Breast cancer

Dr. Ali M. Al-Amri, MD.

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Breast cancer

 Breast cancer is the 2nd cause of

mortality after lung cancer in USA
 Mortality started to decline due to:
Screening program
Better treatment
 30% die ultimately from their cancer

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Risk Factors

 Malnutrition delay menarche and decrease risk

in poor country.
 Menopause >55y…. 2-3 x if not at age 45y
 Alcohol has dose response relationship
 Childbirth <20y >30y increased risk of infertility.
 OCP increased risk by less than 2 fold.

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Breast cancer Risk

 Sporadic risk…= 11%

 Family History:
First-degree R.R 2.1
Second-degree R.R 1.5

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Breast cancer Risk

 Environmental Factors:
Diet
Alcohol
Radiation exposure
Endocrine Factors
Prior treatment of cancer
Emotional factors

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Sporadic Risk

 Sporadic risk…= 11%

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Genetic Risk

 BRCA1
56-87% by age 70y(HBOC syndrome)
 BRCA2
37-84% by age 70y(HBOC syndrome)
 Tp53
50-89% by age 50y(Li Fraumeni syndrome)

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Genetic Risk

 PTEN
30-40% by age 50y(Cowden syndrome)
 MSH2, MLH1
12% life time (Muir-Torre syndrome)
 STK11
high (Peutz-Jegher syndrome)

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Family History

 First-degree
R.R 2.1
 Second-degree
R.R 1.5

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Indications of hereditary susceptibility

 Early onset
 Multiple primary
 Multiple generations affected
 3 or more site-specific cancer
 Presence of rare cancer
 Presence of cancer in a known syndrome

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Breast cancer ( Hereditary vs. sporadic)

 5% of breast cancer due to mutation inherited in

a dominant fashion
 10% due to moderate hereditary factors
 85% sporadic

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Pre-malignant lesions

 Moderate Risk
Atypical ductal hyperplasia 3-5x
Bilateral
Atypical lobular hyperplasia 4-5x
Bilateral
Papilloma with atypia 4-5x
Local

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Pre-malignant lesions

 High Risk
LCIS 9-11x Bilateral
DCIS
Non-comedo 9-11x
Local

Comedo Very high

Local

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Diagnosis

 A- Screening

 B- Symptoms

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Nipple discharge

 Type Frequency Probability of CA

Milky 1% Negligible (N)

Purulent 5% N

Multicolored 10% N

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Nipple discharge

 Type Frequency Probability of CA

Serous 35% 5%
Serosanguinous 30% 15%
Bloody 25% 20%
Watery 5% 50%

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Signs

 No woman should sleep and ignoring:

a mass in her breast.

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FNA

 Show malignant cells but will not

differentiate invasive from non-invasive
tumor.
 Biopsy needed

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Work up for staging

 LFT
 chest x-ray
 bone scan
 CAT scan of chest, abdomen and pelvis
 PET scan?

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Pathology

 Ductal carcinoma 78%

 Lobular carcinoma 9%
 Comedocarcinoma 5%
 Medullary carcinoma 4%
 Colloid carcinoma 3%

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Pathology

 Papillary carcinoma rare

 Inflammatory carcinoma 1%
 Paget’s disease of the breast
 Sarcoma < 1%

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Pathology

 Pathology report is the most important to

decide Stage

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The Halestedian Theory

 Postulate that breast carcinoma spread in an

orderly fashion away from the primary site
and reach distant site through fascial plane
and lymphatic channel. Heamatogenous
spread not denied but occurs late and a
minor events→
Radical Mastectomy

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The Fisherian Theory

 Postulate that metastasis occur through the

blood stream which is intimately linked to the
lymphatic channels.
 It subdivide breast carcinoma to:
a. Those who have the potential for
heamatogenous spread
b. Those who have no potential
→ Modified Radical Mastectomy

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The Spectrum Theory

 It is a Fisherian theory coupled with time. That

means there is a point of time where
metastasis occurs.
→ Simple Mastectomy and ALN
sampling

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Conclusion

 Achieving local regional control doesn’t

guarantee that all patients will be cured but no
patient will be cured without it
 The earlier the treatment the better outcome

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Mastectomy vs. Lumpectomy

 Total mastectomy and ALN sampling preferred if

a. Small breast, Tumor/Breast ratio
b. Clear margin can not be obtained by excision
c. The presence of diffuse micro calcification, all
micro calcification should be
removed
d. Patients choice
e. No medical contraindication to surgery
h. No contraindication to radiation

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Recurrence

 Recurrence 5-30%
Related to the tumor size and the status of
the axillary’s lymph node.
8% if ALN negative
25% if ALN positive
90% of the recurrence in the first 5 years
38% within 1year
60% within 2 years

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Significance of recurrence

 Sign of treatment failure

 Almost always indicate systemic relapse

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Risk stratification

 Extreme Risk
T4, any N
N2, any T
T3, N1
Inflammatory breast cancer

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Risk stratification

 High Risk
Positive axillary’s lymph node
OR Node negative with:
Lymphatic invasion
Vascular invasion
T > 2 cm any grade
T 1-2 cm and grade 3

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Risk stratification

 Intermediate Risk
T size 1-1.9 cm and grade 1-2
No LVI
Node negative

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Risk stratification

 Low Risk
T size < 0.5 cm
No LVI
Node negative
DCIS

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Risk stratification

 Extreme risk, High risk and intermediate risk

Need treatment ( CT ± RT)

‫ٱ‬Low risk
no need for treatment ( CT ± RT)
‫ٱ‬All need hormonal therapy if ER positive

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Predictors of survival

 The most important predictor of survival is

lymph node involvement.

 10-year survival%
35-60% negative nodes
30-40% 4-9 nodes affected
15-30% > 9 nodes affected

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Breast cancer

 Mastitis vs. inflammatory breast cancer

Mastitis IBC
+ - Fever
++ - pain
± ± pedoorange

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Survival rate
 USA
1962 5 y survival rate 63%
1990 5 y Survival rate 85%
Stage 0 96% DFS at 10 Years
Stage I 90% DFS at 10 years
Stage IV < 1% alive at 10 Years
Improvement:
Earlier diagnosis
Effective therapy
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Patients follow up

 Patients Follow up
a. Breast self-examination
b. Regular breast examination by health
care providers
c. Annual mammography
d. No special test available improving the
outcome
e. Family and community support

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Breast cancer

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