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Akinpelu, Angela; Espinosa, Frankie; Lawson, Chatriece

#1 cause of cancer death in women world wide 2nd most common cause of cancer death in the US Most common female malignancy In the US, there is a 1/8 chance a woman will develop breast cancer if she lives to be 90 y/o Surgery is the primary treatment Early-stage is often cured with surgery alone

Incidence and mortality rates are 5 times higher in North America and Northern Europe than Asian and African countries 230,480 new cases of invasive breast cancer were expected to be diagnosed in women in the US

Risk Factor
Age (50 vs <50 yr) Family history of breast cancer First-degree relative Second-degree relative Age at menarche (<12 vs 14 yr) Age at menopause (55 vs <55 yr) Age at first live birth (>30 vs <20 yr) Benign breast disease Breast biopsy (any histologic finding) Atypical hyperplasia Hormone replacement therapy

Relative Risk

1.4-13.6 1.5 1.8 1.2-1.5 1.5-2.0 1.3-2.2

1.8-10.5 4.0-4.4 1.0-1.5

Milk producing sebaceous glands Rest on pectoralis major Attached to muscle wall via Coopers ligaments 15-20 lobes in circular arrangement Fat gives size and shape

Glands at the ends of lobules produce milk Lobes, lobules, and bulbs are linked by a network of ducts Ducts carry milk from bulbs toward areola Ducts join together into larger ducts ending at the nipple, where milk is delivered Network of lymphatics run through the breasts

The external structure of the breast can be divided into 4 quadrants: the upper inner quadrant the lower inner quadrant the lower outer quadrant the upper outer quadrant The upper-outer quadrant of the breast is thicker than the remainder of the breast. Contains a greater bulk of mammary tissue than the other quadrants Both benign and malignant tumors occur most frequently there The breast borders The upper border of breast tissue begins at the collarbone The lower border is at the base of a properly fitted bra The inner border is the edge of the sternum the outer border is the anterior axillary line which is the underarm or arm pit Some women have tails or axillary projections of breast tissue that extend further than the anterior axillary lines into the armpit. It is important this this area be included in the breast self-examination.

Fibrocystic changes
Hyperplasia Fibroadenomas Intraductal papillomas Galactocele

Three Histologic Categories

Nonproliferative lesions Proliferative lesions (hyperplasia) without atypia Atypical hyperplasia

Most common benign breast disorder Present in ~50% of women May involve any or all breast tissues Caused by decrease in progesterone or increase in estrogen Improves in pregnancy and lactation Can be painful, especially premenstrually

Most common benign tumor Composed of both fibrous and glandular tissue Well circumscribed, freely mobile Usually solitary Common before the age of 30 Has malignant potential Excised for definitive diagnosis and cure

Neoplastic growths within ducts Common before or during menopause Rarely palpable Presents as bloody, serous, or turbid discharge from nipple Excisional biopsy of lesion is the treatment of choice May have invasive tendency

Cyst of dilation of duct Filled with thick, inspissated, milky fluid Presents during or shortly after lactation Represents ductal obstruction (i.e., inflammation, hpyerplasia, neoplasia) Multiple cysts often present Can 2 acute mastitis or abscess Tx: needle aspiration; excisional biopsy if bloody

Carcinoma
begins in the epithelial cells of organs (i.e. breast) Nearly all breast cancers are carcinomas (either ductal carcinomas or lobular carcinomas)

Adenocarcinoma
carcinoma that starts in glandular tissue, i.e. ducts and lobules

Invasive (infiltrating) carcinoma


An invasive cancer is one that has already grown beyond the layer of cells where it started

Sarcoma
start in connective tissues such as muscle tissue, fat tissue, or blood vessels

Carcinoma in situ
Early stage of cancer It is confined to the layer of cells where it began
Lobular carcinoma in situ (LCIS) Ductal carcinoma in situ (DCIS)

Cells have not invaded into deeper breast tissues or spread to other organs Referred to non-invasive or pre-invasive breast cancer because it may develop into an invasive breast cancer if left untreated

Arises from terminal duct apparatus Has diffuse distribution, usually non-palpable Incidence is 2.8 per 100,000 women Peak incidence at 40 50 years

If LCIS becomes invasive it is termed as infiltrating lobular carcinoma < 15% of invasive breast cancer Metastasizes to axillary lymph nodes 1st Tends to become multifocal

Most common type of non-invasive breast cancer DCIS is not life-threatening DCIS can increase the risk of developing an invasive breast cancer High risk for cancer reoccurrence At a higher risk for developing a new onset of breast cancer than a person who has never had breast cancer

~80% of all breast cancers DCIS initially microinvades the duct wall Eventually, cancerous cells invade breast tissue Can spread to lymph nodes, then to other areas of the body 2/3 of women are > 55 y/o when diagnosed Also affects men

Uncommon, 1 2% of all breast cancers Histology: single layer epithelial cells, lowgrade nuclei and apical cytoplasmic snoutings (extrusions) arranged in well-formed tubules and glands Has low incidence of lymph node involvement Very high overall survival rate Treatment is often only breast-conserving surgery and local radiation

Uncommon, 1 2% of all breast cancers Two common types:


cystic (noninvasive); low mitotic activity, indolent, good prognosis micropapillary (invasive); centrally located; can present as bloody nipple d/c; strongly ER+ and PR+; more aggressive; frequent lymph node metastasis; correlates with survival

Usually in women > 60 y/o

Relatively uncommon, < 5% Occurs in younger women Typically presents as a bulky palpable mass with axillary lymphadenopathy (30%) DCIS sometimes observed in surrounding normal tissue Usually ER, PR, and HER2 negative TP53 commonly mutated

Relatively uncommon, < 5% of invasive breast cancers Women typically > 70 y/o at presentation Presents as palpable mass or mammographically as poorly defined with rare calcifications Excellent prognosis; > 80% 10-year survival Histologic: types A, B, and AB; mucin production > in type A

Associated with underlying breast cancer in 75% of cases Occurs in ~3% of all breast cancers Arises from excretory ducts skin of nipple and areola Eczematoid appearance Palpable lesion in 2/3 Poor prognosis associated with palpable tumor, lymph node involvement, age < 60 Overall 5- and 10-year survival rates 59% and 44%, respectively

Rare, 1 4% Often seen in pregnancy Develops rapidly, making the affected breast red, swollen and tender; classic peau dorange appearance Cancer cells block the lymphatic vessels in the breast, causing the characteristic appearance of the breast. Considered a locally advanced cancerit has spread from its point of origin to nearby tissue and possibly to nearby lymph nodes Easily confused with a breast infection Seek medical attention promptly if you notice skin changes on your breast Typically is advanced with mets by time of diagnosis

Carcinoma
Painless and freely mobile

Tumor
Fixed into deep fascia extension to the skin causes retraction and dimpling of the skin Ductal involvement nipple retraction Blockage of skin lymphatic's causes lymphedema and thickening of the skin referred to as peau d organge

Tumors spread by:


Local Infiltration
Directly into parenchyma

Lymphatic Spread
Mainly into the axillary nodes Occurs in up to 50% of patients with systematic breast cancer Internal mammary nodes are the 2nd most common affected site Supraclavicular nodes are only involved after axillary nodes 10%-20% of patients screened have detected breast cancers

Hematogenous Spread
Metastasizes mainly to the lungs and liver Other sites include: bone, pleura, adrenals, ovaries and brain

Scale of 0 (describing non-invasive cancers ) to IV (describing invasive cancers )

Stage 0: non-invasive cancers Stage I: invasive, the tumor measures <2cm and no lymph involvement Stage II: is divided into 2 subcategories
IIA:
No tumor in the breast, but cancer cells are found in the lymph nodes axillary OR the tumor < 2 cm and has spread metastasized to the axillary lymph nodes OR the tumor between 2 -5 cm and has not metastasized to the axillary lymph nodes

IIB
the tumor is >2 cm <5 cm and metastasized to the axillary lymph nodes OR the tumor is >5 cm but not metastasized to the axillary lymph nodes

Stage III
IIIA
no tumor is found, but cancer is found in axillary lymph nodes, or cancer may metastasized to lymph nodes near the breastbone OR the cancer is any size and metastasized to axillary lymph nodes

IIIB
the cancer may be any size and metastasized to the chest wall and/or skin of the breast AND may metastasized to axillary lymph nodes, or cancer may have spread to lymph nodes near the breastbone Inflammatory breast cancer

IIIC
there may be no sign of cancer in the breast or, if there is a tumor, it may be any size and may have spread to the chest wall and/or the skin of the breast AND the cancer has spread to lymph nodes above or below the collarbone AND the cancer may have spread to axillary lymph nodes or to lymph nodes near the breastbone

Stage IV
Metastasized to other organs

Screening begins for asymptomatic women The Physician - Physician Assistant has to be familiar with common Benign and Malignant disorders of the breasts along with their therapeutic options The screening process all begins with the patient The Breast Self-Exam (BSE) This means that the MD PA should give the patient pertinent health information tailored to any abnormalities, as well as properly training and educating the patient on how to properly do the BSE

There is no documented proof that performing a Breast Self-Examination directly reduces mortality, but all health professionals agree that it helps lead to an earlier diagnosis, which in turn will indirectly increase mortality A rule of thumb: It is best to perform a monthly Breast Self-Examination after menses has ceased

Proper Technique is KEY Begin in the Upright Position with the arms to the side

After Inspection with the arms to the side then arms in the raised position

Have the patient palpate 2 key areas


1. Supraclavicular 2. Axillae Assessing for any nodes

Then, have the patient lie supine, palpating each quadrant against the chest wall using the flat of the hands Next, have patient palpate their areola Finally, decompress the nipples for any evidence of discharge

To be done annually at the minimum Begin upright and use observation, checking for: a) Symmetry b) Contour c) Skin Changes/Retractions Due to the tethering of skin to an underlying malignancy d) Nipple Retractions Have patient raise their hands above their head to accentuate any abnormalities

Be sure to palpate in the following order 1. Breast 2. Areola 3. Nipple


If any mass is palpated, check if it is fixated to deep tissues by having the patient put her hands on her hips and contracting the pectoralis muscles while she is doing this palpate the: a) Axilla b) Supraclavicular fossa

After completing the exam upright, repeat the exam with the patient supine

Mammogram

A very important component of the screening process, especially in asymptomatic women

The Mammogram should be done in conjunction with the Physical Examination Able to detect malignancies <1cm that would otherwise be clinically unapparent Suspicious findings include:
Densities Fine Calcifications

A small, negligible amount of radiation is emitted about 0.3 cGy, which will not increase the risk of breast cancer Very good diagnostic tool for picking up breast cancer in a study of 3557 breast cancer cases 89% were detected by mammogram 42% were clinically undetectable Start yearly mammograms at 40 years of age

Ultrasound Helps differentiate a cystic vs. solid mass May also show any solid tissue that is potentially malignant Good diagnostic tool for women <30 years of age with palpable focal masses No radiation exposure

MRI Magnetic Resonance Imaging


Before using this diagnostic the healthcare professional must distinguish whether the nodules or tenderness is caused by normal hormone function or whether it is caused from benign or malignant changes

Nuclear Imaging
Not usually indicated for the detection of breast cancer Plays a very useful role in the detection of breast cancer Detection rate of 85% Specificity rate of 89% Tc sestamibi Tc tetrofosmin Tc methylene diphosphonate

3 radiotracers are commonly used

Positron Emission Tomography Scanning PET Scan Most sensitive and specific of all the imaging modalities for breast disease One of the most expensive and least widely used modalities available Utilizes labeled metabolites for detection fluorinated glucose Main use is to help detect recurrences

For definitive diagnosis of neoplasms:


1. Fine Needle Aspiration FNA 2. Open Biopsy

Fine Needle Aspiration FNA Can be performed on an out-patient basis It is both sensitive & specific Remember!
Never accept a negative biopsy result as a definitive when a mammogram indicates a malignancy

Open Breast Biopsy Smaller Masses = Excisional Biopsy Larger Masses = Incisional Biopsy Indications for open biopsy: A mass that exists through out menses Cystic masses that does not decompress with aspiration or has blood in the aspirate Spontaneous serous nipple discharge No mass with a trigger point

Open breast biopsy (contd) Can be done as an in-patient or out-patient


In an out-patient setting use local anesthesia In an in-patient setting use general anesthesia Women with large breast and a small deep mass Non-palpable lesions detected on a mammogram

Do Not use open breast biopsy for:

There is a trend towards conservative surgical approaches to breast cancer with adjuvant radiation and, if necessary chemotherapy or hormonal therapy

Surgery
For many years radical mastectomy was the standard of treatment for breast cancer Survival rates of conservative therapy are equal to those of radical mastectomy Routine axillary lymph node dissection has progressively been replaced by lymphatic mapping and sentinel lymph node resection Breast reconstruction after a mastectomy is an integral part of the treatment of breast cancer, which can be done at the time of mastectomy Conservative surgery is always performed in conjunction with radiation therapy to the breast This approach gives equivalent outcomes to radical mastectomy, and functional and cosmetic results are improved External beam therapy is used with this modality, by giving 4,500 to 5,000 cGy to the entire breast The axilla is not routinely irradiated due to the occurrence of lymphedema

Radiation Therapy

Used in cases of early breast cancer, regardless of lymph node involvement Reduces the risk of relapse by about 33% Reduces the risk of death by about 25% Pre-menopausal women with ER-negative tumors should receive adjuvant therapy Pre-menopausal women with ER-positive tumors should receive adjuvant therapy in addition to chemo therapy The use of Tamoxifen shows a 70% reduction in the risk of cancer in the contralateral breast In patients with proven metastases, symptoms may be palliated with combination chemotherapy

3% breast cancer occur in pregnancy


Complicating ~ 1/3000 pregnancies

Diagnosis is usually delayed because of hypertrophied breast If a mass is suspected, a needle aspiration or open biopsy needs to be performed promptly Surgical treatment is the same as a nonpregnant patient With nodal metastases abortion is advisable in the first trimester with tx of adjuvant chemotherapy because of teratogenic risk, during the 3rd trimester should wait until after delivery

Is related to the stage of the disease and age


Older age has better prognosis

Status of axillary lymph nodes is the single most important prognosticator Patients with negative lymph nodes had an actuarial 5-year survival rate of 83% Pregnant patients has a worse prognosis than non-pregnant patients

Breast Cancer Stage

5-Year Survival Rate for Women 93% 88% 81% 74%

0 I IIA IIB

IIIA IIIB
IIIC IV

67% 41%
49% 15%

Which of the following is a benign breast disorder? a) Fibroadenoma b) DCIS c) Padgets d) LCIS

Which of the following is a benign breast disorder? a) Fibroadenoma b) DCIS c) Padgets d) LCIS

What is the #1 cause of female cancer death worldwide? a) Lung b) Breast c) Cervical d) Ovarian

What is the #1 cause of female cancer death worldwide? a) Lung b) Breast c) Cervical d) Ovarian

Which quadrant has the highest occurrence of benign tumors? a) Upper Inner b) Lower Outer c) Upper Outer d) Lower Inner

Which quadrant has the highest occurrence of benign tumors? a) Upper Inner b) Lower Outer c) Upper Outer d) Lower Inner

Which quadrant has the highest occurrence of malignant tumors? a) Upper Inner b) Lower Outer c) Upper Outer d) Lower Inner

Which quadrant has the highest occurrence of malignant tumors? a) Upper Inner b) Lower Outer c) Upper Outer d) Lower Inner

What is the most effective treatment modality? a) Radiation b) Acupuncture c) Chemotherapy d) Surgery

What is the most effective treatment modality? a) Radiation b) Acupuncture c) Chemotherapy d) Surgery

DCIS Ductal Carcinoma In Situ IDC Invasive Ductal Carcinoma IDC - Less Common Types ILC Invasive Lobular Carcinoma

Inflammatory Breast Cancer


LCIS Lobular Carcinoma In Situ Male Breast Cancer Paget's Disease of the Nipple Phyllodes Tumors of the Breast

Recurrent and Metastatic Breast Cancer

http://www.cancer.org/Cancer/BreastCancer/DetailedGuide/breast-cancer-what-is-breast-cancer Hacker, Neville F., Joseph C. Gambone, and Calvin J. Hobel. "Breast Disease: A Gynecologic Perspective." Hacker and Moore's Essentials of Obstetrics and Gynecology. 5th ed. Philadelphia, PA: Saunders/Elsevier, 2010. Print. "Types of Breast Cancer." BreastCancer.org - Breast Cancer Treatment Information and Pictures. 17 Sept. 2010. Web. 01 Dec. 2011. <http://www.breastcancer.org/symptoms/types/>. "What Is Breast Cancer?" American Cancer Society :: Information and Resources for Cancer: Breast, Colon, Prostate, Lung and Other Forms. 29 Sept. 2011. Web. 1 Dec. 2011. <http://www.cancer.org/Cancer/BreastCancer/DetailedGuide/breast-cancerwhat-is-breast-cancer>. [PPT] For Breast Cancer www.uams.edu/cop/Rxforbreastcancer/low_res.ppt File Format: Microsoft Powerpoint - Quick View For Breast Cancer. A program of the. UAMS College of Pharmacy. Funded through unrestricted educational grants. by Susan G. Komen Breast Cancer