BREAST

DR. WALLACE MEDINA

Breast anatomy
BRCA1
More aggressive breast tumors
Estrogen negative
____ TP53 mutations
Rarely exhibit HER2/neu expression
Personal history of previous breast
cancer
Bilateral cancer
Younger than 50 years old
_____ of breast and ovarian cancer
BRCA2
1-2% early onset breast cancer
ER (+)
Increase risk of non breast cancers
o Prostate = 4.65%
o Gallbladder & bile duct = 4.97%
o Stomach = 2.59%
o Malignant melanoma = 2.58%
DIAGNOSIS
1. CBE/SBE
2. CNB
3. Imaging
a. MMG
b. Ultrasound
c. MRI
Pathology review
Tumor size
Lymph node status
Nuclear grade
Histologic type
HER2/neu & ER/PR status
Extracapsular extension
Vascular and lymphatic invasion
MMG

First imaging modality

___ and diagnostic
Evaluation of the contralateral breast
10-15% failure to detect palpable
lesion
Decrease accuracy for dense breast
LCIS
Detect synchronous lesion or nonpalpable calcifications

The UB preventive Services Task Force

estimates
the
benefits
of
mammography in women aged 50-74
years to be a 30% reduction in risk of
death from breast cancer
For women aged 40-49 years, the risk
of death is decrease by 17%
Screening Recommendations
American Cancer Society
Age
20 -39

SBE
Monthly

40 49
50+

Monthly
Monthly

CBE
Every 3
yrs
Annually
Annually

Breast Imaging Reporting

System
0
Additional imaging
1
Routine imaging
2
Benign
3
Probably benign
4
Suspicious
5
Highly malignant
6
Known malignant

MMG
Diagnosti
c
Annually
annually
and

Data

Ultrasonography
Solid vs. cystic is NONpalpable lesion
Directing FNAB. Core biopsy of lesion
Confirms position of lesion
Localizing non palpable lesion for
excision
Quantify response of tumor and nodal
status to neoadjuvant
MRI

Screening high risk

Evaluation integrity of implants
Annual screening for BRCA carrier
Detection of occult cancer
Characterization
of
indeterminate
lesion after a full assessment with
physical examination, MMG and US
Detection of occult breast carcinoma
in a patient with carcinoma in an
axillary lymph node
Evaluation of multifocal or bilateral
tumor

 Evaluation
of
invasive
lobular
carcinoma which has a high incidence
of multifocal
Evaluation of suspected extensive
high grade intraductal carcinoma
Detection of occult primary breast
carcinoma
in
the
presence
of
metastatic
adenocarcinoma
of
unknown origin
Monitoring
of
the
response
to
neoadjuvant chemotherapy
Detection of recurrent breast cancer
Benign breast tumors
1. Breast cyst
2. Fibroadenoma
3. Hamartoma and adenoma
4. Breast abscess
5. Papilloma and papillomatosis
6. Sclerosing adenosis
7. Radial scar
Classification of Primary Breast Cancer
Noninvasive Epithelial Cancers
1. LCIS
2. DCIS or Intraductal carcinoma
a. Papillary
b. Cribriform
c. Solid
d. Comedo
Comparison of LCIS and DCIS

Age at
presentation
PE

LCIS
(bilateral)
Premenopausa
l
Negative

MMG

Negative

Diagnosis

Incidental

Risk

In all breast
tissue
Observation vs
chemopreventi
on vs bilateral
prophylactic
mastectomy

treatment

DCIS
(ipsilateral)
Postmenopaus
al
Occasional
palpable mass
Microcalcificati
ons
Workup
of
abnormality
At
site
of
diagnosis
Lumpectomy
+
RT
vs
ipsilateral
simple
mastectomy
consider
tamoxifen

DCIS SUBTYPES
DCIS
Characteristi
c
Nuclear grade
ER
Distribution
Necrosis
Local
recurrence
Prognosis

Comedo

Noncomedo

High
Negative
Continuous
Present
High

Low
Positive
Multifocal
Absent
Low

Worse

better

Surgical Treatment of Breast cancer

Modified Radical Mastectomy
Wide local excision and radiation therapy
(BCT)
Axillary dissection
ALND removal of axilllary lymph nodes
levels I&II
SLND - removal of stained Axillary lymph
nodes
Indications for BCT
Small breast CA <4cm
Clinically (-) Axillary lymph node
Breast volume adequate size to allow
uniform dosage of irradiation
Radiation therapist experience to
avoid damage of retained breast
Relative contraindications for BCT
Multifocal disease
History of previous RT to the area of
treatment
Inability to undergo RT for invasive
disease
First or 2nd trimester of pregnancy
Persistent positive margin following
______ of conservation
Breast reconstruction
Immediately done after mastectomy
______ requiring adjuvant radiation

 Implants,
autologous
tissue
(transverse
rectus
abdominis,
latissimus dorsi)
Safe
No increase in local recurrence
Advantages
of
Neoadjuvant
Chemotherapy
Assessment of tumor response to
chemotherapy
Potential decrease in de novo
chemotherapy resistance
Increase in breast conserving surgery
Improved cosmetic results
Treatment of micrometastasis
Decrease the size
Disadvantages
of
Neoadjuvant
Chemotherapy
Loss of prognostic information
o Axillary lymph node status
o Microscopic tumor size
Delayed local and regional therapy
induction of drug resistance
Indications of post-mastectomy RT
(+) or closed margins
Any T4 tumors
4 (+) lymph nodes
Extracapsular extensions
Involvement of pectoralis fascia
Chemotherapeutic agents
cancer
Cyclophosphamide (C)
Methotrexate (M)
5FU (F)
Doxorubicin (A)
Epirubicin (E)
Docetaxel (T)
Paclitaxel (P)

for

breast

Adjuvant chemotherapy
First generation CMF (6cycles) AC (__
cycles)
2nd gen FAC (6cycles), CEF (6cycles), TC
(4cycles)
3rd gen AC paclitaxel, TAC, FECdocletaxel/paclitaxel

Endocrine therapy
a. premenopausal
Tamoxifen 5 years or
LHRH analogue or
Ovarian ablation
b. Post menopausal
Anastrazole 5 years or
Tamoxifen 5 years
Receptor
specimen
Receptor

status

ER(+) PR(+)
ER (+) PR (-)
ER (-) PR (-)
ER (-) PR (+)
Total

of

tumor

Premenopa
usal
222 (45%)
58 (12%)
136 (28%)
72 (15%)

biopsy

postmenop
ausal
520 (63%)
128 (15%)
137 (27%)
41 (5%)

Relationship between steroid receptor

status and patients objective response
to endocrine therapy
Steroid receptor status
ER(+)PR(
+)
137/174

ER(+)PR(
-)
55/164

ER(-)PR(-)

ER(-)PR(
+)

17/165

Targeted therapy
Trastuzumab
50%DFS,
30%
OS
regardless of chemotherapy regimen
_____ improved DFS. OS (early HER2+)
Pertuzumab
Lapatinib
Combination
Pertuzimab
+
Trastuzimab + docetaxel improve DFS
(metastatic HER2+)
Neoadjuvant
Pertuzimab
+
Trastuzimab
+
docetaxel
(LABC,
inflammatory ____)
Adjuvant Endocrine therapy
ER/PR (+) tamoxifen, aromatase
inhibitors LHRH, Oophorectomy
Tamoxifen 40% risk reduction
recurrence, 30% death pre/post
o Tamoxifen 20mg PO OD x 5yrs

Aromatase inhibitors 20% recurrence

postmenopausal
o Aromatase
inhibitors
_______________

The 2012 guidelines recommended the

following
laboratory
studies
for
all
asymptomatic women with early stage
breast cancer (stage I & II):
- CBC with differential count
- LFT and Alkaline phosphatase
In addition, imaging studies (CXray, chest
CTScan, or CT of abdomen and pelvis) can be

considered for women with stage III or

symptomatic disease. Tumor markers (CEA &
CA _______)may be obtained in these patients
Treatment protocols
Local disease Stage 0, I, II or
IIIA(T3N1M0)
o Surveillance, lumpectomy CT,
RT
Preop chemotherapy (Stage IIA IIIA) TAC, ACP, AC, TC
Docetaxel (_____. T), doxorubicin
(adriamycyn, A), cyclophosphamide
(C), paclitaxel (P)