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By James K. Rustad, M.D. Copyright © 2010 All Rights Reserved.

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1 By James K. Rustad, M.D. Copyright © 2010 All Rights Reserved.

2 Lecture Outline Lung Cancer Colon Cancer Pancreatic Cancer Renal Cell Carcinoma Bladder Cancer Men’s Health: Prostate and Testicular Cancer Women’s Health: Ovarian, Endometrial, and Cervical Cancer Breast Cancer

3 Lung Cancer Leading cause of cancer death Adenocarcinoma: most common lung cancer; peripheral location; bronchoalveolar type is associated with multiple nodules, bilateral lung infiltrates, and metastases late in the course. Squamous cell: Presents centrally Large cell/neuroendocrine carcinomas: Least common Small cell lung cancer (SCLC): Cigarette exposure. Usually centrally located and always presumed to be disseminated at time of diagnosis. Tx: Chemo

4 Symptoms/Exam Cough, Hemoptysis, weight loss, or postobstructive pneumonia. Pancoast’s syndrome (apical tumor): Shoulder pain, Horner’s syndrome (ptosis, miosis, anhidrosis), lower brachial plexopathy. Treatment: Surgical removal and radiation. Superior vena cava syndrome: swelling of the face and arm (most often right side), AMS, headache, visual symptoms. Hoarseness: Vocal cord paralysis from entrapment of recurrent laryngeal nerve (more often left). Hypercalcemia: (most often seen with squamous cell carcinoma). Treatment includes fluids, calcitonin, bisphosphonates. Hyponatremia/SIADH: (Small cell). Trousseau’s syndrome: hypercoagulable state (Adenocarcinoma).

5 Symptoms/Exam continued Lambert-Eaton: (Small Cell) progressive weakness usually doesn’t involve respiratory muscles/facial muscles. In patients with affected ocular and respiratory muscles, involvement not as severe as myasthenia gravis. In contrast to MG, symptoms of LEMS tend to be worse in AM, improve w/ exercise and nerve stimulation. Proximal parts of the legs and arms predominantly affected. Autonomic symptoms (dry mouth, impotence). Reflexes usually reduced or absent.

6 Diagnosis Chest CT: nodules that double in size in one year usually malignant. Bronchoscopy or sputum cytology to diagnose centrally located cancers. Staging: Chest and abdominal CT, bone scan, and CT (or MRI) of head.

7 Treatment Non-small cell lung cancer (NSCLC): potentially curable with resection of localized disease (early stage disease, I and II); only modestly responsive to chemo. Locally or regionally advanced disease (supraclavicular or mediastinal lymphadenopathy or chest wall/pleura/pericardium invasion): chemo/radiation, not surgery. Distant mets: Palliative care. For SCLC: Chemo

8 Case Scenario 76 yo M with SOB, cough, blood-streaked sputum. Progressive malaise, weight and appetite loss for 6 months. 40 pack-year smoking history. Physical Exam: Afebrile, VSS. Chest: Barrel- shaped with gynecomastia. Lungs: decreased breath sounds, rales, wheezing, dullness on percussion in L upper lung. Ext: Finger clubbing, dark pruritic rash on both forearms.

9 Differential Diagnosis? DDX: Lung cancer, lymphoma, sarcoidosis, TB. Initial office workup: CBC with decreased hemoglobin, CMP (LFTs with increased transaminases), ABG, increased ESR, CXR shows infiltrate and nodules in upper left lobe. Sputum cytology shows Adenocarcinoma, sputum culture, CT chest with L upper lobe mass. Continuing management: PFT’s Oncology, Surgery, Dietary consult Bronchoscopy with biopsy CT abdomen/pelvis and CT head Antiemetic medication Follow-up: TOB/EtOH cessation, patient/family counseling, follow up 3-4 weeks with CXR and CBC.

10 Colon Cancer Screening Average Risk individual greater than or equal to 50: Annual fecal occult blood X 3 and Flex Sig q5 years. Colonoscopy at 50 then q10 years. If patient not suitable for colonoscopy: Barium Enema q 5-10 years, CT or Spiral CT or virtual Colonoscopy.

11 Colon Cancer Screening (continued) One family member with colon cancer > 55 One family member with colon cancer < 55 or two or more family members One family member with Adenomatous polyp < age 60 Screening at 10 years earlier than relative’s age of diagnosis or at 40: FOBT (annual) and sigmoidoscopy (q 5years). Screening at 10 years earlier than relative’s age of diagnosis or at 40 with colonoscopy (q 10 years). Screen at 10 years earlier than relative’s age of diagnosis or at 40.

12 Colorectal Polyps: follow-up Adenoma: > 1 cm, villous, high grade Dysplasia, > 2 polyps > surveillance q 3 yr (Colonoscopy). Adenoma: surveillance q 5 years (Colonoscopy). Hyperplastic Polyp: Benign tumor: do normal follow up. Colorectal Malignant Polyp: Follow up. If malignant polyp completely removed, margins are clear, no vascular or lymphatic invasion: First follow up in 3 months then every 3 years (Colonoscopy) Malignant Polyp: margins not clear, ill differentiated, vascular or lymphatic invasion: Colectomy.

13 Staging and Treatment Stages I and II = DUKES A and B. Tumor without nodal involvement. Resection and regional lymph node dissection. Stage III (DUKES C). Bowel wall/nodal involvement. Add Flurouracil and Leucoverin for 6 months. Stage IV disease (DUKES D): Distant mets. Add irinotecan to (F and L). Poor prognosis.

14 Post-op follow up Physical exam, FOBT, LFT, CEA q 3-6 months for 3-5 years. Colonoscopy 6-12 months for 3 years. Change in clinical picture, abnormal LFT and/or increasing CEA: Abdominal CT and CXR.

15 Clinical Case 68 yo male presents with blood in stool. Office work up: CBC (decreased hematocrit, increased RDW, decreased MCV, decreased MCHC), CMP, TSH, Stool for ova and parasites. Iron studies show decreased ferritin and serum iron and increased TIBC. ESR increased and stool guaiac + GI consult, Colonoscopy (polyp with adenocarcinoma), CT abd/pelvis with contrast. CEA Treatment: Iron sulfate, General surgery consult (plan partial colectomy). Reassure patient.

16 Pancreatic Cancer Ductal adenocarcinoma accounts for 90% of primary tumors. Symptoms: nausea, anorexia, lumbar back pain, new-onset DM, venous thromboembolism, and painless obstructive jaundice (adenocarcinoma in the head of the pancreas). Diagnostic tests? Increased bilirubin; aminotransferances; normocytic/normochromic anemia, frequent elevation of CA Ultrasound, Abdominal/pelvic CT to evaluate extent of disease. Thin-section helical CT through pancreas can determine if mass is resectable. Endoscopic U/S: excellent anatomic detail.

17 Treatment Pancreaticoduonectomy (Whipple) if resectable tumor. Chemo or raditation for palliative care in advanced or unresectable disease.

18 Renal Cell Carcinoma Case 60 year old male with generalized weakness, left flank discomfort, constipation. 20 pound weight loss over four months. Left flank tenderness on physical. Management? CBC shows Hemoglobin 9.0, CMP shows Ca 15, BUN 40, creatinine 2.0. U/A positive for Red cells, CXR, Abdominal U/S shows left renal mass. Admit to ward, give Bisphosphonate (pamidronate) and IV normal saline. PTH (decreased), monitor Ca daily. CT abdomen and chest to stage (L renal mass), Bone scan, CT head (to stage), check Ferritin/TIBC, serum iron (correct anemia of chronic disease). Consult Oncology and Surgery!

19 Bladder Cancer Most cases are transitional cell carcinoma. Risk factors: smoking, aniline dyes, chronic bladder infections (schistosomiasis). Present with gross hematuria. Dx: UA, cytology, IVP, Cystoscopy with biopsy is diagnostic. Treatment? Carcinoma in situ (CIS): Intravesicular chemo. Invasive cancers without mets: aggressive surgery, radiotherapy or both. Distant mets: chemo alone.

20 Prostate and Testicular Cancer

21 Prostate Cancer Diagnosis based on DRE, PSA level and ultrasound-guided needle biopsy of prostate with biopsy specimens. Any PSA level greater than 4.0 ng/mL or abnormal DRE requires prostate biopsy. Gleason score sums scores of 2 most dysplastic biopsy samples on score of 1-5 (5 = poorly differentiated). 2-4 most favorable prognosis, 5- 6 intermediate, greater than equal to 7 is worst. Watchful waiting may be best approach for elderly patients w/low Gleason scores.

22 Staging/Treatment T1 = tumor confined to small area of prostate. T2 = tumor confined to either one or both lobes of prostate. T3 = extracapsular extension. T4 = Adjacent organ involved. T1 and T2 disease: Radiation therapy plus Radical prostatectomy: (remove prostate, seminal vesicle and ampullae of the vas).

23 T3 and T4 Prostate Cancer with nodal involvement Androgen Deprivation Therapy LevelAgent Pituitary, HypothalamusEstrogen & Leuprolide (LHRH agonist) AdrenalKetoconazole, Aminogluthimide, Glucocorticoid TestisOrchiectomy Prostate CellFlutamide (Antiandrogen)

24 Androgen deprivation The goal is to “starve” prostate cancer of testosterone, which it uses to flourish. Disease typically becomes hormone refractory within 3 years of onset of treatment. Many clinicians wait until patient becomes symptomatic with bone pain before initiating treatment. Bilateral orchiectomy removes all testicular production of testosterone. Castrate levels of serum testosterone achieved in approximately 3 hours after surgery. Ketoconazole is direct inhibitor of testosterone production: blocks cytochrome P-450, directly halting production of adrenal and gonadal testosterone. Castrate levels produced in 8 hours. Luteinizing hormone releasing hormone meds work by agonizing LHRH receptors in the pituitary. Produce initial increase in release of LH and FSH causing “flare phenomenon.” With time, they suppress LH and FSH production by inhibiting HPA axis. Castrate levels in 30 days.

25 Case scenario 72 yo male with BPH and three-month history of low back pain 3/6 in severity and steady with no radiation. DDX: Disk herniation, Lumbar muscle strain, Muscular spasm, Osteoporosis, Prostate cancer, Sciatic irritation, Spinal Stenosis, Tumor in Vertebral canal.

26 Initial Office Work-up CBC, CMP, UA, ESR and PSA(elevated). XR Back, CT Lumbar Spine shows metastatic lesions in L4 and L5. Rectal Echo: Multinodular enlarged prostate, Prostate biopsy pending. Treatment: Acetaminophen. Morphine or Codeine (if pain persists).

27 Continuing Management Bone Scan: Diffuse Mets Prostate biopsy: Adenocarcinoma CT abdomen and biopsy show lymphatic involvement above aortic bifurcation. Rx: Flutamide (anti-androgen) then LHRH agonist. Consider Urology, Radiation treatment, Radiation consult. Follow-up: Patient counseling.

28 Clinical Case 65 yo male with recent onset lower back pain, PSA 45, unremarkable physical. Transrectal ultrasound-guided biopsy shows adenocarcinoma Gleason = 8 on both sides of prostate. Bone scan with areas of increased uptake diffusely, especially lumbar spine region (suspicious for mets) First line treatment? Androgen deprivation: LHRH agonist (must be given with androgen blocker like flutamide due to “flare phenomenon”).

29 Testicular Carcinoma Most common solid malignant tumor in men yo. Risk factors: Cryptorchid testis and Klinefelter’s. Initial finding: unilateral scrotal mass, may be painless. Measure: AFP and HCG. Staging (TNM) eval should also include serum LDH and CT of chest/abdomen and pelvis.

30 Seminomas and nonseminomas The two main types of testicular tumors are seminomas and nonseminomas. Approximately half of all testicular tumors are seminomas, which occur when the germ cells -- the cells that produce sperm -- become cancerous at a very early stage in their development. Nonseminomas are another type of germ cell tumor. These tumors tend to grow and spread more quickly than seminomas. There are many different kinds of nonseminomas, including: Embryonal carcinomas, which arise in more mature germ cells Teratomas, which occur when germ cells differentiate into various tissue types - - such as cartilage, nerve, or muscle -- inside the testes (a process that does not usually occur until after a mature sperm cell combines with a woman's egg) Yolk sac tumors, in which the yolk that is normally present in the embryo becomes cancerous Choriocarcinomas, a particularly aggressive but very rare type of tumor that shares some characteristics with the placenta (the blood-filtering tissue that forms in a woman's uterus) Nonseminomas may contain more than one of these tumor types, and some even contain all of them.

31 TNM Staging The primary tumor (T) may be classified as: T0 -- There is no evidence of cancer. Tis (testicular cancer in situ) -- Cancer cells have been found, but are confined to the testicle. T1 -- The tumor has spread to the membrane surrounding the testicle. T2 -- Cancer may have spread into the lymph or blood vessels at the vesicle. T3 -- The tumor has grown to the spermatic cord, which also may indicate lymph node involvement. T4 -- The tumor has grown into the skin surrounding the testicles (scrotum). Regional lymph nodes (N) categories include: N0 -- There are no cancer cells in the lymph nodes. N1 -- Lymph nodes are smaller than 2 cm in diameter. N2 -- At least one of the lymph nodes is bigger than 2 cm, but smaller than 5 cm in diameter. N3 -- At least one of the lymph nodes is bigger than 5 cm.

32 TNM Staging (continued) Metastasis (M) categories include: M0 -- Cancer cells have not spread to other organs. M1 -- Cancer has spread to other organs. M1a -- Cancer has spread to the lungs or to lymph nodes beyond the abdomen or pelvis. M1b -- Cancer has spread to other, more distant organs, such as the liver or brain. Serum (S), or blood, marker levels categories include: S0 -- Serum marker levels are normal. S1 -- Markers are slightly higher than normal. S2 -- There is a moderate increase in marker levels. S3 -- Marker levels are very high.

33 TNM Staging (continued) Stage I testicular cancer refers to tumors that are confined to the testicle, with no spread of cancer cells to the nearby lymph nodes or other organs. Stage IA reflects the absence of cancer cells in the blood vessels of the testicle; stage IB reflects their presence. Stage IS indicates an increase in serum marker levels in patients with a testicular tumor after radical orchiectomy. In stage II, cancer cells have spread to the lymph nodes in the abdomen or pelvis. Stages IIA, IIB, and IIC indicate increasing size of the lymph nodes. Stages III, IIIA, IIIB, and IIIC refer to cancer that has spread to the lymph nodes in the chest, the lungs, or more distant organs such as the liver or brain. The cancer also may be classified as stage III if there are high blood marker levels.

34 Treatment Early-Stage Seminoma (Stages I-IIA) Removing the testicle in a surgical procedure called radical orchiectomy combined with lifelong follow-up surveillance may be the only therapy needed. Early-Stage Nonseminoma (Stages I-IIB) Treatment of early-stage nonseminoma tumors begins with a radical orchiectomy to remove the affected testicle. If the pathologist does not find cancer cells inside the blood vessels of the testicle, follow-up surveillance will be recommended. If cancer cells are present in the blood vessels, additional surgery to remove lymph nodes from the retroperitoneum (the area of the abdomen behind the abdominal organs) may be necessary. This procedure iscalled retroperitoneal lymph node dissection (RPLND).

35 Treatment (continued) Advanced Testicular Cancer (Stages IS, IIB to III) Chemotherapy is a highly effective treatment for many patients with nonseminoma testicular tumors that have metastasized beyond the testicle to other regions of the body. The standard of care for patients with early-stage nonseminoma tumors includes treatment with the combination of etoposide and cisplatin (EP), or a combination of bleomycin, etoposide, and cisplatin (BEP).

36 Clinical Case 27 yo male comes to office, not feeling well and has been losing weight. Vague abdominal mass in midline that is non-pulsatile and non-tender. Scrotal exam shows enlarged R testicle without sensation. Most likely diagnosis? Loss of testicular sensation and enlarged testis is diagnostic of testicular carcinoma. In advanced stages: spreads by lymphatics to paraaortic lymph nodes (palpable in midline of a thin person).

37 Ovarian, Endometrial and Cervical Cancer

38 Ovarian Cancer In general a disease of Postmenopausal women and prepubertal girls. Repeated ovulation is a risk factor: chronic anovulation, multiparity and breast feeding are protective. OCP > 5 yrs decreases risk. Infertility treatment: increased risk of ovarian cancer. PCOS, HRT: increased risk. Japanese women migrated to USA with increased risk. BRCA1 and BRCA2 high incidences of ovarian cancer.

39 Diagnosis Vague symptoms: lower abdominal discomfort/pressure, gas, bloating, constipation, irregular menstrual cycles/abnormal vaginal bleeding, LBP, fatigue, nausea, indigestion, urinary frequency, or dyspareunia Pelvic U/S, CA-125 (epithelial malignancy), AFP for endodermal sinus tumor, LDH for dysgerminoma, hCG for nongestational choriocarcinoma. Mixed germ cell tumors and embryonal carcinomas can produce various patterns of these markers.

40 Treatment/Prognosis If ovarian cancer suspected, consult GYN-ONC Abdominal hysterectomy with bilateral salpingo- oophorectomy with omentectomy and selective lymphadenectomy. Drug therapy: Cisplatin with Paclitaxel. Prognosis: 75% have advanced disease at time of diagnosis. 5 year survival rate: 17% with distant metastasis, 36% with local spread, 89% with early disease.

41 Clinical Case 60 yo Female G0 presents with 2 month hx of increasing abdominal girth, decreased appetite/early satiety. Pelvic exam with Solid Right adnexal mass. DDX: CHF, Liver cirrhosis, Ovarian mass. Office workup should include?

42 Work-Up CBC, CMP, CA-125 (900). CT Abdomen and Pelvis with 10 X 12 cm right complex ovarian cyst and large amounts of ascites. CXR: Right moderate pleural effusion. EKG, Pap smear, Mammogram, Colonoscopy, GYN consult. Further work-up? In the Wards: Blood type, crossmatch, PT/PTT and INR. Exploratory lap, TAH-BSO, staging. Follow-up: Chemo, CA-125, CBC/CMP.

43 Endometrial Biopsy GradeInterventionPrognosis Simple or Complex Hyperplasia Progestin to reverse hyperplasia Excellent Atypical HyperplasiaHysterectomyExcellent Endometrial CancerTAH/BSO + lymph node dissection, peritoneal washing, external beam radiation +/- Hormonal and Chemotherapy % 5 yr survival RecurrenceFollow up every 3 months for 2 yrs. Then twice a year for three years. 75% recurrences occur within first two years.

44 Endometrial Cancer Surgical Staging StageDescription ITumor limited to endometrium and half of myometrium. IIEndocervical involvement with stromal invasion. IIIVaginal, Adnexal and para-aortic lymph node involvement (+ve peritoneal cytology) IVTumor invades bladder, bowel and distant metastasis.

45 Endometrial Cancer Treatment Radiation for Stage I and II disease. Hormonal or Chemotherapy for Stage II and III disease. High dose Progestin has been tried for recurrent disease.

46 Clinical Case 60 yo F (G0) with LMP 10 years ago presents w/mild vaginal bleeding for last two days. Past hx infertility. DDX: Atrophic endometritis, cervical cancer, endometrial cancer, endometrial polyp. Office work-up: CBC, CMP, PT/PTT, INR, Bleeding time, Pap smear, Endometrial biopsy shows poorly differentiated endometrioid adenocarcinoma. Ultrasound: Pelvis: 10-mm endometrial stripe. GYN consult.

47 Ward Work-Up and Treatment CXR, EKG, CA-125. Treatment: Exploratory lap, TAH-BSO. Depending on staging, patient may benefit from adjuvant therapy (radiation/chemo/hormonal).

48 Abnormal Pap Smear ResultAction Atypical squamous cell of undetermined significance (ASCUS) Reflex HPV testing with referral to Colposcopy (immediate if follow-up cannot be assured or immuno-compromisd) if positive for high risk HPV (16, 18,31,45). Repeat cytology in 12 months if neg. for high risk. Postmenopausal Women with ASCUSTreat Atrophic epithelium with topical estrogen followed by repeat cervical cytology one week after completing treatment. Pregnant womenNo difference in management Signs of infectionAntibiotic followed by HPV DNA testing AdolescentHPV DNA testing may be deferred Atypical Glandular Cell (AGCUS)If 35: Endometrial Biopsy

49 Abnormal Pap Smear (continued) ResultAction LSIL in adultColposcopy LSIL in adolescents1.Serial cytology at 6 and 12 mos or 2.HPV DNA testing at 12 months with referral to Colposcopy for positive results. LSIL in post-menopausal womenSame as adolescents LSIL in Pregnant WomenColposcopy. Any suspicious lesions should be biopsied (lesser lesions to be sampled at clinician’s discretion). Endocervical curettage should not be performed. If unsatisfactory exam, repeat Colposcopy after 6-12 weeks may be useful. HSIL in AdultImmediate referral for Colposcopy

50 Different reporting methods #DysplasiaCINBethesdaFollow-Up 1Benign NormalAs discussed 2Benign w/inflamm. Normal, ASCUS Either repeat or Colposcopy 3Mild dysplasiaCIN ILow grade SILColposcopy 4Moderate dysplasia CIN IIHigh grade SILRefer to GYN,LEEP 5Severe Dysplasia & Carcinoma in Situ CIN IIIHigh grade SILRefer to GYN, Cryosurgery, CO2 laser, Loop resection, Conization.

51 Clinical Case 33 yo G2P1011 presents with vaginal bleeding after intercourse for the last month. Visible cervical lesion on Pelvic exam. DDX: Cervical Cancer, Cervical Polyp, Cervicitis, Ectropion, Vaginal cancer, Vaginitis. Office Work-up? UA, pap smear (HGSIL), G and C culture or PCR, Wet mount, GYN consult, Colposcopy. Cervical biopsy shows invasive squamous cell carcinoma of the cervix. Treatment? Radical hysterectomy vs. Radiation. +/- adjuvant chemo. Console patient.

52

53 Age Based Approach to Palpable Breast Mass AgeMost common lesion Diagnostic Evaluation Comment 15-25Fibro adenomaUltrasound, needle biopsy. Mammogram not necessary. If dx uncertain excision biopsy. Re-examine after menses 1-4 months Fibro adenoma (cyst and cancer uncommon but possible) Ultrasound or aspiration. If bloody: suspect cancer Fibrocystic Changes: cancer, cyst First Mammogram (possibly ultrasound next). If cystic: FNAC If solid: excision biopsy. >50Cancer until proven otherwise. Mammogram then Biopsy. Pre-op eval and counseling. Pregnancy & Lactating Women Lactating adenomas, cysts, mastitis and cancer. Ultrasound, unilateral mammogram and possible MRI

54 Screening Recommendations ProcedureUSPTFAmerican Cancer Society Breast Self ExamNeither recommended nor prohibited. Monthly for women over age 20. Clinical Breast ExamInsufficient evidence to recommend for or against it. Every 3 years age and annually thereafter. MammographyEvery 1-2 years for women aged 40 and above. Annually age 40 or older. MRINone.Patient with BRCA1 and BRCA2 gene or, two first degree relative with breast cancer. Patient had radiation age years.

55 Risk factors for Breast Cancer Family history of Breast Cancer: screening starts 10 years before the youngest first degree relative was diagnosed (i.e. if mother had breast cancer at 45, screening starts at 35 for that patient). Family history of Pre-menopausal Breast Cancer OR combined ovarian and breast cancer OR two first degree relative with breast cancer.

56 BRCA1 and BRCA2 gene Risk for breast cancer is almost 85-90% by 40 years. Some advocate for prophylactic bilateral mastectomy. Ovarian cancer risk is 10-20%. BRCA1 gene has higher rate than BRCA2. BRCA1 and BRCA2 genes: clinical breast exam, pelvic exam, trans-vaginal ultrasound, CA-125 antigen monitoring and mammography every 6-12 months beginning at age 25. Prophylactic surgery (oophorectomy after childbearing age and before menopause) should be discussed.

57 Breast Cancer Risk Factors (continued) Increasing age Early menarche Nulliparity Delayed child bearing Late menopause Proliferative breast disease and atypical hyperplasia Prolonged use of HRT (USPTF recommends against this)

58 Ductal Carcinoma in situ Premalignant condition Non palpable, irregularly shaped ductal calcification on Mammography. If calcification on Mammography: Core or Excision Biopsy -- put a needle in the calcification under CT guidance and remove the tissue around the calcification.

59 Invasive Ductal Carcinoma Most common breast cancer in mid 30s and 50s. Forms solid tumors. Core excision biopsy should be done, even if mammography not suspicious. Treatment: surgery, radiotherapy and also possibly Tamoxifen.

60 Invasive Lobar Carcinoma Age Vague appearance on Mammography Core/excision biopsy Increased risk of bilateral cancer. Prophylactic bilateral mastectomy or mastectomy and close follow-up with prophylactic Tamoxifen.

61 Breast disease (continued) Paget’s disease Inflammatory Carcinoma Presents with dermatitis/macular rash over nipple or areola. Underlying ductal carcinoma almost always present. Biopsy, excision and radiation. Rapidly growing, sometimes painful mass that enlarges the breast. Overlying skin is erythematous, edematous, and warm. Poor prognosis.

62 Breast Cancer Staging Stage I: Tumor 2 cm or less Stage II and III: Tumor and Nodal involvement +/- local involvement Stage IV: Distant Metastasis

63 Treatment of Breast Cancer Breast conservation surgery: 1. Lumpectomy (lump is removed for stage I) 2. Lumpectomy (removal of tumor with confirmed tumor free margins) + lymph node dissection: Tylectomy plus breast radiation. 3. Partial mastectomy and axillary node dissection or Sentinel Lymph Node mapping + radiation therapy. Randomized trial has shown equal survival as Modified Radical Mastectomy.

64 Modified Radical Mastectomy Total removal of breast tissue, overlying skin, areola, nipple, underlying Pectoral fascia (NOT pectoral muscle) and axillary node dissection. Advantage: no radiotherapy necessary.

65 Chemotherapy 1. Cyclophosphamide, Methotrexate and Fluorouracil (CMF). 2. Adriamycin + Cyclophosphamide (AC). 3. Single Agents: Taxanes (Paclitaxel and Docetaxol). 4. Tamoxifen & Anastrozole (Estrogen receptor positive tumor cell). 5. Trastuzumab: (for patient with HER-2/neu oncogen overexpression).

66 Clinical Case 29 year old female presents with 3 days of bloody discharge from the right nipple and a lump (1 cm movable [not-fixed] mass in Right outer/upper quadrant of R breast) and no skin dimpling, erythema, or peau d’orange. Which of the following conditions is most likely cause of the nipple discharge? A) Fibroadenoma B) Fibrocystic change C) Mastitis D) Intraductal carcinoma E) Intraductal papilloma

67 Clinical Case (continued) Which of the following options regarding management of the nipple discharge would you recommend? A) Cytologic studies B) Culture studies C) Mammography D) Excisional biopsy E) Reexamination in 2-4 weeks

68 Clinical Case (continued) Which of the following conditions is the most likely cause of the breast mass? A) Fibroadenoma B) Lobular carcinoma in situ C) Fibrocystic change D) Adenocarcinoma E) Ductal carcinoma in situ

69 Clinical Scenario 50 year old female presents as an outpatient with a painless lump in her right breast. She first noted this mass one month ago. No nipple discharge. On physicial exam: 3 cm, hard, immobile, non-tender mass with irregular borders; no nipple discharge. DDX: Breast cancer, Fibroadeonma, Fibrocystic disease, Mastitis, Papillomas. Management? Mammography (suspicious of tumor), FNA biopsy (malignancy). Counsel patient and consult surgery.

70 Questions? Thank you for your attention!


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