1. Sonography of the Breast Part III
Lecture 13
Staging and Treatment
Harry H. Holdorf PhD, MPA, RDMS (Ab, Ob/Gyn, Br), RVT, LRT(AS), CCP

2. Module Eleven – Breast Cancer Staging and Treatment

3. Staging
Treatment options for breast cancer patients are based on several factors:
Type of cancer
Whether the tumor is hormone receptor positive or negative (ER, PR)
Stage of the cancer
Age of the patient
Patient’s menopausal status
General health of the patient
Patient’s feelings about treatment and side effects

4. Staging is the process of gathering information from all diagnostic studies available to determine how widespread the cancer is.
Following biopsy confirmation, more testing such as blood tests, chest x-ray, bone scan, CT, MRI or PET scan may be performed.
The stage of the cancer is one of the most important factors in selecting treatment options.

5. Breast Cancer Staging Stage Size Lymph Node Involvement
Metastasis to distant site
In Situ No I
< 2cm II
> 2 cm
Possible
If not fixed
III
> 2 cm
> 5 cm
Fixed IV
Any Size
Probable
Yes

6. The TNM Classification System may also be used to help stage a cancer.
T is Tumor – tumor size and spread within the breast is considered.
N is Lymph Nodes – spread to the lymph nodes is considered.
M is Metastasis – Involves spread to distant organs such as the lungs, bones , or Liver
Example: T2N1M0

7. Treatment Once staging has occurred, treatment can be considered.
Treatment of breast cancer is usually divided into two main categories:
Local-Regional Therapy
Goal is to eradicate the disease in the breast and lymph nodes
Types include surgery and radiation therapy.
Systemic Therapy
Goal is to eradicate the disease in all parts of the body
Types include chemotherapy, hormone therapy, and others.

8. Surgery Lumpectomy Total or Simple Mastectomy Radical Mastectomy
Removal of the breast lump and a small amount of surrounding tissue
10 to 20 lymph nodes are also removed and evaluated (Axillary Lymph Node Dissection) – ALND)
Usually followed by radiation therapy
Total or Simple Mastectomy
Removal of the breast
Usually not performed alone
Radical Mastectomy
Removal of the breast, lymph nodes, pectoralis major and pectoralis minor
Extremely disfiguring
Outdated and only performed in extreme cases

9. Reduction Mammoplasty
Reduction Mammoplasty (also breast reduction and reduction Mammoplasty) is the plastic surgery procedure for reducing the size of large breasts.
Also known as reduction Mammoplasty, breast reduction removes excess breast fat, glandular tissue and skin to achieve a breast size in proportion with your body and to alleviate the discomfort associated with overly large breasts.

11. Breast reconstruction
Breast reconstruction is the rebuilding or a breast, usually in women.
Often this includes the reformation of a natural looking areola and nipple.
This procedure involves the use of implants or relocated flaps of the patient’s own tissue.
The Abdominal flap for breast reconstruction is the TRAM flap (Transverse Rectus Abdominis Myocutaneous flap)
In the TRAM flap, a portion of the abdomen tissue group is taken from the patient’s abdomen and transplanted onto the breast site.

12. Axillary Lymph Node Dissection (ALND)
Removal and or sampling of lymph nodes
May be performed with lumpectomy or modified radical mastectomy
Metastatic progression of cancer through the axillary lymph nodes usually proceeds in an orderly manner through level 1 (lateral to pectoralis minor muscle), level 2 (Posterior to pectoralis minor), then level 3 (medial to pectoralis minor).
Typically, surgeons perform a level 1 and 2 ALND procedure. If level 1 and 2 nodes are cancer free, it is extremely unlikely level 3 nodes contain metastatic disease.
Lymphedema is the most common complication.
Scar tissue forms in the lymphatic ducts preventing lymph from draining.

13. Radiation Therapy
Radiation Therapy offers a local or regional therapy for breast cancer.
External Beam Radiation Therapy (EBRT) has been the standard delivery method.
Brachytherapy, a more recently developed technique, is a form of focal therapy where a radioactive seed is placed in the tumor bed of a lumpectomy site.
6 to 7 weeks of daily radiation treatments to the site of the tumor is common.
Side-effects: radiation burn to the chest wall, treatment kills normal cells, fatique.

14. Chemotherapy
Chemotherapy is a type of systemic therapy for breast cancer.
Uses ant-cancer drugs given intravenously (IV) or orally.
6 to 12 month treatments are common
Side-effects: fatique, hair loss, nausea and vomiting, may kill bone marrow cells.
A positive response to Chemotherapy on sonography would be
Decreased tumor size
Decreased blood flow around tumor.

15. Hormone Therapy
Tamoxifen and Ralozifene are popular anti-estrogen agents used to treat breast cancer.
Because many tumors need estrogen to grow (ER+), Tamoxifen and Raloxifene attempt to block estrogen from reaching the tumor.
Both reduce the risk of invasive breast cancer
Only Tamoxifen protects against In Situ cancer
Raloxifene has a lower risk of side effects (endometrial cancer and blood clots)
Dose- one tablet daily
Side-effects: hot flashes, vaginal discharge, hair thinning and increased risk of endometraial hyperplasia and possibly endometrial cancer (especially with Tamoxifen.

16. Biologic Therapy
Targeted biologic therapy allows antibodies to recognize a specific protein on cancer cells and signals the body’s immune system to destroy the cell. A protein common in 25% of breast cancer is Human Epidermal growth factor Receptor 2 (HER2). If a breast cancer is HER2 positive, popular treatments include:
Herceptin
Tykerb
Side effects include heart disease, nausea, vomiting, fever, cough, headache, etc..
Currently, there are numerous ongoing clinical trials for the treatment of breast cancer. Some of which involve gene therapy and stem cell research.

17. The END…Ultrasound of the Breast!!!!!!!!!!!!!!!!!!!!!!!!!!!!!