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Understanding Breast Cancer: Anatomy, Risks, Diagnosis, and Treatment

Learn about breast cancer, including anatomy, risk factors, diagnosis methods, and treatment options. Discover the importance of screening mammography, biopsy techniques, and histologic diagnosis. Understand different types of benign and malignant breast masses, staging, and treatment trials. Stay informed and empowered in the fight against breast cancer.

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Understanding Breast Cancer: Anatomy, Risks, Diagnosis, and Treatment

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  1. Breast Cancer November 16, 2014

  2. Introduction • Most common female cancer • Accounts for 32% of all female cancer • 211,300 new cases yearly and rising • 40,000 deaths yearly

  3. Gross Anatomy • Sappy’s plexus – lymphatics under areolar complex • 75% of lymphatics flow to axilla

  4. Microscopic Anatomy • Stromal tissue • Connective tissue, capillaries, lymphocytes, etc. • Adipose tissue • Ductal tissue • Squamous epithelium • Columnar or cuboidal epithelium • Lobular tissue

  5. Presentation • Breast lump • Abnormal mammogram • Axillary lympadenopathy • Metastatic disease

  6. Familial Breast Cancer • Cause 5-10% of all cancer and 25% in women <30 y/o • BRCA2 • Causes 40% of familial breast CA • 50-70% - breast • 15-45% - ovarian • Increased risk for prostate, colon • BRCA1 • 50-70% - breast • 20-30% - ovarian • Increased risk for prostate, pancreatic, laryngeal,

  7. Screening Mammography • Recommendations • Biannually or annually in 40-49 y/o • Annually in >50 y/o • 15% relative risk reduction • Birads • 0 - Incomplete assessment; need additional imaging evaluation • 1 - Negative; routine mammogram in 1 year recommended • 2 - Benign finding; routine mammogram in 1 year recommended • 3 - Probably benign finding; short-term follow-up suggested (3%) • 4 - Suspicious abnormality; biopsy should be considered (30%) • 5 - Highly suggestive of malignancy; appropriate action should be taken (94%)

  8. Biopsy techniques • FNA • Diagnostic and therapeutic in cystic lesions • Core needle • U/S guided or sterotatic • 90% effective in establishing diagnosis • Atypia – need excision • Sterotatic • Needle localization • Excision biopsy

  9. Risk of Future Invasive Breast Carcinoma Based on Histologic Diagnosis from Breast Biopsies • No Increase • AdenosisApocrine metaplasiaCysts, small or largeMild hyperplasia (>2 but <5 cells deep)Duct ectasiaFibroadenomaFibrosisMastitis, inflammatoryPeriductal mastitisSquamous metaplasia • Slightly Increased (relative risk, 1.5–2) • Moderate or florid hyperplasia, solid or papillaryDuct papilloma with fibrovascular coreSclerosing adenosis, well-developed • Moderately Increased (relative risk, 4–5) • Atypical hyperplasia, ductal or lobular

  10. Benign Breast Masses • Cysts • Fibroadenoma • Hamartoma/Adenoma • Abscess • Papillomas • Sclerosing adenosis • Radial scar • Fat necrosis Papilloma

  11. Maligant Breast Masses • Ductal carcinoma • DCIS • Invasive • Lobular carcinoma • LCIS • Invasive • Inflammatory carcinoma • Paget’s disease • Phyllodes tumor • Angiosarcoma

  12. Ductal carcinoma

  13. DCIS Ductal carcinoma in situ (DCIS) • 1. Solid type* • 2. Cribiform type • 3. Papillary type • 4. Comedo type*

  14. Lobular carcinoma

  15. Invasive Histology • Ductal NOS • Lobular • Mucinous • Tubular • Medullary

  16. Staging • Tumor • Tis: in situ • T1: <2cm • T2: 2-5cm • T3: >5cm • T4: invasion of skin or chest wall • Node • N1: 1-3 axillary nodes or int mam node • N2: 4-9 axillary nodes or palpalbe int mam node • N3: >10 nodes or combo of axillary and int mam nodes • {mic micoroscopic posivitiy, mol molecular posiivity • Metastasis

  17. Staging

  18. Modified Radical Mastectomy • Entire breast tissue and Level I & II nodes • Survival at 10 yrs • Negative nodes – 82% (5% local recurrence) • Positive nodes – 48% (5% local recurrence) Simple mastectomy Modified radical

  19. Breast Treatment Trials • NSABP (1971 with B-04 update in 2002) • Compared radical, vs modified radical +/- radiation • No survival diff for node neg or pos between three arms • 75% of recurrences occur in 5 years • Tumor location not important

  20. Breast Treatment Trials • Ontario study • All pts got lumpectomy, randomized to radiation or no radiation • 25% failure rate without radiation, 5% with • NSABP B-06 • Mastecomy vs lumpectomy vs lumpectomy with radiation • No difference in survival • 39% recur with lumpectomy, reduced to 14% with radiation, 3-4% with mastectomy • 0.5-1% per year recurrence rate for life with BCT and radiation • 2-5% complication rate with radiation (rib fx, pericarditis, cosmesis)

  21. Radiation after mastectomy? • 2 Danish studies and one Britsh study • Recommend in: >3 nodes positive, aggressive/large tumors or extranodal invasion • Decreased local or regional recurrence • +/- survival benefit

  22. Sentinel node biopsy • Contraindications: • Clinically positive nodes, pregnant or nursing, prior axillary surgery, locally advanced disease • False negative rate 3.1% • Macrometases (>0.2cm) so recommended pathology cuts are 0.2 cm • Micrometases (IHC staining) 37% death rate vs 50% of those with macrometases • If sentinel node positive 43% will have other nodes positive and 24% will have >4 nodes positive • NSABP (B-32) in progress

  23. Treatment of DCIS • 600% increase after mammography • Options • Mastectomy – 1% breast ca mortality • Large tumors, multicentric, positive margins after reexcision, • Lumpectomy and radiation • Radiation decreases local recurrence by 50% • Of those that recur 50/50 DCIS vs Invasive • 0-3% chance of dying of maligant breast ca for all DCIS

  24. Treatment of DCIS • Nodal involvement • 3.6% of DCIS pts have positive nodes in mastectomy specimins • By definition DCIS has no access to lymphatics • Size may matter (111 DCIS tumors evaluated) • <45mm – 0% microinvasion • 45-55mm – 17% microinvasion • >55mm – 48% microinvasion

  25. Tamoxifen in DCIS • NSABP (B-24) • Determine benefit of tamoxifen in lumpectomy plus radiation pts • 31% decrease in ipsilateral, 47% in contralateral, 31% decrease all together • Retrospectively looked at ER status • 75% of DCIS is ER+ • 59% reduction in ER+ pts • No significant reduction in ER-

  26. Treatment for invasive breast ca • Locally advanced is likely already metastatic in most • Surgery and radiation alone make no difference on survival • Chemotherapy & +/- Tamoxifen • Neoadjuvant chemotherapy • 7 randomized trials • No survival benefit • 50-80% response • May allow for BCT in large tumors • Sentinel node before chemo

  27. Tamoxifen • Indications • ER + breast ca • LCIS • BRCA1/2 • Increased overall risk • Benefits • Decreases risk of ca in other breast by 47-80% • Draw backs • Increases endometrial ca risk by 2.5, PE 3.0, DVT 1.7 Source: NSABP P-1 trial

  28. Chemotherapy • Early Breast Cancer Trialists’ Collaborative Group • Decreases recurrence (12%) and death (11%) regardless of nodal status • Indications • All patients except node negative, <10mm tumors • Regimens • Multidrug combination chemotherapy • Tamoxifen or aromatse inhibitor - ER positive tumors • Herceptin (trastuzumab) – HER2/neu positive tumors • NSABP B-31 – 33% reduction in risk of death

  29. Other breast cancers • Inflammatory ca • Carcinoma invading lymphatic ducts • Chemotherapy, mastectomy, radiation • 50% survival at 5 years

  30. Other breast cancers Paget’s disease • Intraepithelial extesion of ductal ca • Excision with nipple-areolar complex • Sentinel node if invasive ca • Mastectomy

  31. Other breast cancers • Phyllodes tumor • <1% of breast tumors • Age 30-45 • Similar in appearance to fibroadenoma • 4% recurrence after excision • 0.9% axillary spread • Radiation, chemotherapy, tamoxifen ?? Phyllodes tumor Fibroadenoma

  32. Angiosarcoma • Risk factors • Radiation • Lymphedema • Treatment • Excision, radiation

  33. Male breast cancer • 90% are invasive at time of diagnosis • 80% ER+, 75% PR+, 30% HER2/neu • More invade into pectoralis • Treatment same as for female ca

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