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Breast Cancer

Breast cancer is the most common female cancer, accounting for 32% of all female cancers. There are over 211,000 new cases diagnosed yearly in the United States. Breast cancer can present as lumps, abnormal mammograms, or axillary lymphadenopathy. Treatment options depend on staging and include lumpectomy with radiation or mastectomy with possible chemotherapy, radiation, hormonal, or targeted therapy. Screening mammography is recommended annually starting at age 50 to detect cancers early.

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62 views32 pages

Breast Cancer

Breast cancer is the most common female cancer, accounting for 32% of all female cancers. There are over 211,000 new cases diagnosed yearly in the United States. Breast cancer can present as lumps, abnormal mammograms, or axillary lymphadenopathy. Treatment options depend on staging and include lumpectomy with radiation or mastectomy with possible chemotherapy, radiation, hormonal, or targeted therapy. Screening mammography is recommended annually starting at age 50 to detect cancers early.

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SHIVAJI
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPT, PDF, TXT or read online on Scribd
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Breast Cancer

March 7, 2024
Introduction
 Most common female cancer
 Accounts for 32% of all female cancer
 211,300 new cases yearly and rising
 40,000 deaths yearly
Gross Anatomy

•Sappy’s plexus – lymphatics under areolar complex


•75% of lymphatics flow to axilla
Microscopic Anatomy
 Stromal tissue
 Connective tissue, capillaries, lymphocytes, etc.
 Adipose tissue
 Ductal tissue
 Squamous epithelium
 Columnar or cuboidal

epithelium
 Lobular tissue
Presentation
 Breast lump
 Abnormal mammogram
 Axillary lympadenopathy
 Metastatic disease
Familial Breast Cancer
 Cause 5-10% of all cancer and 25% in women
<30 y/o
 BRCA2
 Causes 40% of familial breast CA
 50-70% - breast
 15-45% - ovarian
 Increased risk for prostate, colon
 BRCA1
 50-70% - breast
 20-30% - ovarian
 Increased risk for prostate, pancreatic, laryngeal,
Screening Mammography
 Recommendations
 Biannually or annually in 40-49 y/o
 Annually in >50 y/o
 15% relative risk reduction
 Birads
 0 - Incomplete assessment; need additional imaging evaluation
 1 - Negative; routine mammogram in 1 year recommended
 2 - Benign finding; routine mammogram in 1 year recommended
 3 - Probably benign finding; short-term follow-up suggested (3%)
 4 - Suspicious abnormality; biopsy should be considered (30%)
 5 - Highly suggestive of malignancy; appropriate action should be
taken (94%)
Biopsy techniques
 FNA
 Diagnostic and therapeutic in cystic lesions
 Core needle
 U/S guided or sterotatic
 90% effective in establishing diagnosis
 Atypia – need excision
 Sterotatic
 Needle localization
 Excision biopsy
Risk of Future Invasive Breast Carcinoma
Based on Histologic Diagnosis from Breast
Biopsies
 No Increase
 Adenosis
Apocrine metaplasia
Cysts, small or large
Mild hyperplasia (>2 but <5 cells deep)
Duct ectasia
Fibroadenoma
Fibrosis
Mastitis, inflammatory
Periductal mastitis
Squamous metaplasia

 Slightly Increased (relative risk, 1.5–2)


 Moderate or florid hyperplasia, solid or papillary
Duct papilloma with fibrovascular core
Sclerosing adenosis, well-developed

 Moderately Increased (relative risk, 4–5)


 Atypical hyperplasia, ductal or lobular
Benign Breast Masses
 Cysts
 Fibroadenoma
 Hamartoma/Adenoma
 Abscess
 Papillomas Papilloma
 Sclerosing adenosis
 Radial scar
 Fat necrosis
Maligant Breast Masses
 Ductal carcinoma
 DCIS
 Invasive
 Lobular carcinoma
 LCIS
 Invasive
 Inflammatory carcinoma
 Paget’s disease
 Phyllodes tumor
 Angiosarcoma
Ductal carcinoma
DCIS
Ductal carcinoma in situ (DCIS)
 1. Solid type*
 2. Cribiform type

 3. Papillary type

 4. Comedo type*
Lobular carcinoma
Invasive
Histology
A. Ductal NOS
B. Lobular
C. Mucinous
D. Tubular
E. Medullary
Staging
 Tumor
 Tis: in situ
 T1: <2cm
 T2: 2-5cm
 T3: >5cm
 T4: invasion of skin or chest wall
 Node
 N1: 1-3 axillary nodes or int mam node
 N2: 4-9 axillary nodes or palpalbe int mam node
 N3: >10 nodes or combo of axillary and int mam nodes
 {mic micoroscopic posivitiy, mol molecular posiivity
 Metastasis
Modified Radical Mastectomy
 Entire breast tissue and Level I & II nodes
 Survival at 10 yrs
 Negative nodes – 82% (5% local recurrence)
 Positive nodes – 48% (5% local recurrence)

Simple mastectomy Modified radical


Breast Treatment Trials

 NSABP (1971 with B-04


update in 2002)
 Compared radical, vs modified
radical +/- radiation
 No survival diff for node neg or
pos between three arms
 75% of recurrences occur in 5
years
 Tumor location not important
Breast Treatment Trials
 Ontario study
 All pts got lumpectomy, randomized to radiation or no radiation
 25% failure rate without radiation, 5% with
 NSABP B-06
 Mastecomy vs lumpectomy vs lumpectomy with radiation
 No difference in survival
 39% recur with lumpectomy, reduced to 14% with radiation, 3-4%
with mastectomy
 0.5-1% per year recurrence rate for life with BCT and radiation
 2-5% complication rate with radiation (rib fx, pericarditis, cosmesis)
Radiation after mastectomy?
 2 Danish studies and one Britsh study
 Recommend in: >3 nodes positive,
aggressive/large tumors or extranodal invasion
 Decreased local or regional recurrence

 +/- survival benefit


Sentinel node biopsy
 Contraindications:
 Clinically positive nodes, pregnant or nursing, prior axillary
surgery, locally advanced disease
 False negative rate 3.1%
 Macrometases (>0.2cm) so recommended pathology cuts are
0.2 cm
 Micrometases (IHC staining) 37% death rate vs 50% of those
with macrometases
 If sentinel node positive 43% will have other nodes positive and
24% will have >4 nodes positive
 NSABP (B-32) in progress
Treatment of DCIS
 600% increase after mammography
 Options
 Mastectomy – 1% breast ca mortality
 Large tumors, multicentric, positive margins after
reexcision,
 Lumpectomy and radiation

 Radiation decreases local recurrence by 50%


 Of those that recur 50/50 DCIS vs Invasive
 0-3% chance of dying of maligant breast ca for all
DCIS
Treatment of DCIS
 Nodal involvement
 3.6% of DCIS pts have positive nodes in
mastectomy specimins
 By definition DCIS has no access to lymphatics
 Size may matter (111 DCIS tumors evaluated)
 <45mm – 0% microinvasion
 45-55mm – 17% microinvasion
 >55mm – 48% microinvasion
Tamoxifen in DCIS
 NSABP (B-24)
 Determine benefit of tamoxifen in lumpectomy plus
radiation pts
 31% decrease in ipsilateral, 47% in contralateral,

31% decrease all together


 Retrospectively looked at ER status

 75% of DCIS is ER+


 59% reduction in ER+ pts
 No significant reduction in ER-
Treatment for invasive breast ca
 Locally advanced is likely already metastatic in
most
 Surgery and radiation alone make no difference on survival
 Chemotherapy & +/- Tamoxifen
 Neoadjuvant chemotherapy
 7 randomized trials
 No survival benefit
 50-80% response
 May allow for BCT in large tumors
 Sentinel node before chemo
Tamoxifen
 Indications
 ER + breast ca
 LCIS
 BRCA1/2
 Increased overall risk
 Benefits
 Decreases risk of ca in other breast by 47-80%
 Draw backs
 Increases endometrial ca risk by 2.5, PE 3.0, DVT 1.7
Source: NSABP P-1 trial
Chemotherapy
 Early Breast Cancer Trialists’ Collaborative
Group
 Decreases recurrence (12%) and death (11%) regardless of
nodal status
 Indications
 All patients except node negative, <10mm tumors
 Regimens
 Multidrug combination chemotherapy
 Tamoxifen or aromatse inhibitor - ER positive tumors
 Herceptin (trastuzumab) – HER2/neu positive tumors
 NSABP B-31 – 33% reduction in risk of death
Other breast cancers
 Inflammatory ca
 Carcinoma invading lymphatic ducts
 Chemotherapy, mastectomy, radiation

 50% survival at 5 years


Other breast cancers
Paget’s disease
 Intraepithelial extesion of ductal ca
 Excision with nipple-areolar complex

 Sentinel node if invasive ca

 Mastectomy
Other breast cancers
 Phyllodes tumor
 <1% of breast tumors
 Age 30-45
 Similar in appearance to fibroadenoma
 4% recurrence after excision
 0.9% axillary spread
 Radiation, chemotherapy, tamoxifen ??

Phyllodes tumor Fibroadenoma


Angiosarcoma
 Risk factors
 Radiation
 Lymphedema
 Treatment
 Excision, radiation
Male breast cancer
 90% are invasive at time of diagnosis
 80% ER+, 75% PR+, 30% HER2/neu
 More invade into pectoralis
 Treatment same as for female ca

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