Early pregnancy, Asian race, early menopause reduce the risk.
Risk factor models
Gail model: ( www.nci.nih.gov ) Uses the following criteria: -current age -age at menarche -age at first child birth -no. of first degree relatives with breast ca -no. of previous benign biopsies -atypical hyperplasia in a prev. biopsy -race
In-situ Carcinomas- DCIS, LCIS; Paget’s disease of nipple
Invasive Cas- Invasive Ductal Ca (80%) Invasive lobular Ca (10%) Other invasive Cas- Medullary, papillary, tubular, cribriform, metaplastic, squamous, adenoid cystic, mucinous, secretory, undifferentiated.
Without e/o invasion
Progresses to invasive if untreated
Usual diagnosis by mammo (asymptomatic)
Histologically- Comedo vs Non- Comedo (papillary, cribriform, micropapillary, solid)
Treatment= excision with negative margins, then RT; Tamoxifen
Prognosis- 95 + % cure rates
Commonly B/L, multifocal
Diagnosis by biopsy; incidental
Increased risk of malignancy- 1%/year, reaching 17-20% life long risk
No treatment required -follow up with CBE, annual mammo;
tamoxifen/raloxifene decrease risk of Ca.
Other pathologic characteristics
Grade ( modified SBR)
Estrogen, Progesterone receptor
Other markers- S- phase Ki-67 DNA ploidy
Her 2 amplification by FISH Estrogen receptor +vity by IHC
Spread of breast cancer
Modes of Spread
Direct invasion- into chest muscles, wall, skin/nipple-areola.
Lymphatic- Locoregional - axilla, supraclavicular, infraclavicular and Internal mammary
Blood- Bones, lungs, liver, brain– Distant metastasis- stage IV
L ocal- Lump, discharge, skin/nipple changes, axillary, arm swelling, ulcer
Pain, tenderness- Inflammatory Ca
Distant- back ache, cough, breathlessness, headache, vomiting, anorexia, etc.
O/E – lump-hard, irregular , nipple retraction, peau de orange/puckering.
Nipple discharge, axillary nodes
FNAC/biopsy of the lump/gland- histology and receptor status studies
Her 2 /neu, DNA ploidy, S phase # - prognostic indicator studies
Evaluation- CBC, RFT, LFT, ALP, S. Ca++, Cardiac evaluation, mammography
Metastatic work up- CXR, USG A+P, Bone scan, ? PET. CT thorax, brain- only if symptoms suggestive .
Breast cancer screening
Women who undergo breast cancer screening mammograms have demonstrated significantly reduced deaths from the disease due to early detection and treatment.
Breast self examination ( BSE )
Clinical breast examination - by physicians
Ductal Lavage – investigational
Others– Breast Scintigraphy, USG, or MRI
An X-ray photograph of the breast
The technique has been in use for about thirty years
Safe and highly accurate
Low kV (25-30 kV), high mA (25-100)
Combined with sonography
Probably the most important tool doctors have
To follow women who've had breast cancer.
Identifies breast cancers too small to palpate on physical examination- 0.5 cm
(classified as T 1 lesion, with high curability)
Different types of calcifications within the breast tissue are visualized, which may be or may not be cancerous.
Reported as a BI-RADS category ( 1 to 5; 5= highly suspicious; 0- incomplete, 6- proven Ca).
All women 50+ (?40+) should get the benefit of annual mammograms and CBEs. Sonography might be added.
With serial mammograms it is possible to detect earliest lesions
Mammograms can save lives as most of the early breast cancers are curable
TNM – clinical & pathological
T stage - T1- < 2 cms in size T2- 2-5 cms T3- >5 cms T4- with chest wall (4a), skin (4b), both (4c), or inflammatory ca (4d)
N stage (clinical) N1- ipsilateral movable axillary nodes N2- ipsilateral matted/fixed nodes; clinically apparent ipsilateral IMNs in absence of axillary nodes N3- ipsilateral infraclavicular, clinically apparent ipsilateral IMNs in presence of axillary nodes, ipsilateral supraclavicular nodes
IIA T2N0M0, T1N1M0
IIB T3N0M0, T2N1M0
IIIA T3N1-2M0, T2N2M0
Depends on: Stage Hormone receptor status Her2/neu receptor status Age
Early stage (EBC)
Locally advanced (LABC)
Treatment modalities- Sx
BCS vs MRM
Contraindications to BCS- 1. multifocal disease 2. extensive microcalcifications 3. unable to get negative margins 4. prior RT 5. Pt preference Relative- CVDs, large tumors, large breasts, pregnancy,
Role of Sentinel l. n. biopsy-
Treatment modalities- ChemoRx
Required for most patients.
Curative: Neoadjuvant or adjuvant; Combination chemo- Anthracycline based; Paclitaxel added for high risk cases; 6-8 cycles (4 months)
Palliative: single or combination chemo
Treatment modalities- RT
Definitive : usually adjuvant;
Must after BCS, in mastectomy patients with high risk of Local recurrence (large tumors, >4 axillary l.n. +, positive margins, etc)
45-50 Gy to whole breast/chest wall; followed by boost to the tumor bed (in BCS) to 10-16 Gy
+/- RT to axillary, Supraclavicular l.n.
Palliative : for specific symptoms- bone mets, brain mets, etc.