Download breast case

49 y.o.
 Female
 Bataan


“bukol sa suso”
1 year PTA – Noted a firm bandlike mass
~1cm at left breast.
Consulted but no treatment
done
5 mos PTA – Noted increase in size to ~2cm
and change in shape, to round.
Felt upper back pain and
numbness of Left arm
Consulted at a private clinic.
FNAB was done showing
malignant cells. Advised
surgery.
1 mo PTA – Sought second opinion at PGH.
Slide review done.
Mammogram requested.
Diagnosed with breast cancer
hence admission for surgery
(-) headache
(-) blurring of vision
(-) cough, cold
(-) dysphagia
(-) dyspnea
(-) chest pain
(-) abdominal pain
(-) diarrhea
(-) constipation
(-) urinary problems
(-) joint pain
(-) dizziness
(-) fever
(-) malaise
(-) weight loss
(+) anorexia
(+) ovarian cyst, Left, 2010, no treatment
(-) Diabetes mellitus, Hypertension,
Bronchial asthma, Pulmonary
tuberculosis, allergies
(-) previous surgeries and hospitalizations
No similar illnesses in the family
(-) Diabetes mellitus, Hypertension,
Bronchial asthma, Pulmonary
tuberculosis
Menarche – 14 y.o.
Menopause – 47 y.o.
Previously
regular menses
G4P4 (4004)
2nd year high school
 Employed as receiving clerks
 No vices

General
Survey:
Vital
Signs:
HEENT:
awake, coherent, not in cardiorespiratory
distress
BP: 110/70 HR: 84 RR: 20 Temperature:
37.5
pink conjunctivae, anicteric sclerae,
(-)cervical lymphadenopathy, (-) anterior
neck mass
Chest/
Lungs:
Breast
exam:
Equal chest expansion, clear breath sounds,
(-) retractions/rales/wheezes
Right: no masses, no axillary nodes, no skin
and nipple changes, no nipple discharge
Left: 3.5x4.5cm firm slightly tender slightly
moveable mass at the 11 o clock direction 10
cm from the nipple, no axillary nodes, no
skin and nipple changes, no nipple discharge
Cardio
vascular:
Adynamic precordium, distinct heart
sounds, normal rate, regular rhythm, (-)
murmurs
Abdomen: Flabby, NABS, soft, nontender, (-)
masses/tenderness
Skin/
Extremities:
Genitalia:
Neurologic:
Full, strong equal pulses, pink nailbeds, (-)
edema (-) jaundice
Deferred
Essentially normal
Benign
no skin change
smooth
soft to firm
mobile
well-defined margins
diffuse, symmetric thickening, which is
common in the upper outer quadrants,
may indicate fibro-cystic changes.
Malignant
hard
immobile
fixed to surrounding skin and soft tissue,
poorly defined or irregular margins.
Likely
Infection
Abscess
Hidradenitis
suppurativa
Mondor’s
disease
mass/lump
tenderness
mass/lump
chronic
condition
tenderness
cord-like
structure
Less likely
no signs of
erythema,
hyperthermia
no signs of
inflammation
cannot explain
other symptoms
cannot explain
other symptoms
acute/self-limited
condition
\ANDI
Fibroadenoma mass/lump
grow 1-2 cm, 
stable 
enlarge
Duct ectasia
palpable
more common
in 35-55 y/o
Periductal
tenderness
mastitis
behind the
nipple-areola
complex
cannot explain
other symptoms
more common in
15-25 y/o
often associated
with thick nipple
discharge
often nipple
discharge,
retraction
ANDI
Cyst
more common
in 35-55 y/o
Incapacitating more common
mastalgia
in 35-55 y/o
Tenderness
Malignancy
mass
anorexia
often subclinical
more common in
25-40 y/o
associated with
severely painful
nodularity
persisting > 1 wk
of menstrual
cycle
can explain
upper back pain
and numbness;
no history of
cancer

Positive for malignant cell, suggestive of
ductal carcinoma
Liver is normal in size measuring 12.2 cm
in its midsagittal axis. Echo pattern is
heterogenous with moderate increase in
parenchymal reflectivity. Intrahepatic
veins and ducts are not dilated.
Negative for solid nor fluid filled masses.
 Impression: Normal size liver with
moderate diffuse parenchymal fatty liver
changes.

Lungs are clear. Heart is mildly enlarged
with left ventricular form. Aorta is
tortuous. Diaphragm and sinuses are
intact.
 Impression: Clear lungs. Left ventricular
cardiomegaly. Tortuous aorta.


AB+
WBC
RBC
Hgb
Hct
MCV
MCH
MCHC
RDW-CV
Platelets
Neut%
Lymph%
Mono%
Eo%
Baso%
Normal
4-11x109/L
4-6x1012/L
120-180g/L
0.370-0.540%
80-100fL
27-31pg
320-360g/L
11-16%
150-450x109/L
0.5-0.7
0.2-0.5
0.02-0.09
0.0-0.06
0.0-0.02
Result
10.0
4.8
141
0.414
86.3
39.3
340
13.4
215
0.700
0.241
0.041
0.015
0.002
BUN
Creatinine
Sodium
Potassium
Chloride
Normal
3.2-8.0 mmol/L
53-133umol/L
135-145mmol/L
4.0-4.5mmol/L
99-110mmol/L
Result
3.50
63
141
3.9
107
Breast cancer St IIA (T2N0Mx)
Genetic + environmental factors
 Genetic

› p53 tumor suppressor gene
› BRCA 1 (17q21)
› BRCA2 (13q12.3)
*hormone-dependent
Spontaneous mutations
 Other factors

› Diet, smoking
Two Types:
 Invasive Ductal Carcinoma
› an infiltrating, malignant and abnormal
proliferation of neoplastic cells in the breast
tissue

Ductal Carcinoma In Situ
› Proliferation of cytologically malignant
breast epithelial cells within the ducts

Carcinoma confined to the ducts or
lobules
Carcinoma in situ:
Lobular carcinoma in situ
Ductal carcinoma in situ

Cancer that has spread from the ducts
and lobules into the breast tissue.
Invasive ductal carcinoma
Medullary carcinoma
Tubular carcinoma
Metaplastic tumors
Colloid carcinoma
Invasive lobular carcinoma
Mixed tumors
Inflammatary breast cancer
TNM Staging
Tumor size
Tis used for carcinoma in situ
T1</= 2cm
T2>2cm but <5cm
T3>/= 5cm
T4any size that has spread to chest wall or
the skin
TNM Staging
Lymphy nodes
Nx cannot be assessed
N0 no regional lymph node metastasis
N1 metastasis in movable ipsilateral axillary
lymph node(s)
N2 Metastasis in ipsilateral axillary lymph
node(s)
fixed or matted, or in clinically
apparent ipsilateral
internal mammary
nodes in the absence of
clinically
evident axillary lymph node metastasis
N2 Metastasis in ipsilateral axillary lymph
node(s)
fixed or matted, or in clinically
apparent
ipsilateral internal mammary
nodes in the absence of
clinically
evident axillary lymph node metastasis
N2a Metastasis in ipsilateral axillary lymph
nodes fixed to one another or to other
structures
N2b Metastasis only in clinically apparent
ipsilateral internal mammary nodes and
in the
absence of clinically evident
axillary lymph
nodes
N3
Metastasis in ipsilateral infraclavicular or
supraclavicular lymph node(s) with or
without axillary lymph node involvement, or
clinically
apparent ipsilateral internal
mammary lymph node(s) and in the
presence of axillary lymph node
N3a Metastasis in ipsilateral infraclavicular lymph
node(s)
N3b Metastasis in ipsilateral internal mammary
lymph node(s) and axillary lymph node(s)
N3c Metastasis in ipsilateral supraclavicular
lymph node(s)
TNM Staging
Distant metastasis
Mx Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis


Given after the primary treatment (surgery);
additional treatment
Designed to treat micrometastases (breast cancer
cells that have escaped the breast and regional
lymph nodes but which have not yet had an
established identifiable metastasis)
› TYPES:
 Adjuvant Radiotherapy--High risk of local recurrence
 Adjuvant Chemotherapy--“Micrometastases”
 Adjuvant Hormonal Treatment--“Micrometastases”

Evaluation of response may be categorized
according to the following parameters:
› No visible tumor, rates of recurrence, disease-free survival
and overall survival

Adjuvant Radiotherapy
› Breast-conserving radiation therapy
 To eradicate local subclinical residual disease
while reducing local recurrence rates by
approximately 75%
 2 general approaches:
 Conventional external beam radiotherapy (EBRT)
 Partial breast irradiation (PBI)
› Post-mastectomy radiation therapy

Adjuvant Chemotherapy
› Taxanes
 Among most active and commonly used
chemotherapeutic agents for the treatment of
early-stage beast cancer
› Anthracyclines
 Anthracycline-containing adjuvant
chemotherapy regimens have been used in
the treatment of early-stage breast cancers

Adjuvant Hormonal Treatment
› Tamoxifen
 Only hormonal therapy currently approved for
adjuvant therapy in patients treated with
breast-conserving surgery and radiation for
DCIS
› Aromatase inhibitors
 anastrozole, letrozole, exemestane
Systemic treatment given before any
planned local treatment (surgery or
radiotherapy)
 Initial treatment for localized cancer in
which there is an alternative but less than
completely effective local treatment

› Objectives:
 Permits in vivo chemosensitivity testing
 Can downstage locally advanced disease
and render it respectable
 May allow breast-conservation surgery to be
performed

Best candidates for neoadjuvant
chemotherapy:
› ER-negative or HER-2 positive expressing
tumors

Anthracycline-based
› FAC (doxorubicin in combination with
fluorouracil and cyclophosphamde)
Docetaxel, paclitaxel
 Trastuzumab

 for patients with HER-2 positive phenotype

Pertuzumab
 Approved in combination with trastuzumab
and docetaxel

Supportive Treatment
› pain control for bone metastases
› drainage of pleural fluid

Systemic Chemotherapy
› visceral metastases

Hormonal and Radiotherapy
› bone and brain metastases

Question of conservative vs. radical
› A number of RCTs have documented that for
stage I and stage II BRCA, mastectomy with
axillary lymph node dissection is equivalent
to breast-conserving therapy with
lumpectomy, axillary dissection and whole
breast irradiation
Contraindications for breast conserving therapy:
Absolute:
 Prior radiation therapy to the breast or chest wall
 Radiation therapy during pregnancy
 Diffuse suspicious or malignant appearing
microcalcifications
 Widespread disease that cannot be incorporated
by local excision through a single incision
 Positive pathologic margin
Contraindications for breast conserving therapy:
Relative:
• Active connective tissue disease involving the skin
(especially scleroderma and lupus)
• Tumors > 5 cm (category 2B)
• Focally positive margin
Women greater than 35 y or premenopausal
women with a known BRCA 1/2 mutation:
• May have an increased risk of ipsilateral breast recurrence
or contralateral breast cancer with breast conserving
therapy
• Prophylactic bilateral mastectomy for risk reduction may
be considered.
•
Considered for women with large IIA, IIB or T3N1M0
tumors who
• meet the criteria for breast-conserving therapy except for
tumor size
• Want to undergo breast-conserving therapy
•
For stage II: no benefit over post-operative
adjuvant chemotherapy
•
Whole breast irradiation
• Inadequate data to support partial breast
irradiation
• Dose/fraction schedules of either 50 Gy in 25
fractions over 35 days or 42.5 Gy in 16
fractions over 22 days
Resection of primary breast cancer with
a margin of normal-appearing breast
tissue
 Excision: Segmental mastectomy,
lumpectomy, partial mastectomy, wide
local excision, tylectomy
 Currently the standard of treatment for
women with stage O, I or II cancer
 Curvilinear incision concentric to the
nipple-areola complex






If on the upper aspect of the breast:
Curvilinear incision concentric to the nippleareola complex
If on the lower aspect: radial incisions
preferred
Breast cancer is removed with an envelope
of normal-appearing breast tissue for a
2mm cancer-free margin
* Additional samples from surgical bed to
prove negative margins
* From the samples: hormone receptor
status determination

Skin-sparing
› Removes all breast tissue, nipple-areola complex
(NAC), scars

Total (simple)
› Removes all breast tissue, NAC, skin

Extended
› Removes all breast tissue, NAC, skin and level I
and level II axillary lymph nodes

Halsted radical mastectomy
› Removes all breast tissue and skin, NAC,
pectoralis major and pectoralis minor + level I, II,
III axillary lymph nodes
Preserves both pectoralis major and
pectoralis minor
 Removes level I and II axillary lymph nodes
but not III

› Patey modification: removes pectoralis minor
muscle and allows complete dissection of level
III axillary lymph nodes
› Modified radical mastectomy permits
preservation of medial (ant. Thoracic) pectoral
nerve
Anatomic boundaries: latissimus dorsi, midline of
sternum, subclavius, caudal extension of breast 2
to 3 cm below inframammary fold


NCCN Breast Cancer Treatment Guidelines: a
typical woman with clinical stage I or stage II
breast cancer requires pathologic assessment
of axillary lymph node status
Sentinel lymph node mapping and resection
› Decreased arm and shoulder morbidity in patients
with breast cancer who undergo lymph node biopsy
compared vs. axillary lymph node dissection
› Not for all women: potential candidates have access
to sentinel lymph node team & clinically negative
axillary lymph node or negative core or FNA biopsy

Prognostic factor
› any measurement available at the time of
surgery that correlates with disease-free or
overall survival in the absence of systemic
adjuvant therapy and, as a result, is able to
correlate with the natural history of the
disease.

Predictive factor
› any measurement associated with response
to a given therapy.
Significance of prognostic and predictive
factors
a. to identify patients with good prognoses for
whom adjuvant systemic therapy would not
provide a large enough benefit to warrant the
risks
b. to identify patients whose prognosis is poor
enough to justify a more aggressive adjuvant
approach
c. to select patients whose tumors are more or less
likely to benefit from different forms of therapy.
Prognostic Factors
 Axillary nodal status
 Tumor size
 Tumor type and grade
 Lymphatic and vascular invasion
 Proliferation markers
 Ethnicity and patient age at diagnosis
 ER/PR status
 HER2/neu
Predictive factors
 ER/PR status
 HER2/neu
most significant prognostic indicator for
patients with early-stage breast cancer
 direct relationship between the number of
involved axillary nodes and the risk for
distant recurrence
 most consistent prognostic factor used in
adjuvant therapy decision making

› it is standard practice to administer adjuvant
therapy to patients with lymph nodes that are
positive
most powerful prognostic factor and is
routinely used to make adjuvant
treatment decisions
 In general, patients with a tumor size of
>1–2 cm warrant consideration of
adjuvant therapy since they may have a
distant recurrence risk of ≥20%.



subtypes such as tubular, mucinous, and
medullary have a more favorable prognosis
than unspecified breast cancer
Scarff-Bloom-Richardson (SBR) classification
› Mitotic index, differentiation, and pleomorphism are
scored from 1 to 3 and the scores from each
category are totaled.
› Tumors with scores from 3 to 5 are well differentiated
(grade 1), from 6 to 7 are moderately differentiated
(grade 2), and 8 to 9 are poorly differentiated (grade
3).

It is primarily used to make decisions for lymph
node-negative patients with borderline tumor
sizes.
recurrence rate for women with was
higher with LVI-positive disease
 used to make decisions for lymph nodenegative patients with borderline tumor
sizes

Includes S-phase fraction (SPF),
thymidine labeling index, mitotic index
 patients with high SPF tumors had a
higher risk of both recurrence and death
compared with those with low SPF
tumors
 elevated SPF is primarily used as
justification to administer adjuvant
therapy to lymph node-negative
patients with borderline tumor sizes


African American and Hispanic women
have a decreased survival from breast
cancer compared with white women
› This source of this disparity is likely
multifactorial, including issues such as lack of
access to care resulting in a higher stage at
diagnosis

some trials showed worse prognosis for
patients younger than 35 years of age
Presence of ER/PR in an invasive breast CA
is both prognostic and predictive
 Women with ER-positive tumors have better
prognosis than women with ER-negative
tumors
 Its optimal use is as predictive factor for the
benefit of adjuvant tamoxifen therapy

› all hormone-positive women who warrant
adjuvant systemic therapy should receive
hormonal therapy unless otherwise
contraindicated
› The c-erbB-2 (HER2/neu) proto-oncogene is located on
17q21 and encodes an Mr 185,000 transmembrane
glycoprotein, p185HER2, with intrinsic tyrosine kinase
activity homologous to the epidermal growth factor
receptor


It is amplified and/or overexpressed in approximately
30% of human breast tumors
HER2/neu overexpression is a prognostic factor that is
associated with a more aggressive tumor.
› Overexpression is associated with increased tumor
aggressiveness, increased rates of recurrence, and
increased mortality in node-positive patients, while the
influence in node-negative patients is more variable.

The optimal use of HER2/neu status may be as a
predictive factor, especially in predicting response to
trastuzumab in the metastatic setting.






Interval history and physical exam every 4-6 months for 5
years, then every 12 months
Annual mammography
Women on tamoxifen: annual gynecologic assessment
every 12 months if uterus present
Women on an aromatase inhibitor or who experience
ovarian failure secondary to treatment should have
monitoring of bone health with a bone mineral density
determination at baseline and periodically thereafter
Assess and encourage adherence to adjuvant endocrine
therapy
Active lifestyle, achieving and maintaining an ideal body
weight (20-25 BMI) may lead to optimal breast cancer
outcomes
History and PE performed every 3-6 months for the first 3
years, every 6-2 months for years 4 and 5, and annually
thereafter.
 For those who have undergone breast-conserving surgery:

› post-treatment mammogram 1 year after the initial
mammogram and at least 6 months after completion of
radiation therapy
› Thereafter, unless otherwise indicated, a yearly mammographic
evaluation should be performed.
Patients at high risk for familial breast cancer syndromes
should be referred for genetic counseling.
 CBCs, chemistry panels, bone scans, chest radiographs,
liver UTZ, CT scans, PET scanning, MRI, or tumor markers
(CEA, CA 15-3, and CA 27.29) is not recommended for
routine breast cancer follow-up in an asymptomatic
patient with no specific findings on clinical examination.
