breast cancer steven jones, md. 2 epidemiology of breast cancer 182,460 american women diagnosed...
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Breast Cancer
Steven Jones, MD
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Epidemiology of Breast Cancer
• 182,460 American women diagnosed each year.
• 40,480 die each year from the disease• Lifetime risk through age 85 is 1 in 8, or
12.5%• 2nd leading cause of cancer deaths among
US women, after lung cancer• Leading cause of death among women age
40-55
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Mammary GlandAnterior view
Lobar/Lactiferous duct
Lobule
Fat
Ampulla Nipple
Areola gland
Areola
Lobular duct
Bre
ast
An
ato
my
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Lobar/Lactiferous Duct Cross Section
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The entire duct may be filled with abnormal, atypical cells.
This condition is actually an early breast cancer.
Ductal Carcinoma In Situ (DCIS)
Lobar/Lactiferous Duct Cross Section
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Cancer cells that break out of the duct and invade the breast tissue.
Invasive Ductal Carcinoma (IDC)
Lobar/Lactiferous Duct Cross Section
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Breast Cancer Risks
• Gender – 1% male• Age - < 30 – rare ; risk rises sharply
after 40• Personal Hx – 0.5-1% per yr in contra
breast• Family Hx- 20-30% of Br Ca have +
fm hx; only 5-10% have an inherited mutation
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Consider BRCA 1 / 2 testing:
• < 35• <50 with another positive relative <
50• Any age with 2 other positive
relatives• Male relative with breast cancer• Jewish ancestry with young age or 1
relative
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Breast Cancer Risks
• Benign Breast disease – Atypical ductal hyperplasia – 4.5-5.0 RR
• Lobular Carcinoma in Situ – 5.4-12.0 RR, 1% per year.
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Excess growth within the duct includes abnormal or atypical cells.
The presence of this condition increases the risk of developing breast cancer.
Atypical Ductal Hyperplasia (ADH)
Lobar/Lactiferous Duct Cross Section
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Lobular Hyperplasia
Atypical Lobular Hyperplasia
Excess growth in the lobules
Lobular Hyperplasia
Atypical lobular hyperplasia may also develop. If atypical lobular hyperplasia progresses in severity a condition referred to as Lobular Carcinoma In Situ (LCIS) may develop.
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Breast Cancer Risks
• Hormonal factors – early menarche, late menopause, age of 1st pregnancy, HRT with progesterone
• Environment, lifestyle, and diet – ionizing radiation increase risk
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High Risk Patients
• Gail model• Chemo prevention• Increased surveillance
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Magnification Views– Improves resolution
– Better determination of the shape, distribution,
and number of microcalcifications
– Questionable density from summation shadows will dissipate
Mam
mog
rap
hy
Additional Views
Current status of the Digital Database for Screening Mammography," M. Heath, K.W. Bowyer, D. Kopans et al, pages 457-460 in Digital Mammography, Kluwer Academic Publishers, 1998.
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0
1
2
3
4
5
Incomplete assessment
Negative
Benign finding
Probably benign
Suspicious
Highly suggestive of malignancy
Additional imaging evaluation
Short interval follow-up
Biopsy should be considered
Appropriate action to be taken
CategoryAssessment Recommendations
BI-
RA
DS
™
Report Organization
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Characteristics of imaged lesions • Size• Shape• Border definition• Internal echogenicity• Posterior enhancement• Architectural changes• Gray scale comparison to adjacent breast tissue
Breast Ultrasound
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Benign vs. Malignant
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Open Surgical BiopsyB
iop
sy O
pti
on
s
Performed in the Operating Room
An incision is made in the breast and a large tissue sample is cut and removed
In some cases, a wire is inserted into the breast to
aid in localizing the abnormality
Possible scarring and disfiguration that can
interfere with future mammograms
More costly than other biopsy methods
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Bio
psy O
pti
on
s
Can be performed in an outpatient setting or doctor’s office
No anesthesia
No sutures
Several needle insertions to collect fluid and/or cellular material
Cyst aspiration for fluids
Unable to mark biopsy site
Fine Needle Aspiration (FNA)
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Bio
psy O
pti
on
sCore Needle Biopsy
Can be performed in an outpatient setting or
doctor’s office
Local anesthesia
No sutures
4 – 6 needle insertions to collect a sufficient amount of breast tissue for an accurate diagnosis
Unable to mark biopsy site
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Cancer Cure?
cut it out or
burn it out
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National Surgical Adjuvant Breast Project
• Radical mastectomy vs
• Simple mastectomy with axillary irradiationvs
• Simple mastectomy with delayed axillary dissection
Started in 1971, 1665 patients enrolled, 25 year follow up
No difference in disease free or overall survival
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Breast Cancer Multifocality
Holland et al.
• Only 37% of cancers are confined to the primary tumor.
• 20% have additional cancer within 2 cms.
• 43% have additional cancer beyond 2 cms.
Holland R, Veling S, Mravunac M, et al. Histologic multifocality of Tis, T1-2 breast carcinomas: implications for clinical trials of breast-conserving treatment. Cancer 1985; 56: 979
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NSABP B-06
• Total mastectomy vs lumpectomy vs lumpectomy plus irradiation
• No significant difference in survival• 14.3% recurrence in lumpectomy
plus radiation group at 25 years• 39.2% recurrence in lumpectomy
without radiation group at 25 years
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Conclusion NSABP B-06
• Lumpectomy followed by breast irradiation is the appropriate therapy for women with breast cancer, provided that the margins of resected specimens are free of tumor and an acceptable cosmetic result can be obtained.
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Axillary Biopsy and Control
• 1. Staging– In the absence of distant mets number
of positive lymph nodes is the most important prognostic factor.
2. Regional ControlIn clinically negative axilla, axillary dissection reduces local occurrence from 20% to 3%
3. Small survival advantage (3-5%)
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Parasternal (internal thoracic) nodes
Subclavian (apical axillary) nodes
Interpectoral(Rotter’s) nodes
Central axillarynodes
Brachial (lateral axillary)
nodes
Subscapular (posterior axillary)
nodes
Pectoral (anterior axillary)
nodes
Mammary GlandAnterior view
Bre
ast
An
ato
my
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Sentinel Lymph Node
• Technetium labeled sulfur colloid• Isosulfan blue (lymphazurin 1%)• Combined – 97% ID’ed; 6% false
negative• 1% anaphylactic reaction to blue dye
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Systemic Therapy
• Cytotoxic chemotherapy • Hormonal therapy – 50% reduction of
recurrence, 26% reduction in mortality
• Targeted therapy - Herceptin – 50% reduction of recurrence.
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NSABP B-18
• Started 1988; 1523 pts, 4 cycles AC• 80% overall response• 13% pathologic complete response• No difference in overall survival• Only 3% had progression of disease• 25% downstaging at axilla• 30% of women will downstage to allow
conversion from mastectomy to BCS
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Indications
• To downstage women with large tumors that cannot undergo BCS with good cosmetic result – 30% of women will downstage.
• Early initiation of systemic treatment• In vivo assessment of response, good
biological model• Less radical surgery needed
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By age 30 1 out of 2,212By age 40 1 out of 235By age 50 1 out of 54By age 60 1 out of 23By age 70 1 out of 14By age 80 1 out of 10Ever 1 out of 8
By age 30 1 out of 2,212By age 40 1 out of 235By age 50 1 out of 54By age 60 1 out of 23By age 70 1 out of 14By age 80 1 out of 10Ever 1 out of 8
Risk of breast cancer increases with age
Feuer EJ, Wun LM. DEVACN: Probability of Developing or Dying of Cancer.
Version 4.0
Bethesda, MD: National Cancer Institute 1999
Facts
& F
igu
res