Breast Cancer
Steven Jones, MD
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 4055
2
Mammary Gland
Breast Anatomy
Anterior view
Lobular duct
Lobule
Ampulla
Nipple
Areola gland
Fat
Areola
3
Lobar/Lactifero
us duct
Lobar/Lactiferous Duct
Cross Section
4
Lobar/Lactiferous Duct
Cross Section
Ductal Carcinoma In Situ
The
entire duct may
(DCIS)
be filled with
abnormal, atypical
cells.
This condition is
actually an early
breast cancer.
5
Lobar/Lactiferous Duct
Cross Section
Invasive Ductal Carcinoma
(IDC)
Cancer cells
that break
out of the
duct and
invade the
breast tissue.
6
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
7
Consider BRCA 1 / 2
testing:
•
•
•
•
•
8
< 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
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.
9
Lobar/Lactiferous Duct
Cross Section
Atypical
Ductal
Hyperplasia
Excess growth
(ADH)
within the duct
includes
abnormal or
atypical cells.
10
The presence of
this condition
increases the risk
of developing
breast cancer.
Lobular Hyperplasia
Excess growth
in the lobules
Atypical Lobular Hyperplasia
11
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
Breast Cancer Risks
• Hormonal factors – early menarche, late
menopause, age of 1st pregnancy, HRT
with progesterone
• Environment, lifestyle, and diet –
ionizing radiation increase risk
12
High Risk Patients
• Gail model
• Chemo prevention
• Increased surveillance
13
Additional Views
Magnification Views
Mammography
– Improves resolution
14
– Better determination of
the shape, distribution,
and number of
microcalcifications
– Questionable density from summation
shadows will dissipate
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.
Report Organization
Category Assessment
0
BI-RADS™
1
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
15
Incomplete
assessment
Recommendations
Breast Ultrasound
Characteristics of imaged lesions
• Size
• Shape
• Border definition
• Internal echogenicity
• Posterior enhancement
• Architectural changes
• Gray scale comparison to adjacent
breast tissue
16
Benign vs. Malignant
17
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
18
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
19
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
20
Cancer Cure?
cut it out
or
burn it out
21
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
22
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.
23
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
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
24
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.
25
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%)
26
Mammary
Gland
Breast Anatomy
Anterior view
27
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
Sentinel Lymph Node
• Technetium labeled sulfur colloid
• Isosulfan blue (lymphazurin 1%)
• Combined – 97% ID’ed; 6% false
negative
• 1% anaphylactic reaction to blue dye
28
Systemic Therapy
• Cytotoxic chemotherapy
• Hormonal therapy – 50% reduction of
recurrence, 26% reduction in mortality
• Targeted therapy - Herceptin – 50%
reduction of recurrence.
29
NSABP B-18
•
•
•
•
•
•
•
30
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
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
31
Facts & Figures
Risk of breast cancer increases with age
By age 30
By age 40
By age 50
By age 60
By age 70
By age 80
Ever
1 out of 2,212
1 out of 235
1 out of 54
1 out of 23
1 out of 14
1 out of 10
1 out of 8
Feuer EJ, Wun LM. DEVACN: Probability of Developing or
Dying of Cancer.
32
Version 4.0
Bethesda, MD: National Cancer Institute 1999