CDM L4 – Flashcard
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One of the first and most frequent areas of nodal metastasis in breast cancer patients is the ___ lymph nodes.
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axillary
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Area adjacent to the tail of the breast
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Low
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Area under the pectoralis minor muscles
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Mid
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Apex of the axilla
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High
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The most frequently involved distant lymph nodes for breast cancer are the _____ (transverse cervical) lymph nodes.
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supraclavicular
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Ninety percent of all breast cancers arise from the glandular epithelial lining of the ducts. Thus, most tumors are _____ in origin.
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intraductal
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a noninfiltrating or in situ lesion
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lntraductal (adeno)carcinoma
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a general term denoting an infiltrating tumor of ductal origin.
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Ductal (duct cell) (adeno)carcinoma
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a well-differentiated tumor of epithelial origin which will often have evidence of lymphoid infiltration in the stroma.
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Medullary (adeno)carcinoma
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a mucin-producing tumor which may have a gelatinous or colloid (glue-like) appearance when sufficient amounts of mucin are present.
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Mucinous (adeno) carcinoma
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arises in the lobules of the breast as the name implies. It is most often diagnosed in situ but will eventually invade the parenchyma. Multiple foci are frequently found including foci in both breasts.
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Lobular (adeno) carcinoma
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is a clinical term used to describe a condition in which there is diffuse involvement of the breast, particularly of the skin, causing widespread erythema, edema, and discoloration. It is generally inoperable and has a poor prognosis.
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Inflammatory carcinoma
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a tumor of ductal epithelial origin in which fibrous connective tissue has formed giving it a hard consistency.
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Scirrhous (adeno) carcinoma
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presents as a weeping eczematoid lesion of the nipple and areola. It occurs as the result of nipple invasion from an underlying ductal carcinoma. The presence of Paget's disease does not alter the staging of the original tumor.
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Paget's disease
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also known as cellular intracanalicular fibroma, is usually a benign disease contrary to the inclusion of "sarcoma" in the name of this tumor. It is one of the rare stromal tumors of the breast and, although it may become very large, cystic, and hemorrhagic, it only infrequently becomes invasive.
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Cystosarcoma phyllodes,
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Bloom-Richardson grading system
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is a semi-quantitative grading method based on three morphologic features of invasive (no-special-type) breast cancers. The morphologic features are: degree of tumor tubule formation (% of Carcinoma Composed of Tubular Structures) tumor mitotic activity nuclear pleomorphism of tumor cells(change in cell size and uniformity).
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PHYSICAL EXAM Key Information
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Clinical size and location of tumor or masses; skin changes (inflammation, ulceration, dimpling, satellite nodules, erythema [redness]), fixation of tumor, involvement of opposite breast, discharge, palpable axillary nodes ("shotty" nodes, fixed or matted nodes), involvement of supraclavicular or cervical nodes.
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TUMOR MARKERS Key Information Prognostic (what treatment to use if the tumor should recur)
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Estrogen Receptor Assay (ERA) A laboratory test of breast cancer tissue to determine the responsiveness of the tumor to hormone manipulation, endocrine therapy or removal of the ovaries. About 55% of ER positive tumors will respond to endocrine therapy. Tumors which are negative for estrogen receptors rarely respond to hormone manipulation. The unit of measurement is femtomoles (fmoles) per milligram of tumor.
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Progesterone Receptor Assay (PRA)
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A laboratory test of breast cancer tissue to determine the responsiveness of the tumor to endocrine therapy or to removal of the ovaries. Progesterone receptor assay increases the reliability of estrogen receptor assay results: a positive progesterone receptor assay indicates greater likelihood that the patient will respond to hormone therapy. The unit of measurement is femtomoles (fmoles) per milligram of tumor.
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Other Breast Cancer Tumor Markers
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C219 Presence is associated with multidrug resistance. CA 15-3 (Cancer Antigen 15-3) Elevated in 76% of metastatic breast cancers. CA 549 (Cancer Antigen 549) Present in 50% of patients with advanced breast cancer. Cathepsin D Distinguishes node-negative patients who may recur (and therefore should receive adjuvant chemotherapy) from node-negative patients who probably will not recur. Elevation indicates a poorer prognosis. CEA (Carcinoembryonic Antigen) Persistent elevated levels indicate residual or recurrent metastatic carcinoma. C-erb B-2 (also called HER-2 or neu oncoprotein) Associated with larger sized tumors, shorter relapse time and lower survival rate.
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PATHOLOGY Key Information
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Cell type, exact size of malignment lesion, presence of multiple tumors in breast, size and number of lymph nodes involved (including micrometastases), extension to adjacent tissues (muscle, fascia, skin). Cytology reports Sentinel lymph node biopsy Selective removal of one or more axillary lymph nodes identified by placing dye or a radioactive agent in the tumor bed and following the flow of the dye to specific lymph nodes. The lymph nodes which trap the dye or radioactivity are the first nodes in the lymphatic drainage of the tumor and as such are more likely to contain metastases if present. If the sentinel lymph nodes are negative, there is a 95% chance that all other axillary lymph nodes are negative also.
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lumpectomy
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the cancerous lump and a margin of normal tissue around it are removed.
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radiation therapy
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high-energy x-rays are used to destroy cancer cells that may still be present in the affected breast or in nearby lymph nodes.
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chemotherapy
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When a tumor is large, identified as aggressive, and/or involves the lymph nodes, some form of systemic adjuvant treatment, such as chemotherapy, is often recommended. This is usually administered postoperatively following surgery to destroy cancer cells that may have escaped into the lymph and blood vessels, thereby reducing the likelihood of a recurrence. On the other hand, a small tumor can shed cancer cells outside the breast.
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HORMONAL THERAPY
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used to prevent the growth, spread, or recurrence of breast cancer. A pathology test on a sample of tumor tissue will reveal if the cancer has estrogen and progesterone receptors. If it has estrogen receptors, it is said to be estrogen-receptor positive; if not, it is said to be estrogen negative. The same is true of progesterone receptors. When a tumor is said to be estrogen-positive or progesterone-positive, it means the tumor depends on the patient's natural hormones to grow.
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monoclonal antibody
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immunotherapy
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an independent prognostic factor for determining the potential of a breast cancer to spread
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axillary lymph node status
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when reviewing physical findings
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look for a description of laterality, tumor size, tumor location and palpation of the axillary lymph nodes
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Cooper's ligaments
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suspensory ligaments
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The chest wall is defined as
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the ribs, intercostal muscle, and serratus anterior muscles. The chest wall is an anatomic landmark for TNM staging
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For staging purposes
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the pectoralis muscles (other skeletal muscles on the chest) and the pectoralis fascia are considered part of the breast rather than the chest wall
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Nodes within the breast stroma or axillary tail of the breast are called
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intramammary
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Nodes between the ribs at the edge of the sternum are
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the internal mammary nodes are also called parasternal or substernal nodes
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supraclavicular nodes
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lie just aboe the clavicle and are defined as regional nodes
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ductal carcinoma
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the most common type of adenocarcinoma, comprising 70-80% of all breast cancers
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Histologic grade for invasive breast cancer is
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based on the degree of tubule formation, number of mitoses, and nuclear pleomorphism in routine sections. These are combined as the Bloom-Richardson (BR) grade
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Tubule formation
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means that the cells are forming glands, as normal breast cells do, so tubule formation is a favorable sign
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Mitoses are the cells that are
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actively dividing and a measure of how rapidly the cancer is growing
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Nuclear pleomorphism means
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looks at the shape of the nucleus in the tumor cells; the more varied the cells are under the microscope, the less favorable the prognosis
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fungating
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ulcerated
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Where to look in the patient's record
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a. History and physical exam report b. Consultation report(s) c. Physician's progress notes
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What information to select and record (record all dates) Signs and symptoms that document:
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1. Duration of symptoms 2. How the breast abnormality was detected (self-exam, mammography, other) 3. Pain, redness, swelling 4. Signs of advanced disease (skin or chest wall involvement, bone pain, other signs
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What information to select and record
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Pertinent findings as to what the physician sees and feels when examining the patient
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Primary breast cancer
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is breast cancer that has not spread beyond the breast or the lymph nodes (glands) under the arm
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BI-RADS Assessment categories
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The American College of Radiology (ACR) established the Breast Imaging Reporting and Database System to help standardize the interpretation of mammograms
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Ultrasound
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is used to visualize cystic and solid masses
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What information to select and record (record all dates)
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1. Area of body being examined (right breast/axilla, left breast/axilla) 2. Laterality 3. Tumor location, including subsite(s), lobe(s) or quadrants 4. Tumor size and extent of tumor 5. Lymph node status 6. Statements regarding regional or distant spread, including location and number of metastatic lesions
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BRCA1/BRCA2
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are genes that in their normal state produce protein compounds that suppress changes that can lead to cancer (tumor-suppressor genes)
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Estrogen (ER) and progesterone (PR) receptor assays
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are measures of protein receptors for two types of female hormones that affect breast cancer tissue ER+/PR - = receive hormone therapy ER-/PR+ = may not receive hormone therapy
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HER2/neu
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a protein in breast tissue that is overproduced in about one-fourth of all breast cancers
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What information to select and record (record all dates) Laboratory tests and tumor markers
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1. Test type 2. Test result 3. Normal test value/range
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BSE
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breast self-exam
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open breast biopsy
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the most common procedure for the diagnosis of breast cancer
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Excisional biopsy
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sometimes called lumpectomy
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extent of local
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confined to breast tissue
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extent of regional
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direct invasion to extramammary tissues or metastasis to regional lymph nodes
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extent of distant
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metastasis beyond regional tissues
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sentinel node
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not a specific lymph node or chain called the sentinel lymph nodes; rather they are the first nodes that could catch tumor cells floating away from a tumor
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operative report
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diagnostic exploratory procedures and/or cancer directed definitive treatment
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STAR Trial
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the Study of Tamoxifen (Nolvadex) and Raloxifene (Evista)
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trastuzumab (Herceptin)
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is a monoclonal antibody that differs from traditional treatments by specifically targeting tumor cells that overexpress the HER2/neu protein found in about 20% of breast cancers
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Following excisional biposy/lumpectomy/partial removal of a breast tumor
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external beam radiation is delivered
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MammoSite
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is targeted radiation therapy (brachytherapy) using higher daily dose that can be delivered in 5 days rather than 5 to 7 weeks
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aromatase inhibitors (AIs)
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shut down the production of estrogen and progesterone in postmenopausal women. Example Arimidex (Anastrozole)
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TDLU
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Each breast lobe is drained by a collecting duct terminating in the nipple. The collecting duct has several branches, which end in a terminal ductal-lobular unit (TDLU), the basic functional and histopathological unit of the breast.
