Dr. Armando V. Tan ** Anatomy 2. Axillary vein 3.

Internal mammary artery

BREAST CANCER

5. Intercostal veins 6. Intercostal arteries Axillary Levels (Lymph Nodes) Level Ilateral to the pectoralis minor muscle Level II beneath the pectoralis minor muscle Level III medial to the pectoralis minor muscle Rotters Node between pectoralis major and minor muscles Average LN surgically harvested: 20 axillary LN 5 internal mammary LN

Blood Supply: 1. Axillary artery

complaint of discharge

Inspection

Palpation Clinical Evaluation of the Breast Components of a Breast Directed History General History Age Complaints Prior mammograms Self-exam Prior lumps, excisions, or biopsies Medications Breast Cancer Hx of breast CA or Risk Factors atypical HPL Breast CA in 1st degree relative Early menarche Late 1st full-term preg Late menopause Personal or family history of GI CA Specific for Duration complaint of Location mass Change over time Cyclicity Chest trauma Specific for Duration complaint of Location pain Quality Severity Cyclicity Radiation Factors affecting pain Specific for Duration Mass

Nipple discharge

Laterality Spontaneous vs provoked Color Discharge volume Visual changes Headache Arms at sides, pressed on hips & over head Size, shape symmetry Skin change (ulceration, erythema, retraction) Nipple inversion, deviation, flaky skin Seated & supine positions Supraclavicular and axillary nodes Clavicle to bra line, midline to axilla Uniform pattern (stripwise vs circular) Press on areola to elicit discharge Location Size, shape, consistency Mobility Tenderness Border definition Laterality Number of ducts involved Color of discharge Consistency of discharge Test for blood (guaiac) Microscopy for fat globules

Etiology of Breast Mass Physiologic Inflammation (mastitis, Causes abscess) Duct ectasia (plasma cell mastitis) Fat necrosis Superficial thrombophlebitis (Mondors ds) Galactocoele

Benign Neoplasm

Malignant Neoplasm

Fibrocystic change Fibroadenoma Intraductal papilloma Cystosarcoma phyllodes Granular cell tumor Pagets disease Ductal CIS Infiltrating Ductal CA Infiltrating Lobular CA

BREAST CANCER RISK FACTORS STRONG Female gender Older age Hereditary breast & ovarian dse BRCA1 &/or BRCA2 gene mutation Family Hx Breast CA Previous breast or ovarian CA MODERATE Early menarche Late menarche Nulliparity Radiation exposure Hyperplasia SLIGHT Exogenous hormones High-fat diet Obesity

Risk Factors: 1. Gender female: male ratio = 100:1 2. Aging 60 years old and older 3. Genetic BRCA1 and BRCA2 4. Family History o 1 first degree relative 2 fold risk o 2 first degree relatives 5 fold risk 5. Personal History of Breast CA 3 4 fold risk 6. Abnormal Breast Pathology o Proliferative changes w/o atypia 2 fold risk Moderate or florid hyperplasia Sclerosing adenosis Papillomas o Proliferative changes w/ atypia 4 5 fold risk Atypical ductal hyperplasia Atypical lobular hyperplasia 7. Menstrual Periods o Early menarche ( age before 12) o Late menopause ( age after 55) 8. Previous chest radiation 9. DES exposure 10.Lifestyle Related Factors o Nulliparity, Late age at 1st pregnancy o OCP use current users sl. Increase risk o Postmenopausal hormone replacement therapy o Obesity o Alcohol intake dose related

SIGNS 1. Lump 2. Skin Dimpling 3. Change in skin color or texture 4. Change in how the nipple looks, like pulling in of the nipple 5. Clear or bloody fluid that leaks out of the nipple Timing of Examination

The best time for breast exam is 5 7 days after cessation of menses when the morphologic influences of hormones are minimal

PHYSICAL EXAM Benign Regular borders Free Malignant Indistinct, irregular borders Fixed to skin,

mobility Cystic texture Pain with palpation DIAGNOSIS

chest wall Hard painless

3. FINE NEEDLE ASPIRATION BIOPSY Useful if positive Negative result does not exclude malignancy 4. CORE NEEDLE BIOPSY Allows tissue diagnosis while avoiding the cost and invasiveness of open biopsy More reliable than FNA 5. NEEDLE LOCALIZED BIOPSY Gold standard for evaluation of a non- palpable, suspicious mammographic finding 6. OPEN (EXCISION) BIOPSY Has the advantage of removing entire mass Question & Answer: 1. What is the preferred imaging modality for a 29 yr old woman with a palpable breast mass? a. Mammogram b. Ultrasound c. CT Scan d. MRI Mammogram not ideal for a woman < 30 yrs old, because of breast density CT Scan - Generally not used for breast lesions MRI - False + rate is 6% leading to unnecessary mastectomy or additional biopsies

1. MAMMOGRAPHY Mammographic signs o Microcalcification clustered, linear branching o Speculated or stellate mass o Irregular, microlobulated borders Benign Malignant Distinct Indistinct, edges stellate, speculated Calcificatio border n patterns, popcorn Clusters of and secretory microcalcificat ion Stability over time instability American Cancer Society CURRENT RECOMMENDATION: o Initial mammography for all women 40 45 years old and annual screening thereafter o Women 30 35 years of age with a family history of breast cancer should consider annual mammography screening and clinical breast examination

2. ULTRASONOGRAPHY Adjunct to mammography Initial imaging study of choice to evaluate a mass in young women Cannot detect small clustered microcalcifications which may be an early sign of cancer Sonographic features of malignancy o Larger longitudinal than transverse dimensions o Angular margins o Speculated borders o Hypoechogenic texture o Distal shadowing behind the mass

2. What is the preferred imaging modality for a 49 years old woman with a palpable breast mass? a. Mammogram b. Ultrasound c. CT Scan d. MRI Mammogram - Can detect palpable and nonpalpable tumors including microcalcifications in this age grp Ultrasound - Not capable of detecting microcalcifications 3. Ultrasound result of a 28 years old with palpable breast mass showed a solid tumor suspicious for malignancy. What kind of biopsy is most appropriate. a. FNAB b. Core needle biopsy c. Incisional d. Excisional FNAB - 95% sensitivity - Needs an experienced cytopathologist - Cannot distinguish between in situ and invasive lesions Core needle Biopsy - Biopsy technique of choice specially in the absence of an experienced cytopathologist - Sensitivity 98.7% - Has the ability to distinguish between in situ carcinoma and invasive carcinoma Incisional biopsy - When open biopsy is indicated for large lesions Excisional biopsy - Solid: Indeterminate or biopsy Indicated when needle is nondiagnostic and is suspicious discordant with physical exam Mammogra and imaging findings - Difficult tom BCS after this do type of biopsy Tissue Biopsy Excision Core Needle Biopsy (preferred)

4. FNA was done on a 25 yr old woman with palpable breast mass which was cystic on ultrasound. Aspirate was non-bloody and the mass completely disappeared. Next step is: a. Send aspirate for cytology b. Do excision biopsy c. Follow-up after 6 weeks Simple cysts are almost never malignant. Aspirated cyst fluid should not be routinely sent for cytologic examination. o The clinical validity of atypia identified in a cyst aspirate fluid is questionable and of low yield. o Hindle et al. routine cytologic exam of cyst aspirate fluid often results in unnecessary surgical biopsy and is not cost effective 5. A 30 year old female underwent FNA for a breast mass. Aspirated fluid was greenish brown in color. After aspiration the mass did not completely resolve. Next step would be: a. Cytology of aspirated fluid b. Excision biopsy c. Follow up after 6 weeks Indications for excision biopsy of a cyst after FNA: o Bloody or serosanguinous aspirate o Residual mass o Recurrent cyst after 2 aspirations

CLINICAL TNM STAGING T: PRIMARY TUMOR o TX o T0 o Tis o T1 T1mi c T1a T1b T1c o T2 o T3 o T4 N: NODES o NX o N0 o N1 o o N2 N3 Unknown No evidence of primary tumor Carcinoma in situ, intraductal CA 2 cm or < 0.1 cm or < > 0.1 cm but =/< 0.5 cm > 0.5 cm but =/< 1 cm > 1 cm but =/< 2 cm > 2 cm but =/< 5 cm > 5 cm Tumor involves chest wall or skin

STAGE 0 STAGE I STAGE II A STAGE II B STAGE III A STAGE III B STAGE IV

Tis T1 T0 T1 T2 T2 T3 T0 T1 T2 T3 T4 Any T Any T

N0 N0 N1 N1 N0 N1 N0 N2 N2 N2 N1, N2 Any N N3 Any N

M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M1

Regional LN cannot be assessed No regional LN metastasis Metastasis to movable ipsilateral axillary LN Metastasis to ipsilateral axillary LN fixed to one another or other structures Metastasis to ipsilateral internal mammary LN Presence of distant metastasis cannot be assessed No distant metastasis Distant metastasis, including mets to supraclavicular LN

M: METASTAS IS o MX o o M0 M1

DUCTAL CARCINOMA IN SITU Precursor of invasive ductal carcinoma Average age: 55 yrs old Mammography o Radiologically dense tissue with multiple punctuate calcifications Histology o Proliferation of ductal epithelium to form papillary ingrowths into duct lumen Treatment options o Wide excision alone o Wide excision with post-op radiation o Simple mastectomy LOBULAR CARCINOMA IN SITU

STAGING OF BREAST CANCER STAGE T N M

Not truly a premalignant lesion but a marker for invasive disease Incidence of coexisting invasive disease is 5% Average age: 45 yrs old Histology: o Distended terminal ducts filled with homogenous cells without mitosis or necrosis Treatment options: o Close follow up Breast exam every 6 months Mammography every year o Bilateral simple mastectomy Bilateral because the risk of subsequent breast cancer is bilateral regardless of original biopsy site Simple because the risk of axillary in metastasis is <2%

SENTINEL NODE MAPPING

MANAGEMENT OPTIONS: STAGE I or II o Lumpectomy, axillary node dissection and post op radiation o Modified radial mastectomy and reconstruction o Chemotherapy o Tamoxifen Can inhibit the growth of ER positive tumors If taken for 5 years, can reduce recurrence by 47% STAGE III A o Mastectomy plus post-op chemotherapy o Induction (presurgery) chemotherapy followed by breast conservation surgery (wide excision) plus post op radiation o Induction chemotherapy followed by mastectomy STAGE III B o Induction chemotherapy followed by mastectomy STAGE IV o Chemotherapy o Radiation INVASIVE LOBULAR CARCINOMA

AXILLARY LYMPH NODE DISSECTION The most powerful prognostic indicator for survival in pts with breast cancer is the presence or absence of lymph node metastases. Risks: o Paresthesia o Axillary seroma formation o Lymphocele formation o Infection o Skin necrosis o Lymphedema of arm

DUCTAL CARCINOMA IN SITU Treatment option: o Breast Conserving Surgery (BCS) and Radiation with or without Tamoxifen o Total Mastectomy with or without Tamoxifen o Breast Conserving Surgery (BCS) without radiation TREATMENT OPTIONS:

 STAGE I, II, III A o BCS/ Lymph Node Resection + Radiation o MRM with or without reconstruction o Sentinel Node followed by Surgery o Adjuvant: Radiation to LN near Breast/ Chest wall Systemic Chemotherapy with or without hormone Hormonal Therapy STAGE IV/ METASTATIC o Hormonal and/or Systemic Chemo with or without Herceptin o Radiation and/or Surgery for relief of pain/other symptoms o High dose chemo- Stem Cell Transplant o Biphosphonate drugs to reduce bone disease, pain INFLAMMATORY BREAST CA PAGETS DISEASE o Presents as an eczematous eruption of the nipple and areola o Often associated with underlying invasive intraductal carcinoma o MGT: Modified Radical Mastectomy Treatment Options for Breast Cancer Surgery Radiation Chemotherapy Hormonal Therapy Biological Therapy Surgery 1. Breast Sparing Surgery - Removes cancer but not the whole breast - Lumpectomy, segmental, partial mastectomy - Removes few axillary LN thru separate small incision/sentinel node biopsy

Most will receive radiation to the breast

2. Mastectomy - Modified radical mastectomy with axillary LN dissection - Simple mastectomy - Prophylactic Mastectomy BRCA carriers Both BCS and Mastectomy have the same overall survival rate Hormonal Therapy - Some breast tumors need hormones to grow - Drugs given to block estrogen like Tamoxifen, estradiol - Surgery (oophorectomy) to premenopausal women - Side effects same as menopausal women - Rarely causes stroke, uterine cancer Chemotherapy - Adjuvant chemotherapy - Neoadjuvant chemotherapy - Given as regimen (2 or more combination) Standard Chemotherapy Regimen o A Adriamycin, Taxotere o AC+T Adriamycin, Cytoxan, Taxol o CMF Cytoxan, Methotrexate, Fluorouracil o CEF Cytoxan, Ellence, Fluorouracil o FAC Fluorouracil, Adriamycin, Cytoxan o CAF Cytoxan, Adriamycin, Fluorouracil o TAC Taxotere, Adriamycin, Cytoxan o GET Genzar, Ellence, Taxol Biological Therapy - Helps immune system fight cancer

Herceptin given as monoclonal antibody to patient with too much HER2 protein (high HER2 means high recurrence after treatment) Side effects: fever, diarrhea, heart failure

PROGNOSIS (Chance of Recovery) The stage of the Cancer (LN involvement, metastasis) The type of Breast Cancer Estrogen receptor and Progesterone receptor levels in tumor tissue Whether cells have high levels of Human Epidermal Growth Factor Type 2 Receptor (HER2/neu) How fast the tumor is growing Womans age, general health and menopausal status Whether the cancer has just been diagnosed or has recurred SURVIVAL RATE Stage 0 Stage I Stage IIA Stage IIB Stage IIIA Stage IIIB Stage IV 92% 81% 67% 54% 20% 100% 100%