2
Mammary
Gland
Breast Anatomy
Anterior view
Parasternal (internal thoracic) nodes
Subclavian (apical axillary) nodes
Interpectoral
(Rotter’s) nodes
Central axillary
nodes
Brachial
(lateral axillary)
nodes
Subscapular
(posterior axillary)
nodes
Pectoral
(anterior axillary)
nodes
3
Mammary Gland
Breast Anatomy
Anterior view
Lobular duct
Lobar/Lactifero
us duct
Lobule
Ampulla
Nipple
Areola gland
Fat
Areola
4
Lobar/Lactiferous Duct
Cross Section
5
Lobar/Lactiferous Duct
Cross Section
Atypical Ductal Hyperplasia
(ADH)
Excess growth within the
duct includes abnormal or
atypical cells.
The presence of this
condition increases the
risk of developing breast
cancer.
6
Lobar/Lactiferous Duct
Cross Section
Ductal Carcinoma In Situ
(DCIS)
The entire duct may be
filled with abnormal,
atypical cells.
This condition is actually an
early breast cancer.
7
Lobar/Lactiferous Duct
Cross Section
Invasive Ductal Carcinoma
(IDC)
Cancer cells that
break out of the
duct and invade
the breast tissue.
8
Lobular Hyperplasia
Excess growth in the
lobules
Atypical 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.
Lobular
Hyperplasia
Epidemiology of Breast Cancer
• 232,340 American women diagnosed each year.
• 39,620 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
10
Breast Cancer Causes
• Hormonal factors – early menarche, late menopause, age
of 1st pregnancy, HRT with progesterone
• Environment, lifestyle, and diet – ionizing radiation
increase risk
11
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
12
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.
CRITERIA FOR REFERRAL FOR GENETIC COUNSELING OF
INDIVIDUALS AT INCREASED RISKFOR BRCA1/2-ASSOCIATED
HEREDITARY BREAST CANCERa,b
• Personal history of breast cancer diagnosed≤ 40
• Personal history of breast cancer diagnosed≤ 50 and
Ashkenazi Jewish ancestry
• Personal history of breast cancer diagnosed≤ 50 and at
least one first- or second-degree relative with breast cancer
≤50and/or epithelial ovarian cancer
aClose
relatives of individuals with the history mentioned in the table are
appropriate candidates for genetic counseling. It is optimal to initiate testing
in an individual with breast or ovarian cancer prior to testing at-risk
relatives.
bCriteria modified from NCCN (109)
Continued….
• Personal history of breast cancer and two or more relatives on the
same side of the family with breast cancer and/or epithelial ovarian
cancer
• Personal history of epithelial ovarian cancer, diagnosed at any age,
particularly if Ashkenazi Jewish
• Personal history of male breast cancer particularly if at least one firstor second-degree relative with breast cancer and/or epithelial ovarian
cancer
• Relatives of individuals with a deleterious BRCA1/2mutation
15
High Risk Patients
• Gail model
• Chemo prevention
• Increased surveillance
16
Report Organization
Category Assessment
0
BI-RADS™
1
Incomplete
assessment
Recommendations
Additional imaging
evaluation
Negative
2
Benign finding
3
Probably benign
Short interval follow-up
4
Suspicious
Biopsy should be considered
Highly suggestive
of malignancy
Appropriate action to be
taken
5
Pathological Variables
Luminal A
HER2-Positive (IHC)
12
ER-Positive(IHC)
96
Grade III
19
Tumor size> 2 cm
53
Node- positive
52
Pathological Variables
Luminal B (%)
HER2-Positive (IHC)
20
ER-Positive(IHC)
97
Grade III
53
Tumor size> 2 cm
69
Node- positive
65
Pathological Variables
HER2-like (%)
HER2-Positive (IHC)
100
ER-Positive(IHC)
46
Grade III
74
Tumor size> 2 cm
74
Node- positive
66
Pathological Variables
Basil-like (%)
HER2-Positive (IHC)
10
ER-Positive(IHC)
12
Grade III
84
Tumor size> 2 cm
75
Node- positive
40
21
Open Surgical Biopsy
 Performed in the Operating
Room
Biopsy Options
 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
22
Fine Needle Aspiration (FNA)
Biopsy Options
 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
23
Core Needle Biopsy
 Can be performed in an
Biopsy Options
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
24
National Surgical Adjuvant Breast Project
• Radical mastectomy
vs
• Simple mastectomy with axillary irradiation
vs
• Simple mastectomy with delayed axillary dissection
Started in 1971, 1665 patients enrolled, 25 year follow up
No difference in disease free or overall survival
25
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
26
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
27
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.
Contraindications for Breast Conserving
Therapy
• Absolute:
• Prior radiation to the breast or chest wall
• Pregnancy
• Muticentric disease
• Diffuse, malignant appearing microcalcifications
Relative Contraindications for BCT
• History of collagen vascular disease
• Very large tumor > 5cms
• Very large breasts
30
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 Control
In clinically negative axilla, axillary dissection reduces local
occurrence from 20% to 3%
3. Small survival advantage (3-5%)
Sentinel Lymph Node
• Technetium labeled
sulfur colloid
• Isosulfan blue
(lymphazurin 1%)
• Combined – 97%
ID’ed; 6% false
negative
• 1% anaphylactic reaction
to blue dye
32
Sentinel Lymph Node
• Technetium labeled sulfur colloid
• Isosulfan blue (lymphazurin 1%)
• Combined – 97% ID’ed; 6% false negative
• 1% anaphylactic reaction to blue dye
33
Systemic Therapy
• Cytotoxic chemotherapy
• Hormonal therapy – 50% reduction of recurrence, 26%
reduction in mortality
• Targeted therapy - Herceptin – 50% reduction of
recurrence.
ALGORITHM FOR ADJUVANT SYSTEMIC
THERAPY FOR BREAST CANCER
ER- and/or PR-Positive ER- and PR-Negative
ERBB2 negativea
Endocrine therapy±
chemotherapy
depending on risk
Chemotherapy
ERBB2 positive
Endocrine therapy+
chemotherapy+
trastuzumab
chemotherapy+
trastuzumab
ER, estrogen receptor; PR, progesterone receptor
aFormerly HER-2
35
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
36
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
Tulane surgery:“ tough
as the marines except the
marines get to eat”