Breast Cancer

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Breast Cancer

• Radiation Oncology II
• 4412

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History

• Recorded 5000 years ago
• Before 20th century-William Halstead performed
  radical mastectomy
• Today we use multidisciplinary approach
• Radiation therapy
• Chemotherapy
• Hormone therapy
• Surgery

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Epidemiology

• Most common malignancy in women
• Second major cause of death (lung 1)
• Men can get breast cancer

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Risk Factors

• Dont have to have risk factors to get breast
  cancer
• Gender- women out number men
• Age- older women/higher probability
• Incidence rises steadily during the reproductive
  years after age 30
• Family history
• Mothers/sisters/daughters doubles the risk

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• According to the ACS
• Although smoking and breast cancer does not have
  a direct link, smoking increases the risk for
  other cancers and affects the overall health of a
  person
• Research does not show a link between breast
  cancer and pollutants. Research is ongoing
• Diet has been inconclusive as a risk factor for
  breast cancer. Diet and weight are risk factors
  for other types of cancers

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BRCA 1 and 2

• The gene BRCA 1 2 is associated with 5 to 8 out
  of 10 women have a likelihood of developing
  breast cancer
• We all have these genes
• These genes become defective

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• BRCA1 is a human tumor suppressor gene that
  produces a protein called breast cancer type 1
  susceptibility protein.
• Originally stood for Berkeley California as this
  was where it was first discovered in 1990.
• This gene was later cloned in 1994 by scientists
  at Myriad Genetics.

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• BRCA1 is expressed in the cells of breast and
  other tissue
• It helps repair damaged DNA or destroys cells if
  DNA cannot be repaired.
• When BRCA1 becomes damaged, damaged DNA is not
  repaired properly and this increases the risks
  for cancer.

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• Certain variations of the BRCA1 gene lead to an
  increased risk for breast cancer.
• Researchers have identified hundreds of mutations
  in the BRCA1 gene, many of which are associated
  with an increased risk of cancer.

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• Women with an abnormal BRCA1 or BRCA2 gene have
  up to an 60 risk of developing breast cancer by
  age 90
• Increased risk of developing ovarian cancer is
  about 55 for women with BRCA1 mutations and
  about 25 for women with BRCA2 mutations

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Prognostic Indicators

1. Lymph node involvement
2. Most significant aspect of staging
3. Higher number of involved nodes increases
   recurrence and decreases survival
4. Usually 10 axillary nodes are evaluated
5. lt3 low risk
6. gt4 high risk
7. gt10 extremely poor prognosis
8. Involvement of internal mammary nodes, lower
   survival

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• 2. Tumor Extent
• Lesions lt0.5 cm 5 year survival
• gt0.5 cm 82 5 year survival
• 3. Histology
• 1. Ductal carcinoma in situ
• Most common non-invasive breast cancer
• Non-invasive
• Nearly all women can be cured

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Ductal Carcinoma in Situ
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• 2. Infiltrating ductal carcinoma
• Most common invasive breast cancer
• Starts in the milk passage or duct
• Invades fatty tissue of breast
• Can spread

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Infiltrating Ductal Carcinoma
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• 3. Infiltrating (invasive) lobular carcinoma
• Starts in the milk glands or lobules
• Spreads
• Usually found in 1 out of 10 cases

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Infiltrating Lobular Carcinoma
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• Lobular carcinoma in situ
• This increases the risk of cancer later
• Patient needs an exam 2-3 times per year
• Mammography every year

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Lobular Carcinoma in Situ
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• Inflammatory carcinoma
• Extremely poor prognosis
• Breast tenderness
• Breast enlargement
• Peau dorange appearance
• Erythema
• Warmth

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Inflammatory Breast Cancer
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Staging

• Staging system is TNM
• Patients are staged for
• The selection of proper treatment
• Evaluation of treatment methods
• Indicates prognosis
• Two methods of staging
• 1. clinical
• Physical workup, operative findings, pathology
• 2. pathological
• Microscopic assessment of the tumor margin

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Diagnosis

• Estrogen and progesterone receptor status
• Tissues are examined for the effects of hormones
  on the cells
• Indicates the potential response to hormonal
  therapy
• Receptor positive patients are more likely to
  respond to hormonal therapy
• Receptor positive tumors usually have a better
  outcome

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Survival (Prognosis)

• Overall 5 year survival after first diagnosis is
  approx. 96
• Regional spread 75
• Distant mets at time of diagnosis 20
• Patients can relapse up to 20 years or more after
  treatment
• Few options for treatment are available after
  relapse

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Anatomy

• Lymphatic drainage
• 1. superficial
• Drains the skin covering the breast
• 2. deep
• Drains the internal breast tissues

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• Three groups of nodes in the breast
• 1. axillary lymph nodes
• Primary deep lymphatic drainage of the breast
• Between 10 38 lymph nodes are in each axilla
• 2. internal lymph nodes
• Located near the edge of the sternum
• Embedded in the fat in the intercostal spaces
• Approx. 4 per side
• 3. supraclavicular nodes
• Lymphatic drainage from the breast to the
  supraclavicular nodes, liver and contralateral
  internal mammary nodes

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Sites of Origin

• The breast is divided into quadrants
• Upper outer
• Upper inner
• Lower outer
• Lower inner
• Most breast cancers will arise in the upper outer
  quadrant- more breast tissue
• Multicentric describes tumors that appear in
  several areas of the breast

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Spread

• Breast cancer tends to grow
• Locally
• Involves the ducts and adjacent tissues
• May spread to local and regional lymphatics
• Involvement of axillary lymph nodes occurs
  orderly and progressively
• Recurrence
• Local recurrence (in the breast)
• Regional recurrence (lymphatics)
• Distant metastatic sites

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• Axillary and internal mammary lymph nodes are the
  most likely sites of regional involvement of
  breast cancer.

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• Distant metastasis
• Bone
• Brain
• Liver
• Lung
• Eyes
• Ovaries
• Adrenal and pituitary glands

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Detection

• With early detection breast cancer is one of the
  most curable malignant diseases.
• Three step health program
• 1. monthly self exam- begin in the early 20s

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• 2. Annual clinical exam- 20s 30s every 3
  years, beginning 40 yrs/age, every year
• 3. Routine mammogram- as recommended by
  established guidelines- right now it is every
  year for women 40 and older

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• Most breast changes are benign
• Approx. 20 of all masses will be malignant
• Most common sign will be a painless lump, usually
  hard with uneven edges
• BUT
• Some can be tender, soft and round

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Other Detection Methods

• Ultrasound- used in addition to mammography-
  distinguished between cystic and solid masses
• Thermography- produces an image of the
  temperature of the overlying skin of the breast.
  The tumor produces heat
• PET
• Bone scan- mets

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• MRI used for women with silicone breast implants,
  extremely dense tissue or changes in breast
  tissue secondary to radiation therapy
• CT- used for mets
• Ductogram (galactogram) fine plastic tube is
  placed into the opening of the duct at the
  nipple. Dye is injected to show masses in the
  duct with x-ray. Fluid can be withdrawn for
  pathology.

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Monthly Self Exam Step One
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Step Two and Three
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Step Four
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Step Five
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Biopsy

• A biopsy is the only way to know for sure that
  there is cancer
• Fine needle biopsy- small gauge needle is placed
  into the breast tissue mass. Blood and suspicious
  tissue is evacuated out and placed on slides.
• Core needle biopsy- partial removal of breast
  mass
• Excisional biopsy (lumpectomy) removal of the
  entire mass with or without a portion of
  surrounding normal tissue.

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Pathology

• Two basic methods are used for obtaining
  pathological information
• 1. gross examination- records the dimensions of
  the specimen, the size of the tumor, and tumors
  relationship to the excisional margin
• 2. microscopic examination- examines the specimen
  under the microscope for tumor histology

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• Biopsy samples look for hormone receptors
• ER positive- Estrogen
• PR positive- Progesterone
• These will respond to hormonal therapy which
  leads to a better prognosis

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TREATMENT
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1. Surgery

• Radical mastectomy
• Removal of the breast with overlying skin
• Removal of the axillary lymph nodes
• Removal of the pectoralis major and minor muscles
• Modified radical mastectomy
• Removal of the breast with overlying skin
• Removal of some or all of the axillary lymph
  nodes
• Pectoralis minor muscle might be removed
• Pectoralis major muscle is left intact

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• Lumpectomy
• Removal of the tumor with a margin of normal
  appearing tissue
• Lymph nodes are sampled through a separate
  axillary incision
• Axillary dissection
• Removal of a sample of axillary lymph nodes on
  the side of the affected breast (staging)

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Lumpectomy
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Skin Sparing Mastectomy
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Modified Radical Mastectomy
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Total (Simple) Mastectomy
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Radical Mastectomy
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2. Chemotherapy(Systemic Drug Therapy)

• Used to destroy, prevent or delay tumor spread
  to distant sites in the body.
• Used alone or in combinations
• Examples
• Cyclophosphamide (C)
• 5-fluorouracil (F)
• Methotrexate (M)
• Adriamycin (doxorubicin) (A)
• Vinblastine
• Mitoxantrone
• Mitomycin C
• Tamoxifen

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Chemotherapy contd

• Endocrine therapy
• Deprives cancer cells of the hormones needed for
  growth

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3. Radiation Therapy

• There are as many techniques for breast
  irradiation as there are radiation oncology
  centers!
• Breast set-ups are technically challenging
• Have to have straightforward, reproducible
  techniques

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• Positioning and immobilization
• Patients affected arm must be mobile before sim
  and treatments are begun
• Patients affected arm must be immobile for day
  to day set ups
• Patient disrobes from waist up
• Clothes, sheets, other articles can keep patient
  from laying flat and straight on the treatment
  table

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• Body must be straight (in the sagittal plane)
• Stand at head of table and look straight down
  patients body. Use the sagittal laser to help.
• Body must be level from side to side
• Levelers (tattoo or marks) on patients side help
• Patients contralateral arm should rest on the
  table top with palm down

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• If patients hand is on abdomen or grasping a
  belt, this can result in distortion of the
  thoracic anatomy.
• Will cause rotation and/or displacement of the
  uninvolved breast in the treatment field
• The patients involved arm is raised and
  supported far enough in a cephalad direction
• Avoids treating upper arm
• Can help reduce or eliminate skin folds in the
  axilla and supraclavicular areas

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• When treating breast or chest wall- patients
  head should be straight
• When treating peripheral lymphatics- head will be
  turned
• Feet held together- keeps patient from crossing
  feet and rotating the lower abdomen
• Patients with large and/or pendulous breasts
  often have breast tissue displaced up into the
  infra clavicular area

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• Patients with large or pendulous breasts can be
  placed on a slant board
• Helps to keep the head and thorax elevated
  relative to their pelvis and lower extremities
• Keeps breast tissue in a more normal location
• Helps to alleviate the problem of deep skin folds
  in the supraclavicular area

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Different Radiation Techniques

• BREAST TANGENTS
• Wedges are used for dose homogeneity
• Bolus is not usually recommended to intact
  breast- skin is not at risk for recurrence
• Usually 4680-5040 cGy 180/200 per fraction
• Tumor bed boosted to a total of 6000-6600 cGy
• SUPRACLAVICULAR- 4680 cGy 180/fraction
• PAB- can be added to bring midline axillary dose
  to 4680 cGy

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• Intact Breast or Chest Wall
• Women who require only breast or chest wall
  irradiation are treated with tangential
  (glancing) fields
• This maximizes coverage of the tissues at risk
• Minimizes the radiation dose to underlying
  structures, primarily heart and lung
• Usually use lower energies
• Feet are directed away from the collimator to
  correct for geometrical distortion of the
  radiation beam
• Isocentric technique is preferred

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• Supraclavicular field
• Portal is angled 10-15 degrees to prevent
  exposure of the spinal cord and esophagus
• The supraclavicular field is planned before the
  tangential fields.
• This field is used with patients who usually have
  4 or more positive axillary nodes or
  extracapsular extension

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• Posterior Axillary Boost field (PAB)
• Usually used to increase the mid-axillary dose to
  the prescribed level
• The dose from the anterior supraclavicular field
  may be insufficient
• Setup parallel opposed to the supraclavicular
  field
• Uses the identical inferior margin, preserving
  the vertical straight edge

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• Internal mammary lymph nodes
• Small percent of patients may be at risk for
  internal mammary node involvement
• Electron beam treatment is used
• Treats the nodes but gives a high skin dose

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• Breast boost
• To the tumor bed after completion of tangential
  irradiation
• Delivered with electrons or implant
• The location and length of scar does not
  accurately reflect the position and size of the
  tumor bed
• Clips placed on tumor bed at the time of surgery
  can help with localization

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Skin Reactions

• Skin folds tend to intensify skin reactions,
  bolus effect
• Keep area clean and dry
• Avoid sun exposure to affected area
• Use cornstarch
• Do not shave under affected arm

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• Discourage use of lotions, creams, deodorants,
  powders in treatment areas, may contain perfumes,
  alcohol or metals
• Use soft and loose fitting clothing
• Avoid hot water bottles, ice packs, heating pads
  in area of treatment
• Cornstarch should not be used with moist
  desquamation, can cause fungal growth and wound
  infection

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• Skin doses
• 30 Gy erythema, dryness
• 40 Gy dry desquamation, flaking of skin,
  especially in skin folds
• 50 Gy moist desquamation, complete break down of
  skin. Patient may need to take a break from
  treatment for some healing of the skin.

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