breast cancer and management

1. The Breast
Lea Angela Pineda–Peralta, MD, FPCS, FPSGS

2. Anatomy

3. BLOOD SUPPLY
• Perforating
branches of the
internal mammary
artery
• Lateral branches of
the posterior
intercostal arteries
• Branches from the
axillary artery

4. VENOUS DRAINAGE
• Perforating
branches of the
internal thoracic
vein
• Perforating
branches of the
posterior
intercostal veins
• Tributaries of the
axillary vein

5. LYMPHATIC DRAINAGE
• Axillary vein group
(lateral)
• External mammary group
(anterior or posterior
group)
• Scapular group
• Central group
• Subclavicular group
(apical)
• Interpectoral group
(Rotter’s nodes)

6. LYMPHATIC DRAINAGE
• Level I
– Axillary vein group
– External mammary
– Scapular group
• Level II
– Central
– Intercostal
• Level III
– Subclavicular

7. NIPPLE DISCHARGE
BENIGN SUSPICIOUS
Non – bloody Bloody
Non spontaneous Spontaneous
Bilateral Unilateral
Multi duct Single duct
Non surgical treatment Surgical treatment
No mass With mass

8. INTRADUCTAL PAPILLOMA
• arise in the major ducts, usually in pre-
menopausal
• nipple discharge, serous or bloody
• No increased risk of developing breast
cancer

9. GYNECOMASTIA
• Benign enlargement
of the male breast
• Due to proliferation of
the glandular
component
• Unilateral or bilateral
• Palpable mass of
tissue at least 0.5cm
in diameter (usually
underlying the nipple)

10. GYNECOMASTIA
• PHYSICAL FINDINGS
• Ridge of glandular tissue is felt > 0.5cm in
diameter
• 4 typical features
– Centrally located glandular tissue
– Symmetrical in shape
– Bilateral
– Tender to palpation

12. GYNECOMASTIA
• No predisposition to breast cancer
• Klinefelter’s syndrome (XXY)
– Gynecomastia is evident
– Associated with increased risk of breast cancer

13. GYNECOMASTIA
• Physiologic Gynecomastia
– Excess of circulating estrogens in
relation to circulating testosterone
– Occurs during 3 phases of life:
a. Neonatal
b. Adolescence
c. Senescence

16. INFECTIOUS & INFLAMMATORY
DISORDER OF THE BREAST
• BACTERIAL INFECTION
– Staphylococcus aureus
– Streptococcus sp.
• Tenderness, erythema, hyperthermia
• Subcutaneous, subareolar, interlobular
(periductal) & retromammary abscesses
(unicentric or multi-centric)
– Antibiotics & repeated aspiration (utz
guided)
– I & D

17. INFECTIOUS & INFLAMMATORY
DISORDER OF THE BREAST
• MYCOTIC INFECTIONS
– Blastomycosis or sporotrichosis
– Intraoral fungi
– tx: antifungal agents

18. BENIGN BREAST DISORDERS

19. BENIGN BREAST DISORDERS
• Cyst
– observe
– Fine needle aspiration
• Fibroadenoma
– Observation
– excision

20. BENIGN BREAST DISORDERS
• Sclerosing adenosis
– Distorted breast lobules & usually occurs int
eh context of multiple microcysts or presents
with a palpable mass
– Excision biopsy
• Radial scar
– Central sclerosis & various degrees of
epithelial proliferation, apocrine metaplasia &
papilloma formation up to 1cm in diameter
– Excision biopsy

21. Radial scars/
Complex sclerosing lesions
• Radial scar - <1cm
• Complex sclerosing lesion –
> 1cm
• Stellate-like elastosis w/ or
w/o the presence of
associated lobulocentric
cysts, usual ductal
hyperplasia, adenosis &
microcalcifications

22. • No discrete central mass
with long radiating spicules
• Architectural distortion
indistinguishable from
architectural distortion of
invasive cancer

23. Atypical ductal hyperplasia
• Formed from a uniform
population of small or
medium-sized cells,
which are regularly
arranged
• Atypical epithelial cells
are contained within only
one to two ductal spaces
& the lesion measure
2mm or less in maximum
dimension in any given
focus
• Histologically similar to
low-grade DCIS : <2mm

24. • ADH identified by CNB,
rates of upgrade to DCIS
is 20% following
surgical excision

25. Recommendations
• Excision for lesions ≥21mm
• Follow up for lesions <6mm with complete removal
of microcalcifications
• Follow up or excision for 6 to 21mm lesions with
respectively less or >2 atypical ductal hyperplasia
foci
* Caplain A, Drouet Y, Peyron M, et al. Management of patients diagnosed with atypical ductal hyperplasia
by vacuum-assisted core biopsy: a prospective assessment of the guidelines used at our institution. Am J
Surg. 2014;207;24-31.

26. BREAST CANCER

27. BREAST CANCER
• Surgery
• Chemotherapy
• Radiation therapy
• Endocrine therapy
• Targeted therapy
• Immunotherapy

29. BRCA1
• Autosomal dominant
• Functions as a tumor suppressor gene, loss of
both alleles is required for the initiation of cancer
• Female mutation carriers - 85% lifetime risk for
developing breast cancer & 40% for ovarian ca
• BRCA1 associated breast cancers
– IDCA, poorly differentiated, most are triple negative
– Early age of onset; higher prevalence of bilateral
breast CA
– Ashkenazi Jewish population

30. BRCA2
• Autosomal dominant
• 85% breast cancer risk , 20% ovarian ca risk
• Male – 6% breast cancer risk
• Breast cancer – IDCA, well differentiated,
hormone positive
– Early age of onset
– Bilateral
– Associated cancers: ovarian, prostate, pancreatic,
gallbladder, bile duct, stomach, melanoma

31. Cancer prevention for
BRCA mutation carriers
• Risk reducing mastectomy &
reconstruction
• Risk reducing salpingo-oophorectomy
• Intensive surveillance for breast & ovarian
CA
• Chemoprevention

32. BREAST CANCER
• Most common site-specific cancer in
women
• Leading cause of death from cancer for
women ages 20 – 50 years

34. Breast biomarkers
• Estrogen receptor (ER)
• Progesterone receptor (PR)
• Her2neu

35. Allred scoring system
• based on the percentage of cells that
stain by IHC for ER/PR (0-5) & intensity of
that staining (0-3)
• Score: 0 – 2 à negative
3 – 8 à positive

37. Her2 neu
• Negative (0, 1+)
• Equivocal (2+)
• Positive (3+)
If equivocal do FISH

38. Breast cancer
biologic subtypes
• Luminal type
– Hormone receptor positive, Her2(-)
• Her2 like (Her2 enriched)
– Her2(+)
• Basal like (triple negative)

39. Anatomic & Prognostic
Staging
Clinical Prognostic Stage
• History, PE, imaging, biopsy before any
treatment
• cT, cN, c/pM, grade, Her2, ER, PR

40. Anatomic & Prognostic
Staging
Pathologic Prognostic Stage
• Applies to patients who undergo surgical
resection as the initial treatment of cancer
• pT, pN, c/pM, grade, her2, ER, PR,

42. Primary Tumor (T)
• based primarily on the size of the invasive
component of the cancer
• Largest contiguous dimension of a tumor
focus
• T1mi (microinvasive carcinoma)
– Invasive tumor foci 1mm or smaller
• T4
– Tumor of any size w/ direct extension to chest
wall &/or to the skin (ulceration or skin
nodules)

43. Primary Tumor (T)
• T4
– Adherence/invasion to the pectoralis muscle
in NOT extension to the chest wall
– Chest wall includes ribs, intercostal muscles,
serratus anterior muscle

44. Tis
• Tis (Stage 0)
– DCIS
– In-situ papillary neoplasms (papillary DCIS,
encapsulated papillary carcinoma, solid
papillary carcinoma in-situ)
– Paget disease of the breast

45. Nodes
• Isolated tumor cells (ITC)
– small clusters of cells not larger than 0.2mm,
or single tumor cells, or fewer than 200 cells
in a single histologic cross section
– pN0(i+) or pN0(i+)(sn)

46. Nodes
• Micrometastasis
– Tumor deposits larger than 0.2mm but not
larger than 2mm in largest dimension
– pN1mi or pN1mi (sn)
• Macrometastasis
– Tumor deposit larger than 2mm

48. Treatment response category to
neoadjuvant chemotherapy based
on AJCC
• Complete response (cCR & pCR)
– Absence of evidence of cancer in breast &
LNs
– Presence of in-situ cancer after treatment in
the absence of invasive disease is pCR

49. Treatment response category to
neoadjuvant chemotherapy based on
AJCC
• Partial response (cPR or pPR)
– Decrease in either or both T or N compared to
the clinical (pre-treatment) assignment & with
no increase in either T or N
• No response (NR)
– No apparent change in either T or N
compared to the clinical assignment or an
increase in T or N category at the time of
pathologic evaluation

50. RECIST

51. DUCTAL CARCINOMA IN- SITU
(DCIS)
• No invasion of the basement membrane
• Stage 0, Tis
• Multicentric
– Occurrence of a 2nd breast cancer outside the
breast quadrant of the primary cancer (or at
least 4cm away)
• Multifocal
– Occurrence of a 2nd cancer w/in the same
quadrant as the primary cancer (or w/in 4cm
of it)

52. DUCTAL CARCINOMA
IN SITU (DCIS)
• Predominantly occurs in women but
accounts for 5% of male breast cancers
• Proliferation of epithelium that lines the
minor ducts, resulting in papillary growths
w/in the duct lumina
• Calcium deposition in areas of necrosis &
a common MMG finding
• Anatomic PRECURSOR of invasive ductal
carcinoma

53. DUCTAL CARCINOMA
IN SITU (DCIS)
• PRESENTATION
– Abnormal mmg finding w/ no breast related
symptoms or findings on PE
– Palpable mass, nipple discharge or Paget
disease

54. DUCTAL CARCINOMA
IN SITU (DCIS)
• MAMMOGRAM
– 90% of women w/ DCIS have suspicious MCC
on mmg
– DCIS – 80% of all breast cancers presenting
w/ calcifications
– All suspected patients w/ DCIS should have
bilateral MMG w/ magnification views to
assess the morphology full extent of the MCC

56. DUCTAL CARCINOMA
IN SITU (DCIS)
• DIAGNOSTIC EVALUATION
– Core biopsy under stereotactic guidance
– Wire localization & excision

57. DUCTAL CARCINOMA
IN SITU (DCIS)
• TREATMENT
– Mastectomy
– Breast conserving therapy
• Lumpectomy, wide excision, partial
mastectomy)
– Sentinel lymph node biopsy
• For high risk features

60. DUCTAL CARCINOMA
IN SITU (DCIS)
• PROGNOSIS
– Excellent

61. PAGET DISEASE
• Chronic, eczematous eruption of the
nipple
• Ulcerating, weeping lesion
• Usually associated w/ extensive DCIS &
may be associated w/ an invasive cancer
• Palpable mass (+/-)
• Histology: large, pale, vacuolated cells
(Paget cells) in the rete pegs of the
epithelium

62. PAGET DISEASE
• CLINICAL PRESENTATION
– Scaly, raw, vesicular or ulcerated lesion that
begins on the nipple then spreads to the
areola
– Occasional bloody discharge
– Usually unilateral
– Pain, burning, &/or pruritus

63. PAGET DISEASE
• DIAGNOSTIC WORK UP
– An underlying breast cancer (in situ or
invasive) is present in 85 – 88% of cases
– Palpable mass in 50% of cases; mass is often
located >2cm from NAC
– 20% of cases have MMG abnormality but no
palpable mass
– 25% of cases, (-) for underlying mass and
MMG abnormality, but an occult DCIS is
present

64. PAGET DISEASE
• SKIN BIOPSY
– Nipple scrape cytology
– Full thickness wedge biopsy or punch biopsy
of the nipple
• MAMMOGRAM & ULTRASOUND
• BIOPSY OF UNDERLYING
ABNORMALITIES

67. INVASIVE DUCTAL
CARCINOMA
• 80% of breast cancer
• w/ macroscopic or microscopic axillary
lymph node metastases in up to 25% of
screen detected cases & up to 60% of
symptomatic cases
• Solitary, firm mass

68. INVASIVE DUCTAL
CARCINOMA
• MAMMOGRAM
– Spiculated hyperdense lesions
– Oval or lobulated lesions, irregular shape
– Microlobulated, ill-defined borders
– Microcalcifications

69. INVASIVE DUCTAL
CARCINOMA
• ULTRASOUND
– Marked hypoechogenecity
– Acoustic posterior shadowing
– Branched pattern or microlobulation
– Taller than wide
– Angular margins/ irregular borders
– Microcalcifications
– Spiculations

70. MANAGEMENT OF
BREAST CANCER
• BREAST SURGERY
– Modified radical mastectomy
– Simple mastectomy
– Breast conserving surgery
• AXILLARY SURGERY
– Axillary lymph node dissection
– Sentinel lymph node biopsy
• RECONSTRUCTION

71. SURGERY
BREAST AXILLA
Partial mastectomy (BCS) + RT
(BCT)
Sentinel lymph node biopsy
Total mastectomy +/- reconstruction
(immediate vs. delayed)
Axillary lymph node biopsy

72. Special considerations for BCT

75. MANAGEMENT OF
BREAST CANCER
• CHEMOTHERAPHY
– Neoadjuvant chemotherapy
• To down size the tumor à BCS
• Can be given in pregnant patients
– Adjuvant chemotherapy
• RADIATION THERAPY
– For BCS
– Node positive
– For recurrent disease
– large tumor size

77. TNBC

78. TNBC

80. MANAGEMENT OF
BREAST CANCER
• ANTI ESTROGEN THERAPY
– TAMOXIFEN
• Pre menopausal
• ER+
• Side effects:
– Bone pain
– Hot flashes
– Nausea, vomiting
– Fluid retention
– Thrombotic evens (<3%)
– Endometrial cancer (1.6% - 3.1%)

81. MANAGEMENT OF
BREAST CANCER
• ANTI ESTROGEN THERAPY
– AROMATASE INHIBITORS
• Post menopausal, ER+
• Side effects:
– Osteoporosis
– Increased fracture rates

82. MANAGEMENT OF
BREAST CANCER
• ANTI HER2 neu THERAPY
– Her2 neu+
– Trastuzumab
• Side effect: cardiotoxicity

83. RECURRENT/STAGE IV (MI)

90. PHYLLODES TUMOR
• Uncommon fibroepithelial breast tumors
• Behave like benign fibroadenoma
(propensity to recur locally following
excision w/o wide margins)
• “Phyllodes” – leaf-like, papillary projections
• 1% of breast neoplasm
• Median age: 42 – 45yrs
• Develops in the breast connective tissue,
called “stroma”

91. PHYLLODES TUMOR
• Smooth, multinodular, well defined, firm
mass, mobile, painless
• Grows rapidly
• Benign, borderline, malignant
• LN mets is rare
• Imaging: MMG & UTZ
• Core needle biopsy
– Difficulty differentiating from fibroadenoma

92. PHYLLODES TUMOR
BENIGN BORDERLINE MALIGNANT
Stromal cellular
atypia
Increased stromal
cellularity w/ Mild
to moderate
atypia
Greater stromal
cellularity & atypia
Marked stromal
cellularity & atypia
Mitotic activity <4mitoses/10hpf 4-9 mitoses/10hpf >10mitoses/10hpf
Tumor margin Circumscribed Microscopic
Infiltrative
Infiltrative
Stromal
overgrowth
None None present

95. BREAST CANCER DURING
PREGNANCY
• 1/3000 pregnant women
• Axillary lymph node metastases are
present in up to 75%
• Prognosis is similar to that of non-
pregnant women w/ breast cancer

96. BREAST CANCER DURING
PREGNANCY

97. BREAST CANCER IN MALES
• Occurs in less than 1% of the male
population
• Firm, nontender mass
• Same survival rate as women
• 80% are hormone receptor positive

98. QUESTION
• Which of the following statement is true for
breast cancer in males?
a. Is commonly associated with mutation in BRCA 1
gene
b. Survival is the same as to women with breast cancer
c. Sentinel lymph node biopsy is contraindicated
d. Previous history of gynecomastia

99. QUESTION
• A 39-year-old lady, single, nulligravid presented with a 6cm
hard, irregular mass at the 1:00 position, 4cm from the nipple of
the left breast with associated palpable axillary lymph node.
CNB showed invasive breast carcinoma (ductal, NOS) with
DCIS component, Luminal A. She underwent neoadjuvant
chemotherapy which resulted to decreased size of the mass to
0.5cm. She then underwent modified radical mastectomy. On
final histopathology result, a 0.5cm DCIS was identified with no
axillary lymph node metastasis. What is the treatment response
category of this patient?
a. pCR
b. pPR
c. NR
d. disease progression

100. QUESTION
• T4 category
a.6cm IDCA
b.Invasion to pectoralis muscle
c. Dermal involvement
d.Satellite nodule

101. QUESTION
• A 35-year-old lady presented with a 12cm right breast mass.
On breast imaging, additional enlarged axillary lymph nodes
with intact hilum were noted. Biopsy revealed malignant
phyllodes tumor. What is the appropriate management?
a. Total mastectomy
b.Neoadjuvant chemotherapy followed by partial
mastectomy with sentinel lymph node biopsy
c. Radiation therapy
d.Modified radical mastectomy

102. QUESTION
• A 42-year-old lady, married, G2P2, diagnosed with a 2cm
invasive breast carcinoma by CNB with no palpable axillary
lymph node. She underwent partial mastectomy with
sentinel lymph node biopsy. SLNB showed 2/4 nodes
positive for metastasis. What will be your next step?
a. Modified radical mastectomy
b. Partial mastectomy + SLNB + RT
c. Partial mastectomy + SLNB
d. Partial mastectomy + SLNB + ALND

103. • References
– Bland KI, Copeland EMI, eds.(2009) The
Breast: Comprehensive Management of
Benign & Malignant Disease . Philadelphia:
WB Saunders
– Brunicardi FC, ed (2015) Schwartz’s
Principles of Surgery. Mc Graw Hill.
– NCCN guidelines on Breast Cancer
– Uptodate
– AJCC 8th edition

104. Thank you!