Breast cancer is the most common female cancer, accounting for over 200,000 new cases yearly in the United States. Screening mammography is recommended annually starting at age 50 to detect breast cancer early. Treatment options depend on tumor size, lymph node involvement, and receptor status, and may involve lumpectomy or mastectomy with radiation and/or chemotherapy, tamoxifen, or other targeted therapies. While most breast cancers are carcinomas, other rare types include angiosarcoma and phyllodes tumors.

1. Breast Cancer

2. IntroductionMost common female cancerAccounts for 32% of all female cancer211,300 new cases yearly and rising40,000 deaths yearly

3. Gross AnatomySappy’s plexus – lymphatics under areolar complex

4. 75% of lymphatics flow to axillaMicroscopic AnatomyStromal tissueConnective tissue, capillaries, lymphocytes, etc.Adipose tissueDuctal tissueSquamous epitheliumColumnar or cuboidal epitheliumLobular tissue

5. PresentationBreast lumpAbnormal mammogramAxillarylympadenopathyMetastatic disease

6. Familial Breast CancerCause 5-10% of all cancer and 25% in women <30 y/oBRCA2Causes 40% of familial breast CA50-70% - breast15-45% - ovarianIncreased risk for prostate, colonBRCA150-70% - breast20-30% - ovarianIncreased risk for prostate, pancreatic, laryngeal,

7. Screening MammographyRecommendationsBiannually or annually in 40-49 y/oAnnually in >50 y/o15% relative risk reductionBirads0 - 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 techniquesFNADiagnostic and therapeutic in cystic lesionsCore needleU/S guided or sterotatic90% effective in establishing diagnosisAtypia – need excisionStereotaticNeedle localizationExcision biopsy

9. Risk of Future Invasive Breast CarcinomaNo Increase AdenosisApocrinemetaplasiaCysts, small or largeMild hyperplasia (>2 but <5 cells deep)Duct ectasiaFibroadenomaFibrosisMastitis, inflammatoryPeriductal mastitisSquamousmetaplasiaSlightly Increased (relative risk, 1.5–2) Moderate or florid hyperplasia, solid or papillaryDuct papilloma with fibrovascular coreSclerosingadenosis, well-developedModerately Increased (relative risk, 4–5) Atypical hyperplasia, ductal or lobular

10. Benign Breast MassesCystsFibroadenomaHamartoma/AdenomaAbscessPapillomasSclerosing adenosisRadial scarFat necrosisPapilloma

11. Maligant Breast MassesDuctal carcinomaDCISInvasiveLobular carcinomaLCISInvasiveInflammatory carcinomaPaget’s diseasePhyllodes tumorAngiosarcoma

12. Ductal carcinoma

13. DCISDuctal carcinoma in situ (DCIS)1. Solid type*2. Cribiform type3. Papillary type4. Comedo type*

14. Lobular carcinoma

15. Invasive HistologyDuctal NOSLobularMucinousTubularMedullary

16. StagingTumorTis: in situT1: <2cmT2: 2-5cmT3: >5cmT4: invasion of skin or chest wallNodeN1: 1-3 axillary nodes or intmam nodeN2: 4-9 axillary nodes or palpable intmam nodeN3: >10 nodes or combo of axillary and intmam nodes{micmicoroscopicposivitiy, mol molecular posiivityMetastasis

17. Modified Radical MastectomyEntire breast tissue and Level I & II nodesSurvival at 10 yrsNegative nodes – 82% (5% local recurrence)Positive nodes – 48% (5% local recurrence)Modified radicalSimple mastectomy

18. Breast Treatment TrialsNSABP (1971 with B-04 update in 2002)Compared radical, vs modified radical +/- radiationNo survival diff for node neg or pos between three arms75% of recurrences occur in 5 yearsTumor location not important

19. Breast Treatment TrialsOntario studyAll pts got lumpectomy, randomized to radiation or no radiation25% failure rate without radiation, 5% withNSABP B-06Mastecomyvs lumpectomy vs lumpectomy with radiationNo difference in survival39% recur with lumpectomy, reduced to 14% with radiation, 3-4% with mastectomy0.5-1% per year recurrence rate for life with BCT and radiation2-5% complication rate with radiation (rib fx, pericarditis, cosmesis)

20. Radiation after mastectomy?2 Danish studies and one Britsh studyRecommend in: >3 nodes positive, aggressive/large tumors or extranodal invasionDecreased local or regional recurrence+/- survival benefit

21. Sentinel node biopsyContraindications:Clinically positive nodes, pregnant or nursing, prior axillary surgery, locally advanced diseaseFalse negative rate 3.1%Macrometases (>0.2cm) so recommended pathology cuts are 0.2 cmMicrometases (IHC staining) 37% death rate vs 50% of those with macrometasesIf sentinel node positive 43% will have other nodes positive and 24% will have >4 nodes positiveNSABP (B-32) in progress

22. Treatment of DCIS600% increase after mammographyOptionsMastectomy – 1% breast ca mortalityLarge tumors, multicentric, positive margins after reexcision, Lumpectomy and radiationRadiation decreases local recurrence by 50%Of those that recur 50/50 DCIS vs Invasive0-3% chance of dying of malignant breast ca for all DCIS

23. Treatment of DCISNodal involvement3.6% of DCIS pts have positive nodes in mastectomy specimensBy definition DCIS has no access to lymphaticsSize may matter (111 DCIS tumors evaluated)<45mm – 0% microinvasion45-55mm – 17% microinvasion>55mm – 48% microinvasion

24. Tamoxifen in DCISNSABP (B-24)Determine benefit of tamoxifen in lumpectomy plus radiation pts31% decrease in ipsilateral, 47% in contralateral, 31% decrease all together Retrospectively looked at ER status75% of DCIS is ER+59% reduction in ER+ ptsNo significant reduction in ER-

25. Treatment for invasive breast caLocally advanced is likely already metastatic in mostSurgery and radiation alone make no difference on survivalChemotherapy & +/- TamoxifenNeoadjuvant chemotherapy7 randomized trialsNo survival benefit50-80% responseMay allow for BCT in large tumorsSentinel node before chemo

26. TamoxifenIndicationsER + breast caLCISBRCA1/2Increased overall riskBenefitsDecreases risk of ca in other breast by 47-80% Draw backsIncreases endometrial ca risk by 2.5, PE 3.0, DVT 1.7Source: NSABP P-1 trial

27. ChemotherapyEarly Breast Cancer Trialists’ Collaborative GroupDecreases recurrence (12%) and death (11%) regardless of nodal statusIndicationsAll patients except node negative, <10mm tumorsRegimensMultidrug combination chemotherapyTamoxifen or aromatse inhibitor - ER positive tumorsHerceptin (trastuzumab) – HER2/neu positive tumorsNSABP B-31 – 33% reduction in risk of death

28. Other breast cancersInflammatory caCarcinoma invading lymphatic ductsChemotherapy, mastectomy, radiation50% survival at 5 years

29. Other breast cancersPaget’s diseaseIntraepithelial extesion of ductal caExcision with nipple-areolar complexSentinel node if invasive caMastectomy

30. Other breast cancersPhyllodes tumor<1% of breast tumorsAge 30-45Similar in appearance to fibroadenoma4% recurrence after excision0.9% axillary spreadRadiation, chemotherapy, tamoxifen ??Phyllodes tumorFibroadenoma

31. AngiosarcomaRisk factorsRadiationLymphedemaTreatmentExcision, radiation

32. Male breast cancer90% are invasive at time of diagnosis80% ER+, 75% PR+, 30% HER2/neuMore invade into pectoralisTreatment same as for female ca