Breast CancerRiaz Rahman, MSIII

Epidemiology & Risk Factors

Screening Recommendations

*In women between 35 and 60 years of age, breast masses are cancerous until proven

otherwise*

Mammography Types of Mammographic Abnormalities:

Masses, Asymmetric densities, Microcalicifications

Breast Imaging and Database System (BI-RADS): a quality-control system designed to standardize reporting mammography results and estimate breast cancer risk

.

Interpretation of Mammographic Findings When abnormalities are found on screening,

additional imaging is usually necessary: Microcalcifications: magnification mammography Masses/Asymetric Densities: magnification + ultrasound

“Probably Benign” (BIRADS 3): warrants Follow-Up only, Risk of Malignancy: 2% of lesions prove to be malignant Observe affected patients regularly

“Suspicious” (BIRADS 4): warrants biopsy. Risk of Malignancy: 15%-35% of lesions prove to be

malignant Initial diagnosis by stereotactic guided Core-Needle

Biopsy Positive biopsy result permits directive surgical planning

Ductal Carcinoma in Situ Often multifocal, with several histologic

patterns Comedo, micropapillary, cribriform Mammography: incidental microcalcifications 10%-20% of DCIS lesions have an infiltrative

component Careful examination and complete excision is

important Incomplete excision: 10-year risk of invasive

carcinoma = 30% Gold Standard Treatment:

Simple Mastectomy with or without reconstruction Wide excision and radiation therapy drops

recurrence to 22% Nodal dissection is not necessary, nodal

metastasis is rare

Progression of Breast Duct Lining

Lobar Carcinoma in Situ & Atypical Ductal Hyperplasia Lobar Carcinoma in Situ

LCIS is usually an incidental finding at histopathology When found adjacent to benign mass surveillance Malignant disease marker; 15%-20% chance of development of

invasive cancer in either breast in 20 next years Almost no risk of axillary metastasis Treatment: Close observation with examination and

mammography every 6 months for the next several years Atypical Ductal Hyperplasia

Similar in appearance to DCIS; 15%-50% prove malignant Associated risk of cancer is 4-5x higher (depends on histology) Needle localization and excision are appropriate Treatment is similar to DCIS (complete excision & observation)

Paget’s Disease & Fibrocystic Disease Paget’s Disease of the Breast

Chronic eczematoid lesion of the nipple 95% have underlying carcinoma; DCIS/infiltrating

carcinoma Associated masses are present in approximately

50% of cases, these patients should undergo mastectomy and staging

If lesion is confined to the nipple (~10%) treatment may involve excision of the nipple areolar complex or radiotherapy

Fibrocystic Disease of the Breast “Lumpy” tender breasts, usually before menstrual

periods Cysts, fibrosis, sclerosing adenosis, apocrine

change, hyperplasia Associated with a low risk of cancer. Risk increases

when hyperplastic epithelium demonstrates atypia on biopsy

Primary Breast Mass Fibroadenoma

Most common breast tumor in women <25yo Benign lesion, more common in African Americans Firm, rubbery, painless, movable, well-circumscribed Excision establishes diagnosis, observation may be

appropriate Phyllodes Tumor

Giant cell fibroadenomas: “cystosarcoma phyllodes” Large, bulky mass of variable malignant potential Occasional ulceration of overlying skin Increased number of mitoses per high power field

increases chance of malignancy Treatment is local excision with generous margins

Staging of Breast Cancer

Prognostic Indicators of Breast Cancer

Surgical Management of Breast Cancer Surgical Principles:

Establish a diagnosis Completely eradicate the primary tumor Determine if regional nodes are involved with metastasis Wide excision with radiation therapy for local tumors Mastectomy recommended for a multicentric/larger tumors. Removal of axillary nodes is necessary for accurate staging

Modified Radical Mastectomy (Auchincloss) Most commonly performed mastectomy Surgeon removes breast tissue, skin, axillary lymph nodes Pectoralis major muscle is spared. Radiation typically not

used Patey Modification: Transection of pec. minor + Level III

nodes

Surgical Management Traditional Radical Mastectomy (Halsted procedure)

Very disfiguring: breast tissue, skin, pectoralis major, pectoralis minor, and axillary lymph nodes are all removed

Rarely performed today, early studies foun no difference in survival between modified radical vs. traditional radical

Simple Mastectomy: removal of breast tissue, nipple-areolar complex and skin. Often done for LCIS/DCIS

Reconstruction: Immediate reconstruction avoids a 2nd operation, allows

exact defect to be duplicated/replaced, & yields excellent cosmetic results

Silicone gel, saline-filled prostheses, or vascularized flaps may all be used depending on patient size & amount of skin and breast

C/I: primary lesions involving chest wall, stage III or IV cancer

Surgical Management Lumpectomy/Segmental Mastectomy

Breast conserving therapy that provides much better cosmetic result compared to modified radical mastectomy

Involves removal of primary lesion with clear gross and histologic margins, accompanied by axillary node sampling and local radiotherapy to the entire breast.

Appropriate for a solitary tumor <5cm in size, provided breast size is acceptable and the patient is a good candidate for post-operative radiation therapy (which greatly reduces recurrence)

May involve irradiation of the axillary nodes, internal mammary nodes, and supraclavicular nodes, if more than four nodes are positive or if extrascapular invasion is present.

Anatomy of the Breast

Anatomy of the Breast

Lymphatic Drainage of the Breast

Surgical Management

Nonsurgical Therapy for Breast Disease

Follow-Up Patients with breast cancer should follow-up

with their physician at least twice a year. Annual CXR and liver function studies are

appropriate Patients who have had lumpectomy with

radiation should undergo mammography of the affected breast every 6 months for 2 years, followed by yearly mammograms

5-year survival rates: Early stage: 15% Stage I: 93% Stage II: 72%

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