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    for tlk for tlk Presentation Transcript

    • Breast Cancer
    • 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
      Axillarylympadenopathy
      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
      Stereotatic
      Needle localization
      Excision biopsy
    • Risk of Future Invasive Breast Carcinoma
      No Increase
      AdenosisApocrinemetaplasiaCysts, small or largeMild hyperplasia (>2 but <5 cells deep)Duct ectasiaFibroadenomaFibrosisMastitis, inflammatoryPeriductal mastitisSquamousmetaplasia
      Slightly Increased (relative risk, 1.5–2)
      Moderate or florid hyperplasia, solid or papillaryDuct papilloma with fibrovascular coreSclerosingadenosis, well-developed
      Moderately Increased (relative risk, 4–5)
      Atypical hyperplasia, ductal or lobular
    • Benign Breast Masses
      Cysts
      Fibroadenoma
      Hamartoma/Adenoma
      Abscess
      Papillomas
      Sclerosing adenosis
      Radial scar
      Fat necrosis
      Papilloma
    • 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
      Ductal NOS
      Lobular
      Mucinous
      Tubular
      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 intmam node
      N2: 4-9 axillary nodes or palpable intmam node
      N3: >10 nodes or combo of axillary and intmam nodes
      {micmicoroscopicposivitiy, 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)
      Modified radical
      Simple mastectomy
    • 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
      Mastecomyvs 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 malignant breast ca for all DCIS
    • Treatment of DCIS
      Nodal involvement
      3.6% of DCIS pts have positive nodes in mastectomy specimens
      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