breast cancer presentation final copy
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Akinpelu, Angela; Espinosa, Frankie; Lawson, Chatriece
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#1 cause of cancer death in women world wide
2nd most common cause of cancer death in the
US
Most common female malignancy
In the US, there is a 1/8 chance a woman will
develop breast cancer if she lives to be 90 y/o Surgery is the primary treatment
Early-stage is often cured with surgery alone
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Incidence and mortality rates are 5 times higher
in North America and Northern Europe thanAsian and African countries
230,480 new cases of invasive breast cancer
were expected to be diagnosed in women in the
US
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Risk Factor Relative Risk
Age (50 vs
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Milk producingsebaceous glands
Rest on pectoralismajor
Attached to muscle wallvia Coopers ligaments
15-20 lobes in circulararrangement
Fat gives size andshape
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Glands at the ends oflobules produce milk
Lobes, lobules, and bulbsare linked by a network of
ducts Ducts carry milk from
bulbs toward areola
Ducts join together into
larger ducts ending at thenipple, where milk isdelivered
Network of lymphaticsrun through the breasts
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The external structure of the breast can be divided into 4
quadrants:
the upper inner quadrant
the lower inner quadrant
the lower outer quadrant
the upper outer quadrant
The upper-outer quadrant of the breast is thicker than the
remainder of the breast.
Contains a greater bulk of mammary tissue than the
other quadrants
Both benign and malignant tumors occur most
frequently there
The breast borders
The upper border of breast tissue begins at the
collarbone
The lower border is at the base of a properly fitted bra
The inner border is the edge of the sternum
the outer border is the anterior axillary line which is the
underarm or arm pit
Some women have tails or axillary projections of breast
tissue that extend further than the anterior axillary lines
into the armpit. It is important this this area be
included in the breast self-examination.
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Fibrocystic changes
Hyperplasia Fibroadenomas
Intraductal papillomas
Galactocele
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Three Histologic Categories
Nonproliferative lesions
Proliferative lesions (hyperplasia) without
atypia Atypical hyperplasia
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Most common benign breast disorder
Present in ~50% of women May involve any or all breast tissues
Caused by decrease in progesterone or
increase in estrogen
Improves in pregnancy and lactation
Can be painful, especially premenstrually
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Most common benign tumor
Composed of both fibrous and glandular tissue
Well circumscribed, freely mobile
Usually solitary
Common before the age of 30
Has malignant potential
Excised for definitive diagnosis and cure
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Neoplastic growths within ducts
Common before or during menopause
Rarely palpable
Presents as bloody, serous, or turbid discharge
from nipple
Excisional biopsy of lesion is the treatment ofchoice
May have invasive tendency
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Cyst of dilation of duct
Filled with thick, inspissated, milky fluid
Presents during or shortly after lactation
Represents ductal obstruction (i.e., inflammation,
hpyerplasia, neoplasia)
Multiple cysts often present Can 2 acute mastitis or abscess
Tx: needle aspiration; excisional biopsy if bloody
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Carcinoma
begins in the epithelial cells of organs (i.e. breast) Nearly all breast cancers are carcinomas (either
ductal carcinomas or lobular carcinomas)
Adenocarcinoma
carcinoma that starts in glandular tissue, i.e. ductsand lobules
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Invasive (infiltrating) carcinoma
An invasive cancer is one that has already grown beyondthe layer of cells where it started
Sarcoma start in connective tissues such as muscle tissue, fat
tissue, or blood vessels
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Carcinoma in situ
Early stage of cancer
It is confined to the layer of cells where it began Lobular carcinoma in situ(LCIS)
Ductal carcinoma in situ(DCIS)
Cells have not invaded into deeper breast tissues or
spread to other organs Referred to non-invasive or pre-invasive breast
cancer because it may develop into an invasive breast
cancer if left untreated
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Arises from terminal duct apparatus
Has diffuse distribution, usually non-palpable
Incidence is 2.8 per 100,000 women
Peak incidence at 40 50 years
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If LCIS becomes invasive
it is termed as infiltrating
lobular carcinoma < 15% of invasive breast
cancer
Metastasizes to axillary
lymph nodes 1st
Tends to become multi-
focal
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Most common type of non-invasive breast cancer
DCIS is notlife-threatening
DCIS can increase the risk of developing an
invasive breast cancer
High risk for cancer reoccurrence
At a higher risk for developing a new onset of
breast cancer than a person who has never had
breast cancer
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~80% of all breastcancers
DCIS initiallymicroinvades the ductwall
Eventually, cancerouscells invade breast tissue
Can spread to lymph
nodes, then to otherareas of the body
2/3 of women are > 55 y/owhen diagnosed
Also affects men
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Uncommon, 1 2% of all breast cancers
Histology: single layer epithelial cells, low-
grade nuclei and apical cytoplasmic snoutings(extrusions) arranged in well-formed tubules
and glands
Has low incidence of lymph node involvement
Very high overall survival rate
Treatment is often only breast-conserving
surgery and local radiation
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Uncommon, 1 2% of all breast cancers
Two common types:
cystic (noninvasive); low mitotic activity, indolent,good prognosis
micropapillary (invasive); centrally located; can
present as bloody nipple d/c; strongly ER+ and
PR+; more aggressive; frequent lymph nodemetastasis; correlates with survival
Usually in women > 60 y/o
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Relatively uncommon, < 5%
Occurs in younger women
Typically presents as a bulky palpable
mass with axillary lymphadenopathy (30%)
DCIS sometimes observed in surrounding
normal tissue
Usually ER, PR, and HER2 negative
TP53commonly mutated
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Relatively uncommon, < 5% of invasive
breast cancers
Women typically > 70 y/o at presentation Presents as palpable mass or
mammographically as poorly defined with
rare calcifications
Excellent prognosis; > 80% 10-year survival
Histologic: types A, B, and AB; mucin
production > in type A
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Associated with underlying breastcancer in 75% of cases
Occurs in ~3% of all breastcancers
Arises from excretory ducts skinof nipple and areola
Eczematoid appearance
Palpable lesion in 2/3
Poor prognosis associated withpalpable tumor, lymph nodeinvolvement, age < 60
Overall 5- and 10-year survivalrates 59% and 44%, respectively
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Rare, 1 4%
Often seen in pregnancy
Develops rapidly, making the affectedbreast red, swollen and tender; classicpeau dorange appearance
Cancer cells block the lymphatic vessels inthe breast, causing the characteristicappearance of the breast.
Considered a locally advanced cancerithas spread from its point of origin tonearby tissue and possibly to nearbylymph nodes
Easily confused with a breast infection Seek medical attention promptly if younotice skin changes on your breast
Typically is advanced with mets by time ofdiagnosis
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Carcinoma
Painless and freely mobile
Tumor
Fixed into deep fascia
extension to the skin causes retraction and dimpling
of the skin
Ductal involvement nipple retraction
Blockage of skin lymphatic's causes lymphedema
and thickening of the skin referred to as peaud
organge
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Tumors spread by:
Local Infiltration
Directly into parenchyma
Lymphatic Spread Mainly into the axillary nodes
Occurs in up to 50% of patients with systematic breast cancer
Internal mammary nodes are the 2nd most common affected
site
Supraclavicular nodes are only involved after axillary nodes 10%-20% of patients screened have detected breast cancers
Hematogenous Spread
Metastasizes mainly to the lungs and liver
Other sites include: bone, pleura, adrenals, ovaries and brain
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Scale of 0 (describing non-invasive cancers ) to IV (describing
invasive cancers )
Stage 0: non-invasive cancers
Stage I: invasive, the tumor measures
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IIB the tumor is >2 cm 5 cm but not metastasized to the axillary lymph nodes
Stage III IIIA
no tumor is found, but cancer is found in axillary lymph nodes, or cancer may
metastasized to lymph nodes near the breastbone OR the cancer is any size and metastasized to axillary lymph nodes
IIIB the cancer may be any size and metastasized to the chest wall and/or skin of the
breast AND may metastasized to axillary lymph nodes, or cancer may have spreadto lymph nodes near the breastbone
Inflammatory breast cancer
IIIC there may be no sign of cancer in the breast or, if there is a tumor, it may be any
size and may have spread to the chest wall and/or the skin of the breast AND
the cancer has spread to lymph nodes above or below the collarbone AND
the cancer may have spread to axillary lymph nodes or to lymph nodes near thebreastbone
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Stage IV
Metastasized to other organs
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Screening begins for asymptomatic women
The Physician - Physician Assistant has to befamiliar with common Benign and Malignant
disorders of the breasts along with their therapeuticoptions
The screening process all begins with the patientThe Breast Self-Exam (BSE)
This means that the MD PA should give the patientpertinent health information tailored to anyabnormalities, as well as properly training andeducating the patient on how to properly do theBSE
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There is no documented proof that performing a
Breast Self-Examination directly reduces
mortality, but all health professionals agree that ithelps lead to an earlier diagnosis, which in turn
will indirectly increase mortality
A rule of thumb: It is best to perform a monthlyBreast Self-Examination after menses has
ceased
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Proper Technique is KEY
Begin in the Upright Positionwith the arms to the
side
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After Inspection with the arms to the side then
arms in the raised position
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Have the patient palpate 2 key areas
1. Supraclavicular
2. Axillae
Assessing for any nodes
Then, have the patient lie supine, palpating
each quadrant against the chest wall using the
flat of the hands Next, have patient palpate their areola
Finally, decompress the nipples for any
evidence of discharge
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To be done annuallyat the minimum
Begin upright and use observation, checkingfor:
a) Symmetryb) Contour
c) Skin Changes/Retractions Due to thetethering of skin to an underlying malignancy
d) Nipple Retractions Have patient raise theirhands above their head to accentuate anyabnormalities
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Be sure to palpate in the following order
1. Breast
2. Areola
3. Nipple If any mass is palpated, check if it is fixated to deep
tissues by having the patient put her hands on her hipsand contracting the pectoralis muscles while she isdoing this palpate the:
a) Axillab) Supraclavicular fossa
After completing the exam upright, repeat theexam with the patient supine
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Mammogram
A veryimportantcomponent of the screening
process, especially in asymptomaticwomen
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The Mammogram should be done in conjunction with thePhysical Examination
Able to detect malignancies
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Ultrasound
Helps differentiate a cystic vs. solid mass
May also show any solid tissue that is
potentially malignant
Good diagnostic tool for women
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MRI Magnetic Resonance Imaging Before using this diagnostic the healthcare professional
must distinguish whether the nodules or tenderness iscaused by normal hormone function or whether it iscaused from benign or malignant changes
Nuclear Imaging Not usually indicated for the detection of breast cancer
Plays a very useful role in the detection of breast cancer
Detection rate of 85%
Specificity rate of 89% 3 radiotracers are commonly used
Tc sestamibi
Tc tetrofosmin
Tc methylene diphosphonate
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Positron Emission Tomography Scanning
PET Scan
Most sensitive and specific of all the imaging
modalities for breast disease
One of the most expensive and least widely
used modalities available
Utilizes labeled metabolites for detectionfluorinated glucose
Main use is to help detect recurrences
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For definitive diagnosis of neoplasms:
1. Fine Needle Aspiration FNA
2. Open Biopsy
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Fine Needle Aspiration FNA
Can be performed on an out-patient basis
It is bothsensitive & specific
Remember!
Neveraccept a negative biopsy result as a definitive
when a mammogram indicates a malignancy
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Open Breast Biopsy
Smaller Masses = Excisional Biopsy
Larger Masses = Incisional Biopsy
Indications for open biopsy:
A mass that exists through out menses
Cystic masses that does not decompress with
aspiration or has blood in the aspirate
Spontaneous serous nipple discharge
No mass with a trigger point
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Open breast biopsy (contd)
Can be done as an in-patient or out-patient In an out-patient setting use local anesthesia
In an in-patient setting use general anesthesia
Do Not use open breast biopsy for:
Women with large breast and a small deep mass
Non-palpable lesions detected on a mammogram
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There is a trend towards conservative
surgical approaches to breast cancer with
adjuvant radiation and, if necessary
chemotherapy or hormonal therapy
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Surgery For many years radical mastectomy was the standard of treatment for
breast cancer
Survival rates of conservative therapy are equal to those of radicalmastectomy
Routine axillary lymph node dissection has progressively been replaced
by lymphatic mapping and sentinel lymph node resection Breast reconstruction after a mastectomy is an integral part of the
treatment of breast cancer, which can be done at the time ofmastectomy
Radiation Therapy Conservative surgery is always performed in conjunction with radiation
therapy to the breast
This approach gives equivalent outcomes to radical mastectomy, andfunctional and cosmetic results are improved
External beam therapy is used with this modality, by giving 4,500 to5,000 cGy to the entire breast
The axilla is not routinely irradiated due to the occurrence oflymphedema
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Used in cases of early breast cancer, regardlessof lymph node involvement
Reduces the risk of relapse by about 33%
Reduces the risk of death by about 25%
Pre-menopausal women with ER-negativetumors should receive adjuvant therapy
Pre-menopausal women with ER-positive tumorsshould receive adjuvant therapy in addition to
chemo therapy The use of Tamoxifen shows a 70% reduction inthe risk of cancer in the contralateral breast
In patients with proven metastases, symptomsmay be palliated with combination chemotherapy
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3% breast cancer occur in pregnancy Complicating ~ 1/3000 pregnancies
Diagnosis is usually delayed because ofhypertrophied breast
If a mass is suspected, a needle aspiration oropen biopsy needs to be performed promptly
Surgical treatment is the same as a non-pregnant patient
With nodal metastases abortion is advisable inthe first trimester with tx of adjuvantchemotherapy because of teratogenic risk,during the 3rd trimester should wait until afterdelivery
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Is related to the stage of the disease and age
Older age has better prognosis
Status of axillary lymph nodes is the single most
important prognosticator
Patients with negative lymph nodes had an
actuarial 5-year survival rate of 83%
Pregnant patients has a worse prognosis thannon-pregnant patients
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BreastCancerStage
5-YearSurvivalRate forWomen
0 93%
I 88%
IIA 81%
IIB 74%
IIIA 67%IIIB 41%
IIIC 49%
IV 15%
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Which of the following is a benign breast
disorder?
a) Fibroadenoma
b) DCIS
c) Padgets
d) LCIS
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Which of the following is a benign breast
disorder?
a) Fibroadenoma
b) DCIS
c) Padgets
d) LCIS
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What is the #1 cause of female cancer death
worldwide?
a) Lung
b) Breast
c) Cervical
d) Ovarian
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What is the #1 cause of female cancer death
worldwide?
a) Lung
b) Breast
c) Cervical
d) Ovarian
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Which quadrant has the highest occurrence of
benign tumors?
a) Upper Inner
b) Lower Outer
c) Upper Outer
d) Lower Inner
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Which quadrant has the highest occurrence of
benign tumors?
a) Upper Inner
b) Lower Outer
c) Upper Outer
d) Lower Inner
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Which quadrant has the highest occurrence of
malignant tumors?
a) Upper Inner
b) Lower Outer
c) Upper Outer
d) Lower Inner
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Which quadrant has the highest occurrence of
malignant tumors?
a) Upper Inner
b) Lower Outer
c) Upper Outer
d) Lower Inner
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What is the most effective treatment modality?
a) Radiation
b) Acupuncture
c) Chemotherapy
d) Surgery
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What is the most effective treatment modality?
a) Radiation
b) Acupuncture
c) Chemotherapy
d) Surgery
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DCIS
Ductal Carcinoma In Situ
IDC Invasive Ductal Carcinoma
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IDC - Less Common Types
ILC Invasive Lobular Carcinoma
Inflammatory Breast Cancer
LCIS Lobular Carcinoma In Situ
Male Breast Cancer
Paget's Disease of the Nipple
Phyllodes Tumors of the Breast
Recurrent and Metastatic Breast Cancer
http://www.cancer.org/Cancer/BreastCancer/DetailedGuide/breast-cancer-what-is-breast-cancer
Hacker, Neville F., Joseph C. Gambone, and Calvin J. Hobel. "Breast Disease: A Gynecologic Perspective." Hacker and Moore's
Essentials of Obstetrics and Gynecology. 5th ed. Philadelphia, PA: Saunders/Elsevier, 2010. Print.
"Types of Breast Cancer." BreastCancer.org - Breast Cancer Treatment Information and Pictures. 17 Sept. 2010. Web. 01 Dec.
2011. .
"What Is Breast Cancer?"American Cancer Society :: Information and Resources for Cancer: Breast, Colon, Prostate, Lung and
Other Forms. 29 Sept. 2011. Web. 1 Dec. 2011. .
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For Breast Cancer
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