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Breast Cancer

Breast Cancer. Steven Jones, MD. Epidemiology of Breast Cancer. 182,460 American women diagnosed each year. 40,480 die each year from the disease Lifetime risk through age 85 is 1 in 8, or 12.5% 2 nd leading cause of cancer deaths among US women, after lung cancer

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Breast Cancer

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  1. Breast Cancer Steven Jones, MD

  2. Epidemiology of Breast Cancer • 182,460 American women diagnosed each year. • 40,480 die each year from the disease • Lifetime risk through age 85 is 1 in 8, or 12.5% • 2nd leading cause of cancer deaths among US women, after lung cancer • Leading cause of death among women age 40-55

  3. Mammary Gland Anterior view Lobar/Lactiferous duct Lobular duct Breast Anatomy Lobule Ampulla Nipple Areola gland Fat Areola

  4. Lobar/Lactiferous Duct Cross Section

  5. The entire duct may be filled with abnormal, atypical cells. This condition is actually an early breast cancer. Lobar/Lactiferous Duct Cross Section Ductal Carcinoma In Situ (DCIS)

  6. Cancer cells that break out of the duct and invade the breast tissue. Lobar/Lactiferous Duct Cross Section Invasive Ductal Carcinoma (IDC)

  7. Breast Cancer Risks • Gender – 1% male • Age - < 30 – rare ; risk rises sharply after 40 • Personal Hx – 0.5-1% per yr in contra breast • Family Hx- 20-30% of Br Ca have + fm hx; only 5-10% have an inherited mutation

  8. Consider BRCA 1 / 2 testing: • < 35 • <50 with another positive relative < 50 • Any age with 2 other positive relatives • Male relative with breast cancer • Jewish ancestry with young age or 1 relative

  9. Breast Cancer Risks • Benign Breast disease – Atypical ductal hyperplasia – 4.5-5.0 RR • Lobular Carcinoma in Situ – 5.4-12.0 RR, 1% per year.

  10. Excess growth within the duct includes abnormal or atypical cells. The presence of this condition increases the risk of developing breast cancer. Lobar/Lactiferous Duct Cross Section Atypical Ductal Hyperplasia (ADH)

  11. Excess growth in the lobules Lobular Hyperplasia Lobular Hyperplasia Atypical Lobular Hyperplasia Atypical lobular hyperplasia may also develop. If atypical lobular hyperplasia progresses in severity a condition referred to as Lobular Carcinoma In Situ (LCIS) may develop.

  12. Breast Cancer Risks • Hormonal factors – early menarche, late menopause, age of 1st pregnancy, HRT with progesterone • Environment, lifestyle, and diet – ionizing radiation increase risk

  13. High Risk Patients • Gail model • Chemo prevention • Increased surveillance

  14. Additional Views Magnification Views • Improves resolution • Better determination of the shape, distribution, and number of microcalcifications • Questionable density from summation shadows will dissipate Mammography Current status of the Digital Database for Screening Mammography," M. Heath, K.W. Bowyer, D. Kopans et al, pages 457-460 in Digital Mammography, Kluwer Academic Publishers, 1998.

  15. Report Organization Category Assessment Recommendations 0 1 2 3 4 5 Incomplete assessment Additional imaging evaluation Negative Benign finding BI-RADS™ Probably benign Short interval follow-up Biopsy should be considered Suspicious Highly suggestive of malignancy Appropriate action to be taken

  16. Breast Ultrasound Characteristics of imaged lesions • Size • Shape • Border definition • Internal echogenicity • Posterior enhancement • Architectural changes • Gray scale comparison to adjacent breast tissue

  17. Benign vs. Malignant

  18. Open Surgical Biopsy • Performed in the Operating Room • An incision is made in the breast and a large tissue sample is cut and removed In some cases, a wire is inserted into the breast to aid in localizing the abnormality • Possible scarring and disfiguration that can interfere with future mammograms • More costly than other biopsy methods Biopsy Options

  19. Fine Needle Aspiration (FNA) • Can be performed in an outpatient setting or doctor’s office • No anesthesia • No sutures • Several needle insertions to collect fluid and/or cellular material Cyst aspiration for fluids • Unable to mark biopsy site Biopsy Options

  20. Core Needle Biopsy • Can be performed in an outpatient setting or doctor’s office • Local anesthesia • No sutures • 4 – 6 needle insertions to collect a sufficient amount of breast tissue for an accurate diagnosis • Unable to mark biopsy site Biopsy Options

  21. Cancer Cure? cut it out or burn it out

  22. National Surgical Adjuvant Breast Project • Radical mastectomy vs • Simple mastectomy with axillary irradiation vs • Simple mastectomy with delayed axillary dissection Started in 1971, 1665 patients enrolled, 25 year follow up No difference in disease free or overall survival

  23. Breast Cancer MultifocalityHolland et al. • Only 37% of cancers are confined to the primary tumor. • 20% have additional cancer within 2 cms. • 43% have additional cancer beyond 2 cms. Holland R, Veling S, Mravunac M, et al. Histologic multifocality of Tis, T1-2 breast carcinomas: implications for clinical trials of breast-conserving treatment. Cancer 1985; 56: 979

  24. NSABP B-06 • Total mastectomy vs lumpectomy vs lumpectomy plus irradiation • No significant difference in survival • 14.3% recurrence in lumpectomy plus radiation group at 25 years • 39.2% recurrence in lumpectomy without radiation group at 25 years

  25. Conclusion NSABP B-06 • Lumpectomy followed by breast irradiation is the appropriate therapy for women with breast cancer, provided that the margins of resected specimens are free of tumor and an acceptable cosmetic result can be obtained.

  26. Axillary Biopsy and Control • 1. Staging • In the absence of distant mets number of positive lymph nodes is the most important prognostic factor. 2. Regional Control In clinically negative axilla, axillary dissection reduces local occurrence from 20% to 3% 3. Small survival advantage (3-5%)

  27. Parasternal (internal thoracic) nodes Subclavian (apical axillary) nodes Interpectoral (Rotter’s) nodes Central axillary nodes Brachial (lateral axillary) nodes Subscapular (posterior axillary) nodes Pectoral (anterior axillary) nodes Mammary Gland Anterior view Breast Anatomy

  28. Sentinel Lymph Node • Technetium labeled sulfur colloid • Isosulfan blue (lymphazurin 1%) • Combined – 97% ID’ed; 6% false negative • 1% anaphylactic reaction to blue dye

  29. Systemic Therapy • Cytotoxic chemotherapy • Hormonal therapy – 50% reduction of recurrence, 26% reduction in mortality • Targeted therapy - Herceptin – 50% reduction of recurrence.

  30. NSABP B-18 • Started 1988; 1523 pts, 4 cycles AC • 80% overall response • 13% pathologic complete response • No difference in overall survival • Only 3% had progression of disease • 25% downstaging at axilla • 30% of women will downstage to allow conversion from mastectomy to BCS

  31. Indications • To downstage women with large tumors that cannot undergo BCS with good cosmetic result – 30% of women will downstage. • Early initiation of systemic treatment • In vivo assessment of response, good biological model • Less radical surgery needed

  32. Risk of breast cancer increases with age Facts & Figures Feuer EJ, Wun LM. DEVACN: Probability of Developing or Dying of Cancer. Version 4.0 Bethesda, MD: National Cancer Institute 1999

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