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Breast cancer video 1


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Breast cancer video 1

  1. 1. BREAST CANCER Robert Miller
  2. 2. • Breast cancer most common cancer in women (29% cases)• Life time risk of 12.38% (one in eight)• Median age at diagnosis is 61 but (5% 30s, 18% in 40’s, 25% 50’s) Age Distribution 5 Year Survival by Stage
  3. 3. What You Need to Understand About BreastCancer Before Deciding on Treatment
  4. 4. What You Need to Know About Breast Cancer Before Deciding on Treatment• Understand the basic anatomy (lobules, ducts and lymph nodes)• Breast imaging studies (mammograms or ultrasound) CT, MRI, PET• Stage (particularly lymph node status)• Biopsy or pathology report tell you about the biology (how aggressive) of the cancer 1. Pectoralis Muscle, 2. Fatty Breast Tissue, 3. Breast Cancer, 4. Breast Glands (lobules), 5. Milk Ducts
  5. 5. Lymph Nodes supraclavicular Internal mammary axillaryThe tail of thebreast may extendhigh into theaxilla
  6. 6. Imaging
  7. 7. Imaginga case of advancedcancer… 3 views of thesame tumor in a womanwith a 2.7 cm breastcancerMost women arediagnosed at an earlystage with abnormalcalicifications on theirmammogram
  8. 8. Mammograms may often show areas ofcalcification, which can be benign ormalignant
  9. 9. Mammograms may often show areas ofcalcification, these may be malignant. In ductalcarcinoma in situ (DCIS), there is normally no massbut just an area of calcification
  10. 10. Micro-calcificationscan be verysubtleBiopsy of thisarea showed8mm DCIS
  11. 11. Biopsy = DCIS with focal micro-invasion
  12. 12. Larger area offat micro- calcifications may have invasive gland cancer Path = 2.9 cm area of high grade DCIS plus invasive ductal cancer
  13. 13. Breast MRI ScanIn a woman with dense breasts, the mammogram was normal but the MRI showed the cancer
  14. 14. benignBreastMRIPath = 2.2 cmcancer inright breast,left breastwas benign(Falsepositive?)
  15. 15. Breast MRIWill show the breast tumoras well as the lymph nodesMastectomy = 6cm lobular cancer with 41 outof 42 lymph nodes positive for cancer spread
  16. 16. Breast MRI ScanA = BreastB = axillaC = internalmammary nodes
  17. 17. CT Scan Anatomy
  18. 18. PET Scan Anatomy for Breast Cancer
  19. 19. PET - CT Scan Anatomy - Reconstruction
  20. 20. Small relapse on the reconstructed right breast, just above the implant
  21. 21. PET Scan: previous right mastectomy butcancer has recurred arising from the rib
  22. 22. PET Scans are usually reserved for moreadvanced cases of breast cancer
  23. 23. PEM (Positron Emission Mammography)
  24. 24. Sentinel NodeTechnique and Biopsy Sentinel Node
  25. 25. Sentinel Node Technique nodes Breast cancer
  26. 26. Stage is based on the tumor size (T1 – T4) T 0 = DCIS T1 = 2cm T2 = > 2 – 5cm T3 = > 5cm
  27. 27. Stage is based on lymph node spread (N1 – N3) N0 = no nodes N1 = 1 -3 nodes N2 = 4 – 9 nodes N3 = 10 nodes or SCV or IMC
  28. 28. Odds of Spread to Sentinel Node The bigger the tumor the more likely it has spread to the lymph nodes Tumor size in cm If the biopsy shows a more aggressive form of cancer (high grade cancer) or cancers cells are seen in vessels (LV) then there is a high chance the cancer has spread to the nodes Grade and LV invasion
  29. 29. Breast Cancer Stage
  30. 30. So the stage if based on both the tumor size or the lymphnode status, so stage IIB would be T2N1 or T3N0 N0 T3 N1 T2
  31. 31. Mortality based on size of cancer and number of lymph nodes involved 6 + Nodes 3 + Nodes 0 + Nodes Tumor size in cm
  32. 32. Mortality based on cancer grade for node negative and node positive cancers 2cm tumor with 3 + nodes 2cm tumor with 0 + nodes Cancer Grade
  33. 33. Understanding a Pathology Report1. Invasive or Not (DCIS, LCIS)2. Histology: what type of cancer3. Grade: fast or slow growing4. Hormone Receptors: is it sensitive to estrogen or progesterone5. HER2 (human epidermal growth factor receptor 2) a genetic mutation
  34. 34. ductal cellsductal carcinoma In situ Invasive ductal carcinoma(DCIS)
  35. 35. 20% of breastcancers in the USare stage 0 or non-invasive (ducalcarcinoma in situDCIS or lobularcarcinoma in situLCIS)
  36. 36. Earliest form of canceris often DCIS (ductalcarcinoma in situ) thenit progresses toinvasive ductalcarcinoma
  37. 37. DCIS – Ductal Carcinoma In Situ
  38. 38. Types of Invasive Breast CancerHistology Common AggressiveInvasive Ductal 50 – 75% AverageInvasive Lobular 10 – 15% AverageMedullary 1 – 5% MoreMucinous (colloid) 1 – 5% LessPapillary (<1%) LessTubular (1 – 5% Less
  39. 39. Cancer Cell A genetically altered or mutated normal cell that results in uncontrolled growth and spreadIf the cell has not mutated too much it almost looks like a normal cell(and would be called low grade or well differentiated) wouldprobably still have a normal response to estrogen and be lessaggressive (less likely to spread or grow rapidly)
  40. 40. Breast Cancer GradeGrade Description 5Y Survival1 (low) Well-differentiated, slow growing 95%2 (most common) Moderately formed 75%3 (high) Poorly formed, aggressive 50%
  41. 41. Hormone ReceptorsNormal breast cells are sensitive to hormones (estrogen and progesterone) and have chemical receptors that the hormones attach to. About 60 to 70 % of breast cancer cells with still have these receptors.This is good for two reasons:1. The cancer cells are less mutated (or dangerous) and the patients prognosis (outlook) is better2. Instead of just chemotherapy the woman may benefit from a hormone blocking drug like Tamoxifen (if she’s premenopausal) or an aromatase inhibitor like Femara, Aromasin or Arimidex
  42. 42. HER2 (Human Epidermal Growth Factor Receptor Type 2)About 20 to 30% of the cancers will have the genetic mutation that leads toabnormal function of the HER2 gene. This is considered a more serious type ofcancer but there are antidote drugs available like Herceptin (trastuzamab) againstthese cells
  43. 43. HER2(Human Epidermal Growth Factor Receptor Type 2)
  44. 44. Gene expression array methodologyA) RNA from a tumor probes for thousands of genes have been affixed. B) The red(relative overexpression in tumor) and green (relative underexpression in tumor)intensities can be analyzed simultaneously. C) Depending on the supervision of theanalysis, tumors can be subtyped (as shown here), or can be analyzed for gene setsassociated with clinical outcome.
  45. 45. Genetic ProfilesMay show that some women with favorable breast cancer (estrogen + andnode -) may need more than just Tamoxifen / analyze the cancer for thepresence (expression of 21 breast cancer genes)
  46. 46. Genetic ProfilesMay show that some women withfavorable breast cancer (estrogen+ and node -) may need morethan just Tamoxifen 27% of women had a high risk gene profile and 30.5% relapsed after Tamoxifen and they may have done better with chemotherapy
  47. 47. MammaPrint is the first and only FDA-cleared IVDMIA breast cancer recurrence assay. The unique 70-gene signature of MammaPrint provides you with the unprecedented ability to identify which early-stagebreast cancer patients are at risk of distant recurrence following surgery, independent of EstrogenReceptor status and any prior treatment.Unlike previous generation genomic tests, MammaPrint interrogates all of the critical molecularpathways involved in the breast cancer metastatic cascade. It analyzes 70 critical genes that comprise adefinitive gene expression signature and stratifies patients into two distinct groups — low risk or highrisk of distant recurrence. With MammaPrint, there are no intermediate results.Hormonal therapy alone (e.g. Tamoxifen) may be sufficient to further reduce her risk if your patient isLow Risk by MammaPrint, when combined with traditional risk factors. Conversely, if she is High Riskby MammaPrint and has additional risk variables, more aggressive therapy including chemotherapy maybe recommended.
  48. 48. BREAST CANCER Robert Miller