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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3063_Библиотеки_им_академика_М_И_Перельмана
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Initial Management
Setting: outpatient
Diagnostic/Therapeutic Plan
Test Results
CCS NOTE
Always ask for an oncology consult when you have an oncology patient needing
chemotherapy.
Assessment
The routine detection of breast mass on examination is the most common presentation of breast
cancer. Differentiation between malignant and benign disease is crucial. Malignant disease is
characterized on examination by irregular borders, being fixed to fascia, skin dimpling, and
Intraductal papilloma5.
Mammography
Needle biopsy
3.5-cm mass with irregular borders in retroareolar region of left breast; no other lesions
seen in either breast
Needle biopsy: Invasive ductile carcinoma; estrogen receptor; progesterone receptor-
positive
391
nipple discharge. Bloody cysts should always be investigated. Mammograms are used to rule
out other lesions that are not palpable. A normal mammogram does not obviate the need for
biopsy of a suspicious solid mass.
Mammography should be done even though you need a breast biopsy for 2 reasons. The first is
to see if there is bilateral disease. The second is to see if there is more than one location of
breast cancer in the same breast. Multifocal breast cancer means you cannot do a lumpectomy
with radiation. Mammography should be done before the breast biopsy because the biopsy
damages the architecture of breast.
Further Management
CLINICAL PEARL
Do mammogram first, then biopsy next. The mammogram comes before the biopsy
because biopsy would alter the mammogram.
Test Results
Discussion
Sentinel lymph node biopsy
HER2/Neu antigen
Sentinel lymph node biopsy: Positive
HER2/Neu antigen: Positive
392
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Breast cancer will affect approximately 12% of women in the United States and 3.5% will die
of the disease. It is the leading cause of death among American women age 40–55.
Family history is an important risk factor. Its significance increases with the number of
immediate relatives involved, bilateral disease, and their age at onset. The risk may approach
50% if both mother and sister had disease age <50. However, 75% of breast cancer patients do
not have a relative with a history of breast cancer.
Another major risk factor is number of ovulatory cycles a woman undergoes. Early menarche
and late menopause are associated with increased risk due to increased lifetime exposure to
estrogen. High-dose oral contraceptives and estrogen replacement may be associated with
increased risk because of estrogen exposure, but lower-dose estrogen preparations are not
clearly shown to increase risk. Nulliparity also carries increased risk.
A history of fibrocystic disease is not considered a risk factor.
Screening has shown to be of greatest benefit in women age >50, but whether to start screening
at age 40 or 50 is still considered controversial and many physicians recommend this to their
patients.
Stage I Tumors <2 cm without lymph node disease
Stage II Lesions >2 and/or lymph node involvement
Stage III Locally advanced disease including
inflammatory breast cancer
Stage IV Metastatic disease; primary sites of metastases
include bone, lung, pleura, liver, and the CNS
393
Sentinel lymph node biopsy is performed to see if an axillary dissection is necessary. A dye is
injected into the operative site. The first node to pick up the dye is the “sentinel” node. If there
is no cancer in it, then a further lymph node dissection is not needed.
Treatment for local disease is modified radical mastectomy and axillary dissection, or
lumpectomy and axillary dissection followed by radiation therapy to the involved field. These
2 options are associated with the same overall survival. For tumors >1 cm, adjuvant
chemotherapy is given to reduce the risk of recurrence by approximately 30%. The most
common regimen is doxorubicin, cyclophosphamide, docetaxel. Stage II disease is more
difficult to manage and usually requires preoperative (neoadjuvant) chemotherapy/radiation
therapy to create a resectable disease. Stage IV disease is incurable with standard
chemotherapy. Research has shown that high-dose chemotherapy with autologous bone marrow
rescue actually worsens survival. Chemotherapy and radiation therapy are used in this setting
for palliative purposes.
CLINICAL PEARL
Screening with mammography has been shown to be most effective age >50;
however, this is a controversial topic among various groups. Many physicians still
initiate screening at age 40. You will not be tested on controversial topics because
there is no one right answer.
Lumpectomy with radiation is equally as effective as modified radical mastectomy.
There is a higher rate of focal recurrence when lumpectomy is used, but overall
outcomes are unchanged.
Adjuvant therapy:
Breast cancer in premenopausal women is aggressive; therefore, treatment is
usually chemotherapy after removal of the tumor
—
Breast cancer in post-menopausal women should be treated with aromatase
inhibitors if estrogen-receptors are positive; if receptors are negative,
—
394
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Therapies which lower mortality in breast cancer:
Follow-up Management
Final Diagnosis
Breast cancer, stage II
chemotherapy is used as adjuvant treatment
Surgical removal: either mastectomy or lumpectomy with breast radiation
Tamoxifen or raloxifene (selective estrogen receptor modifiers) for pre-menopausal women
Aromatase inhibitors (anastrazole, letrozole) for post-menopausal women
Anti-HER2/Neu (trastuzumab +/- pertuzumab)
Chemotherapy
Lumpectomy with lymph node dissection with radiation (breast and axillary area)
Adjuvant chemotherapy
Trastuzumab with HER2/Neu positive persons
Tamoxifen or aromatase inhibitors for either ER or PR positive persons for 5–10 yrs
395
Case 7
Chief Complaint
“I want to be checked out for cancer.”
History and Physical Examination
A 52-year-old woman comes to the office stating that her sister was recently diagnosed
with breast cancer and so she wants to be tested for cancer. She reached menarche at age
10 and is now premenopausal. She has had no pregnancies. In addition to her younger
sister, an aunt was diagnosed with breast cancer. Her mother died secondary to ovarian
cancer, and a grandfather had a history of colon cancer.
Upon examination her BP is 110/70 mm Hg and pulse 80/min. She is anxious. Rectal exam
shows guaiac-negative stool. Breast exam shows no palpable masses and no axillary
adenopathy.
CCS NOTE
The case simulations will likely be more focused in the preventive medicine of cancer
than in the specific treatment of individual cancers.
Initial Management
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Setting: outpatient
Diagnostic/Therapeutic Plan
Test Results
Assessment
In patients who have several family members with breast or ovarian cancer, the possibility of a
familial cancer syndrome is raised. BRCA-1 refers to a genetic mutation in a DNA repair gene
that is associated with increased risk for both breast and ovarian cancer; it is transmitted in an
autosomal dominant fashion. It is associated with early-onset disease with a penetrance of 85%
by age 70.
The management of what to do when the BRCA gene is positive is not clear. Prophylactic
tamoxifen reduces the risk of cancer by 50% and should be considered where there are 2 first-
degree relatives with breast cancer. An overall survival advantage for prophylactic bilateral
mastectomy over rigorous screening in BRCA-1 mutated patients has yet to be shown.
Lynch syndrome is associated with hereditary non-polyposis colorectal cancer (HNPCC),
endometrial cancer, and ovarian cancer. Li-Fraumeni syndrome is related to inherited
abnormalities in the p53 tumor-suppressor gene, and is associated with early breast cancer,
soft-tissue sarcoma, brain tumors, adrenal cortical cancer, and leukemia. There are guidelines
Screening mammography
Colonoscopy
Pap smear
No abnormalities
Colonoscopy: single polyp removed, 1 cm, benign pathology
Pap: low-grade squamous intraepithelial lesion (SIL)
397
in place for how to screen patients with a strong family history of HNPCC (Amsterdam
criteria), but these are beyond the scope of USMLE testing.
The patient described here has several risk factors for breast cancer. In addition to her family
history, she has a history of early menarche, late menopause, and nulliparity. Her examination
and mammogram do not suggest the presence of a malignancy. A Pap smear of low-grade SIL
usually requires immediate colposcopy to evaluate a possible lesion. However, because many
of these lesions spontaneously regress, some physicians favor a repeat Pap smear in 6 mos. If
several repeat tests are normal, then the Pap is done every 2–3 yrs.
Further Management Plan/Results
CCS NOTE
The exam will likely expect you to follow the U.S. Preventive Health Services Task
Force (USPSTF) recommendations for standard of care, but these sometimes differ
from individual specialty guidelines. The exam does not follow individual
recommendations from private or for-profit organizations.
Discussion
There is general agreement that women age >50 should undergo mammography yearly, but
many physicians will still initiate screening at age 40.
Cervical cancer is associated with multiple sexual partners and early promiscuity. The
etiologic agent is HPV virus. Pap smear screenings and vaccination strategies have shown a
Colposcopy: normal
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major impact on incidence and mortality. Screening should start at age 21 and be performed
yearly. Following 3 normal examinations, in some settings, Pap can be performed every 3 yrs
and can generally be discontinued age >65.
The interval between screenings can be increased to every 5 yrs at age 30–65 if HPV testing is
also done. The age of onset of sexual activity no longer matters.
Prostate-specific antigen (PSA) testing is no longer recommended routinely. PSA screening in
the average-risk patient does not improve mortality and may even worsen it because of the
morbidity derived from biopsy and surgical management.
Starting Age Frequency Ending Age
Mammography 50 Yearly 70
Pap Smear 21 Every 3 yrs or every
5 yrs with HPV
testing
65
Colonoscopy 50 Every 10 yrs None
Follow-up Management
Final Diagnosis
Cancer screening in average risk patients
Repeat Pap smear in 6 mos
Follow up colonoscopy in 3 to 5 yrs
Repeat mammogram in 1 year
399
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