The Breast

KRISTOFF ARMAND E. TAN

HANNAH LOIS KANGLEON-TAN
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Part 1

Embryology and Anatomy

Physiology
Course Benign Breast Conditions

Outline Part 2

Breast Cancer
Screening and Staging
Diagnosis and Treatment

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RISK FACTORS
For Developing Breast Cancer

Genetics
Hormonal Non-Hormonal
• Sporadic 65-75%
• Increased estrogen exposure • Radiation
• Familial 20-30%
- Early menarche • Alcohol consumption
• Hereditary 5-10%
- Late menopause • High fat intake
- Nulliparity
- Obesity
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GAIL MODEL
Risk Assessment
Models
Average Risk = 12%

• Gail Model
• Claus Model
• BRCAPRO Model
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RISK MANAGEMENT
For High Risk Patients

Active Surveillance and

Screening Lifestyle Modification
About Me

Chemoprevention Risk Reducing Surgery

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BRCA1 vs BRCA2
COMPARISON

BRCA1 BRCA2
GERMLINE located on located on
MUTATIONS chromosome arm 17q chromosome arm 13q

Breast cancer risk: 85% Breast cancer risk: 85%

Ovarian cancer risk: 40% Ovarian cancer risk: 20%

Likely hormone negative Likely hormone negative

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DISTANT METASTASIS
PRIMARY BREAST CANCER

NATURAL
HISTORY

AXILLARY NODE METASTASIS

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DISTANT METASTASIS
PRIMARY BREAST CANCER

NATURAL
HISTORY

AXILLARY NODE METASTASIS

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DISTANT METASTASIS
PRIMARY BREAST CANCER

NATURAL
HISTORY

AXILLARY NODE METASTASIS

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Carcinoma In Situ

Cancer cells are in situ or invasive depending

on whether or not they invade through the
basement membrane.
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LOBULAR CARCINOMA IN SITU

• Originates from the terminal duct lobular units

• Develops only in the female breast
• Cytoplasmic mucoid globules are a distinctive
cellular feature
• Usually an incidental finding
• A marker of increased risk for invasive breast
cancer
• NOT an anatomic precursor
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DUCTAL CARCINOMA IN SITU

• Predominantly seen in female breast
- 5% in male breast
• papillary growths within the duct lumina
• Classified based on nuclear grade and
necrosis
• Risk for invasive cancer - fivefold
• Anatomic precursor of IDC
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INVASIVE BREAST CARCINOMA

1. Paget’s disease of the nipple

2. Invasive ductal carcinoma (AdenoCa), 80%
3. Medullary carcinoma, 4%
4. Mucinous (colloid) carcinoma, 2%
5. Papillary carcinoma, 2%
6. Tubular carcinoma, 2%
7. Invasive lobular carcinoma, 10%
8. Rare cancers (adenoid cystic, squamous, apocrine)
DIAGNOSIS OF BREAST CANCER Inspection
• Symmetry
Examination • Size
• Shape
• Skin and nipple changes

Palpation

• All quadrants up to boundaries

• Axillary lymph node assessment
DIAGNOSIS OF BREAST CANCER Mammography
• Supplements history and PE
Imaging • Radiation to low to cause cancer
• MLO view – greater volume
• CC view – better compression and medial aspect
DIAGNOSIS OF BREAST CANCER Mammography
• Supplements history and PE
Imaging • Radiation to low to cause cancer
• MLO view – greater volume
• CC view – better compression and medial aspect

Ultrasonography
• Determine echogenic qualities
• Lymph node assessment
• Used along with biopsy techniques
DIAGNOSIS OF BREAST CANCER Mammography
• Supplements history and PE
Imaging • Radiation to low to cause cancer
• MLO view – greater volume
• CC view – better compression and medial aspect

Ultrasonography
• Determine echogenic qualities
• Lymph node assessment
• Used along with biopsy techniques

Magnetic Resonance Imaging

• BRCA patients
• Unknown primary
• Assess neoadjuvant therapy and recurrence
DIAGNOSIS OF BREAST CANCER

Non-Palpable Lesions
Biopsy • Stereotactic techniques

Palpable Lesions
• Fine Needle Aspiration
• Core Needle Biopsy
• Open Biopsy (Excision or Incision)

An open and core needle biopsy specimen

can be checked for tumor biomarkers
TUMOR
BIOMARKERS
Hormone Receptors ER and PR

Growth Factor Receptors HER-2/neu

Indices of Apoptosis P53, Bcl-2

Indices of Proliferation Ki-67

Indices of Angiogenesis VEGF

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Clinical Staging
of Breast Cancer

Tumor Size

T1 T2 T3 T4
T <2 cm 2 – 5 cm >5 cm
skin or chest
wall involved

Lymph Nodes
NO N1 N2
N No lymph node
involvement
Solitary lymph
node
Matted lymph
nodes

Metastasis M0
Without M1
M distant
metastasis
With distant
metastasis
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Clinical Staging
of Breast Cancer

Easy way to remember staging

• Stage IV – M1

• Stage IIIB – T4

• Stage IIIA – N2

• Stage IIB – T + N = 3 Exception to the rule!

T3 N1 M0 = Stage IIIA
• Stage IIA – T + N = 2

• Stage I – T1
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Clinical Staging
of Breast Cancer

Easy way to remember staging

• Stage IV – M1

• Stage IIIb – T4 Locally advanced

(Inoperable)
• Stage IIIa – N2

• Stage IIb – T + N = 3
Early Invasive
• Stage IIa – T + N = 2 (Operable)

• Stage I – T1
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Clinical Staging
of Breast Cancer

Easy way to remember staging

• Stage IV – M1

• Stage IIIb – T4 Locally advanced

Neoadjuvant Surgery
(Inoperable)
• Stage IIIa – N2

• Stage IIb – T + N = 3
Early Invasive
Surgery Adjuvant
• Stage IIa – T + N = 2 (Operable)

• Stage I – T1
How is Breast Cancer
Treated?

• Treated by Stage

• Early Invasive – Surgery + adjuvant

• Locally advanced – Neoadjuvant +

surgery

• Local AND systemic treatment

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• Surgery for breast

Course of Mastectomy vs BCS
Treatment • Surgery for axilla
ALND vs SLNB
Locoregional • Radiotherapy
If with positive LN or margins
Or if BCS was done
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• Chemotherapy
Course of Almost all cases, OncotypeDX
Treatment • Hormonal Therapy (Tamoxifen/AI)
If ER or PR positive
Systemic • Anti Her2 Therapy (Trastuzumab)
If HER2 positive
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Other Considerations

Breast Cancer in Pregnancy

• 1 in every 3000 pregnant women

• No radiotherapy until delivery

• MRM at 1st and 2nd trimester

• BCS at 3rd trimester

• Risk of abortion and birth defects

from chemotherapy
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Other Considerations

Phyllodes Tumor
• Benign, Borderline or Malignant

• Difficult to diagnose with imaging and

FNA

• Excision with 1cm margins

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Other Considerations

Male Breast Cancer

• Benign, Borderline or Malignant

• Difficult to diagnose with imaging and

FNA

• Excision with 1cm margins

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RISK FACTORS AND ASSESSMENT

MODELS

THERAPEUTIC MANAGEMENT

Infographic
The Breast
Part 2
slide

DIAGNOSTIC MANAGEMENT