Breast cancer is the most common female cancer in the US and the second most common cause of cancer death in women. Risk factors include age, family history, lifestyle factors, and reproductive history. Evaluation of breast complaints requires a thorough history, physical exam including triple assessment with mammography, ultrasound and biopsy. Staging involves assessing tumor size, lymph node involvement and metastasis. Treatment may involve neoadjuvant chemotherapy, surgery such as mastectomy or lumpectomy with radiation, and adjuvant systemic therapy.

1. BREAST CANCER

2. • The most common female cancer in the US
• The second most common cause of cancer death in women
• The main cause of death in women ages 40 to 59
Siegel R, Ward E, Brawley O, Jemal A. Cancer statistics, 2011: The impact of eliminating socioeconomic and
racial disparities on premature cancer deaths. CA Cancer J Clin 2011; 61:212.

4. RISK FACTORS
• Age and gender
• Race and ethnicity
• Benign breast disease
• Personal history of breast cancer
• Lifestyle and dietary factors
• Reproductive and hormonal factors
• Family history and genetic factors
• Exposure to ionizing radiation
• Environment factors
• Smoking

6. EVALUATION OF BREAST COMPLAINTS REQUIRES A
VIGILANT AND SYSTEMATIC APPROACH TO
ENSURE THAT CANCERS ARE DIAGNOSED AND
TREATED PROMPTLY AND BENIGN BREAST DISEASE
RECEIVES APPROPRIATE ATTENTION AND CARE.

7. HISTORY
• Any change in the general appearance of the breast
• New or persistent skin changes
• New nipple inversion
• Nipple discharge
• The characteristics of any breast pain
• The presence of a breast lump (mass) and its evolution
• The precise location of any breast lump
• Whether a lump waxes and wanes during the menstrual cycle

8. TRIPLE ASSESSMENT
• Physical examination
• Mammography
• Needle biopsy

9. EXAMINATION
• Inspection
• Palpation

13. CLASSIC CHARACTERISTICS OF CANCEROUS LESION
• Single lesion
• Hard
• Immovable
• Irregular borders

14. MAMMOGRAPHY

15. SCREENING MAMMOGRAM

16. DIAGNOSTIC MAMMOGRAM
• The majority of breast cancers are associated with abnormal mammographic
findings
• If an abnormality is found at mammographic screening, supplemental
mammographic views and possibly ultrasound should be used for further
characterization.
• Some of the most aggressive cancers appear between normal screening
mammograms and are therefore termed interval cancers

17. DIAGNOSTIC MAMMOGRAM
• Younger women may present with large tumors prior to the age at which
screening is usually recommended,
• When women present with a suspicious new mass, diagnostic mammograms
should be part of the initial workup, despite young age or having had a
negative routine screening mammogram.

18. MAMMOGRAM
• Mammographic findings suggestive of a breast cancer:
• Soft tissue masses
• Clustered micro-calcifications

21. BREAST IMAGING REPORTING AND DATA SYSTEM (BI-
RADS)
Assessment category Recommendation Probability of malignancy
0: Incomplete Need for further evaluation Not applicable
1: Normal Normal interval follow-up 0 percent
2: Benign Normal interval follow-up 0 percent
3: Probably benign
A short interval follow-up is
recommended
≤2 percent
4: Suspicious abnormality A biopsy should be considered
>2 to 95 percent
(a) Low-risk
(b) Intermediate-risk
(c) Moderate to high-risk
5: Highly suggestive of
malignancy
Biopsy or surgery should be
performed
≥95 percent
6: Biopsy-proven carcinoma

22. ULTRASONOGRAPHY
• Ultrasound can be used to differentiate between solid and cystic breast
masses that are palpable or detected mammographically.
• ultrasound evaluation of the axilla can be used to detect lymph nodes that are
suspicious for axillary metastases.
• Ultrasound provides guidance for interventional procedures of suspicious
areas in the breast or axilla.

23. BREAST MRI
• Highly sensitive
• Can identify foci of cancer that are not evident on physical examination,
mammogram, or ultrasound.
• Not recommended as a routine component of the diagnostic evaluation of
breast cancer for most women because
• Limited specificity
• Increases the number of unnecessary biopsies
• Delays definitive treatment
• Increases the number of patients undergoing mastectomy

24. BREAST MRI
• For patients with axillary nodal metastases and a clinically occult primary
tumor.
• When the clinical extent of disease is larger than what is appreciated by
mammography
• To assess posterior tumor extension and pectoralis fascia or muscle
involvement if that will determine a change in surgical approach or the use of
neoadjuvant therapy.

25. BREAST MRI
• For women with Paget’s disease of the breast who have a negative physical
examination and mammogram.
• In women with locally advanced breast cancer who are being considered for
upfront (neoadjuvant) systemic therapy.
• For women with very high risk for contralateral disease.
• For women who are planning extensive reconstructive surgery, breast MRI
may be used to identify occult contralateral cancers.

26. BIOPSY
• In the patient with a suspicious mammographic abnormality or palpable
breast mass, the obligatory diagnostic technique is biopsy.
• Surgical biopsy should not be utilized as a diagnostic tool unless percutaneous
palpation-guided or image-guided biopsy is not feasible.

27. BIOPSY
• Fine Needle Aspiration Biopsy
• Core Needle Biopsy
• Stereotactic Biopsy
• Incisional Biopsy
• Excisional Biopsy
• Skin Punch Biopsy

28. DIAGNOSTIC ALGORITHMS

30. AGE < 30

31. AGE > 30

32. SYSTEMIC EVALUATION
• Indications for radiological staging beyond a general work-up depend upon
the stage of disease.
• For those patients who presents with early stage (I to IIIA) disease, the use of
imaging studies to detect distant metastases are generally limited to patients
with a higher pre-test probability of distant metastases.

33. SYSTEMIC EVALUATION
• Distant metastases in breast cancer most commonly occur in the lung, liver,
and bone.
• Radiologic imaging techniques
• Chest radiography
• Abdominal/pelvic computed tomography (CT) scanning
• Ultrasonography
• Magnetic resonance imaging (MRI)
• Bone scans

34. TNM STAGING

35. Tumor Size (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
Tis (DCIS) Ductal carcinoma in situ
Tis (LCIS) Lobular carcinoma in situ
Tis
(Paget's)
Paget's disease of the nipple NOT associated with invasive carcinoma and/or carcinoma in situ in
the underlying breast parenchyma.
T1 Tumor ≤20 mm in greatest dimension
T1mi Tumor ≤1 mm in greatest dimension
T1a Tumor >1 mm but ≤5 mm in greatest dimension
T1b Tumor >5 mm but ≤10 mm in greatest dimension
T1c Tumor >10 mm but ≤20 mm in greatest dimension
T2 Tumor >20 mm but ≤50 mm in greatest dimension
T3 Tumor >50 mm in greatest dimension
T4 Tumor of any size with direct extension to the chest wall and/or to the skin (ulceration or skin nodules)
T4a Extension to the chest wall, not including only pectoralis muscle adherence/invasion
T4b
Ulceration and/or ipsilateral satellite nodules and/or edema (including peau d'orange) of the skin,
which do not meet the criteria for inflammatory carcinoma
T4c Both T4a and T4b
T4d Inflammatory carcinoma

36. Regional Lymph Nodes (N)
NX Regional lymph nodes cannot be assessed (eg, previously removed)
N0 No regional lymph node metastases
N1 Metastases to movable ipsilateral level I, II axillary lymph node(s)
N2
Metastases in ipsilateral level I, II axillary lymph nodes that are clinically fixed or matted; or in
clinically detected ipsilateral internal mammary nodes in the absence of clinically evident axillary
lymph node metastases
N2a Metastases in ipsilateral level I, II axillary lymph nodes fixed to one another (matted) or to other structures
N2b
Metastases only in clinically detected‡ ipsilateral internal mammary nodes and in the absence of clinically
evident level I, II axillary lymph node metastases
N3
Metastases in ipsilateral infraclavicular (level III axillary) lymph node(s) with or without level I, II
axillary lymph node involvement; or in clinically detected ipsilateral internal mammary lymph
node(s) with clinically evident level I, II axillary lymph node metastases; or metastases in ipsilateral
supraclavicular lymph node(s) with or without axillary or internal mammary lymph node
involvement
N3a Metastases in ipsilateral infraclavicular lymph node(s)
N3b Metastases in ipsilateral internal mammary lymph node(s) and axillary lymph node(s)
N3c Metastases in ipsilateral supraclavicular lymph node(s)

37. Distant Metastasis (M)
M0 No clinical or radiographic evidence of distant metastases
cM0(i+)
No clinical or radiographic evidence of distant metastases, but deposits of
molecularly or microscopically detected tumor cells in circulating blood, bone
marrow, or other nonregional nodal tissue that are no larger than 0.2 mm in a
patient without symptoms or signs of metastases
M1
Distant detectable metastases as determined by classic clinical and radiographic
means and/or histologically proven larger than 0.2 mm

38. 0 Tis N0 M0
IA T1 N0 M0
IB
T0 N1mi M0
T1 N1mi M0
IIA
T0 N1 M0
T1 N1 M0
T2 N0 M0
IIB
T2 N1 M0
T3 N0 M0
IIIA
T0 N2 M0
T1 N2 M0
T2 N2 M0
T3 N1 M0
T3 N2 M0
IIIB
T4 N0 M0
T4 N1 M0
T4 N2 M0
IIIC Any T N3 M0
IV Any T Any N M1

39. NEOADJUVANT SYSTEMIC THERAPY
• For patients with locally advanced, inoperable and inflammatory breast
cancer, neoadjuvant systemic therapy has become standard treatment.
• For patients with operable, early stage breast cancer, neoadjuvant systemic
therapy results in long-term distant disease-free survival and overall survival
comparable to that achieved with adjuvant systemic therapy.
• there is insufficient evidence that neoadjuvant systemic therapy offers benefit
over primary surgery followed by appropriate adjuvant therapy for smaller
tumors and/or no clinically apparent axillary lymph node involvement
van der Hage JA, van de Velde CJ, Julien JP, et al. Preoperative chemotherapy in primary
operable breast cancer: results from the European Organization for Research and Treatment
of Cancer trial 10902. J Clin Oncol 2001; 19:4224.

40. CANDIDATES
• Locally advanced, inoperable breast cancer
• IIIA, IIIB, IIIC and inflammatory breast cancer
• Early stage, operable breast cancer
• Main indication is BCS (>3cm)
• IIA, IIB, or IIIA
• Patients with surgical contraindications and elderly
Evans TR, Yellowlees A, Foster E, et al. Phase III randomized trial of doxorubicin and docetaxel
versus doxorubicin and cyclophosphamide as primary medical therapy in women with breast
cancer: an anglo-celtic cooperative oncology group study. J Clin Oncol 2005; 23:2988.

41. PRE-TREATMENT EVALUATION
• histopathological confirmation of invasive carcinoma
• assessment of ER, PR and HER2 status
• Placement of radiopaque clips to mark the primary tumor location
• Assessment of axillary lymph node status

42. RESPONCE
Response assessment
Target lesions
CR
Disappearance of all target lesions and reduction in the short axis measurement of all pathologic lymph nodes to
≤10 mm
PR ≥30 percent decrease in the sum of the longest diameter of the target lesions compared with baseline
PD
≥20 percent increase of at least 5 mm in the sum of the longest diameters of the target lesions compared with
the smallest sum of the longest diameter recorded
OR
The appearance of new lesions including those detected by FDG-PET
SD Neither PR nor PD
Non-target lesions
CR Disappearance of all non-target lesions and normalization of tumor marker levels
IR, SD
Persistence of one or more non-target lesions and/or the maintenance of tumor marker levels above normal
limits
PD
The appearance of one of more new lesions or unequivocal progression.
If patient has measurable disease, an increase in the overall level, or substantial worsening in non-target lesions,
such that tumor burden has increased, even if there is a SD or PR in target lesions.
If no measurable disease, an increase in the overall tumor burden comparable in magnitude to the increase that
would be required to declare PD in measurable disease (eg, an increase in pleural effusions from trace to large,
or an increase in lymphangitic disease from localized to widespread).

43. LOCOREGIONAL THERAPY
• Mastectomy
• Breast Conserving Surgery
• Sentinel Lymph Node Biopsy (SLNB)
• Negative  ALND not performed
• Positive  ALND performed
+/- RT

44. POST OP RADIOTHERAPY
• Breast conserving surgery
• Patients with locally advanced breast cancer (stage III disease) treated with
mastectomy
• Majority of patients with histologically positive lymph nodes remaining after
preoperative chemotherapy