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  • 1. Breast Cancer
  • 2. Introduction
    Most common female cancer
    Accounts for 32% of all female cancer
    211,300 new cases yearly and rising
    40,000 deaths yearly
  • 3. Gross Anatomy
    • Sappy’s plexus – lymphatics under areolar complex
    • 4. 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
  • 5. Presentation
    Breast lump
    Abnormal mammogram
    Axillarylympadenopathy
    Metastatic disease
  • 6. 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,
  • 7. 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%)
  • 8. 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
  • 9. 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
  • 10. Benign Breast Masses
    Cysts
    Fibroadenoma
    Hamartoma/Adenoma
    Abscess
    Papillomas
    Sclerosing adenosis
    Radial scar
    Fat necrosis
    Papilloma
  • 11. Maligant Breast Masses
    Ductal carcinoma
    DCIS
    Invasive
    Lobular carcinoma
    LCIS
    Invasive
    Inflammatory carcinoma
    Paget’s disease
    Phyllodes tumor
    Angiosarcoma
  • 12. Ductal carcinoma
  • 13. DCIS
    Ductal carcinoma in situ (DCIS)
    1. Solid type*
    2. Cribiform type
    3. Papillary type
    4. Comedo type*
  • 14. Lobular carcinoma
  • 15. Invasive Histology
    Ductal NOS
    Lobular
    Mucinous
    Tubular
    Medullary
  • 16. 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
  • 17. 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
  • 18. 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
  • 19. 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)
  • 20. 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
  • 21. 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
  • 22. 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
  • 23. 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
  • 24. 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-
  • 25. 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
  • 26. 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
  • 27. 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
  • 28. Other breast cancers
    Inflammatory ca
    Carcinoma invading lymphatic ducts
    Chemotherapy, mastectomy, radiation
    50% survival at 5 years
  • 29. Other breast cancers
    Paget’s disease
    Intraepithelial extesion of ductal ca
    Excision with nipple-areolar complex
    Sentinel node if invasive ca
    Mastectomy
  • 30. 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
  • 31. Angiosarcoma
    Risk factors
    Radiation
    Lymphedema
    Treatment
    Excision, radiation
  • 32. 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