BREAST CANCER

• 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.

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

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.

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

TRIPLE ASSESSMENT

• Physical examination

• Mammography

• Needle biopsy

EXAMINATION

• Inspection

• Palpation

CLASSIC CHARACTERISTICS OF CANCEROUS LESION

• Single lesion

• Hard

• Immovable

• Irregular borders

MAMMOGRAPHY

SCREENING MAMMOGRAM

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

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.

MAMMOGRAM

• Mammographic findings suggestive of a breast cancer:

• Soft tissue masses

• Clustered micro-calcifications

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

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.

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

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.

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.

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.

BIOPSY

• Fine Needle Aspiration Biopsy

• Core Needle Biopsy

• Stereotactic Biopsy

• Incisional Biopsy

• Excisional Biopsy

• Skin Punch Biopsy

DIAGNOSTIC ALGORITHMS

AGE < 30

AGE > 30

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.

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

TNM STAGING

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

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 ipsilateralsupraclavicular 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)

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

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

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.

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 docetaxelversus 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.

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

RESPONCEResponse 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 recordedORThe 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).

LOCOREGIONAL THERAPY

• Mastectomy

• Breast Conserving Surgery

• Sentinel Lymph Node Biopsy (SLNB)• Negative ALND not performed

• Positive ALND performed

+/- RT

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