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BREASTJames Taclin C. Banez M.D., FPSGS, FPCS
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ANATOMY:
Boundaries Development / Hormones
Arterial blood supply
Lymphatic drainage
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EVALUATION
A. Clinical Manifestation:
B. Physical Examination:
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Mammography
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EVALUATION
C. Radiological Examination:2. Computed Tomography or Magnetic
Resonant Imaging:
To expensive
For detection of vertebral metastasis
3. Ultrasonography
No radiation exposure
Can differentiate cystic lesions from solid mass
Can not detect less than 5mm.
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PET Scan
PET scan Normal
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PET Scan
PET scan
abnormal
PET in woman with breast CA
that has spread to bone
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EVALUATIONC. Radiological
Examination:4. Interventional Technique:
Ductography:
Inject radio-opaque contrast
media into the mammary duct
D. Biopsy: positive result isdiagnostic
1. Excision biopsy
2. Incision biopsy
3. True-cut or core biopsy (Vim-Silverman)
4. Fine needle biopsy
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BENIGN LESIONS OF THE BREAST
1. Non-proliferative
lesions:a. Chronic Cystic Mastitis
(Fibrocystic disease,fibroadenosis,
Schimmelbuschs dse.) most common breast lesion
(30-40y/o)
Hormonal imbalance (exactetiology - ?)
Increase estrogenproduction producingexaggerated responses
Some parts of the breast ishyper-reacting
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BENIGN LESIONS OF THE BREAST1. Non-proliferative lesions:
a. Chronic Cystic Mastitis (Fibrocystic disease,
fibroadenosis, Schimmelbuschs dse.) Manifestations:
1. Unilateral / Bilateral
2. Rubbery in consistency, not encapsulated
3. Size changes / can be tender ---> related to menstrual cycle
4. 15% presents a nipple discharge5. (-) risk factor of carcinoma degeneration
6. Co-exist w/ breast carcinoma (mammography is suggested)
Schmmelbusch disease:classic diffuse cystic disease
Bloodgood cyst: single, tense, large blue domed cyst
Treatment: Conservative for small and not very painful and tender lesions
Danazol alleviate mod to severe painful & tender
- synthetic FSH and LH analog
- Suppresses FSH and LH
- 100 400mg
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BENIGN LESIONS OF THE BREAST
2. Fibroadenoma: Well circumscribed lesion, movable, smooth,
lobulated, encapsulated, painless, notassociated w/ nipple discharge
Etiology (?), could also be due to hormonalimbalance
Size does not regress after menstruation
Treatment: Excision biopsy (rule out malignancy)
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Fibroadenoma
Giant Fibroadenoma
Giant Fibroadenoma
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BENIGN LESIONS OF THE BREAST
3. Intra-ductal Papilloma:
Proliferation of the ductal epithelium; 75% occursbeneath the epithelium
Commonly causes Bloody Nipple Discharge
Palpable mass 95% is intra-ductal papilloma
Non-palpable mass possibility of malignancy is increased:(Ductography)
a. Paget disease of the nipple
b. Adenoma of the nipple
c. Deep lying carcinoma w/ ductal invasion Treatment:
Excision of a palpable mass by biopsy
Non-palpable mass --> do wedge resection of thenipple/areola based on ductographic result or PE (+) bloodydischarge
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Papilloma
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BENIGN LESIONS OF THE BREAST4. Phyllodes Tumor
Diagnostic problem separating it from fibroadenoma and itsrare variant that is malignant, sarcoma
Bulk of the mass is made up of connective tissue, with mixedareas of gelatinous, edematous areas. Cystic areas are due tonecrosis and infarct degenerations
Phyllodes has greater activity and cellular component than
fibroadenoma (3mitoses/hpf); while malignant component hasmitotic figure.
80% are benign, usually large bulky lesions (tear dropappearance) Malignant component is dependent on:
a. Number of mitotic figures/hpf
b. Vascular invasionc. Lymphatic invasions
d. Distant metastasis
Treatment: Excision biopsy:
Benign no further treatment, observe
Malignant total mastectomy / MRM
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Phyllodes Tumor
Malignant phyllodes tumor, right Benign Phyllodes tumor
mammography
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BENIGN LESIONS OF THE BREAST
5. Mammary Duct Ectasia (Plasma cell mastitis,Comedomasttitis & Chronic mastitis)
Sub-acute inflammation of the ductal systemusually beginning in the subareolar area w/ ductalobstruction
Usually present as a hard mass beneath or nearareola w/ either nipple or skin retraction due toincrease fibrosis
Appears during or after menopausal period w/ hx.Of difficulty of nursing
Histologically, the duct are dilated and filled w/debris and fatty material w/ atrophic epithelium.Sheets of plasma cells in the periductal area.
Treatment:
Excision biopsy
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Ductal Ectasia
Gross Histology
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BENIGN LESIONS OF THE BREAST
6. Galactocele:
Cystic or solid mass w/ or w/o tenderness
Occurs during or after lactation
Due to obstruction of a duct distended w/milk
Treatment:
w/ abscess ---> incision and drain Solid mass ---> excision biopsy
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BENIGN LESIONS OF THE BREAST
7. Fat necrosis: Present as a solid
mass, usually
asymptomatic w/ or w/o history
of trauma
Treatment:
Excison biopsy
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BENIGN LESIONS OF THE BREAST
8. Acute Mastitis / Abscess: Bacterial infection usually during 1st week of
lactation
s/sx of inflammation
Treatment:
Proper hygiene
Cellulitis ----> antibiotis / analgesic
Abscess ----> incision and drain
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BENIGN LESIONS OF THE BREAST
9. Gynecomastia: Development of female type of breast in male
Usually unilateral, if bilateral look for systemic causes:
a. Hepatic cirrhosis (for elderly alcoholic)
b. Estrogen medication for prostatic CA
c. Tumor producing estrogen/progesterone
Pituitary / Adrenal / Testes
CT scan / PE
Treatment:
Subcutaneous mastectomy (if other lesions, producingestrogen/progesterone, present)
Tumor secreting estrogen ---> tx primary cause
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BENIGN LESIONS OF THE BREAST
10.Developmental Abnormality:a. Amastia
b. Polymastia
c. Atheliad. Polythelia
Treatment: - plastic surgery
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Malignant Lesions of the Breast One of the leading cause of death from CA
Etiology: - multifactorial1. Sex: male : female ratio (1 : 100)
2. Age: almost unknown for pre-pubertal age
20 40 y/o steady increase incidence
40 50 y/o (menopausal) plateau
> 50 y/o higher incidence
3. Genetic: Mother with carcinoma ---> (2 3x) daughter
(+) family history ----> younger, bilateral4. Dietary influence:
Increase in developed countries (except) Japan
Increase in upper class society
Dietary: Increase in animal fat
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Malignant Lesions of the Breast
5. Hormonal Usage: Oral contraceptive has adverse effect if taken for
prolonged time at early age or when before the 1st fullterm pregnancy
No effect if taken 25 39y/o
Slight increase risk if estrogen usage by peri-menopausal for hormonal replacement
6. Physical Stature:
Obesity ---> increase fat cells ----> increase tissueconcentration
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Malignant Lesions of the Breast
6. Multiple primary neoplasm:
Hx of primary breast CA ---> 4x fold increase ofprimary CA
Hx of primary CA of uterus and ovary ----> 1-1.5 risk
7. Irradiation:
Multiple exposure
Had radiotherapy for breast CA of contralateral breast
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Malignant Lesions of the Breast
8. Other factorsa. 1st pregnancydue to estrogen
b. Long term nursing
> 36 months
No ovulation for 9 mos.
Decrease estrogen
c. Age of menopause
Late menopause (55y/o) higher risk
d. Infertility
Higher risk
E t bli h d Ri k f t F B t i F l
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Risk factor High risk Low risk Relative risk
Age old young >4.0
Socioeconomic status high low 2.0 4.0
Marital status Never married Ever married 1.1 1.9
Place of residence urban rural 1.1 1.9
Race > 45 years< 40 years
white black 1.1 1.9
black white 1.1 1.9
Nulliparity yes no 1.1 1.9
Age of first full-term pregnancy > 30 y/o < 20 y/o 2.0 4.0
Oophorectomy premenopausally no yes 2.0 4.0
Age at menopause late early 1.1 1.9
Age at menarchy early late 1.1 - 1.9
Weight, postmenopausal women heavy thin 1.1 1.9
Hx of benign or cancer in one breast yes no 2.0 4.0
Hx of breast Ca 1st degree relative yes no 2.0 4.0
Mother or sister w/ hx. Of breast CA yes no > 4.0
Hx. Of primary ovarian or endometrial CA yes no 1.1 9.0
Mammographic parenchymal patterns Dysplasticparenchyma
Normal parenchyma 2.0 4.0
Radiation to chest Large doses Minimal doses 2.0 4.0
Established Risk factors For Breast cancer in Females:
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Malignant Lesions of the Breast
Natural history (Schirrhousadenocarcinoma)
Doubling time (2-9mos)
1 cell ---> 30DT/5 yrs ---> 1cm. Mass/20DT ---> increase size & fibrosis ----> dimpling(retraction) ---> invade the lymphatics --->edema ----> invade regional LN/venous ---->
systemic. Successful implantation depends on:
1. Number of cells
2. Character of cell
3. Host resistance
Hi t l i l Cl ifi ti f B t C
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Histological Classification of Breast Cancer
Cancers of the Mammary Gland can be Classified:
1. Histogenesis duct, lobule (acini)
2. Histologic Characteristic adenocarecinoma, epidermoid CA, etc.3. Gross Characteristic Scirrhous, colloid, medullary, papillary, tubular
4. Invasive Criteria Infiltrating, in-situ
Non-infiltrating (In-situ) Carcinoma of duct and lobules:
Increase diagnosis due to mammography
DCIS : LCIS (3:1)
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1. LOBULAR CARCINOMA in SITU:
Considered as a risk factor
Observed only in females, premenopousal
No involvement of the basement membrane
Tx: 1. Closed observation 2. Hormonal treatment (Tamoxifen/
aromatase inhibitor) for 5years
3. Surgery (bilateral mastectomy) w/ immediate reconstruction
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Lobular Carcinoma in situ
(LCIS)
Fine needle aspiration Histology
Gross
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Non-infiltrating (In-situ) Carcinoma of
duct and lobules:2. Tubular Carcinoma In
Situ: Absence of invasion of
surrounding stroma hence
confined w/in the basementmembrane
Type:
1. PAPILLARY:
Duct epithelium are
thrown into papillaewith loss ofcohesiveness,disorientation of cellswith pleomorphism andincrease mitotic figure
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Non-infiltrating (In-situ) Carcinoma ofduct and lobules:
2. Tubular Carcinoma InSitu:
2. SOLID
3. CRIBRIFORM4. COMEDOCARCINO
MA: Hyperplasia is more
extreme choking the entire
duct w/ masses of cellsdeveloping central necrosisof cells
Most aggressive
Treatment: treated as an
early cancer
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Non-infiltrating (In-situ) Carcinoma of duct andlobules:
LCIS DCISAge 44 - 47 54 58
Incidence 2 - 5% 5 - 10%
Clinical Signs None Mass, Pain, Nipple discharge
Mammographic signs None Microcalcification
Incidence of SynchronousInvasive CA
5% 2 46%
Multicentricity 60 90% 40 80%
Bilaterality 50 70% 10 20%
Axillary metastasis 1% 1 2%
Subsequent carcinomas:IncidenceLateralityInterval to diagnosisHistology
25 35%Bilateral
15 20 yrsductal
25 70%Ipsilateral5 10 yrs
ductal
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Infiltrating Carcinoma of theBreast:
1. Pagets disease of the nipple (1%): Primary carcinoma of mammary duct that invaded
the skin
Chronic eczematoid lesion of the nipple Tenderness, itching, burning and intermittent
bleeding
Palpable mass in the subareolar area
PAGET cells: Characterictic cells
Large cell w/ clear cytoplasm andbinucleated
80% non-infiltrating CA
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Pagets Nipple
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2. Scirrhous carcinoma: (fibrocarcinoma,sclerosing CA):
78% (most common)
Increased Desmoplastic response toinvading CA cells (protective)
Neoplastic cells are arranged in small clustersor in single rows occupyning a space betweencollagen bundles
Originate in the myoepithelial cells of themammary duct
Desmoplastic ---> shortend Coopers ligament---> dimpling over the tumor
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Schirrous Ductal Carcinoma
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3. Medullary carcinoma:
2-15%
Large round cancer cells arranged inbroad plexiform mass surrounded by
lymphocytes and lymphatic follicles Soft, bulky and large tumors w/ necrotic areas
5 year survival = 85 90%
Good prognosis
M d ll C i f th
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Medullary Carcinoma of the
Breast
radiology gross
Gross histology
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4. Mucinous (Colloid) carcinoma:
2% Soft, bulky w/ ill defined borders
Cancer cells floats in large mucinous
lakes Cut surface is glistening, glaring and
gelatinous
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Mucinous (Colloid)
Carcinoma
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4. Tubular carcinoma
Well differentiated
Ducts lined by a single layer of welldifferentiated cancer cells
Absence of myoepithelial w/ well
defined basement membrane Common in premenopausal and detected w/
mammography
5 yr survival ---> 100% if the CA contain 90%or more of tubular components
T b l C i f th
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Tubular Carcinoma of the
Breast
radiologyhistology
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6. Papillary carcinoma: 2 %; present in 7th decade Thrown into papilla w/ well defined
fibrovascular stalks and multilayeredepithelium
Has the lowest frequency of axillary nodalinvolvement; has the best 5 and 10 yrssurvival rates
Even if w/ axillary metastases, it is stillindolent and slowly progressive diseasethan the common adenocarcinoma
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Papillary Carcinoma
Histology
Mammogram
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6.Adenoid cystic
carcinoma: Indestinguishab
le from adenoid
cysticcarcinoma ofthe salivarygland
Rare axillaryinvolvement.
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8. Carcinoma of Lobular origin: 10% of breast CA; LCIS 3%
Small cell w/ round nucleus, inconspicuousnucleoli and scant, indistinct cytoplasm.
Arises from the terminal ducts and acini
Similar to colloid CA were mucin displacedthe nucleus, resembling signet-ring
carcinoma of the GIT. High propensity for bilaterality (35-60%),
multicentricity (88%) and multifocality
9. Squamous Carcinoma: Metaplasia w/in the lactiferous duct system
Similar to epidermoid CA of the skin
Metastasize thru the lymphatic
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Squamous cell Carcinoma
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10.Sarcoma of the Breast: (Fibrosarcoma,liposarcom, leiomyosarcoma, malignant fibroushistiocytoma, etc.)
Large, painless breast mass w/ rapid growth
Mammography ---> false (-)
Grossly: --> it lacks the cut gabbage surface ofphyllodes
Histologically: Spindle cell neoplasm that grows expansile
and its margin either pushes or infiltrateadjacent structures
It invades the fat and tend to intervene between
the glandular aspect of the breast parenchyma andexpands the lobules and intralobular spaces
Treatment: --> total mastectomy
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Sarcoma of the Breast
Gross Histology
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11.Lymphoma of the Breast:
Similar to other malignant lymphoma
Mastectomy w/ axillary LN sampling Tx: radiotherapy / chemotherapy
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12.Inflammatory Carcinoma of theBreast
1.5 3% Clinically: erythema, Peau-d orange, skin
ridging w/ or w/o a mass. Skin is warmsometimes scaly and indurated (cellulitis), nippleretract.
Diagnosis: biopsy Histologically: ---> no predominant
histological type. Subdermal lymphatic and vascular channels are
permeated w/ highly undifferentiated tumor
Characteristically: ---> absence of PMN andlymphocyte near the tumor
Rapid growth and majority has (+) cervical LNand distant metastasis
Inflammatory Carcinoma of
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Inflammatory Carcinoma of
the Breast
TNM Staging System for Breast Carcinoma
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TNM Staging System for Breast Carcinoma Primary Tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
TisCA in situ (LCIS / DCIS), Pagets dse of the nipple w/o tumor
T1 2 cm or less T1a 0.5 cm. or less
T1b - > 0.5 cm. to 1 cm.
T1c - > 1cm. to 2 cm.
T2 2 to 5 cm.
T3 - > 5 cm.
T4any size w/ direct extension to chest wall or skin T4a extension to chest wall
T4b edema / ulceration of the skin / satelite nodule
T4c both T4a and T4b
T4d Inflammatory carcinoma
TNM St i S t f B t C i
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TNM Staging System for Breast Carcinoma Regional Lymph Nodes (N)
NX Not assessed (previously removed)
N0 No regional LN metastasis N1 (+) movable ipsilateral axillary LN
N2 (+) LN fixed to one another
N3 (+) Ipsilateral INTERNAL MAMMARY LN
Pathological Classification LN (pN): pNX not assessed
pNO (-)
pN1 (+) movable ipsilateral axillary LN
pN1a (+) micrometastasis (0.2 cm or less)
pN1b any larger than 0.2 cm but less than 2 cm
pN1bi - (+) 1-3 LN
pN1bii - (+) 4 or more LN
pN1biii extension of tumor beyond the capsule
pN1biv (+) LN > than 2 cm
pN2 Axillary LN fixed with each other
pN3 (+) internal mammary LN
TNM Staging System for Breast Carcinoma
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TNM Staging System for Breast Carcinoma Distant Metastasis (M):
MX not assessed
M0 (-)
M1(+) including metastasis
Stage Grouping: Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage IIA T0 N1 M0
T1 N1a M0
T2 N0 M0
Stage IIB T2 N1 M0
T3 N0 M0
Stage IIIA T0 T2 N2 M0
T3 N1-2 M0
Stage IIIB T4 Any N M0
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Survival Rates for patients w/ Breast Cancer
Relative to Clinical Stage
Clinical staging(American Joint Committee)
Crude 5-yr
survival(%)
Range
Survival(%)
STAGE I Tumor < 2cm in diameterNodes, if present, not felt to contain metastasesw/o distant metastases
85 82 - 94
STAGE II Tumors > 5 cm in diameterNodes, if palpable, not fixedw/o distant metastasis
66 47 74
STAGE III Tumor > 5cm in diameterTumor any size w/ invasion of skin attached to
chest wallNodes in supraclavicular areaWithout distant metastases
41 7 80
STAGE IV With distant metastases 10 -
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Survival Rates for patients w/ Breast Cancer
Relative to Histologic Stage
Histologic Staging(NSABP)
Crude survival(%)
5yr 10yr
5-yr Disease-free survival
(%)
All patients 63.5 45.9 60.3
Negative axillary lymph nodes 78.1 64.9 82.3
Positive axillary lymph nodes 46.5 24.9 34.9
1 - 3 positive axillary lymph nodes 62.2 37.5 50.0
> 4 positive axillary lymph nodes 32.0 13.4 21.1
Relationship Between Morphologic Types of Invasive
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Relationship Between Morphologic Types of Invasive
Breast Cancer, Lymph Node Involvement, and Patient
Survival
Type Frequency % w/ nodalinvolvement
% Survival5 yr 10 yr
Ductal w/ productivefibrosis
78 60 54 38
Lobular 9 60 50 32
Medullary 4 44 63 50
Comedo 5 32 73 58
Colloid 3 32 73 59
Papillary 1 17 83 56
Treatment:
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Treatment:1. Benign: hormonal, surgery (excision biopsy), antibiotics
2. Malignant:
Selection of patients a. stage of lesion
b. medical condition of pt
Criteria of Inoperability / Incurability(Haangensen)
a) extensive edema of the skin over the breast b) satellite nodule in the skin over the breast
c) inflammatory carcinoma of the breast
d) parasternal tumor nodule
e) supraclavicular metastasis
f) edema of the arm
g) distant metastasis
h) Any 2 or more of the following locally advances cancer
i. ulceration of skin
ii. Edema of skin less 1/3
iii. Solid fixation of tumor to the chest wall
S i l M t
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Surgical Management:
1. Radical Mastectomy(Willi Meyer, Halsted) Stage III, IV
2. Extended Radical Mastectomy Hardley 21% of outer quadrant and 44%
inner quadrant tumor has (+) internalmammary nodal involvement.
1. Wangesteen (Classical RM + Internalmammary mediastinal and supraclavicular LN)
2. Urban (CRM + ipsilateral half of sternum, partof 2nd to 5th rib and pleura and internalmammary LN)
Surgical Management:
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Surgical Management:
4. Modified RadicalMastectomy:1. Patey preserved
pectoralis major
2. Madden / Auchinclosspreserved both thepectoralis major andminor
5. Total mastectomy w/or w/o radiation:1. Crile Total mastectomy
2. Mc Whirter Totalmastectomy and radiation(Axilla,
supraclavicular andinternal mammary nodes)
5. Subcutaneous Mastectomy:
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5. Subcutaneous Mastectomy: Nipple is retained / for T1s
6. Quandrantectomy, axillary,radiotherapy (QUART)
Quadrant of the breast that has the CA is resected
(quadrant of breast tissue, skin and
superficial pectoralis fascia) Unacceptable cosmetic result
5 Partial Mastectomy and Radiation:
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5. Partial Mastectomy and Radiation: Lumpectomy, segmental resection or tylectomy
Histologically free margin of breast CA (1cm)
Advent of supervoltage radiotherapy with skinsparing effect
Frozen section evaluation of margin
To determine adjuvant chemotherapy adequate
sampling of axillary LN (level I), curvilinear incisionshould be done
If LN (+) ----> adjuvant chemotherapy
Indications for Conservative
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Indications for ConservativeSurgery:
1. Small breast CA < 4cm2. Clinically (-) axillary LN
3. Breast volume adequate size to allow
uniform dosage of irradiation
4. Radiation therapist experience to avoiddamage of retained breast
R di th
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Radiotherapy: Local control
Pre-operative / post-operative radiation
Breast irradiationpositioning Acute effects ofbreast irradiation
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External Beam Therapy
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Brachytherapy
Ch th
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Chemotherapy: CMF, CAF, CA, AV, doxorubicin
Side effect: nausea, vomiting, myelosuppression,alopecia, thrombocytopenia, exercise intolerance
Hormonal Therapy: Receptor Assay (ER/PR):
1 gm of fresh tissue obtained by using cold scalpel and should bedetermined w/in 20-30 min.
ER (-) < 10% respond to endocrine ablation or exogenous
estrogen
ER (+) > 60% responds
premenopausal 30% (only due to masking effect of endogenousestrogen)
Menopausal 60%
PR (+) 15% of premenopausal benefit from 15%
H l Th
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Hormonal Therapy:
1. Ablation:
Oophorectomy Replaced by medical adrenelectomy, etc.
Irradiation,
Chemotherapy,or Goserelin
Surgical
(oophorectomy)
Mechanism of action of goserelin 1
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Mechanism of action of goserelin - 1
LHRH
(hypothalamus)Pre/post-
menopausal
Premenopausal
Adrenocorticotrophic
hormone
(ACTH)
Adrenal
glands
Pituitary gland
Prolactin
Growth hormone
OestrogensProgesterone
Corticosteroids
Progesterone
Androgens Oestrogens
Peripheral conversion
Ovary
goserelin - down-
regulation of
LHRH receptors
Gonadotrophins(FSH + LH)
l h
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Hormonal Therapy:
2.Anti-estrogen:
a. Tamoxifen a non-steroidal anti-estrogeniccompound that compete w/ estrogen atreceptor site.
Estrogen receptor assay should bedetermined; if negative chance of successis very low
Mechanism of action of
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Mechanism of action of
tamoxifen
as an antitumor agent
Local effects - independent of
oestrogen receptor
+
-
stromal
cell
Increase TGF
Anti-estrogen effects
- blockage of estrogen receptor
Decrease TGF
Aromatase inhibition within
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Aromatase inhibition within
the breast tumour cell
ANDROGENS OESTROGENS
P-450 Aromatase
+ NADPH-cytochrome P-450 reductase
(Testosterone,
androstenedione,
16-OH-testosterone)
(Oestradiol, oestrone)
Aromatase Inhibitors
tumour
growth
Therapeutic Approach for Breast Cancer
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Therapeutic Approach for Breast Cancer
A. Carcinoma in Situ:
1. DCIS:
a. Breast conserving surgery + radiation therapy w/ or w/o tamoxifen
b. Total mastectomy w/ or w/o tamoxifen
c. Breast-conserving surgery w/o radiation therapy
2. Lobular Carcinoma in Situ:
a. Observation after diagnostic biopsy
b. Tamoxifen to decrease the incidence of subsequent breast cancer
c. Study, Tamoxifen versus raloxifene in high-risk postmenopausalwomen
d. Bilateral prophylactic total mastectomy, w/o axillary dissection
Therapeutic Approach for Breast Cancer
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p pp
B. Stage I & II
Modified radical mastectomy
(+) LN (-) LN (-) LN
Low risk High risk
Hormonal / observe chemotherapy
chemotherapy
High Risk Patients (Stage I):
A. Histologic criteria: 1. Poor cytologic differentiation
2. Lymphatic permeation
3. Blood vessel invasion
4. Poor circumscritption
B. Rapid growth rate, by clinical history or thymidine labeling index
Therapeutic Approach for Breast Cancer
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Therapeutic Approach for Breast Cancer
3. Advance Breast Cancer (III / IV):
Palliative Mastectomy
(+) Estrogen (-) Estrogen
Chemotherapy/Hormonal/Chemotherapy/Radiotherapy
Radiotherapy
Therapeutic Approach for Breast Cancer
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Therapeutic Approach for Breast Cancer
4. Inflammatory Breast Carcinoma:
3 5% 5 year survival
Main role of surgery is in the diagnosis
Primary therapy is chemotherapy and radiotherapy and if possiblesurgery (mastectomy).
CAF ----- regression ------> extended mastectomy (level I) ----------> irradiation of axillary and skin flap (30% - 5 yr survival)
5. Breast Cancer and Pregnancy/Lactation:
The risk of aggressive and distant metastasis is profound due to highlevel of estrogen and progesterone secreted from the placenta andcorpus luteum.
Treat patient as if she is not pregnant
Lactation should be suppressed promptly, even if biopsy was benignbecause milk from transected lactiferous will drain via the biopsy site
If patient is undergoing radiotherapy and chemotherapy for breastCA, advice patient not to get pregnant. ( advice not to usecontraceptive pills).
Treatment:
MRM / Segmental resection + radiation (after delivery) + axillar ---> chemothera is dela ed on the 2nd trimester sin le
Therapeutic Approach for Breast Cancer
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6. Breast Cancer in Men:
Factors:
a. Klinefelter syndromeb. Estrogen therapy
c. Testicular feminizingsyndromes
d. Irradiation
e. Trauma Age: 60-70y/o
s/sx: breast mass, nippleretraction and/or discharge,ulceration and pain.
Commonly ER positive andwell differentiated
Prognosis is similar w/ female
Treatment:
MRM + radiation if with
ulceration and high grade
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