5Microscopic structure 1.Glandular tissueProduces milk as final product15-20 lobules completely separated, with radial disposition around the nippleGalactofore ducts – nipple (small dilated area in the areola, opening in the nipple)
6Microscopic structure 2 Conective tissueCreates structure/supportIncluded are the suspensory ligamentsConnects the breast to the skin and fascia of the pectoralis major
7Microscopic structure 3 Fatty tissueParticipates to the structure of the breastAnterior, posterior and within the lobulesVaries according to diet and can produce major variations in the volume of the breast
8Areola Specialized skin adapted for lactation Nipple in the middle Sebaceous glands visible on the surface (Montgomery)Contains smooth muscles which participate in milk evacuation during lactationHighly innervated area
9Male breast Rudimentary, areola and nipple Glandular tissue + fatty tissue are – most often- rudimentary or absent. Normal <2cm
10Breast developmentSignificant changes in volume and shape according toAgePhysiologic statusIn adolescence structure becomes nodular and the volume and structure changes during menstrual cycle.
11Aging Volume diminishes Changes in structural proportions – glandular tissue diminishes and is replaced by fatChanges in position due to loss in the elasticity of suspensor structuresLoss of axillary hairSclerosing of ducts
12Blood vessels and lymphatics Please review anatomy
14Congenital malformations Breast develops from the mammary folds (ectodermic epithelium) on a virtual line (axilla – inguinal ligament)On this line mammary buds develop and regress spontaneouslyAt birth – breast is fully developed and may produce milk under maternal hormonal influence (first days crises)
16AmastiaOne of the mammary bud lack of development
17Polymastia Frequent malformations More gland with incomplete developmentOn the axillary lineMammary ectopySupranumerary breast may have complete structure and milk secretionMay generate diseases like a normal gland
18Ately - Politely Congenital absence of the nipple Breast can be normal in structureLactation is impossibleMore nipples with or without areolaWith or without breast tissue
19Abnormal positions of the nipple Difficulties during breast feedingMajor confusion = retraction of the nipple characteristic of breast cancer
22Surgical correction for esthetic reasons Asymmetry HypotrophyReversed form hypertrophyUni/bilateralMycromastySurgical correction for esthetic reasonsAsymmetryMajor difference between left and right breastEsthetic and psychological problemsEasy to solve: surgical reduction or breast implantGynecomastyNormal/pathologic not mathematical limitUni/bilateralPrimary gonadal dysfunction or secundary endocrine imbalanceAdolescent?! ~ normalSurgical removal
23Trauma of the breast Breast contusion Acute compression on the costal gridDuring lactation lesions are more complex:Large galactofore ducts may breakIncreases risk of infectionSteatonecrosis of fat tissueResidual lesion after contusionAseptic necrosis of fat tissue – fat liquefy – pseudocysts form and finally = fibrotic scarClinical examination: hard nodule, not well delimited – frequent confused with malignanciesRESECTION BIOPSY
24Traumatic lesions of the breast WoundsMost frequently stab wounds (precordial area)In non-lactating breast – no special problemLactating breastWound involving galactofore ducts – high risk of infectionIntra-glandular dissemination via ductsFistula – require the mother to stop lactation
26Major forms According to type of tissue Types Mastitis: primary infection of glandular structuresParamastitis (perimastitis) inflammation of connective tissue surrouding glandular structuresTypesAcuteChronic
27MastitisEthologyAlmost exclusively during lactation, usually in the first 2-3 weeksMore frequently after the first child and in women with neglect in the care of the breast (local contamination in all cases)Bacteria penetrate through small lesions produced in the area of the areola and affect-later on- structures in surrounding tissues
28Mastitis – stages of development GALACTOFORITISIsolated infection of galactofore ducts (one or more then one lobules)PRESENTATION:Increase in the volume of the breastPain, both spontaneous and on mombilization.Accentuated during breast feedingPressure on the nipple: milk + puss through one orifice: differential diagnosis BUDIN signNon significant general signs of inflammation- fever 38No axillary lymph nodes enlargements at this stageEVOLUTION:- breast feeding should stop (ATB) + breast emptying.- potentially reversible after antibiotics and anti-inflammatory drugs- may progress to abscess formation
29Mastitis - stages BREAST ABSCESS CLINICAL PRESENTATION: Suppurative inflammation progresses in connective tissue outside glandular massCLINICAL PRESENTATION:Accentuated local signs + general signs of inflammationBreast is extremely painfulDeformation of the breast: globally enlarged but also not regular shape (small abscesses are more prominent in contour)Budin sign = presentVenous stasis – visible veins on the surface of the breastLymphangitis but no inflammatory lymph node enlargements
30Mastitis BREAST ABSCESS Treatment: ATB + surgical drainage Recurrent infection : more then one lobule infected in different evolution stages – serial abscess formationPossible diffusion of infection in the fatty tissues surrounding the breastPARAMASTITISBREAST FLEGMONOUS INFECTION
31ParamastitisInflammation of the fatty tissue of the breast by inoculationDirectComplication of mastitisForms:Areolas abscessSubcutaneous abscessRetro-mammary abscess
32Areolas abscessAcute inflammation of glands on the surface of the areolaCLINICAL PRESENTATION:Small tumor in the area of the areolaVery thin skin – tendency to evacuate spontaneouslyLactation should be discontinued
33Subcutaneous abscess Develops subcutaneous Associates lymphangitis Easy to observe collection, superficial, is drained or spontaneous fistulisation
34Retro-mammary abscess Inflammation of the fat in the back of the breastEthiology: mastitis developed in a lobule situated deep in the breastWell developed inflammation signsSPECIFIC: the breast appears as pushed forward due to inflammation behindFloating sensationVery painful when mobilized
36FormsHard (wood-like) chronic mastitis (evolution of an acute mastitis)GalactoceleTuberculosis history ofSifilis medicine
37Hard (wood-like) mastitis Evolution of an acute formTendency to develop very slowlyNew findingsHard nodulesOrange-skin appearance (adherence to skin)Permanent retraction of the nippleLymph node enlargementsConfusion with breast cancer
38GalactoceleParticular form of chronic mastitis developing during lactationPseudocyst- cavity of the abscess communicates with one or more large ducts. Contains milk or milky secretionPressure on the nipple – secretion containg puss and milk
39Galactocele Exploration ASYMETRIC breast enlargement ”tumor” with a regular surfaceFluctuencePainlessDeformableThumb printNo inflammatory signsSecretion contains milk+ puss
41Fibrocystic disease (Reclus) Most frequent disease of the breastHormonal influence (most frequent year and unlikely during menopause)Determined factor: estrogen or an imbalance between estrogen and progesteron
42Microscopic lesionsTypical epithelial lesions are encountered also in the normal breast but have been classified as pathologicalTypical lesions:Cysts (macro and microscopical)PapilomatosisAdenosisFibrosisEpithelial ducthyperplasis
43Clinical presentation Numerous “tumors” uni-/bilateral with no or few symptoms = PAIN is the most important one and points for explorartion of the breastNipple dischargeSymptoms vary during cycle, aggravates premenstrual, nodules change in shape and size and may also disappear.
44Differential diagnosis Pain breastVariations in symptoms cancerMammography may help (not beneficial in very young women – breast structure too dense to allow for a good evaluation)Ultrasound + Doppler is probably the best method of evaluationGuided biopsy in cases with doubtful lesions
45Treatment Surgical biopsy if any doubt Limited excision under local or general anaestesiaPunction for decompression of large cysts (+cytology)FOLLOW UP
46Prognostic Alternating periods of rest and exacerbation of symptoms Auto-examination of the breast and seek medical advise if changes developRisk of cancer is minimally increased only in patients with epithelial dysplasia
47Solitary cyst Dystrophic lesion in young women 30-40 years Large cystic TUMOR with no signs of maligancy. Malignant characteristics would be apparent in such a size.CYST (hard, very hard, well circumscribed)US: liquid contentTreatment : punction to evacuate and clinical follow-up
49DefinitionsBreast cancer is a growth of abnormal cells usually within the ducts (which carry the milk to the nipple) or lobules (glands for milk production) of the breast.In more advanced stages of the disease, these out-of-control cells invade nearby tissues or travel throughout the body to other tissues or organs
50How does breast cancer develop? 1. Normal ducts 2. Intraductal Hyperplasia 3. Atypical Ductal Hyperplasia 4. Ductal Carcinoma In Situ 5. Invasive Ductal Cancer
51Epidemiology Incidence and prevalence Each year the disease is diagnosed in over one million women worldwide and is the cause of death in over 400,000 women, second leading cause of death in womenBreast cancer can occur in men, although the incidence is much lower, amounting to around 1% of all breast cancers.
52Risk factorsAge; Nearly 80% of all newly diagnosed invasive breast cancer cases occur in women aged 50 and older and is less common in premenopausal women.Family history of breast cancer.Paget´s disease accounts for 1% of all breast CA, is associated with an infiltrating, and intraductal carcinoma.
53Mutations in these genes are associated with a lifetime Genetic factors; some cancers have a genetic component and can be inherited.It is estimated that between 5 and 10% of breast cancer can be attributed to one of two predisposing genes:BRCA1 on chromosome 17.BRCA2 on chromosome 13.Mutations in these genes are associated with a lifetime
55Risk factors Hormone factors: Early menarche women who started their period before 12 years of age.Late menopause women who go through menopause after age 55Pregnancy history: women who have their first child after the age of 30 or who have had fewer pregnancies or no pregnancies.Breast density: women with less fatty, denser breasts, which are normally older women, have an increased chance of breast cancer.Obesity after menopause women who were overweight based on a body mass index (BMI) greater than 25 are 1 to 2 times more likely to die from breast cancer than women with a normal BMI.
56Risk factorsIonizing radiation; In 2005, the National Toxicology Program classified X radiation and gamma radiation as known human carcinogens.Compelling scientific evidence points to some of the 100,000 synthetic chemicals in use today as contributing to the development of breast cancer, either by altering hormone function or gene expression.
57Risk factorsThere is broad agreement that exposure over time to estrogens in the body increases the risk of breast cancer.Hormone replacement therapy (HRT) and hormones in oral contraceptives increase this risk – limited increase with oral contraceptives
58Risk factors Breast disease Atpyical Hyperplasia Intraductal carcinoma in situIntralobular carcinoma in situDietFatAlcohol
60Types of breast cancer In situ Invasive Intraductal (DCIS) Intralobular (LCIS)InvasiveInfiltrating ductal carcinomaTubular carcinomaMedullary carcinomaMucinous carcinomaThere are 2 primary classifications of in situ breast cancer. These are ductal carcinoma in situ and lobular carcinoma in situ. Ductal carcinoma or non-infiltrating or intraductal carcinoma is malignant epithelial cells confined to the mammary ducts with no evidence of invasion of the basement membranes. In the past, DCIS was treated with mastectomy, which resulted in cure for 98% of patients. Screening programs have increased the diagnosis of DCIS. With more women being diagnosed with DCIS, breast-conserving therapy is more desirable. This has become a most controversial area in the treatment of breast cancer.Lobular ductal carcinoma in situ is not detectable clinically or by mammography. It is considered a risk factor for breast cancer, but not a precursor. The general approach is for careful observation. Bilateral prophylactic mastectomy has been used to treat LDIS.The categories of invasive carcinoma are infiltrating ductal carcinoma (75%), tubular carcinoma, modularly carcinoma, and mucinous carcinoma.
61In Situ Breast CancerIn Situ Breast Cancer remains within the ducts or lobules of the breasts.This type of cancer is only detected by mammograms – not by a physical examination.If the cancer is in the duct it is called Ductal Carcinoma in situ.If the cancer is in the lobule of the breast, it is called Lobular Carcinoma in situ.This type of cancer is most common among pre-menopausal women.There is also a slight chance that if a woman has this type of cancer she is at risk that it would occur in the other.
62Infiltrating Breast Cancer Breast cancer is considered infiltrating or invasive if the cancer cells have penetrated the membrane that surrounds a duct or lobule.This type of cancer forms a lump that can eventually be felt by a physical examination.Breast cancer cells cross the lining of the milk duct or lobule, and begin to invade adjacent tissues. This type of cancer is called "infiltrating cancer." In this picture, you can see the breast cancer cells invading the milk duct.
63More on Infiltrating Breast Cancer Infiltrating cancer of the ductCalled “Infiltrating Ductal Carcinoma”It is the most common type of breast cancer.Cancer cells that are invading the fatty tissue around the duct, they stimulate the growth of non-cancerous scar like tissue that surrounds the cancer making it easier to spot.Infiltrating cancer of the lobulesCalled “Infiltrating Lobular Carcinoma”Occurs when cells stream out in a single file into the surrounding breast tissue.This type of cancer is harder to detect on a mammogram because there is no fibrous growth.
64Other Types of Breast Cancer Cystosarcoma PhyllodesInflammatory CancerAccounts for less than one percent of all breast cancers and looks as though the breast is infected.Breast Cancer During PregnancyPaget’s Disease
65TNM Criteria T = Primary Tumor N = Regional Lymph nodes Tis = carcinoma in situT1 = less than 2 cm in diameterT2 = between 2 and 5 cm in diameterT3 = more than 5 cm in diameterT4 = any size, but extends to the skin or chest wallN = Regional Lymph nodesN0 = no regional node involvementN1 = metastasis to movable same side axillary nodesN2 = metastasis to fixed same side axillary nodesN3 = metastasis to same side internal mammary nodesM = Distant MetastasisM0 = no distant metastasisM1 = distant metastasis
66Stage 1 Tumor < 2.0 cm in greatest dimension No nodal involvement (N0)No metastases (M0)Stage 1 breast cancer involves primarily small tumors (less than or equal to 2 cm) with no known lymph node involvement and no metastases to other organs. About 40 to 50% or women present at this stage. 30% will relapse following local regional treatment.
67Stage II Tumor > 2.0 < 5 cm or Ipsilateral axillary lymph node (N1)No Metastasis (M0)In general, stage 2 breast cancers are characterized by either slightly larger primary tumor than stage 1 (between 2 and 5 cm) or if there is lymph node involvement.About 70% of stage II patients will relapse following treatment.
68Stage III Tumor > 5 cm (T3) or ipsilateral axillary lymph nodes fixed to each other or other structures (N2)involvement of ipsilateral internal mammary nodes (N3)Inflammatory carcinoma (T4d)In general, stage III consists of large tumors (greater than 5 cm) with signs of inflammatory breast cancer. Also if ipsilateral nodes are involved where the tumor has caused the node to be fixed to another node or to other structures it is designated stage 3. Also metastasis to ipsilateral internal mammary lymph nodes gets a designation of stage 3.
69Stage IV (Metastatic breast cancer) Any TAny NMetastasis (M1)Stage 4 means any metastatic breast cancer no matter what size the tumor or if there is nodal involvement or not. If it is metastatic, it is stage 4. In general, stage 4 is not considered curable. The goals are to increase the quality of life and extend survival time.
70Screening and Symptoms Breast Cancer: Symptoms and Screening
72Clinical examination Performed by doctor or trained nurse practitioner Annually for women over 40At least every 3 years for women between 20 and 40More frequent examination for high risk patientsLet’s begin by looking at the clinical exam. Clinical breast exams are recommended annually for women over 40 and at least every 3 years for women between 20 and 40. It should be performed by a physician or a trained nurse practitioner. If the woman has a high risk of breast cancer, her physician may recommend frequent examination. Clinical breast exam has been shown to decrease breast cancer mortality.
73Mammography X-ray of the breast Has been shown to save lives in patients 50-69Data mixed on usefulness for patients 40-49Normal mammogram does not rule out possibility of cancer completelyMammography is the next method of breast cancer screening. It is an x-ray of the breast but uses the lowest radiation doses. It is the mainstay of breast cancer detection with an 85 to 90% diagnostic accuracy rate which is very high and can detect breast cancers the size of a freckle. However, a normal mammogram does not rule out the possibility of cancer completely. On the other hand, screening mammography has been shown to save lives. This is especially true in women over 50, where routine mammogram leads to a 25 to 30% decrease in breast cancer mortality.
74MammographyAmerican Cancer Society recommends:Women (asymptomatic) 40 years of age and older should have a mammogram every year.The American cancer society recommends that asymptomatic women 40 years of age and older should have a mammogram every year.
75ThermographThermograph is one of the newest ways to detect breast cancer.Thermograph is a thermal image of the breast tissue.It can also detect cancer before the traditional mammogram can.
76Breast Self Examination Opportunity for woman to become familiar with her breastsMonthly exam of the breasts and underarm areaMay discover any changes earlyBegin at age 20, continue monthlyMonthly breast self-exam or BSE is monthly examination of the breasts and underarm area by the patient where she is looking and feeling for changes. It is an opportunity for the patient to become familiar with her breasts so if there is a change, she’ll be able to detect it more quickly. Breast self-exam should begin at the age of 20 and continue monthly. In, November 2002, the United States Preventative Services Task Force found that evidence is insufficient to recommend teaching BSE. They found fair evidence that BSE caused false-positive results which increased costs to the health care system. Because there have not been any good studies done to decide the benefit/risk ratio of BSE, this group dropped BSE from its recommendations. Many doctors still teach BSE during clinical breast exams and feel there is benefit to a woman being familiar her own body. More studies need to be done.
77When to do BSE Menstruating women- 5 to 7 days after the beginning of their periodMenopausal women -same date each monthPregnant women –Takes about 20 minutesPerform BSE at leastonce a monthExamine all breast tissueDespite the controversy, because some women will still want to utilize BSE, the guidelines are included in this presentation. Premenopausal women should perform BSE five to seven days following the start of menstruation. Postmenopausal women and pregnant women should mark their calendar and perform BSE the same day each month. BSE usually takes around 20 minutes and it is important that all breast tissue be examined during the self-exam. Although there have been no studies, which demonstrate a survival advantage to performing monthly BSE, it remains a cornerstone of the recommendation for early breast cancer detection by the ACS and NCI.
78Why don’t more women practice BSE? FearEmbarrassmentYouthLack of knowledgeToo busy, forgetfulnessWhy don’t more women practice BSE?Some fear finding a lump or cancer.Some are embarrassed or have difficulty touching oneself. There are taboos in some cultures about touching one’s own body.Many women think they are too young- I will worry later about cancer.Life-saving health habits formed early become a routine part of daily life and pay off later. This is why more emphasis is being place on reaching teenagers.Another big reason for not performing self-exams is a lack of knowledge of how to perform BSE, lack of confidence. Women say they are too busy or cite forgetfulness. These reasons may also be linked to fear.Since most women or their partners find breast changes, BSE can be a life saver.
79Abnormal signs and symptoms So, lets look at abnormal signs and symptoms.Breast tumors can produce puckering, dimpling, or retractions by disrupting underlying structures. Also, if a tumor is blocking the lymphatic drainage, the pores of the breast skin may become more prominent. This results in an orange peel appearance.In breast self-exam, the nipple should always be squeezed to check for discharge. Any new discharge should be reported to the physician. A milky or clear discharge can be a normal finding in women anytime following childbirth. Greenish discharges are often a sign of mastitis and infection. A bloody discharge is strongly suggestive of breast cancer and should be reported immediately.Any new thickening of the skin or lump or “knot” in the breast should be reported to a physician. It is normal for an adult breast to feel granular, nodular, or lumpy especially premenstrually. However, any new mass or enlargement of an existing mass should be reported to a physician. Breast cancers tend to be hard, with no clear borders and immobile ( attached to skin or underlying structures).A retracted or inverted nipple can be normal and in itself is not a problem. However the recent inversion of a nipple could be a sign of breast cancer.PuckeringDimplingRetractionNipple dischargeThickening of skin or lump or “knot”Retracted nipple
80Abnormal signs and symptoms A recent change in breast size, especially unilaterally can be of concern if not related to a normal physiological change.Breast pain or tenderness during the menstrual period is normal. However, prolonged tenderness may be a sign of breast cancer. It is important to note that most malignant breast lesions are not painful.Inflammatory signs of cancer can be rash or edema.A change in the direction the nipple is pointing may also be a sign of breast cancer.Scaling on nipples can also indicate a problem. Scaling around both nipples could be due to allergy to soap or powder but scaling around one nipple often indicates an abnormality.And then finally a sore on the breast that does not heal should be examined by a physician.Change in breast sizePain or tendernessRednessChange in nipple positionScaling around nipplesSore on breast that does not heal
81Common Symptoms A change in how the breast or nipple feels Lump or thickening in or near the breast or in the underarm areaNipple tendernessA change in how the breast or nipple looksChange in the size or shape of the breastNipple turned inward into the breastChange in the skin of the breast (“orange” skin, scaly, red, or swollen)Nipple discharge (fluid)
82How is Breast Cancer Diagnosed? Screening and/or diagnostic mammographyUltrasoundMRI scanBiopsy is necessary to confirm a diagnosisBlood tests are often used to determine if the cancer has spread outside the breastAdditional tests may be used to determine stage
83Methods of Detection Clinical exam by MD or nurse Mammography Monthly breast self-exam (BSE)Methods of DetectionThere are 3 main screening methods for breast cancer. These are clinical exam by a physician or nurse, mammography, and monthly breast self exam.
84Diagnostic alternatives Screening – abnormal image requiring histologyNodule: discovered during BSE requires clinical examination + immaging + histologyNodule discovered during clinical examination (same)LARGE tumor with clinical characteristics of breast cancer – diagnostic obvious, BUT immaging and histology compulsory
85Conventionell Mammography Screening A mammogram is an x-ray of the breast, may find tumors that are too small to feel.May find ductal carcinoma in situ, abnormal cells in the lining of a breast duct, which may become invasive cancer in some women.858585
86Mammogram Main radiographic examination for breast cancer detection Breast cancer Lesions can be either:MicrocalcificationsNodules : typically irregular lesionThere could be false negative or false positive
87UltrasoundMay be used along with a mammogram to evaluate breast abnormalities.Performed by a radiologistAllows images from almost any orientationExcellent at imaging cystsHelps for a guided biopsy or FNAExplores a suspicious lymph node.Limits:lacks the detail of conventional mammographyUnable to image microcalcifications-> not approved as a screening tool for breast cancer diagnosis
88Ultrasonography- Diagnosis Ultrasonography is useful as a diagnostic adjunct to differentiate cystic from solid tissue in women with nonspecific thicheningDoppler effect888888
89Biopsy- DiagosisIf the clinical breast exam, mammogram or ultrasound shows an area of possible concern, a biopsy is usually the next step.A biopsy is the removal of cells or tissues of concern so that they can be viewed under a microscope and further tested by a pathologist.898989
90Needle Aspiration Needle aspiration Cytology Nature of cells: cancerous or notAdvantages: rapid, minimal discomfort, no incision complicating local therapy, immediate resultsLimits: no difference between in situ from and invasive cancer, false-negative
91Biopsy Biopsy « tru-cut », mamotome Histology DIAGNOSISBiopsyBiopsy « tru-cut », mamotome HistologyAdvantages: rapid, minimal to moderate discomfort, no surgical incision, guided by ultrasoundLimits: false-negative, sampling error with larger lesionsL ’aspiration à l ’aiguille fine réalise une « cytoponction », éventuellement radioguidée.Cette technique est la plus utilisée, simple, indolore, elle permet de ramener du matériel de qualité pour l ’immuno-histochimie ( 5 % de faux négatifs ).L ’association de la clinique à la radiologie et à la cytoponction procure une fiabilité de 99 %.La biopsie au trocart de type « tru-cut » représente un geste plus lourd avec un risque d ’hématome et le matériel obtenu n ’est pas toujours satisfaisant pour l ’immuno-histochimie.Une biopsie-excision chirurgicale, radio-guidée ou non, pourra être effectuée en fonction de la présence ou non de lésion clinique.Dans tous les cas un diagnostic histologique préalable est nécessaire à une chimiothérapie ou à une radiothérapie première.
92Chest x-ray To determine if the breast cancer has spread to the lungs. 9292
93Bone Scan A common place for breast cancer to spread is to the bones. A bone scan is often done to assure there is no detectable metastasis to the bones.9393
94positron emission mammography (a PEM scan) The PEM system’s camera and detectors are closer to the area affected with cancer, which produces a very sharp, detailed image of tumors and cancerous tissue.With PEM, cancers can be seen as small as 1.5 – 2mm, about the width of a grain of rice949494
95(MRI) To Improve Breast Cancer Detection Magnetic ResonanceImaging Technology(MRI) To Improve Breast Cancer DetectionMRI combines the use of powerful magnets and radio wave pulses.Used to detect breast cancer in some women at higher riskMRI can also be used before surgery to identify areas of the breast affected by the tumor.959595
96PreventionNo intervention can completely prevent cancer; there are ways to reduce riskProphylactic mastectomy (preventive removal of breasts) and prophylactic oophorectomy (preventive removal of ovaries) for women at high riskChemoprevention (drugs that lower breast cancer risk) with tamoxifen (Nolvadex) or raloxifene (Evista)Risk assessment tools can help those without strong family history discover risk of developing breast cancer
97How is Breast Cancer Treated? Treatment depends on stage of cancerMore than one treatment may be usedSurgeryRadiation therapyChemotherapyHormone therapyTargeted therapy
98Factors Considered in Treatment Decisions The stage and grade (how different cancer cells look from healthy cells) of the tumorThe tumor’s hormone receptor status (estrogen receptor [ER], progesterone receptor [PR]) and human epidermal growth factor receptor-2 (HER2) statusGenetic description of the tumorThe presence of known mutations to breast cancer genesThe woman’s menopausal status, age, and general health
99Cancer Treatment: Surgery Generally, surgery to remove the tumor followed by radiation therapy is initial treatmentFor invasive cancer, lymph nodes are removed and evaluatedMore invasive surgery (such as mastectomy) is not always better; discuss with your doctorBreast reconstruction (plastic surgery) is an option after mastectomy
100Principles of Surgery Early Breast Cancer Targets: breast and nodes Objectives: to remove the tumor, to get histologic data Curative treatmentAdvanced and metastatic breast cancerTarget: assessible massObjectives: to reduce tumor volume, to remove one isolated metastasis (pulmonary or liver), to treat complications of the disease (spinal compressions…) Palliative treatment
101Partial Mastectomy (Lumpectomy) ContraindicationsA. Previous history of Radiation TherapyB. More than one cancer in same breastC. Large tumor, small breast, cosmetic deformityD. Nipple involvement
102Surgery Terms Excisional Biopsy vs. Lumpectomy Partial Mastectomy vs. LumpectomyIncisional Biopsy
103Mastectomy Difference between Total (simple) Mastectomy Modified Radical Mastectomy
104Skin Sparing Mastectomy Skin sparing mastectomy preserves the majority of the breast skin and the inframammary foldThe entire nipple and areola are removed
105Is Radical Mastectomy still in use? What is it?
106Subcutaneous Mastectomy Is Subcutaneous Mastectomy a cancer operation?How does it differ from Total Mastectomy?
107Sentinel Node Biopsy Major advance Almost no risk of lymphedema Blue dyeNuclear medicine
108Sentinel Lymph Node Biopsy Quickly becoming the gold standardMay be as accurate or more accurate than ALN dissection while limiting the complications and costsInvolves injection off Technitium-99 sulfur colloid and or 1% isosulfan blue dye
109Histological information after surgery of early breast cancer Type of tumor: invasive or in situ, adenocarcinoma or others, ductal or lobular,…Definitive sizeHistopronosis grade (SBR)Vascular and lymphnode embolsMargins +++Hormonal receptorsHER2 status (IHC and/or FISH)
111Reconstruction: Tissue expander Encapsulated silicone implant reconstruction corrected with tissue expansion. The capsule is first excised, and the tissue expander is used to create an oversized pocket for the implant.
112Reconstruction: Latissimus Dorsi following autogenous latissimus reconstruction w/o implant. Opposite breast reduction mammoplasty required for symmetry.
113Reconstruction: TRAMfollowing left free TRAM reconstruction. Skin replacement included all skin between scar & inframammary fold. Nipple reconstruction, opposite mastopexy done at separate procedure.
114Breast Reconstruction in the Skin Sparing Mastectomy TRAM flapLatissimus flapImplant/ExpanderSilicone is preferred and is available on study protocolTram flap with nipple reconstruction and tatooing
115Cancer Treatment: Adjuvant Therapy Treatment given in addition to surgery to reduce the risk of recurrenceMay include radiation therapy, chemotherapy, targeted therapy, and hormone therapy
116Cancer Treatment: Radiation Therapy The use of high-energy x-rays to destroy cancer cellsUsually used to treat breast cancer after surgeryExternal-beam: outside the bodyInternal: uses implants inside the bodyMore precise ways to direct radiation to the tumor and shorter treatment courses are being studied in clinical trialsSide effects may include fatigue, swelling, and skin changes
117Radiotherapy principles TREATMENTRadiotherapy principlesObjectivesEradicate residual disease thus reduce local recurrenceIncrease DFS (disease free survival) and OS (overall survival)Radiation therapy warranted after breast-conservative surgerySometimes indicated after mastectomy
118Systemic treatment: principles Systemic treatment is recommended under certain circumstances based on prognostic factors and guidelinesTreatment objectives:Reduce the distant metastasisIncrease Time to progression (TTP),Prolong overall survivalIn all cases of LABC or MBCPrinciples:ChemotherapyEndocrine therapyTargeted therapies
119Cancer Treatment: Chemotherapy Use of drugs to kill cancer cellsMay be given before surgery to shrink a large tumor (neoadjuvant chemotherapy) or after surgery to reduce the risk of recurrence (adjuvant chemotherapy)A combination of medications is often used
120Cancer Treatment: Hormone Therapy Used to lower risk of recurrence for cancers that test positive for ER and/or PRTamoxifen is a common hormone therapy effective in many premenopausal and postmenopausal womenAromatase inhibitors (AIs) are also used alone or following tamoxifen use as treatment for postmenopausal women, including anastrozole (Arimidex), letrozole (Femara), and exemestane (Aromasin)Tamoxifen and AIs also used for metastatic cancer; fulvestrant (Faslodex) is another option
121Targeting the Estrogen Pathway Block receptor SERM (selective estrogen receptor modulators) Tamoxifen treatment Raloxifene prevention Decrease ligand Aromatase inhibitors Oopherectomy GnRH analogsTargeting the estrogen pathway is appealing from both treatment and prevention approaches to breast cancer since estrogen is a well recognized growth factor for the majority of breast cancers. In the prevention setting the two leading ways that the estrogen pathway has been targeted is with drugs that work at the receptor, the SERMS tam and raloxifene or agents that interfere with estrogen synthesis by targeting the aromatase enzyme and decreasing the ligand, like the AIs.the estrogen receptor is preferentially expressed in breast as well as a number of other tissues. Tamoxifen (shown here) disrupts the estrogen pathway by binding to the nuclear ER thereby preventing circulating estrogen from binding.121
122Cancer Treatment: Targeted Therapy Treatment that targets genes, proteins, or tumor cell environment that helps cancer grow and surviveHER2-targeted therapy: trastuzumab (Herceptin) for HER2-positive breast cancer either with or after adjuvant chemotherapy; lapatinib (Tykerb) plus capecitabine (Xeloda) for advanced or metastatic cancerAnti-angiogenic therapy (blocks blood vessels): bevacizumab (Avastin) for metastatic or recurrent breast cancerDrugs that block bone destruction (bisphosphonates)