Master the board step 3

Master the Boards: USMLE Step 3
Sentinel node biopsy follows an abnormal mammogram: A dye or tracer is
placed into the operative field. The first node it goes to is biopsied. This is the
“sentinel node.”
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If this node is free of cancer, then an axillary node dissection is not necessary.
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If the node does have cancer, then an axillary lymph node dissection is
performed.
BRCA
BRCA genetic testing is not a routine screening test. All that can be said for
sure about BRCA is:
Use tamoxifen if 2 or more
first-degree relatives have
breast cancer.
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BRCA is associated with an increased risk of familial breast cancer.
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BRCA is associated with an increased risk of ovarian cancer.
Treatment
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Best initial therapy: Lumpectomy with radiation treatment of the site at the
breast is equal to modified radical mastectomy.
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Primary preventive therapy: Tamoxifen should be used in any patient
with multiple first-degree relatives (mother, sister) with breast cancer.
Tamoxifen decreases risk by 50 percent. Start at age 40.
A 42-year-old woman has a 2-cm breast cancer tumor removed by lumpectomy,
and the breast is irradiated. The cancer is negative for estrogen receptors and
positive for progesterone receptors. Three of 14 nodes removed from the axilla
are positive for cancer. What is the next best step in management?
a. Adjuvant chemotherapy and radiation of the axilla
b. Tamoxifen for 5 years
c. Anastrozole (aromatase inhibitor) for 5 years
d. Tamoxifen and adjuvant chemotherapy
e. Oophorectomy and chemotherapy
Answer: D. Tamoxifen is used whenever there are either estrogen receptors or progesterone
receptors positive. If both receptors are positive, tamoxifen will be of greater
benefit. Adjuvant chemotherapy is used whenever the axillary nodes are positive or the
cancer is > 1 cm in size.
Hormonal Inhibition Therapy
Tamoxifen or raloxifene is used if either the estrogen or progesterone receptors
are positive. The response is greater if both are positive. Following are the
adverse effects of tamoxifen:
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Deep venous thrombosis (DVT)
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Hot flashes
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Endometrial cancer
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