.
 Iron studies show decreased ferritin and serum iron and
increased TIBC. ESR increased and stool guaiac +
 GI consult, Colonoscopy (polyp with adenocarcinoma), CT
abd/pelvis with contrast. CEA
 Treatment: Iron sulfate, General surgery consult (plan
partial colectomy). Reassure patient.
Pancreatic Cancer
 Ductal adenocarcinoma accounts for 90% of primary
tumors.
 Symptoms: nausea, anorexia, lumbar back pain, new-onset
DM, venous thromboembolism, and painless obstructive
jaundice (adenocarcinoma in the head of the pancreas).
 Diagnostic tests?
 Increased bilirubin; aminotransferances;
normocytic/normochromic anemia, frequent elevation of
CA 19-9. Ultrasound, Abdominal/pelvic CT to evaluate
extent of disease. Thin-section helical CT through
pancreas can determine if mass is resectable. Endoscopic
U/S: excellent anatomic detail.
Treatment
 Pancreaticoduonectomy
(Whipple) if resectable
tumor.
 Chemo or raditation for
palliative care in
advanced or
unresectable disease.
Renal Cell Carcinoma Case
 60 year old male with generalized weakness, left flank
discomfort, constipation. 20 pound weight loss over four
months. Left flank tenderness on physical.
 Management?
 CBC shows Hemoglobin 9.0, CMP shows Ca 15, BUN 40,
creatinine 2.0. U/A positive for Red cells, CXR, Abdominal
U/S shows left renal mass.
 Admit to ward, give Bisphosphonate (pamidronate) and IV
normal saline. PTH (decreased), monitor Ca daily. CT
abdomen and chest to stage (L renal mass), Bone scan, CT
head (to stage), check Ferritin/TIBC, serum iron (correct
anemia of chronic disease). Consult Oncology and Surgery!
Bladder Cancer
 Most cases are transitional cell carcinoma.
 Risk factors: smoking, aniline dyes, chronic bladder

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infections (schistosomiasis).
Present with gross hematuria.
Dx: UA, cytology, IVP, Cystoscopy with biopsy is
diagnostic.
Treatment?
Carcinoma in situ (CIS): Intravesicular chemo.
Invasive cancers without mets: aggressive surgery,
radiotherapy or both.
Distant mets: chemo alone.
Prostate and Testicular Cancer
Prostate Cancer
 Diagnosis based on DRE, PSA
level and ultrasound-guided
needle biopsy of prostate with 612 biopsy specimens. Any PSA
level greater than 4.0 ng/mL or
abnormal DRE requires prostate
biopsy.
 Gleason score sums scores of 2
most dysplastic biopsy samples
on score of 1-5 (5 = poorly
differentiated).
 2-4 most favorable prognosis, 56 intermediate, greater than
equal to 7 is worst.
 Watchful waiting may be best
approach for elderly patients
w/low Gleason scores.
Staging/Treatment
 T1 = tumor confined to
small area of prostate.
 T2 = tumor confined to
either one or both lobes
of prostate.
 T3 = extracapsular
extension.
 T4 = Adjacent organ
involved.
 T1 and T2 disease:
Radiation therapy plus
Radical prostatectomy:
(remove prostate,
seminal vesicle and
ampullae of the vas).
T3 and T4 Prostate Cancer with nodal
involvement
 Androgen Deprivation Therapy
Level
Agent
Pituitary, Hypothalamus
Estrogen & Leuprolide (LHRH
agonist)
Adrenal
Ketoconazole, Aminogluthimide,
Glucocorticoid
Testis
Orchiectomy
Prostate Cell
Flutamide (Antiandrogen)
Androgen deprivation
 The goal is to “starve” prostate cancer of testosterone, which it uses to
flourish. Disease typically becomes hormone refractory within 3 years
of onset of treatment. Many clinicians wait until patient becomes
symptomatic with bone pain before initiating treatment.
 Bilateral orchiectomy removes all testicular production of
testosterone. Castrate levels of serum testosterone achieved in
approximately 3 hours after surgery.
 Ketoconazole is direct inhibitor of testosterone production: blocks
cytochrome P-450, directly halting production of adrenal and gonadal
testosterone. Castrate levels produced in 8 hours.
 Luteinizing hormone releasing hormone meds work by agonizing
LHRH receptors in the pituitary. Produce initial increase in release of
LH and FSH causing “flare phenomenon.” With time, they suppress
LH and FSH production by inhibiting HPA axis. Castrate levels in 30
days.
Case scenario
 72 yo male with BPH and three-month history of low
back pain 3/6 in severity and steady with no radiation.
 DDX: Disk herniation, Lumbar muscle strain,
Muscular spasm, Osteoporosis, Prostate cancer, Sciatic
irritation, Spinal Stenosis, Tumor in Vertebral canal.
Initial Office Work-up
 CBC, CMP, UA, ESR and PSA(elevated).
 XR Back, CT Lumbar Spine shows metastatic lesions in
L4 and L5.
 Rectal Echo: Multinodular enlarged prostate, Prostate
biopsy pending.
 Treatment: Acetaminophen. Morphine or Codeine (if
pain persists).
Continuing Management
 Bone Scan: Diffuse Mets
 Prostate biopsy: Adenocarcinoma
 CT abdomen and biopsy show lymphatic involvement
above aortic bifurcation.
 Rx: Flutamide (anti-androgen) then LHRH agonist.
Consider Urology, Radiation treatment, Radiation
consult.
 Follow-up: Patient counseling.
Clinical Case
 65 yo male with recent onset lower back pain, PSA 45,




unremarkable physical.
Transrectal ultrasound-guided biopsy shows
adenocarcinoma Gleason 4 + 4 = 8 on both sides of
prostate.
Bone scan with areas of increased uptake diffusely,
especially lumbar spine region (suspicious for mets)
First line treatment?
Androgen deprivation: LHRH agonist (must be given
with androgen blocker like flutamide due to “flare
phenomenon”).
Testicular Carcinoma
 Most common solid
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malignant tumor in men
20-35 yo.
Risk factors: Cryptorchid
testis and Klinefelter’s.
Initial finding: unilateral
scrotal mass, may be
painless.
Measure: AFP and HCG.
Staging (TNM) eval should
also include serum LDH
and CT of chest/abdomen
and pelvis.
Seminomas and nonseminomas
 The two main types of testicular tumors are seminomas and nonseminomas.
Approximately half of all testicular tumors are seminomas, which occur when
the germ cells -- the cells that produce sperm -- become cancerous at a very
early stage in their development.
 Nonseminomas are another type of germ cell tumor. These tumors tend to
grow and spread more quickly than seminomas. There are many different kinds
of nonseminomas, including:
 Embryonal carcinomas, which arise in more mature germ cells
 Teratomas, which occur when germ cells differentiate into various tissue types - such as cartilage, nerve, or muscle -- inside the testes (a process that does not
usually occur until after a mature sperm cell combines with a woman's egg)
 Yolk sac tumors, in which the yolk that is normally present in the embryo
becomes cancerous
 Choriocarcinomas, a particularly aggressive but very rare type of tumor that
shares some characteristics with the placenta (the blood-filtering tissue that
forms in a woman's uterus)
 Nonseminomas may contain more than one of these tumor types, and some
even contain all of them.
TNM Staging
 The primary tumor (T) may be classified as:
 T0 -- There is no evidence of cancer.
 Tis (testicular cancer in situ) -- Cancer cells have been found, but are confined
to the testicle.
 T1 -- The tumor has spread to the membrane surrounding the testicle.
 T2 -- Cancer may have spread into the lymph or blood vessels at the vesicle.
 T3 -- The tumor has grown to the spermatic cord, which also may indicate
lymph node involvement.
 T4 -- The tumor has grown into the skin surrounding the testicles (scrotum).
 Regional lymph nodes (N) categories include:
 N0 -- There are no cancer cells in the lymph nodes.
 N1 -- Lymph nodes are smaller than 2 cm in diameter.
 N2 -- At least one of the lymph nodes is bigger than 2 cm, but smaller than 5
cm in diameter.
 N3 -- At least one of the lymph nodes is bigger than 5 cm.
TNM Staging (continued)
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Metastasis (M) categories include:
M0 -- Cancer cells have not spread to other organs.
M1 -- Cancer has spread to other organs.
M1a -- Cancer has spread to the lungs or to lymph nodes
beyond the abdomen or pelvis.
M1b -- Cancer has spread to other, more distant organs,
such as the liver or brain.
Serum (S), or blood, marker levels categories include:
S0 -- Serum marker levels are normal.
S1 -- Markers are slightly higher than normal.
S2 -- There is a moderate increase in marker levels.
S3 -- Marker levels are very high.
TNM Staging (continued)
 Stage I testicular cancer refers to tumors that are confined to the
testicle, with no spread of cancer cells to the nearby lymph nodes
or other organs. Stage IA reflects the absence of cancer cells in
the blood vessels of the testicle; stage IB reflects their presence.
Stage IS indicates an increase in serum marker levels in patients
with a testicular tumor after radical orchiectomy.
 In stage II, cancer cells have spread to the lymph nodes in the
abdomen or pelvis. Stages IIA, IIB, and IIC indicate increasing
size of the lymph nodes.
 Stages III, IIIA, IIIB, and IIIC refer to cancer that has spread to
the lymph nodes in the chest, the lungs, or more distant organs
such as the liver or brain. The cancer also may be classified as
stage III if there are high blood marker levels.
Treatment
 Early-Stage Seminoma (Stages I-IIA)
 Removing the testicle in a surgical procedure called radical
orchiectomy combined with lifelong follow-up surveillance may
be the only therapy needed.
 Early-Stage Nonseminoma (Stages I-IIB)
 Treatment of early-stage nonseminoma tumors begins with a
radical orchiectomy to remove the affected testicle. If the
pathologist does not find cancer cells inside the blood vessels of
the testicle, follow-up surveillance will be recommended. If
cancer cells are present in the blood vessels, additional surgery to
remove lymph nodes from the retroperitoneum (the area of the
abdomen behind the abdominal organs) may be necessary. This
procedure iscalled retroperitoneal lymph node dissection
(RPLND).
Treatment (continued)
 Advanced Testicular Cancer (Stages IS, IIB to III)
 Chemotherapy is a highly effective treatment for many
patients with nonseminoma testicular tumors that
have metastasized beyond the testicle to other regions
of the body. The standard of care for patients with
early-stage nonseminoma tumors includes treatment
with the combination of etoposide and cisplatin (EP),
or a combination of bleomycin, etoposide, and
cisplatin (BEP).
Clinical Case
 27 yo male comes to office, not feeling well and has
been losing weight. Vague abdominal mass in midline
that is non-pulsatile and non-tender. Scrotal exam
shows enlarged R testicle without sensation.
 Most likely diagnosis?
 Loss of testicular sensation and enlarged testis is
diagnostic of testicular carcinoma. In advanced
stages: spreads by lymphatics to paraaortic lymph
nodes (palpable in midline of a thin person).
Ovarian, Endometrial and Cervical Cancer
Ovarian Cancer
 In general a disease of Postmenopausal women and
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prepubertal girls.
Repeated ovulation is a risk factor: chronic
anovulation, multiparity and breast feeding are
protective.
OCP > 5 yrs decreases risk.
Infertility treatment: increased risk of ovarian cancer.
PCOS, HRT: increased risk.
Japanese women migrated to USA with increased risk.
BRCA1 and BRCA2 high incidences of ovarian cancer.
Diagnosis
 Vague symptoms: lower abdominal
discomfort/pressure, gas, bloating, constipation,
irregular menstrual cycles/abnormal vaginal bleeding,
LBP, fatigue, nausea, indigestion, urinary frequency, or
dyspareunia
 Pelvic U/S, CA-125 (epithelial malignancy), AFP for
endodermal sinus tumor, LDH for dysgerminoma,
hCG for nongestational choriocarcinoma. Mixed germ
cell tumors and embryonal carcinomas can produce
various patterns of these markers.
Treatment/Prognosis
 If ovarian cancer suspected, consult GYN-ONC
 Abdominal hysterectomy with bilateral salpingo-
oophorectomy with omentectomy and selective
lymphadenectomy. Drug therapy: Cisplatin with
Paclitaxel.
 Prognosis: 75% have advanced disease at time of
diagnosis.
 5 year survival rate: 17% with distant metastasis, 36%
with local spread, 89% with early disease.
Clinical Case
 60 yo Female G0 presents with 2 month hx of
increasing abdominal girth, decreased appetite/early
satiety. Pelvic exam with Solid Right adnexal mass.
 DDX: CHF, Liver cirrhosis, Ovarian mass.
 Office workup should include?
Work-Up
 CBC, CMP, CA-125 (900).
 CT Abdomen and Pelvis with 10 X 12 cm right complex
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ovarian cyst and large amounts of ascites.
CXR: Right moderate pleural effusion.
EKG, Pap smear, Mammogram, Colonoscopy, GYN
consult.
Further work-up?
In the Wards: Blood type, crossmatch, PT/PTT and
INR. Exploratory lap, TAH-BSO, staging.
Follow-up: Chemo, CA-125, CBC/CMP.
Endometrial Biopsy
Grade
Intervention
Prognosis
Simple or Complex
Hyperplasia
Progestin to reverse
hyperplasia
Excellent
Atypical Hyperplasia
Hysterectomy
Excellent
Endometrial Cancer
TAH/BSO + lymph node
dissection, peritoneal
washing, external beam
radiation +/- Hormonal
and Chemotherapy.
65-90% 5 yr survival
Recurrence
Follow up every 3 months
for 2 yrs. Then twice a
year for three years.
75% recurrences occur
within first two years.
Endometrial Cancer Surgical Staging
Stage
Description
I
Tumor limited to endometrium and half
of myometrium.
II
Endocervical involvement with stromal
invasion.
III
Vaginal, Adnexal and para-aortic lymph
node involvement (+ve peritoneal
cytology)
IV
Tumor invades bladder, bowel and
distant metastasis.
Endometrial Cancer Treatment
 Radiation for Stage I and II disease.
 Hormonal or Chemotherapy for Stage II and III
disease.
 High dose Progestin has been tried for recurrent
disease.
Clinical Case
 60 yo F (G0) with LMP 10 years ago presents w/mild
vaginal bleeding for last two days. Past hx infertility.
 DDX: Atrophic endometritis, cervical cancer,
endometrial cancer, endometrial polyp.
 Office work-up: CBC, CMP, PT/PTT, INR, Bleeding
time, Pap smear, Endometrial biopsy shows poorly
differentiated endometrioid adenocarcinoma.
 Ultrasound: Pelvis: 10-mm endometrial stripe. GYN
consult.
Ward Work-Up and Treatment
 CXR, EKG, CA-125.
 Treatment: Exploratory lap, TAH-BSO. Depending on
staging, patient may benefit from adjuvant therapy
(radiation/chemo/hormonal).
Abnormal Pap Smear
Result
Action
Atypical squamous cell of undetermined
significance (ASCUS)
Reflex HPV testing with referral to
Colposcopy (immediate if follow-up cannot
be assured or immuno-compromisd) if
positive for high risk HPV (16, 18,31,45).
Repeat cytology in 12 months if neg. for high
risk.
Postmenopausal Women with ASCUS
Treat Atrophic epithelium with topical
estrogen followed by repeat cervical cytology
one week after completing treatment.
Pregnant women
No difference in management
Signs of infection
Antibiotic followed by HPV DNA testing
Adolescent
HPV DNA testing may be deferred
Atypical Glandular Cell (AGCUS)
If < 35 Colposcopy and sampling of
endocervical canal. If > 35: Endometrial
Biopsy
Abnormal Pap Smear (continued)
Result
Action
LSIL in adult
Colposcopy
LSIL in adolescents
1. Serial cytology at 6 and 12 mos or
2. HPV DNA testing at 12 months with
referral to Colposcopy for positive
results.
LSIL in post-menopausal women
Same as adolescents
LSIL in Pregnant Women
Colposcopy. Any suspicious lesions
should be biopsied (lesser lesions to be
sampled at clinician’s discretion).
Endocervical curettage should not be
performed. If unsatisfactory exam,
repeat Colposcopy after 6-12 weeks may
be useful.
HSIL in Adult
Immediate referral for Colposcopy
Different reporting methods
#
Dysplasia
CIN
Bethesda
Follow-Up
1
Benign
Benign
Normal
As discussed
2
Benign
w/inflamm.
Benign
w/inflamm.
Normal,
ASCUS
Either repeat
or Colposcopy
3
Mild dysplasia
CIN I
Low grade SIL
Colposcopy
4
Moderate
dysplasia
CIN II
High grade SIL Refer to
GYN,LEEP
5
Severe
Dysplasia &
Carcinoma in
Situ
CIN III
High grade SIL Refer to GYN,
Cryosurgery,
CO2 laser,
Loop
resection,
Conization.
Clinical Case
 33 yo G2P1011 presents with vaginal bleeding after

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
intercourse for the last month. Visible cervical lesion on
Pelvic exam.
DDX: Cervical Cancer, Cervical Polyp, Cervicitis,
Ectropion, Vaginal cancer, Vaginitis.
Office Work-up?
UA, pap smear (HGSIL), G and C culture or PCR, Wet
mount, GYN consult, Colposcopy. Cervical biopsy shows
invasive squamous cell carcinoma of the cervix.
Treatment?
Radical hysterectomy vs. Radiation. +/- adjuvant chemo.
Console patient.
Age Based Approach to Palpable Breast Mass
Age
Most common
lesion
Diagnostic
Evaluation
Comment
15-25
Fibro adenoma
Ultrasound, needle
biopsy. Mammogram
not necessary.
If dx uncertain excision
biopsy. Re-examine after
menses 1-4 months.
25-35
Fibro adenoma (cyst
and cancer uncommon
but possible)
Ultrasound or
aspiration.
If bloody: suspect
cancer.
35-50
Fibrocystic Changes:
cancer, cyst
First Mammogram
(possibly ultrasound
next).
If cystic: FNAC
If solid: excision biopsy.
>50
Cancer until proven
otherwise.
Mammogram then
Biopsy.
Pre-op eval and
counseling.
Pregnancy & Lactating
Women
Lactating adenomas,
cysts, mastitis and
cancer.
Ultrasound, unilateral
mammogram and
possible MRI
Screening Recommendations
Procedure
USPTF
American Cancer
Society
Breast Self Exam
Neither recommended
nor prohibited.
Monthly for women over
age 20.
Clinical Breast Exam
Insufficient evidence to
Every 3 years age 20-40
recommend for or against and annually thereafter.
it.
Mammography
Every 1-2 years for women
aged 40 and above.
Annually age 40 or older.
MRI
None.
Patient with BRCA1 and
BRCA2 gene or, two first
degree relative with
breast cancer. Patient
had radiation age 10-30
years.
Risk factors for Breast Cancer
 Family history of Breast Cancer: screening starts 10
years before the youngest first degree relative was
diagnosed (i.e. if mother had breast cancer at 45,
screening starts at 35 for that patient).
 Family history of Pre-menopausal Breast Cancer OR
combined ovarian and breast cancer OR two first
degree relative with breast cancer.
BRCA1 and BRCA2 gene
 Risk for breast cancer is almost 85-90% by 40 years.
 Some advocate for prophylactic bilateral mastectomy.
 Ovarian cancer risk is 10-20%. BRCA1 gene has higher
rate than BRCA2.
 BRCA1 and BRCA2 genes: clinical breast exam, pelvic
exam, trans-vaginal ultrasound, CA-125 antigen
monitoring and mammography every 6-12 months
beginning at age 25. Prophylactic surgery
(oophorectomy after childbearing age and before
menopause) should be discussed.
Breast Cancer Risk Factors (continued)
 Increasing age
 Early menarche
 Nulliparity
 Delayed child bearing
 Late menopause
 Proliferative breast disease and atypical hyperplasia
 Prolonged use of HRT (USPTF recommends against
this)
Ductal Carcinoma in situ
 Premalignant condition
 Non palpable, irregularly shaped ductal calcification
on Mammography.
 If calcification on Mammography: Core or Excision
Biopsy -- put a needle in the calcification under CT
guidance and remove the tissue around the
calcification.
Invasive Ductal Carcinoma
 Most common breast
cancer in mid 30s and
50s.
 Forms solid tumors.
 Core excision biopsy
should be done, even if
mammography not
suspicious.
 Treatment: surgery,
radiotherapy and also
possibly Tamoxifen.
Invasive Lobar Carcinoma
 Age 45-56
 Vague appearance on
Mammography
 Core/excision biopsy
 Increased risk of
bilateral cancer.
 Prophylactic bilateral
mastectomy or
mastectomy and close
follow-up with
prophylactic Tamoxifen.
Breast disease (continued)
Paget’s disease
Inflammatory Carcinoma
 Presents with
 Rapidly growing, sometimes
dermatitis/macular rash over
nipple or areola.
 Underlying ductal carcinoma
almost always present.
 Biopsy, excision and
radiation.
painful mass that enlarges the
breast.
 Overlying skin is
erythematous, edematous,
and warm.
 Poor prognosis.
Breast Cancer Staging
 Stage I: Tumor 2 cm or less
 Stage II and III: Tumor and Nodal involvement +/-
local involvement
 Stage IV: Distant Metastasis
Treatment of Breast Cancer
 Breast conservation surgery:
 1. Lumpectomy (lump is removed for stage I)
 2. Lumpectomy (removal of tumor with confirmed
tumor free margins) + lymph node dissection:
Tylectomy plus breast radiation.
 3. Partial mastectomy and axillary node dissection or
Sentinel Lymph Node mapping + radiation therapy.
Randomized trial has shown equal survival as
Modified Radical Mastectomy.
Modified Radical Mastectomy
 Total removal of breast tissue, overlying skin, areola,
nipple, underlying Pectoral fascia (NOT pectoral
muscle) and axillary node dissection.
 Advantage: no radiotherapy necessary.
Chemotherapy
 1. Cyclophosphamide, Methotrexate and Fluorouracil




(CMF).
2. Adriamycin + Cyclophosphamide (AC).
3. Single Agents: Taxanes (Paclitaxel and Docetaxol).
4. Tamoxifen & Anastrozole (Estrogen receptor
positive tumor cell).
5. Trastuzumab: (for patient with HER-2/neu oncogen
overexpression).
Clinical Case
 29 year old female presents with 3 days of bloody discharge





from the right nipple and a lump (1 cm movable [not-fixed]
mass in Right outer/upper quadrant of R breast) and no
skin dimpling, erythema, or peau d’orange. Which of the
following conditions is most likely cause of the nipple
discharge?
A) Fibroadenoma
B) Fibrocystic change
C) Mastitis
D) Intraductal carcinoma
E) Intraductal papilloma
Clinical Case (continued)
 Which of the following options regarding





management of the nipple discharge would you
recommend?
A) Cytologic studies
B) Culture studies
C) Mammography
D) Excisional biopsy
E) Reexamination in 2-4 weeks
Clinical Case (continued)
 Which of the following conditions is the most likely





cause of the breast mass?
A) Fibroadenoma
B) Lobular carcinoma in situ
C) Fibrocystic change
D) Adenocarcinoma
E) Ductal carcinoma in situ
Clinical Scenario
 50 year old female presents as an outpatient with a
painless lump in her right breast. She first noted this
mass one month ago. No nipple discharge. On
physicial exam: 3 cm, hard, immobile, non-tender
mass with irregular borders; no nipple discharge.
 DDX: Breast cancer, Fibroadeonma, Fibrocystic
disease, Mastitis, Papillomas.
 Management?
 Mammography (suspicious of tumor), FNA biopsy
(malignancy). Counsel patient and consult surgery.
Questions?
 Thank you for your attention!