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Breast Cancer

Breast Cancer. April 1, 2014. Introduction. Most common female cancer Accounts for 32% of all female cancer 211,300 new cases yearly and rising 40,000 deaths yearly. Gross Anatomy. Sappy’s plexus – lymphatics under areolar complex 75% of lymphatics flow to axilla. Microscopic Anatomy.

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Breast Cancer

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  1. Breast Cancer April 1, 2014

  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 • 75% of lymphatics flow to axilla

  4. 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 • Axillary lympadenopathy • 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 • Sterotatic • Needle localization • Excision biopsy

  9. Risk of Future Invasive Breast Carcinoma Based on Histologic Diagnosis from Breast Biopsies • No Increase • AdenosisApocrine metaplasiaCysts, small or largeMild hyperplasia (>2 but <5 cells deep)Duct ectasiaFibroadenomaFibrosisMastitis, inflammatoryPeriductal mastitisSquamous metaplasia • Slightly Increased (relative risk, 1.5–2) • Moderate or florid hyperplasia, solid or papillaryDuct papilloma with fibrovascular coreSclerosing adenosis, 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 int mam node • N2: 4-9 axillary nodes or palpalbe int mam node • N3: >10 nodes or combo of axillary and int mam nodes • {mic micoroscopic posivitiy, mol molecular posiivity • Metastasis

  17. Staging

  18. 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) Simple mastectomy Modified radical

  19. 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

  20. 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 • Mastecomy vs 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)

  21. 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

  22. 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

  23. 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 maligant breast ca for all DCIS

  24. Treatment of DCIS • Nodal involvement • 3.6% of DCIS pts have positive nodes in mastectomy specimins • 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

  25. 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-

  26. 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

  27. 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

  28. 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

  29. Other breast cancers • Inflammatory ca • Carcinoma invading lymphatic ducts • Chemotherapy, mastectomy, radiation • 50% survival at 5 years

  30. Other breast cancers Paget’s disease • Intraepithelial extesion of ductal ca • Excision with nipple-areolar complex • Sentinel node if invasive ca • Mastectomy

  31. 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

  32. Angiosarcoma • Risk factors • Radiation • Lymphedema • Treatment • Excision, radiation

  33. 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

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