Breast Cancer (For Clerks)

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com/millenialdesigns
Breast Cancer (Internal Med)

Clinical Clerk Borja, Alexandra
History About Diagnosis Work-up Management
Overcome through courage

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Objectives
• Present history and physical examination of a patient with breast cancer
• Discuss breast cancer
• Outline the differential diagnosis for this case
• Discuss the work-ups to be requested
• Administer proper care and management to our patient


• B.C.
• 48-year old
• Female
Case
Present Illness
Past Medical
Obstetric
CC: breast mass, left
Family
Personal/Social
Review of Systems
Physical Examination

1 week PTA Day of Admission

• CC: palpable breast mass • Admission for surgical procedure
– breast mass excision
• Approx. 2x2cm noted accidentally
• No changes in breast mass size
• Non-tender
• No associated symptoms
• No associated weight loss or malaise
Case
Present Illness
Past Medical
Obstetric 5 day PTA 2 day PTA
Family • No changes in size since first • No changes in breast mass size
noted
Personal/Social • No associated symptoms
• Sought consult and scheduled
Review of Systems for Core needle biopsy • Biopsy: low grade infiltrating ductal carcinoma
Physical Examination • Scheduled for excision

• No Diabetes mellitus
• No Hypertension
• No heart disease
Case
Present Illness • No allergies
Past Medical
• No previous accidents
Obstetric
Family • No previous surgeries
Personal/Social
Review of Systems

OBSTETRIC HISTORY
Menstruation Menarche at 11 years old, regular, 28-30 days interval, 5-7
days duration, 2-3 pads/day, (+) dysmenorrhea
Obstetric G4P4(4004)
G1 – 2000, male, NSD
G2- 2004, female, NSD
Case G3 – 2007, male, NSD
Present Illness G4 – 2012, female, NSD
Past Medical Gynecologic (-) Sexually Transmitted Infections
(+) UTI – current pregnancy, treated with nitrofurantoin
Obstetric
(+) Papsmear – unrecalled years
Family
Sexual Coitarche at 19 years old, 4 sexual partners, 1 current sexual
Personal/Social partner
Review of Systems No dyspareunia, no post-coital bleeding
Physical Examination Contraceptive (+) Pills – discontinued since 2011
(+) Bilateral Tubal Ligation – 2012

• Prostatic cancer – paternal uncle
Case
Present Illness
Past Medical
Obstetric
Family
Personal/Social
Review of Systems

• Lives together with family (daughter, sister, and mother)

• Self-employed
Case • Denies smoking

Present Illness • Denies drinking alcoholic beverages
Past Medical
• Denies elicit drug use
Obstetric
Family
Personal/Social
Review of Systems

GENERAL
• Unremarkable. No fatigue, sleeplessness, weight loss,
fever or night sweats
Case
Present Illness SKIN
Past Medical • Unremarkable. No itching and petechial rashes
Obstetric
• No changes in color, hair or nails, or size or color of
Family
moles
Personal/Social
Review of Systems

HEENT
• Unremarkable. No yellow discoloration in the palpebral
conjunctiva, no visual changes, blurring of visions, pain,
discharge, cataract, and glaucoma
Case
• No earaches, ear discharge, tinnitus and vertigo
Present Illness
Past Medical • No colds, nasal stuffiness, discharge, itching and
Obstetric epistaxis
Family • No bleeding, sore tongue, dry mouth, hoarseness,
Personal/Social excessive salivation, dysphagia
Review of Systems

RESPIRATORY
• Unremarkable. No signs of wheezing, and hemoptysis
observed
Case
Present Illness CARDIOVASCULAR
Past Medical • Unremarkable. No signs of chest pain or discomfort
Obstetric
• No orthopnea, edema, and paroxysmal nocturnal
Family
dyspnea
Personal/Social
Review of Systems • No electrocardiogram results

GASTROINTESTINAL
• Unremarkable. No trouble swallowing, heartburn,
nausea, or changes in appetite
• No change in bowel movements or habits, rectal
Case
bleeding, black or tarry stools, hemorrhoids,
Present Illness
constipation, diarrhea, abdominal pain, food intolerance,
Past Medical
excessive belching or passing of gas
Obstetric
Family • No jaundice, liver or gall bladder problems, or hepatitis
Personal/Social
Review of Systems

URINARY
• Unremarkable. No flank pain, dysuria, incontinence,
passage of stone, nocturia, polyuria, oliguria, frequency
on urination, hematuria, discharge and pain on urination
Case
Present Illness
Past Medical NERVOUS
Obstetric • Unremarkable. No headache, dizziness and
Family lightheadedness
Personal/Social
• No head injury, no seizure, tremors, loss of memory,
Review of Systems
paralysis, involuntary movements, and loss of sensation

MUSCULOSKELETAL
• Unremarkable. No muscle pain, joint pain, stiffness and
limitation of motion
• No bone deformity
Case
Present Illness
Past Medical ENDOCRINE
Obstetric
• Unremarkable. No goiter, heat or cold intolerance,
Family
polydipsia, and polyphagia
Personal/Social
Review of Systems

PSYCHIATRIC
• Unremarkable. No mood swings, behavioural changes,
anxiety or depression
Case
Present Illness HEMATOLOGIC
Past Medical • Unremarkable. No bruising, bleeding, or past
Obstetric transfusions
Family
Personal/Social
Review of Systems

VITAL SIGNS
• BP – 110/60 HR – 76
• RR – 18 Temp – 36.6
Case
Present Illness
Past Medical ANTHROPOMETRICS
Obstetric • Weight – 72kg Height – 162cm
Family
• BMI – 27.4
Personal/Social
Review of Systems
Physical
Examination

GENERAL SURVEY
• Awake, appears acutely ill, not in cardiorespiratory
distress
Case
Present Illness
SKIN
Past Medical
Obstetric • Skin is consistent with a women her age
Family • No presence of bruises or sites of bleeding in the body
Personal/Social
Review of Systems
Physical
Examination

HEENT
• Atraumatic head
• Anicteric sclerae, pink palpebral conjunctivae
Case
• No nasoaural discharge
Present Illness
Past Medical • Pinkish mouth and throat
Obstetric
Family
Personal/Social
Review of Systems
Physical
Examination

CHEST & LUNGS

• No retractions, alar flaring, or use of accessory muscles
• Symmetrical chest expansion
Case
• Clear breath sounds
Present Illness
Past Medical
Obstetric CARDIOVASCULAR
Family
• Adynamic precordium
Personal/Social
Review of Systems • No adventitious heart sounds
Physical • Normal rate, regular rhythm
Examination

BREAST
• 2.5x2.0 cm mass, immobile, firm, irregular borders
palpated on the right upper quadrant of the breast, right
Case • No palpable lymph nodes
Present Illness
• No discharge from the nipples, bilaterally
Past Medical
Obstetric
Family
Personal/Social
Review of Systems
Physical
Examination

ABDOMEN
• Soft, flabby
• Normoactive bowel sounds
Case
• Non-tender, non-distended
Present Illness
Past Medical
Obstetric BACK & SPINES
Family
• No abnormal curvature
Personal/Social
Review of Systems
Physical
Examination

EXTREMITIES
• No gross deformities
• Full and equal pulses on all extremities
Case
• CRT <2 seconds
Present Illness
Past Medical
Obstetric NEUROLOGIC
Family
• No focal neurologic deficits
Personal/Social
Review of Systems
Physical
Examination

Diagnostic Tests
• Core Biopsy Results:
• 100% positivity for estrogen receptors with high
Case intensity, 90% for progesterone receptors with
Present Illness high intensity and 100% positivity for HER2 (3 + )
Past Medical • MRI Results:
Obstetric
• homogenous hyper-intense irregular mass with
Family
indistinct margin
Personal/Social
Review of Systems
Physical
Examination

Breast Cancer • A cancer that develops from breast tissue

Overview
Classification
Pathophysiology • Typical signs include breast mass, changes in breast
Etiology shape, dimpling of the skin, nipple discharge, inversion
Epidemiology of the nipple, and skin changes
• Signs of distant spread may include bone pain, enlarged

lymph nodes, shortness of breath, or yellowing of the
skin

Breast Cancer • However, many early breast cancers are asymptomatic

Overview and even larger tumors may present as a painless mass
Classification
Pathophysiology
Etiology • Pain or discomfort is not usually a symptom of breast
Epidemiology cancer and only 5% of patients with a malignant mass
present with breast pain

Breast Cancer • Breast cancer is the common term for a set of breast
Overview tumor subtypes with distinct molecular and cellular
Classification origins and clinical behavior
Pathophysiology
Etiology
Epidemiology • Histopathology
• Grading
• Staging

Breast Cancer Histopathology

Overview
Classification
Pathophysiology
Etiology
Epidemiology

Breast Cancer Histopathology

Overview
• Wherein classification is based on characteristics
Classification
observed under light microscopy
Pathophysiology
Etiology
Epidemiology o Carcinoma-in-situ constitutes about 15-30% of breast
biopsies but have favorable a prognosis, with 5-year
survival rates of 97-99%
o Invasive carcinoma constitutes the other 70-85% with

invasive ductal carcinoma being the most common
subtype, representing about 80%

Breast Cancer Grading

Overview
Classification
Pathophysiology
Etiology
Epidemiology

The most important

prognostic variables
are
provided by tumor
staging: tumor size
(T), lymph node
status (N) and
detectable distant
metastases (M)


Overview
• Compares the microscopic similarities of breast cancer
Classification
cells to normal breast tissue
Pathophysiology
Etiology
Epidemiology • Classifies the cancer as: (1) well differentiated (low-
grade); (2) moderately differentiated (intermediate-
grade); and (3) poorly differentiated (high-grade)
• Grading of a given cancer is derived by assessing the

cellular appearance of the tumor


Overview
• Nottingham system for breast cancer grading
Classification
Pathophysiology
Etiology • Grades breast carcinomas by adding up scores for tubule
Epidemiology formation, nuclear pleomorphism, and mitotic count,
each of which is given 1 to 3 points


Overview
• Tubule formation assesses what percent of the tumor
Classification
forms normal duct structures
Pathophysiology
Etiology Description Score
Epidemiology Tubular formation >75% of the tumor 1
Tubular formation in 10 to 75% of the tumor 2
Tubular formation <10% of the tumor 3
• The higher the grade the more disorderly the cell

appears, hence worse prognosis


Overview
• Nuclear pleomorphism assesses whether the cell nuclei
Classification
are uniform or whether they are larger, darker, or
Pathophysiology
irregular
Etiology
Epidemiology Description Score
Nuclei with minimal or mild variation in size and shape 1
Nuclei with moderate variation in size and shape 2
Nuclei with marked variation in size and shape 3
• The higher the grade the more variation is seen in nuclei

size and shape, hence worse prognosis


Overview
• Mitotic count assesses how many mitotic figures (dividing
Classification
cells) can be seen in 10x high power microscope field
Pathophysiology
Etiology
Area per HPF
Epidemiology Score
0.096 0.12 0.16 0.27 0.31
0-3 0-4 0-5 0-9 0-11 1
4-7 5-8 6-10 10-19 12-22 2
>7 >8 >10 >19 >22 3
• The higher the grade the more cells there are that are
dividing, hence worse prognosis


Overview
• Overall, the scores for each of these three criteria are
Classification
added together to give a final score:
Pathophysiology
Etiology
Epidemiology
Score Grade Prognosis
3-5 Grade 1 (well-differentiated) Best
6-7 Grade 2 (moderately differentiated) Medium
8-9 Grade 3 (poorly differentiated) Worst


Overview
• Lower-grade tumors, with a more favorable prognosis,
Classification
can be treated less aggressively, and have a better
Pathophysiology
survival rate
Etiology
Epidemiology
• Higher-grade tumors are treated more aggressively, and
their intrinsically worse survival rate may warrant the
adverse effects of more aggressive medications

Breast Cancer • Breast cancer is the common term for a set of breast
Overview tumor subtypes with distinct molecular and cellular
Classification origins and clinical behavior. Most of these are epithelial
Pathophysiology tumors of ductal or lobular origin. Worldwide, breast
Etiology cancer is the most frequently diagnosed life-threatening
Epidemiology cancer in women and the leading cause of cancer death
among women.

Breast Cancer GERMLINE SUSCEPTIBILITY IN BREAST CANCER

Overview
• BRCA1
Classification
Pathophysiology
• 60–80% lifetime chance of developing breast
Etiology
cancer and about a 33% chance of developing
Epidemiology
ovarian cancer
• exclusively negative for estrogen and progesterone
receptors (ER, PgR) and for human epidermal
receptor 2 (HER2) (so-called “triple negative” breast
cancers)
• ~20% of women with triple negative breast cancers
will be positive for deleterious germline BRCA1
SNPs

Breast Cancer GERMLINE SUSCEPTIBILITY IN BREAST CANCER

Overview
• BRCA2
Classification
Pathophysiology
• more likely to be ER positive, compared to those in
Etiology
BRCA1 families (“triple negative”).
Epidemiology • men with BRCA2 deleterious SNPs also have a
higher risk of breast cancer,

Breast Cancer GENE EXPRESSION PATTERNS (the considerations for

Overview treatment)
Classification
• Luminal – ER (+) but HER2 (-)
Pathophysiology
• Luminal A: most responsive to endocrine therapy and
Etiology has a favorable prognosis
Epidemiology • highest levels of ER expression and PgR but low for HER2;
usually low-grade
• Luminal B: has worse prognosis, more responsive to
chemotherapy
• PgR negative, expresses HER2 (not to be mistaken as HER2
amplified)
• HER2 amplified – poor prognosis, responsive to
Trastuzumab

Breast Cancer GENE EXPRESSION PATTERNS (the considerations for

Overview treatment)
Classification
• Basal
Pathophysiology
Etiology
• ER/PgR-negative and HER2-negative tumors (so-
Epidemiology
called triple negative), tend to be high-grade
• BRCA1 mutations
• Normal breast-like
• Prognosis similar to luminal group B
• Claudin-low
• Often triple negative, but low expressions of cell-
cell junction

Breast Cancer RISK FACTORS FOR BREAST CANCER

Overview
• being female
Classification
Pathophysiology • being aged>50 years old
Etiology • Early menarche, late first full-term pregnancy, late
Epidemiology menopause
• Duration of maternal nursing
• Central obesity
• Oral contraceptive use, hormonal replacement therapy
• Exposure to radiation

Breast Cancer • Breast cancer incidence in the Philippines is among the

Overview highest in Asia
Classification
Pathophysiology
Etiology • Estimated prevalence of BRCA mutations among
Epidemiology unselected patients in the Philippine General Hospital
(PGH) in 1998 was 5.1%, with a prevalence of 4.1% for
BRCA2 mutations alone

Breast Cancer • In the years 1991, 1994 and 1997

Overview
 97% of incident cases of early breast cancer
Classification
underwent modified radical mastectomy
Pathophysiology
 18% had postoperative radiotherapy
Etiology
Epidemiology
 51% had adjuvant hormone treatment
 47% received adjuvant chemotherapy

Breast Cancer • Survival of incident cases in 1993 to 2002 was compared

Overview to that of Filipino-Americans and Caucasians
Classification
Pathophysiology
Etiology • Age-adjusted 5-year relative survival
Epidemiology  58.6% - Metro Manila residents
 89.6% - Filipino-Americans
 88.3% - Caucasians

Breast Carcinoma About

• Malignant condition
Differentials
Breast Cyst
Hamartoma Demographics
Duct Ectasia
• Most common diagnosed cancer amongst women
Fat Necrosis
• Leading cause of cancer death in women 40-49 years of
age

Breast Carcinoma Signs and Symptoms

• Breast mass with or without nipple discharge, no pain
Differentials
Breast Cyst • On breast exam: hard, immobile, and solitary mass with
Hamartoma irregular margins
Duct Ectasia • With or without skin changes
Fat Necrosis
Histopathology
• Molecular alterations in epithelial cells

Breast Carcinoma Diagnostics

• Mammography
Differentials
Breast Cyst
o Spiculated soft tissue mass with microcalcification
Hamartoma • Ultrasound
Duct Ectasia o Spiculated, hypoechoic lesion, shadowing, internal
Fat Necrosis calcification

Breast Carcinoma • Patient B.C. falls within the demographic of Breast CA
Differentials
Breast Cyst • Presentation of her CC resembles the characteristics of
Hamartoma Breast CA
Duct Ectasia
Fat Necrosis
• However there is a need to rule out similar conditions
that present with breast mass as not all are malignant
and may require less aggressive management


• Benign condition
Differentials
Breast Cyst • Simple cyst: no increased risk of malignancy
Hamartoma • Complicated cyst: <1% risk of malignancy
Duct Ectasia
• Complex cyst: <1% to 23% risk of malignancy
Fat Necrosis
Demographics
• Common among premenopausal, perimenopausal, and
postmenopausal women
• Also seen amongst HRT users


• Breast mass with or without pain, no nipple discharge
Differentials
Breast Cyst • On breast exam: solitary cluster of small masses or ill-
Hamartoma defined mass; smooth, firm, and frequently tender
Duct Ectasia • No skin changes
Fat Necrosis
Histopathology
• Non-proliferative breast lesions


• Ultrasound
Differentials
Breast Cyst
o Simple cyst: well-circumscribed, posterior acoustic
Hamartoma
enhancement without internal echoes
Duct Ectasia
o Complicated cyst: homogenous low-level internal
Fat Necrosis echoes due to without solid components
o Complex cyst: thick walls greater than 0.5 mm with
solid component
• Fine Needle Aspiration Biopsy (Biopsy)

Breast Carcinoma Rule In Rule Out

 Same demographic × Non-tender mass
Differentials  Breast mass
Breast Cyst  Ill-defined mass
Hamartoma  Firm
Duct Ectasia
Fat Necrosis
• This condition is benign but poses risk for malignant
conversion
• Differentiation from carcinoma is essential for
management
• Ultrasound and Biopsy will be required


Differentials
Breast Cyst • May co-exist with a breast malignancy
Hamartoma
Duct Ectasia
Demographics
Fat Necrosis
• Common in women older than 35 years of age


• Breast mass without pain, no nipple discharge
Differentials
Breast Cyst • On breast exam: soft breast lump, breast enlargement
Hamartoma without palpable mass
Duct Ectasia • With or without skin changes
Fat Necrosis
Histopathology
• Benign proliferation of fibrous, glandular, and fatty tissue
• Thin capsule of connective tissue


• Ultrasound
Differentials
Breast Cyst • Mammography
Hamartoma o well-described, discrete, solid, and encapsulated
Duct Ectasia lesion
Fat Necrosis


 Same demographic × Soft lump
Differentials  Asymptomatic × Breast enlargement without
Breast Cyst  Breast mass palpable mass
Hamartoma
Duct Ectasia
Fat Necrosis
• Also a benign condition that resembles breast CA in it’s

asymptomatic nature
• Essential to rule out for the purposes of management
• Ultrasound and Mammography are required


Differentials
Breast Cyst
Duct Ectasia
• Common among perimenopausal women
Fat Necrosis


• Breast mass with or without pain and nipple discharge
Differentials
Breast Cyst • On breast exam: unremarkable
Hamartoma • No skin changes
Duct Ectasia
Fat Necrosis
Histopathology
• Distention of subareolar ducts


• Ultrasound
Differentials
Breast Cyst
o dilated milk ducts or fluid-filled ducts
Hamartoma
Duct Ectasia
Fat Necrosis


 Same demographic × Breast pain
Differentials  Breast mass
Breast Cyst  Asymptomatic
Hamartoma
Duct Ectasia
Fat Necrosis
• Benign condition that can resolve spontaneously
• Differentiates from Breast CA as this mass is caused by
retention of fluid in the ducts rather than a cancerous
mass
• Ultrasound required


Differentials
Breast Cyst
Duct Ectasia
• Common amongst women
Fat Necrosis
• May mimic malignant features


• Breast mass with or without pain, no nipple discharge
Differentials
Breast Cyst • On breast exam: hard or soft mass, solitary and mobile
Hamartoma • No skin changes
Duct Ectasia
Fat Necrosis
Histopathology
• Collection of liquefied fat


• Ultrasound
Differentials
Breast Cyst
o Collection of liquefied fat
Hamartoma o Oil cysts
Duct Ectasia
Fat Necrosis


 Same demographic × Absence of recent surgery
Differentials  Breast mass, firm and hard × Absence of trauma
Breast Cyst × Mobile mass
Hamartoma
Duct Ectasia
Fat Necrosis
• Preceded by trauma or surgical manipulation of the

breast
• Mimics malignancy but is benign
• Ultrasound required

Mammography • Low-dose x-ray−based modality for imaging the breast

Ultrasound
MRI
Biopsy • Used both for screening of asymptomatic women or
diagnostic for symptomatic women (i.e. breast mass or
Complete Blood
nipple discharge)
Count
Chest X-ray (PA view)
• Sensitive to microcalcifications up to at less than 100 µm
Na, K, Crea
Random Blood Sugar
12 lead ECG • Mammography often detects a lesion before it is palpable
by clinical breast examination and up to 1 to 2 years
before noted by breast self-examination

Mammography 2015 ACS recommendations for women at average risk of breast

Ultrasound cancer are as follows:
MRI • regular screening mammography at age 45 years
Biopsy • aged 45-54 years should be screened annually
• 55 years and older should transition to biennial screening or
Complete Blood have the opportunity to continue screening annually
Count
Chest X-ray (PA view) • begin annual screening at 40-44 years of age
Na, K, Crea • continue screening mammography as long as their overall
Random Blood Sugar health is good and they have a life expectancy of 10 years or
12 lead ECG
longer
• Clinical breast examination is not recommended for breast
cancer screening in average-risk women at any age

Mammography • Useful adjunct to mammography

Ultrasound
MRI
• Generally employed to assist in the clinical examination of a
Biopsy
suspicious lesion detected on mammography or physical
examination
Complete Blood
Count
Chest X-ray (PA view) • However, as a screening tool, ultrasonography is limited by a
Na, K, Crea number of factors, most notably its failure to detect
Random Blood Sugar microcalcifications and its poor specificity (34%)
12 lead ECG
• Also useful in the guidance of biopsies and therapeutic
procedures

Mammography • Explored as a modality for detecting breast cancer in

Ultrasound women at high risk and in younger women
MRI
Biopsy
• A combination of T1, T2, and 3-D contrast-enhanced MRI
Complete Blood techniques has been found to possess high sensitivity
Count (approximating 86-100% in combination with
Chest X-ray (PA view) mammography and clinical breast examination) to
Na, K, Crea malignant changes in the breast
Random Blood Sugar
12 lead ECG

Mammography Indications
Ultrasound • Characterization of an indeterminate lesion after a full assessment with
MRI physical examination, mammography, and ultrasonography
Biopsy • Detection of occult breast carcinoma in a patient with carcinoma in an
axillary lymph node
Complete Blood
• Evaluation of suspected multifocal or bilateral tumor
Count • Evaluation of invasive lobular carcinoma, which has a high incidence of
Chest X-ray (PA view) multifocality
Na, K, Crea • Evaluation of suspected extensive high-grade intraductal carcinoma
Random Blood Sugar • Detection of occult primary breast carcinoma in the presence of
12 lead ECG
metastatic adenocarcinoma of unknown origin
• Monitoring of the response to neoadjuvant chemotherapy
• Detection of recurrent breast cancer

Mammography Contraindications
Ultrasound
• Contraindication to gadolinium-based contrast media
MRI
(eg, allergy or pregnancy)
Biopsy
• Patient’s inability to lie prone
Complete Blood • Marked kyphosis or kyphoscoliosis
Count
Chest X-ray (PA view) • Marked obesity
Na, K, Crea • Extremely large breasts
Random Blood Sugar
• Severe claustrophobia
12 lead ECG

Mammography • Percutaneous vacuum-assisted large-gauge core-needle biopsy

Ultrasound (VACNB) with image guidance is the recommended diagnostic
MRI approach for newly diagnosed breast tumors
Biopsy
• Core biopsies can minimize the need for operative intervention
Complete Blood (and subsequent scarring, and provide accurate pathologic
Count diagnosis for appropriate management
Na, K, Crea • Excisional biopsy, as the initial operative approach, has been
Random Blood Sugar shown to increase the rate of positive margins
12 lead ECG
• Open excisional biopsy is reserved for lesions where the

diagnosis remains equivocal despite imaging

Mammography • In patient’s case, a core biopsy was taken and was

Ultrasound diagnosed as a
MRI
• Low grade infiltrating ductal carcinoma with
Biopsy positive estrogen and progesterone receptors
and positive HER 2 (3 + )
Complete Blood
Count
Na, K, Crea
Random Blood Sugar
12 lead ECG

Mammography • For surgical clearance

Ultrasound
MRI
Biopsy
Complete Blood
Count
Chest X-ray (PA
view)
Na, K, Crea
Random Blood
Sugar
12 lead ECG

• Initial clinical approach is dependent on

the ovulatory and menopausal status
of the patient
• Mammography is done primarily to rule

out occult abnormalities in the
noninvolved tissue, and not to rule out
carcinoma
• FNA is often used when a mass can be

palpated to distinguish a cyst from a
solid mass (if FNA or FNAB is done
before mammography or ultrasound, a
2-week interval should be allowed)

• While and ultrasound can distinguish a

cyst from a solid mass, FNA is the
preferred method when a mass is
palpable because the procedure is
both diagnostic and therapeutic
• FNA frequently establishes the

etiology of a cyst as benign, provides
pain relief in a symptomatic cyst
• This method also allows expedient

diagnosis in the office setting, which, in
some cases, relieves anxiety for the
patient

• If FNA reveals a solid mass, further

investigation is warranted
• For premenopausal women, the first step is to

examine the patient at the follicular phase of
her ovarian cycle
• If the mass persists, referral for evaluation and

possible open biopsy should be considered
• Masses can resolve with time; therefore, it is

acceptable to follow the patient at 3-month
intervals if the area is likely to be benign
• If a mass persists after 3 months, the patient

should be referred to a surgeon for evaluation

• To lower the risk of missing a

cancerous mass in the absence of an
open biopsy, the principles of "triple
diagnosis" are recommended
• This is the application of 3

simultaneous steps in evaluating a
breast mass: clinical assessment by
palpation, by mammography, and by
FNAB
• If the mass is "suspicious" by any

one of these methods, open biopsy
is warranted

Surgical • May consist of lumpectomy or total mastectomy

Medical
• If with clinically negative nodes, surgery typically includes

sentinel lymph node (SLN) dissection for staging the
axilla

Surgical Lumpectomy Margins:

Medical
• Positive margins are associated with at least a 2-fold
increase in ipsilateral breast tumor recurrence (IBTR)
• Negative margins optimize IBTR
• IBTR rates are reduced with the use of systemic therapy;


Surgical • Systemic Adjuvant Therapy

Medical
• Combination Regimen
• Neoadjuvant Therapy
• Targeted Chemotherapy

Surgical Systemic Adjuvant Therapy

Medical
• Taxanes
• Anthracyclines
• Pertuzumab
• Ado-trastuzumab emtansine
• Trastuzumab
• Tamoxifen
• Aromatase inhibitors (AIs)

Targeted Chemotherapy in Early Stage BC

• Cyclin-dependent kinase (CDK) inhibitors
• Small-molecule epidermal growth factor receptor (EGFR) tyrosine

kinase inhibitors (TKIs)
• Blockade by antiangiogenic agents
• PI3K/Akt/mammalian target of rapamycin (mTor) inhibitors
• Poly(adenosine diphosphate [ADP] ̶ ribose) polymerase (PARP)

inhibitors]

Surgical • Tamoxifen and raloxifene, are approved for reduction

Medical of breast cancer risk in high-risk women
• Tamoxifen use for 5 years reduces risk of breast cancer

for at least 10 years in premenopausal women,
particularly ER-positive invasive tumors
• Women 50 years or younger have few adverse effects

with tamoxifen, and vascular/vasomotor adverse effects
do not persist after treatment

Surgical • Tamoxifen and raloxifene are equally effective in

Medical reducing the risk of ER-positive breast cancer in
postmenopausal women
• Raloxifene is associated with lower rates of

thromboembolic disease, benign uterine conditions, and
cataracts than tamoxifen is
• Evidence does not allow determination of whether either

agent decreases mortality from breast cancer

Surgical ASCO guidelines recommend the following:

Medical
• For premenopausal or postmenopausal women with

increased risk for breast cancer, offer tamoxifen (20
mg/day for 5 years) to reduce the risk of invasive ER-
positive breast cancer
• In postmenopausal women, raloxifene (60 mg/day

for 5 years) may also be considered

Surgical ASCO guidelines recommend the following:

Medical
• Off-label use of Exemestane (25 mg/day for 5 years)

should be discussed as an alternative to reduce the risk
in postmenopausal women
• All 3 agents should be discussed (including risks and

benefits) with women aged 35 years or older without a
personal history of breast cancer who are at increased
risk of developing invasive breast cancer

SURGERY +
ADJUVANT THERAPY
Surgical
WITH • The definitive treatment
MONOCLONAL
ANTIBODIES AND • Schedule simple mastectomy and sentinel node
ENDOCRINE
THERAPY
biopsy
• Results:
• Surgical specimen showed a tumor of 2.2 × 1.9 cm which
was 0.4 cm from the nearest surgical margin
• It was heterogeneous, gelatinous, white-grayish, with
lobulated margins and firm

SURGERY +
ADJUVANT THERAPY
Medical
WITH • Start patient on Trastuzumab 4 mg/kg on initial
MONOCLONAL
ANTIBODIES AND dose via infusion over 90 min followed by 2 mg/kg
ENDOCRINE via infusion over 30 min wkly for 1 yr or until
THERAPY
disease recurrence.
• Start patient on Pertuzumab 840 mg on initial
dose via infusion over 60 minutes. Maintenance:
420 mg over 30-60 minutes once every 3 weeks
• Start patient on Tamoxifen 20mg/day PO for 5
years for reduction of breast cancer recurrence.



• Surgical specimen showed a tumor of 2.2 × 1.9 cm which

was 0.4 cm from the nearest surgical margin
Conclusion • It was heterogeneous, gelatinous, white-grayish, with

lobulated margins and firm

• Microscopically, the tumor showed multiple large lakes

of extracellular mucin; inside them numerous tumor cells
of medium to large size, with scant moderate amount of
eosinophilic cytoplasm were found
Conclusion
• Patient was given adjuvant hormonal therapy of

tamoxifen for 5 years and trastuzumab IV and
pertuzumab IV because of positivity for ER/PgR
receptors and expression of HER2

References • Laudico, Adriano & Redaniel, Maria Theresa & Lumague,

Maria Rica & Mapua, Cynthia & Uy, Gemma & Pukkala, Eero
& Pisani, Paola. (2009). Epidemiology and clinicopathology of
breast cancer in Metro Manila and Rizal Province, Philippines.
Asian Pacific journal of cancer prevention : APJCP. 10. 167-72.
• https://
emedicine.medscape.com/article/1947145-guidelines#g2
• Harrison’s 20th Edition
• Her-2 positive mucinous carcinoma breast cancer, case
report //https
://www.ncbi.nlm.nih.gov/pmc/articles/PMC5752214/?fbclid=I
wAR0NoQ-VGFWGurHkxelbaPKAi16HX9ZjBNOn-6NcXsAIWot
G-_

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Breast Cancer (Internal Med)

History About Diagnosis Work-up Management

Overcome through courage

Breast Cancer (Internal Med)

History About Diagnosis Work-up Management

• Discuss breast cancer

• Outline the differential diagnosis for this case

• Discuss the work-ups to be requested

• Administer proper care and management to our patient

Breast Cancer (Internal Med)

History About Diagnosis Work-up Management

Breast Cancer (Internal Med)

History About Diagnosis Work-up Management

1 week PTA Day of Admission

Breast Cancer (Internal Med)

History About Diagnosis Work-up Management

Breast Cancer (Internal Med)

History About Diagnosis Work-up Management

Breast Cancer (Internal Med)

History About Diagnosis Work-up Management

• Prostatic cancer – paternal uncle

Breast Cancer (Internal Med)

History About Diagnosis Work-up Management

• Lives together with family (daughter, sister, and mother)

Case • Denies smoking

Breast Cancer (Internal Med)

History About Diagnosis Work-up Management

Breast Cancer (Internal Med)

History About Diagnosis Work-up Management

Breast Cancer (Internal Med)

History About Diagnosis Work-up Management

Breast Cancer (Internal Med)

History About Diagnosis Work-up Management

Breast Cancer (Internal Med)

History About Diagnosis Work-up Management

Breast Cancer (Internal Med)

History About Diagnosis Work-up Management

Breast Cancer (Internal Med)

History About Diagnosis Work-up Management

Breast Cancer (Internal Med)

History About Diagnosis Work-up Management

Breast Cancer (Internal Med)

History About Diagnosis Work-up Management

Breast Cancer (Internal Med)

History About Diagnosis Work-up Management

Breast Cancer (Internal Med)

History About Diagnosis Work-up Management

CHEST & LUNGS

Breast Cancer (Internal Med)

History About Diagnosis Work-up Management

Breast Cancer (Internal Med)

History About Diagnosis Work-up Management

Breast Cancer (Internal Med)

History About Diagnosis Work-up Management

Breast Cancer (Internal Med)

History About Diagnosis Work-up Management

Breast Cancer (Internal Med)

History About Diagnosis Work-up Management

Breast Cancer • A cancer that develops from breast tissue

• Signs of distant spread may include bone pain, enlarged

Breast Cancer (Internal Med)

History About Diagnosis Work-up Management