Breast Cancer Clinics

8/13/2019 Breast Cancer Clinics

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Boundaries: sternum, axilla, pectoralis major, serratus

anteriorBreast tissue epithelial parenchyma elements (1015%) and

stroma 15 to 20 lobes Cooper ligaments(bands of fibrous tissue extending

from fascia to dermis that support the breast) Lobes aredivided into lobulesmade of alveolar glands

and end in lactiferous ducts, which dilate to sinusesbeneath the areola and open into a nipple orifice. Sebaceous glands, apocrine sweat glands, no hairfollicles. Tubercles of Morgagni(nodular elevations formed by

Montgomery gland openings at periphery of areolawhich secrete milk.)


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Blood supply Internal mammary artery (IMA) and lateral thoracic arteries.

a. IMA artery perforators: supply the medial and central breast. b. Lateral thoracic: supply the upper outer quadrant.

Venous drainage follows arterial supply.Lymphatics Skin and nipple (areolar complex): drain initially to superficial subareolarplexus, and then to a deeper plexus. Sites of drainage: 97 to the axilla and 3 to the internal mammarynodes. All quadrantscan drain into the internal mammary nodes.Axilla borders include the axillary vein (superior), latissimus dorsi (lateral),

serratus anterior (medial), pectoralis major (anterior), and subscapularis(posterior)

Nerves: long thoracic nerve (serratus), thoracodorsal bundle (latissimus), andintercostobrachialnerves (sensory upper middle arm) Node levels

a. Level I: inferior and lateral to pectoralis minorb. Level II: behindpectoralis minorc. Level III: medialto pectoralis minor against chest wall


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Role of hormones Estrogen: ductal dilation . Androgen causesdestruction.

Growth hormone: ductal elongation andbranching. Estrogen and progesterone are needed

as well. During puberty, growth of both glandular andstromal elements occurs.

Cyclical increases in menstrual cycle influencebreast macroscopic and microscopic structure.

Premenstrual period: patient may feel fullness, nodularity, and

sensitivity


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History1. Presenting complaint a. Most common presenting complaint is breast mass. b. Other presenting complaints: pain, change in size or shape of

breast, nipple discharge, or skin changes. c. Radiographic abnormalities: calcifications or architectural distortion on mammogram, mass on ultrasound or MRI finding.

2. Baseline menstrual status and breast cancer risk factorsa. Current menopausal status.

b. Risk factor assessment: menstrual history, use of oralcontraceptives and hormone replacement therapy, number andage of pregnancies, family history of breast and/or ovarian cancerand age of diagnosis.


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1. Inspection Comparison of bilateral chest. Check nipple-areola complex for symmetry, retraction, and skin

changes Inspect the skin for erythema, ulceration, dimpling, or

eczematous changes.

Inspect the breasts in varying arm positions relaxed, abovehead, and on hips with pectoralis muscles contracted.

2. Palpation a. Palpate for cervical and supraclavicular lymphadenopathy. b. Palpate breast for masses/lumps/ridges. c. Palpate axilla for lymphadenopathy d. Examine abdomen for hepatomegaly. e. Examine extremities for peripheral edema or bone pain.


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A. Fibrocystic changes not premalignant. women in their 30s and 40s. disappear after menopause.

B. Fibroadenomas well-defined, palpable, rubbery, mobile masses occur as multiple

lesions in 10% to 15% of patients. 20 and 50 years of age. involute after menopause

C. Cysts D. Intraductal papilloma (Nipple Discharge) E. Lipoma: benign encapsulated adipose tissue F. Mammary duct ectasia

perimenopausal and postmenopausal women. dilatation of subareolar ducts.


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A. Atypical lobular hyperplasia (ALH) five times relative risk of developing breast cancer.

B. Atypical ductal hyperplasia (ADH) proliferation and atypia of the epithelium

13% development of breast cancer (4 risk).

C. Lobular carcinoma in situ (LCIS) incidental finding or core or excisional biopsy

8 to 10 times risk, of developing invasive carcinomain the same or opposite breast.


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Lesion of the nipple and areolar complex caused by largemalignant cells nonpalpable mass is usually due to DCIS. A palpable mass usually indicates invasive ductal carcinoma.

Diagnosis

Scrape cytology, epidermal shave biopsy, punch biopsy, wedgeincision biopsy, or nipple excision.Management Patients with disease extending beyond the central portion of the

breast by physical examination or imaging studies shouldundergo mastectomy.

Patients choosing breast conservation(lumpectomy with excisionof nippleareolar complex) should combine surgery andradiation.

Sentinel lymph node biopsymay be performed if invasive breastcancer is present.


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Incidence Estimated number of new invasive breast cancer (2008) is

182,400 females and 2000 males. Potentially 1 in 8 American women affected. Estimated number of deaths (2008) 42,000 and mortality is

decreasing.Risk factors Age: most common risk factor

a. risk is 2.5% for women aged 35 to 55 years. b. risk is higher in younger African-American women, but becomes higher

in Caucasian women after age 40.

Family history. Prior personal history of breast cancer Hereditary factors

BRCA1 or BRCA2 BRCA2 increases risk of male breast cancer, prostate cancer, and

pancreaticcancer. Both maternally and paternally inherited. Chance of mutation varies with ethnicity (higher in Ashkenazi Jews).


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Hormonalfactors Estrogens Early age at menarche, late age at first pregnancy,

postmenopausal obesity Long duration of lactation reduces risk in

premenopausal women combination postmenopausal hormone replacement

Environmentalfactors and diet ionizing radiation (patients with Hodgkin lymphoma)

Diet and weight gain

link between weight gain as an adult and thedevelopment of breast cancer.

LCIS ADH(Atypical ductal hyperplasia)

(Being a woman is already a risk factor obviously)


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A. Noninvasive breast cancer:

1. Ductal carcinoma in situ (DCIS) a. Pathology

Proliferation of malignant epithelial cells is confined bythe basement membrane of the duct-lobular system.

Cannot spread to lymphatics because the disease isconfined to the duct.

2.Clinical presentation a. Nipple discharge, Pagets disease of the nipple, mass

3. Mammographic presentation (most common)

a. Pleomorphic microcalcifications.

4. Surgical management

a. Lumpectomy and radiation : most common treatment

b. Mastectomy


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B. Invasive Cancer1. Types

a. Ductal: the most common type (approximately80%).

b. Lobular: second most common type.c. Mammary: tumor with ductal and lobularfeatures.d. Medullary: less likely to have axillary nodeinvolvement

2. Pathologya. Infiltration of cells across the basementmembrane and into surrounding stroma.b. Estrogen receptors (ER) and progesteronereceptors (PR).

ER-positive tumors account for approximately 70%of breast cancersc. Her-2/neu: poor prognosis(doc says itindicates an aggressive tumor)


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3. Diagnosis

History and Physical examination

Imaging All patients need bilateral mammogram.

Ultrasound for all palpable masses.

Consider adding bilateral breast MRI in certaincircumstances.

Biopsy All patients with palpable lesions can undergo core or

vacuum assisted needle biopsy without image guidance.

All patients with nonpalpablemammographic

abnormalities need stereotactic core biopsy. All patients with nonpalpable ultrasound abnormalities

should undergo ultrasound guided core biopsy.


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Surgical managementLumpectomy(also known as partialmastectomy) Most commonly recommended for stages I/II

disease, depending on patient preference

May use neoadjuvantchemotherapy (givenbefore the surgery)Mastectomy(with or without immediatereconstruction)Skin-sparing mastectomy (removal of nipple-areolar complex only) is used in patients whodesire immediate reconstructionReconstruction


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Bilateral mammogram CXR(to check for lung metastasis)

LFTs(to check for liver metastasis)

Serum calcium level, alkalinephosphatase(bone metastasis)

Other tests, depending on signs/symptoms(e.g., head CT if patienthas focal neurologicdeficit, to look for brain metastasis)


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Radiationtherapy after a modified radicalmastectomy Stage IIIA

Stage IIIB

Pectoral muscle/fascia invasion

Positive internal mammary LN

Positive surgical margins

4 positive axillary LNs postmenopausal


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Chemotherapy all patients with receptor negative disease. all patients with positive nodal involvement all patients with tumors greater than 1cm.

Adriamycin and cyclophosphamide. A taxane for tumors with poor prognosis

Hormonal therapy: for ER-positive and PR-positive cancers SERMs (Tamoxifen)

Aromatase inhibitors (AI) (i.e. Arimidex, Femara, Aromasin)Antibody therapy (Traztusamab)

To treat Her-2/neu positive cancers.Radiation therapy

Delivery is delayed until after chemotherapy if chemotherapy isrequired.


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Premenopausal, node +,ER +:Chemotherapy and tamoxifen Premenopausal, node -,ER +:Tamoxifen Postmenopausal, node +,ER +:Tamoxifen, +/- chemotherapy Postmenopausal, node +,ER -:Chemotherapy, +/- tamoxifen

I did not discuss this but doc wanted to show us next meeting


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Uncommon disease, where the mean age atpresentation is 10 years more than in women

Risk factors

Klinefelter syndrome, BRCA2 mutations,family history, hepatic disorders, radiationexposure.

Approximately 80% are hormone-receptor

positive


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Breast Cancer Clinics

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