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Breast Cancer

Breast Cancer . Radiation Oncology II 4412. History . Recorded 5000 years ago Before 20 th century-William Halstead performed radical mastectomy Today we use multidisciplinary approach Radiation therapy Chemotherapy Hormone therapy Surgery. Epidemiology.

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Breast Cancer

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  1. Breast Cancer Radiation Oncology II 4412

  2. History • Recorded 5000 years ago • Before 20th century-William Halstead performed radical mastectomy • Today we use multidisciplinary approach • Radiation therapy • Chemotherapy • Hormone therapy • Surgery

  3. Epidemiology • Most common malignancy in women • Second major cause of death (lung #1) • Men can get breast cancer

  4. Risk Factors • Don’t have to have risk factors to get breast cancer • Gender- women out number men • Age- older women/higher probability • Incidence rises steadily during the reproductive years after age 30 • Family history • Mothers/sisters/daughters doubles the risk

  5. According to the ACS: • Although smoking and breast cancer does not have a direct link, smoking increases the risk for other cancers and affects the overall health of a person • Research does not show a link between breast cancer and pollutants. Research is ongoing • Diet has been inconclusive as a risk factor for breast cancer. Diet and weight are risk factors for other types of cancers

  6. BRCA 1 and 2 • The gene BRCA 1 & 2 is associated with 5 to 8 out of 10 women have a likelihood of developing breast cancer • We all have these genes • These genes become defective

  7. BRCA1 is a human tumor suppressor gene that produces a protein called breast cancer type 1 susceptibility protein. • Originally stood for Berkeley California as this was where it was first discovered in 1990. • This gene was later cloned in 1994 by scientists at Myriad Genetics.

  8. BRCA1 is expressed in the cells of breast and other tissue • It helps repair damaged DNA or destroys cells if DNA cannot be repaired. • When BRCA1 becomes damaged, damaged DNA is not repaired properly and this increases the risks for cancer.

  9. Certain variations of the BRCA1 gene lead to an increased risk for breast cancer. • Researchers have identified hundreds of mutations in the BRCA1 gene, many of which are associated with an increased risk of cancer.

  10. Women with an abnormal BRCA1 or BRCA2 gene have up to an 60% risk of developing breast cancer by age 90 • Increased risk of developing ovarian cancer is about 55% for women with BRCA1 mutations and about 25% for women with BRCA2 mutations

  11. Prognostic Indicators • Lymph node involvement • Most significant aspect of staging • Higher number of involved nodes increases recurrence and decreases survival • Usually 10 axillary nodes are evaluated • <3 low risk • >4 high risk • >10 extremely poor prognosis • Involvement of internal mammary nodes, lower survival

  12. 2. Tumor Extent • Lesions <0.5 cm= 5 year survival • >0.5 cm= 82% 5 year survival • 3. Histology • 1. Ductal carcinoma in situ • Most common non-invasive breast cancer • Non-invasive • Nearly all women can be cured

  13. Ductal Carcinoma in Situ

  14. 2. Infiltrating ductal carcinoma • Most common invasive breast cancer • Starts in the milk passage or duct • Invades fatty tissue of breast • Can spread

  15. Infiltrating Ductal Carcinoma

  16. 3. Infiltrating (invasive) lobular carcinoma • Starts in the milk glands or lobules • Spreads • Usually found in 1 out of 10 cases

  17. Infiltrating Lobular Carcinoma

  18. Lobular carcinoma in situ • This increases the risk of cancer later • Patient needs an exam 2-3 times per year • Mammography every year

  19. Lobular Carcinoma in Situ

  20. Inflammatory carcinoma • Extremely poor prognosis • Breast tenderness • Breast enlargement • Peau d’orange appearance • Erythema • Warmth

  21. Inflammatory Breast Cancer

  22. Staging • Staging system is TNM • Patients are staged for: • The selection of proper treatment • Evaluation of treatment methods • Indicates prognosis • Two methods of staging: • 1. clinical • Physical workup, operative findings, pathology • 2. pathological • Microscopic assessment of the tumor margin

  23. Diagnosis • Estrogen and progesterone receptor status • Tissues are examined for the effects of hormones on the cells • Indicates the potential response to hormonal therapy • Receptor positive patients are more likely to respond to hormonal therapy • Receptor positive tumors usually have a better outcome

  24. Survival (Prognosis) • Overall 5 year survival after first diagnosis is approx. 96% • Regional spread 75% • Distant mets at time of diagnosis 20% • Patients can relapse up to 20 years or more after treatment • Few options for treatment are available after relapse

  25. Anatomy • Lymphatic drainage • 1. superficial • Drains the skin covering the breast • 2. deep • Drains the internal breast tissues

  26. Three groups of nodes in the breast: • 1. axillary lymph nodes • Primary deep lymphatic drainage of the breast • Between 10 & 38 lymph nodes are in each axilla • 2. internal lymph nodes • Located near the edge of the sternum • Embedded in the fat in the intercostal spaces • Approx. 4 per side • 3. supraclavicular nodes • Lymphatic drainage from the breast to the supraclavicular nodes, liver and contralateral internal mammary nodes

  27. Sites of Origin • The breast is divided into quadrants • Upper outer • Upper inner • Lower outer • Lower inner • Most breast cancers will arise in the upper outer quadrant- more breast tissue • Multicentric describes tumors that appear in several areas of the breast

  28. Spread • Breast cancer tends to grow: • Locally • Involves the ducts and adjacent tissues • May spread to local and regional lymphatics • Involvement of axillary lymph nodes occurs orderly and progressively • Recurrence • Local recurrence (in the breast) • Regional recurrence (lymphatics) • Distant metastatic sites

  29. Axillary and internal mammary lymph nodes are the most likely sites of regional involvement of breast cancer.

  30. Distant metastasis • Bone • Brain • Liver • Lung • Eyes • Ovaries • Adrenal and pituitary glands

  31. Detection • With early detection breast cancer is one of the most curable malignant diseases. • Three step health program: • 1. monthly self exam- begin in the early 20’s

  32. 2. Annual clinical exam- 20’s & 30’s every 3 years, beginning 40 yrs/age, every year • 3. Routine mammogram- as recommended by established guidelines- right now it is every year for women 40 and older

  33. Most breast changes are benign • Approx. 20% of all masses will be malignant • Most common sign will be a painless lump, usually hard with uneven edges • BUT • Some can be tender, soft and round

  34. Other Detection Methods Ultrasound- used in addition to mammography- distinguished between cystic and solid masses • Thermography- produces an image of the temperature of the overlying skin of the breast. The tumor produces heat • PET • Bone scan- mets

  35. MRI used for women with silicone breast implants, extremely dense tissue or changes in breast tissue secondary to radiation therapy • CT- used for mets • Ductogram (galactogram) fine plastic tube is placed into the opening of the duct at the nipple. Dye is injected to show masses in the duct with x-ray. Fluid can be withdrawn for pathology.

  36. Monthly Self Exam Step One

  37. Step Two and Three

  38. Step Four

  39. Step Five

  40. Biopsy • A biopsy is the only way to know for sure that there is cancer • Fine needle biopsy- small gauge needle is placed into the breast tissue mass. Blood and suspicious tissue is evacuated out and placed on slides. • Core needle biopsy- partial removal of breast mass • Excisional biopsy (lumpectomy) removal of the entire mass with or without a portion of surrounding normal tissue.

  41. Pathology • Two basic methods are used for obtaining pathological information: • 1. gross examination- records the dimensions of the specimen, the size of the tumor, and tumor’s relationship to the excisional margin • 2. microscopic examination- examines the specimen under the microscope for tumor histology

  42. Biopsy samples look for hormone receptors • ER positive- Estrogen • PR positive- Progesterone • These will respond to hormonal therapy which leads to a better prognosis

  43. TREATMENT

  44. 1. Surgery • Radical mastectomy • Removal of the breast with overlying skin • Removal of the axillary lymph nodes • Removal of the pectoralis major and minor muscles • Modified radical mastectomy • Removal of the breast with overlying skin • Removal of some or all of the axillary lymph nodes • Pectoralis minor muscle might be removed • Pectoralis major muscle is left intact

  45. Lumpectomy • Removal of the tumor with a margin of normal appearing tissue • Lymph nodes are sampled through a separate axillary incision • Axillary dissection • Removal of a sample of axillary lymph nodes on the side of the affected breast (staging)

  46. Lumpectomy

  47. Skin Sparing Mastectomy

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