3Early Detections reduces the risk of dying from breast cancer. New slide
4Cancer Diagnosis: Defining the Cancer The first step in designing the treatment plan is carefully defining the cancerClinical examinationRadiology testsPathology testsBlood tests
5Breast Cancer Signs and Symptoms Skin rednessAsymmetryEnlargementNipple retractionDimplingMass in axilla (armpit)WarmthNoneLump or massPain in breastTendernessThickeningFirmnessNipple dischargeFix the symmetry of this slide. The second column and the first do not match even though both have 7 entries.
13Mammography Sensitivity in Younger Women Screening mammograms miss up to 25% of breast cancers in women in their 40s, compared to 10% of cancers for older women
14Right breast 12 o’clock invasive ductal carcinoma 11 mm on mammo and US, has US bx. Multiple MRI masses and non-mass-like enhancement at 12 o’clock spanning 40 mm. Invasive ductal carcinoma and ductal carcinoma in situ by MRI guided core needle biopsy, breast conservation candidate due to breast size.Ultrasound
15Breast MRI Important new tool for imaging the breast High sensitivity Detection and characterization of otherwise-occult breast carcinoma
16Breast Cancer Diagnosis Any breast change or lump needs to be evaluatedBreast cancer needs to be diagnosed by biopsyFine needle aspirationCore needle biopsySurgical biopsyChange toFine needle aspirationRemove “Stereotactic”Change to surgical BIOPSY
17Mammotone & Minimally Invasive Breast Biopsy (MIBB) The Mammotone and MIBB are different from the core needle biopsy in that a needle is inserted once and multiple specimens are removed through contiguous sampling. Core needle biopsies require the needle to be inserted multiple times.Both the Mammotone and MIBB biopsy utilize a vacuum system. A probe is inserted and samples of tissue are collected in a chamber. Tissue samples are removed by action of a gentle vacuum.
18Advantages of Needle Biopsies Simple procedure – does not require surgeryAccurateQuick – only takes a few minutesNot painfulInexpensiveQuick results
19Disadvantages of Needle Biopsies Entire lump is not removedOpen biopsy may be necessaryFor Fine Needle Only:Specialist needed to read resultsIn situ cancer not distinguishable from invasive cancer
20Image Guided Biopsy in Clinical Practice Allows treatment planningBetter cosmesisCan mark site with clipLess costlyNeeds specialized equipmentMay still require confirmatory pathology in minority of casesAdvantages are..Now standard
21Breast Biopsy Non-Surgical Surgical A core needle biopsy of the area is recommendedNon-SurgicalSurgical
23Right breast 12 o’clock invasive ductal carcinoma 11 mm on mammo and US, has US bx. Multiple MRI masses and non-mass-like enhancement at 12 o’clock spanning 40 mm. Invasive ductal carcinoma and ductal carcinoma in situ by MRI guided core needle biopsy, breast conservation candidate due to breast size.Ultrasound
24Image Guided BiopsyImage guided biopsy developed that can be done in radiation suite- abnormalities on mammogram- such as these calcs shown on left can be imaged and bx. Exceeding impt in era of mammo screening with more lesions detected before any lump can be detected.
27Needle BiopsiesFine Needle – A thin, hollow needle is used to remove a sample of tissue. The procedure is quick and can be done in a doctor’s office.Core Needle – A larger needle is inserted through a small incision in the skin, and a small core of tissue is removed. This type of needle biopsy is done with the assistance of mammography or ultrasound imaging using stereotactic techniques with the aid of the computer, which calculates the precise location of the lump.
28Incisional BiopsyA surgical procedure where only a portion of a tumor is removedGenerally reserved for lumps that are largerPerformed under local anesthesia in a hospital or outpatient clinic
29Excisional BiopsyA surgical procedure that removes the entire suspected area plus some surrounding normal tissue.Standard procedure for lumps that are smaller than an inch or so in diameterSimilar to a lumpectomyPerformed under local anesthetic or general anesthesia in a hospital or outpatient clinic
30Advantages of Open Biopsies Quick – takes only one hourMore accurate than a needle biopsyLarger samples provide information for treatment planExcisional Only:Removes entire lumpMay be the only surgical treatment needed
31Disadvantages of Open Biopsies Surgical procedureExpensiveSide effects such as infection or blood collection under the skinExcisional Only:Removing tissue can change the look and feel of the breast
32Cancer is diagnosed in 1 of 5 breast biopsies Diagnosis
35Breast cancer Spread to lymph nodes SupraclavicularSubclavicularDistal (upper)axillaryCentral (middle)Proximal (lower)MediastinalInternal mammaryInterpectoral(Rotter’s)31. Breast Cancer: Spread to Lymph NodesAxillary lymph nodes are most commonly involved in breast cancer. Internal mammary nodes can be involved if the tumor affects the internal part of the breast. Supraclavicular metastasis is rare unless axillary or internal mammary metastases are present.
36Breast Cancer: Stage I T1 N0 M0 T1a: T 0.5 cm T1b: 0.5 cm < T 1 cmT1c: 1 cm < T 2 cmT1T 2 cm35. Breast Cancer: Stage IStage I disease T1 N0 M0 is common. T1 tumors are 2 cm in dimension. T1a tumors are 0.5 cm. T1b tumors are >0.5 cm, but 1 cm in greatest dimension. T1c tumors are 1 cm, but no more than 2 cm in greatest dimension. This early breast cancer is often diagnosed on screening mammograms.N0 = no regional lymph node metastasis M0 = no distant metastasis
37Breast Cancer: Stage IIA }T0T1N1 M0T2 N0 M0T0No evidenceof tumor36. Breast Cancer: Stage IIAStage IIA is also common. It is T0 N1 M0, T1 N1 M0, or T2 N0 M0. T2 lesions are over 2 cm and up to 5 cm.T22 cm < T < 5 cmN1 = metastasis to movable ipsilateral axillary lymph node(s) M0 = no distant metastasis
38Breast Cancer: Stage IIB T2 N1 M0T3 N0 M0T337. Breast Cancer: Stage IIBStage IIB lesions are either T2 N1 M0 or T3 N0 M0 tumors. T3 tumors are >5 cm. The prognosis of these cancers is intermediate. Pathologic confirmation of the diagnosis is mandatory (N1a is micrometastasis 0.2 cm; N1b is metastasis to lymph nodes >0.2 cm).T > 5 cmN1 = metastasis to movable ipsilateral axillary lymph node(s) (p) N1a, N1b M0 = no distant metastasis
39Breast Cancer: Stage IIIA T3 N1 M0T0T1T2T3N2 M038. Breast Cancer: Stage IIIAStage IIIA tumors are T0-3 N2 M0 or T3 N1 M0. N2 lesions are fixed to one another or to other structures. The prognosis for this stage is not good. Chemotherapy is usually used for treatment.Metastasis to ipsilateral axillary lymph node(s)N1 = movableN2 = fixed to one another or to other structuresM0 = no distant metastasis
40Breast Cancer: Stage IIIB T4 any N M0Any T N3 M0T4Tumor of any sizewith direct extensionto chest wall or skinT4d = inflammatorycarcinoma39. Breast Cancer: Stage IIIBStage IIIB disease is either T4 any N M0 or any T N3 M0. T4 lesions are tumors of any size with extension to chest wall or skin. T4a involves only extension to the chest wall, while T4b presents as edema, skin ulceration on the breast, or satellite skin nodules to the same breast. T4c involves both T4a and T4b.N3 = metastasis to ipsilateral internal mammary lymph node(s)M0 = no distant metastasis
41Breast Cancer: Stage IV Any T any N M140. Breast Cancer: Stage IVStage IV, or metastatic, breast cancer is a lethal disease. The most common sites of metastases are soft tissue (skin or draining lymph nodes), bone, and viscera (eg, liver, lung).M1 = distant metastasis (including metastases to cervical, or contralateral internal mammary lymph nodes)
42Staging for Distant Disease: Breast Cancer FDG PET scanBone ScanPatient APatient BMultiple bone metastasesTumor in the breast, but not elsewhereThe most common sites of distant disease in breast cancer are the bones, liver and lungs
43BREAST CANCER 5-year survival: Number of positive axillary lymph nodes 0%20%40%60%80%5-Year Survival123456-1011-1516-20>20Number of Positive Nodes42. Breast Cancer: 5-year Survival as Function of the Number of Positive Axillary Lymph NodesAs the number of involved lymph nodes increases, 5-year survival rates decrease.Harris J, et al. Cancer: Principles & Practice of Oncology. 5th ed. 1997;
44How effective is therapy for breast cancer? Relative 5 Year Survival (%)Site1974-19761983-19851992-19971996-2003Breast75788689.8Progress last few decades-screening and systemic therapy.SEER, , DCP, NCI, 2009