Sarah presented a middle age woman with a history of schizophrenia, HFpEF, possibly COPD, who presented from her Board and Care facility due to inability to ambulate. She was able to provide much of a history but her exam was normal. Her labs were notable for alk phos in the 700-1000 range, and mildly elevated AST/ALT in the 60-70s. An abdominal US revealed hepatic steatosis but really nothing else… Her medical history was also obscure since she receives her care from multiple institutions.
She was incidentally found to have a breast mass on exam, and subsequent work up for her elevated alk phos unfortunately revealed metastatic breast cancer.
Elevated Alk Phos
Background: Alk Phos is derived from mainly bone and liver, higher in men, varies with age (higher in kids, thought to be due to physiologic osteoblastic activity)
GGT (gamma glutamyl transpeptidase): liver specific, can be used to verify if alk phos elevation is due to biliary disease if GGT is also elevated.
Most common tumor in women
- > 50
- Personal Hx
- Strong family Hx of pre-menopausal breast cancer
- Genetic BRCA 1 & 21
- Personal hx or ovarian or endometrial cancer
- Dense breasts
- OCP use for > 15 years
- Late menopause
- Screen F > 50 or < 5-10 yrs prior to age in 1st degree relative with breast cancer, and then Q2yr
- More frequent screening recommended for specific mutations, i.e. BRCA, TP53, then MRI Q year
- How about F with breast implants? MRI, CT, or mammogram? The recommendation is still mammogram but with multiple views
|Local disease in situ||No malignancy beyond basement membrane||Lumpectomy + RT, or mastectomy. If ER +, use tamoxifen/aromatase inhibitors|
|Lobular carcinoma in situ (LCIS)||Isolated to lobule, within basement membrane, not exactly cancer yet but high risk||ER+ use tamoxifen/AI to dec risk of development into invasive breast cancer.
NSABP-P1 trial: Pt with LCIS tx with tamoxifen dec risk of invasive breast cancer, but inc risk of endometrial cancer esp in > 50yo
|Infiltrating ductal carcinoma, LN negative||Spread beyond BM, need to sample sentinel LN, if negative, no further need for dissection.||Wide excision of mass with free margins + RT, adjuvant chemo for size > 1cm. Tamoxifen/AI if ER +|
|Infiltrating ductal carcinoma with LN positive||Same as above but LN +, warrants further LN dissection, automatic adjuvant chemo||Wide excision (modified radical mastectomy), RT + adjuvant chemo + Tamoxifen/AI if ER+.|
|Local invasive dz involving skin or chest wall||Chemo followed by mastectomy, + tamox/AI if ER+|
Lymph node positivity is the most important prognostic factor, followed by tumor size, then receptors, and then grade.
For diagnosis, always get excision biopsy for dx, FNA has low sensitivity, hence even if negative, always follow by excisional bx.
Receptors and Management
|Pre-menopausal||Chemo + tamoxifen||Chemo||+ trastuzumab|
|Post-menopausal||Aromatase inhibitors + chemo||Chemo||+ trastuzumab|
Tamoxifen: Use for 10 years if ER/PR+. Dec risk of new breast cancer and effective for metastatic dz of receptor positive.
Down side: inc risk of endometrial cancer 3x, inc thromboembolic risk.
Aromatase inhibitors: Watch out for osteoporosis