Breast cancer - Chronic
Definition
A malignancy of the epithelial lining of the terminal ductal-lobular unit of the breast.
Medical History
* Aging
* Adult (>18-65 years) , Primigravida
* Early menarche
* Past medical history of Breast cancer
* Family history of Breast cancer
* Genetic predisposition
* Past medical history of Atypical hyperplasia of breast
* Past medical history of Ovarian cancer
* Obesity [Obesity - Chronic]
* Nulliparous
* Delayed menopause
* Estrogen use
* Environmental Exposure
* Alcohol intake - finding
* Radiation injury
Findings
* Breast lump
* Discharge from nipple
* Retraction of nipple
* Breasts asymmetrical
* Dimpling of surface of breast
* Peau d'orange surface of breast
* Erythema
* Scaly skin
* Pain of breast
* Lymphadenopathy
Tests
Evaluation of patients with signs or symptoms of breast disease or abnormalities on screening mammography or other imaging modality
* Bilateral mammography: Current mammography images should be compared with prior breast imaging studies. Appropriate surveillance or treatment is determined by results that are designated by Breast Imaging Reporting and Data System (BI-RADS®) categories as incomplete, negative, benign, probably benign, suspicious, highly suspicious, or known biopsy-proven malignancy .
Evaluation of masses detected with mammography, palpable masses, or other breast findings
* Ultrasonography of breast: Breast sonograms should be correlated with signs and symptoms and mammograms or other imaging studies, including prior sonograms if available. Breast Imaging Reporting and Data System (BI-RADS®) categories include size, shape, orientation, margin, echogenicity, lesion boundary, attenuation, special cases, and surrounding tissue .
Evaluation of masses suspicious or suggestive of malignancy , cysts, or complex masses
* Biopsy of breast: The definitive diagnosis of breast cancer requires pathologic review of a fixed specimen of breast tissue, which may be obtained by core needle biopsy (preferred in many cases ), fine needle aspiration, or surgical excision .
Select cases of suspected breast cancer
* Excision of lesion of breast: Surgical excision is indicated for biopsy results showing ADH, ALH, or LCIS, or other pathology that requires additional tissue . Surgical excision also is indicated for cysts with an intracystic mass or wall thickening , and large or rapidly enlarging fibroadenomas .
Workup for invasive breast cancer
* Estrogen-progesterone receptor assay measurement, Specimen from breast: Steroid hormone receptor status should be used to identify premenopausal and postmenopausal patients with invasive and metastatic breast cancer most likely to benefit from endocrine therapy .
Workup for invasive breast cancer
* Human epidermal growth factor receptor 2 (HER2) gene detection, Specimen from breast: Trastuzumab therapy, with or without adjuvant cytotoxic chemotherapy, is recommended in most patients with human epidermal growth factor receptor 2 (HER2)-positive breast cancer.
Workup for lobular carcinoma in situ (LCIS)
* History AND physical examination
* Bilateral mammography
* Pathologist review
Workup for ductal carcinoma in situ (DCIS)
* History AND physical examination
* Bilateral mammography
* Pathologist review
* Estrogen receptor assay (ERA)
Patients with ductal carcinoma in situ (DCIS) at high risk for hereditary breast cancer
* Genetic counseling
Workup for early-stage breast cancer (clinical stage I, IIA, IIB) or operable locally advanced breast cancer (clinical stage T3, N1, M0)
* History AND physical examination
* Complete blood count
* Platelet count
* Hepatic function panel
* Serum alkaline phosphatase measurement
* Bilateral mammography
* Pathologist review
* Estrogen-progesterone receptor assay measurement
* Human epidermal growth factor receptor 2 (HER2) gene detection
Optional additional tests for early-stage breast cancer (clinical stage I, IIA, IIB) or operable locally advanced breast cancer (clinical stage T3, N1, M0)
* Ultrasonography of breast
* MRI of breast
* Radioisotope scan of bone
* CT of abdomen
* Abdominal ultrasound
* MRI of abdomen
* Chest imaging
* Genetic counseling
Workup for locally advanced invasive breast cancer (clinical stage IIIA [except T3, N1, M0], IIIB, and IIIC)
* History AND physical examination
* Complete blood count
* Platelet count
* Hepatic function panel
* Serum alkaline phosphatase measurement
* Chest imaging
* Bilateral mammography
* Pathologist review
* Estrogen-progesterone receptor assay measurement
* Human epidermal growth factor receptor 2 (HER2) gene detection
Optional additional tests for locally advanced invasive breast cancer (clinical stage IIIA [except T3, N1, M0], IIIB, and IIIC)
* Ultrasonography of breast
* MRI of breast
* Radioisotope scan of bone
* CT of abdomen
* Abdominal ultrasound
* MRI of abdomen
Workup for initial diagnosis of metastatic breast cancer (clinical stage IV) or recurrent breast cancer
* History AND physical examination
* Complete blood count
* Platelet count
* Hepatic function panel
* Chest imaging
* Radioisotope scan of bone
* Radiographic imaging of bone
Additional studies that may be required for initial diagnosis of metastatic breast cancer (clinical stage IV) or recurrent breast cancer
* CT of abdomen
* MRI of abdomen
* Pathologist review
* Estrogen-progesterone receptor assay measurement
* Human epidermal growth factor receptor 2 (HER2) gene detection
Differential Diagnosis
* Carcinoma in situ of breast
* Infiltrating duct carcinoma of breast
* Lobular carcinoma of breast
* Inflammatory carcinoma of breast
* Paget's disease
* Fibrocystic breast changes
* Fibroadenoma of breast
* Cyst of breast
* Breast lobule hyperplasia
* Duct papilloma of breast
* Mastitis
* Fat necrosis of breast
* Malignant phyllodes tumor of breast
Treatment
Drug Therapy
Adjuvant hormonal therapy in premenopausal women with invasive breast cancer, with or without ovarian suppression or ablation therapy
TAMOXIFEN CITRATE
Adjuvant hormonal therapy in postmenopausal women with invasive breast cancer
ANASTROZOLE
LETROZOLE
EXEMESTANE
TAMOXIFEN CITRATE
Adjuvant chemotherapy for invasive breast cancer, non-trastuzumab combinations
DOXORUBICIN HYDROCHLORIDE - CYCLOPHOSPHAMIDE
EPIRUBICIN HYDROCHLORIDE - CYCLOPHOSPHAMIDE
CYCLOPHOSPHAMIDE
FLUOROURACIL
CYCLOPHOSPHAMIDE
DOXORUBICIN HYDROCHLORIDE - CYCLOPHOSPHAMIDE
Doxorubicin followed by cyclophosphamide/methotrexate/5-fluorouracil (A followed by CMF)
EPIRUBICIN HYDROCHLORIDE - CYCLOPHOSPHAMIDE
Epirubicin followed by cyclophosphamide/methotrexate/5-fluorouracil (E followed by CMF)
DOXORUBICIN HYDROCHLORIDE - CYCLOPHOSPHAMIDE
Doxorubicin/cyclophosphamide followed by paclitaxel (AC followed by T)
DOCETAXEL
DOXORUBICIN HYDROCHLORIDE - CYCLOPHOSPHAMIDE
Dose-dense doxorubicin/cyclophosphamide followed by paclitaxel (dose-dense AC followed by T)
DOXORUBICIN HYDROCHLORIDE - PACLITAXEL
Dose-dense doxorubicin followed by paclitaxel followed by cyclophosphamide (dose-dense A-T-C)
FLUOROURACIL
5-fluorouracil/epirubicin/cyclophosphamide followed by docetaxel (FEC followed by T)
DOCETAXEL
Adjuvant chemotherapy for invasive breast cancer, trastuzumab combinations
TRASTUZUMAB
Trastuzumab following adjuvant chemotherapy
DOXORUBICIN HYDROCHLORIDE - CYCLOPHOSPHAMIDE
Doxorubicin/cyclophosphamide followed by paclitaxel with trastuzumab (AC followed by T with trastuzumab)
DOCETAXEL
Docetaxel with trastuzumab followed by 5-fluorouracil/epirubicin/cyclophosphamide (FEC)
Chemotherapy combinations for metastatic disease
FLUOROURACIL
CAPECITABINE
GEMCITABINE HYDROCHLORIDE - PACLITAXEL
IXABEPILONE
LAPATINIB
PACLITAXEL
VINORELBINE
Single agent chemotherapy for metastatic disease
CAPECITABINE
DOCETAXEL
DOXORUBICIN HYDROCHLORIDE LIPOSOME
EPIRUBICIN HYDROCHLORIDE
IXABEPILONE
PACLITAXEL
PACLITAXEL PROTEIN-BOUND
TRASTUZUMAB
VINORELBINE
Procedural Therapy
Select patients with DCIS, early stage invasive disease, or locally advanced disease
* Lumpectomy of breast
Select patients with DCIS, early stage invasive or locally advanced disease, and women with recurrent cancer initially treated with lumpectomy
* Mastectomy
Select patients with DCIS, most patients with early stage invasive or locally advanced disease , and palliative treatment for patients with limited symptomatic metastases
* External beam radiotherapy
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