Management of Breast Disease

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Management of Breast Disease

• Joseph A. Lucci III, M.D.
• Department of Obstetrics and Gynecology
• Division of Gynecologic Oncology

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Breast Disease
Role of Primary Care Physician

• Reproductive Health
• Diagnosis
• Treatment
• Cancer Screening

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Breast Anatomy
COMPONENTS

• Skin
• Fat
• Gland
• Connective Tissue
• Vessels

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Breast Anatomy
TOPOGRAPHY

• Body
• Tail
• Nipple Complex

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Breast Anatomy
GLAND

• 10 20 Ducts
• Duct Drains Lobe
• Lobe Contains 20 40 Lobules
• Lobule Contains 10 100 Alveoli

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Breast Anatomy
FASCIAL SUPPORT

• Campers Fascia
• Pectoral Fascia
• Coopers Ligaments

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Breast Anatomy
VASCULATURE

• ARTERIAL
• Internal Mammary
• Lateral Thoracic
• LYMPHATICS
• Drainage
• Nodal Levels

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Breast Anatomy
NODAL LEVELS

• Level I Lateral Pectoralis Minor
• Level II Deep Pectoralis Minor
• Level III Medial Pectoralis Minor

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Breast Cancer Location
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Components of Appropriate Screening Program

• Professional Physical Examination
• Breast Self Examination (BSE)
• Mammography

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Breast Exam
SITTING POSITION

• OBSERVE
• Mass Effect
• Arm Position
• PALPATE
• Breast
• Nodes

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Breast Exam
LYING POSITION

• Positioning
• Palpation
• Discharge

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Breast Disease
Nipple Discharge 432 Patients

• Benign 88
• Malignant 12

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Nipple Discharge

• Galactorrhea
• Intraductal papilloma
• Duct ectasia
• Carcinoma

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Screening RecommendationsProfessional Breast Exam
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Screening RecommendationsBreast Self Exam (BSE)

• Recommended monthly for all women over the age of
  20

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Breast Disease
IMAGING

• MAMMOGRAPHY
• 2 Views
• Magnification
• ULTRASOUND

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Carcinoma
Tabar L, Dean P. Teaching atlas of mammography.
2nd ed. New York, New York Thieme Inc 198591.
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Comedo Carcinoma
Dean P. Teaching atlas of mammography. New York,
New York Thieme Inc 1985168
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Ductal Carcinoma
Tabar L, Dean P. Teaching atlas of mammography.
2nd ed. New York, New York Thieme Inc. 1985169
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Breast CancerMammographic Screening
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Absolute Indicationsfor Breast Biopsy

• Biopsy any suspicious palpable lesions.
• Biopsy any suspicious area seen on mammogram, but
  not palpable

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Breast Mass Presumed Benign
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FIBROCYSTIC CHANGES

• 50 80 of all women
• Etiology
• Diagnosis
• Treatment

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FIBROCYSTIC CHANGESDiagnosis

• Palpation
• Mammography
• Ultrasound
• Aspiration
• Biopsy

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Fibrosystic Changes
TREATMENT

• OCPS
• Methylxanthines
• Nicotine
• Vitamin E
• Hormones
• Bromocriptine

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Fibrosystic Changes
CANCER RISK

• Extent of Proliferative Changes
• Variable

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Proliferative Breast Disease
CANCER RISK
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Sclerosing Lesions

• Fibrocystic Changes
• Small, Irregular
• Resembles CA
• DX FNA
• TX Excision

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Sclerosing Duct Hyperplasia
Tabar L, Dean P. Teaching atlas of mammography.
2nd ed. New York, New York Thieme Inc. 1985106
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Adenoma

• Age 20 30 yrs
• Groups
• Tubular
• Lactating
• DX FNA
• TX Observe, Excision

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Fibro-adeno-lipoma
Tabar L, Dean P. Teaching atlas of mammography.
2nd ed. New York, New York Thieme Inc. 198525
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Lipoma
Tabar L, Dean P. Teaching atlas of mammography.
2nd ed. New York, New York Thieme Inc. 198521
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Fibroadenoma

• Age 20 49 yrs
• Firm, Painless
• Bilateral 15 25
• DX FNA
• TX Observe, Excise

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Fibroadenoma
Tabar L, Dean P. Teaching atlas of mammography.
2nd ed. New York, New York Thieme Inc. 1985200
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Phylloides Tumor

• Age 30 55 yrs
• Slow Growing
• Epithelial and Stromal
• 10 Sarcoma
• DX FNA
• TX Excision

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Cystosarcoma Phylloides
Tabar L, Dean P. Teaching atlas of mammography.
2nd ed. New York, New York Thieme Inc. 198563
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Intraductal Papilloma

• Age 45 50 yrs
• Bloody Discharge
• Unilateral, small
• TX Excision
• CA Risk Rare, Multiple Lesions

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Intraductal Papilomatosis
Tabar L, Dean P. Teaching atlas of mammography.
2nd ed. New York, New York Thieme Inc. 1985192
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Intraductal Papillomatosis
Tabar L, Dean P. Teaching atlas of mammography.
2nd ed. New York, New York Thieme Inc. 198548
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Ductal Ectasia

• Age Perimenopausal
• Bilateral
• Sticky, Thick, Green Discharge
• DX Exam
• TX ABX, Excision
• CA Risk Rare

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Breast CancerUS Statistics, 2000

• 182,800 new cases in women
• 40,800 deaths in women
• 18 women will develop breast cancer in lifetime

Greenlee et al, CA Cancer J Clin 2000, 507-33
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Cancer Incidence 1998
Cancer Facts and Figures ACS, 1998
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Breast CancerFive Year Survival (1989-95)
Greenlee et al, CA Cancer J Clin 2000, 507-33
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Breast Cancer

• Incidence has plateaued since 1987
• Mortality rates have been stable or declining
• 5 year survival for localized disease has improved

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Presentation of Breast Cancer(744 Patients)
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Breast Cancer
RISK FACTORS

• Sex
• Parity
• Menses
• Socioeconomic
• Race
• Diet
• Weight

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Breast Cancer Risk AssessmentModified Gail Model

• Age
• Family history of breast cancer
• Age at first live birth, if any
• Number of breast biopsies
• History of atypical hyperplasia
• Age at menarche
• Race

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Breast CancerFamily History
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Breast Cancer Risk Factors
based on data from Collaborative Group on
Hormonal Factors in Breast Cancer. Lancer. 1997
350-1047.
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Breast Cancer
DECREASED RISK

• Early Pregnancy
• Castration
• Exercise
• Avoid ETOH

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Chemical Structure of Estradiol and Selected SERMs
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BCPT Design Schema
Eligible Women at High Risk (5-yr risk 1.66 or
age over 60)
Randomization n 13,388
Tamoxifen 5 years n 6681
Placebo 5 Years n 6707
Fisher et al. J Natl Cancer Inst 1998
901371-1388.
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BCPT Objectives

• Primary End Point
• Incidence of invasive breast cancer
• Secondary End Points
• Breast cancer mortality
• Incidence of cardiovascular events
• Incidence of bone fractures

Fisher et al. J Natl Cancer Inst 1998.
901371-1388
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BCPT Results Invasive Breast Cancer
Fisher et al. J Natl Cancer Inst 1998
901371-1388
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BCPT Results Invasive Breast Cancer Cases by
Previous Pathology
Not statistically significant Fisher et al. J
Natl Cancer Inst 1998901371-1388
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Tamoxifen Chronic Effects NSABP P-1
Per 1000 Women/Yr
Tamoxifen
Placebo
Fisher et al. J Natl Cancer Inst 1998
901371-1388.
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Endometrial Cnacer NSABP P-1
Rate Per 1000/Yr
Number
Tamoxifen
Tamoxifen
Placebo
Placebo
Event
Fisher et al. J Natl Cancer Inst 1998
901371-1388.
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BCPT QOL Symptoms Reported at Least Once Over 36
Months
Day et al. J Clin Oncol 1999. 17(9)2659-2669
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More study
Postmenopausal women With osteoporosis (n 7704)
Raloxifene 60 mg/d
Raloxifene 120 mg/d
Palcebo
Cummings SR et al. Proc Am Soc Clin Oncol.
199817-2a
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Raloxifene and Breast CancerPrevention Trials

• MORE Trial
• Breast Cancer risk not specifically addressed at
  entry
• 70 reduction at 33 months
• 9 trials 10,575 patients
• Mean follow-up 40 months
• 67 breast cancer events
• 55 reduction in relative risk

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Carcinoma
Tabar L, Dean P. Teaching atlas of mammography.
2nd ed. New York, New York Thieme Inc. 198595
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Breast Cancer
STAGING

• Evaluation
• HP
• CXR
• Bone Scan
• Labs
• TNM

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Breast Cancer
TREATMENT

• Surgery
• Radiation
• Chemotherapy
• Hormones

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Breast Cancer
SURGICAL THERAPY

• In SITU
• Location
• Tumor Size
• Breast Size
• Patient Age
• Patient Preference
• Mammographic Appearance

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Breast Cancer
SURGICAL THERAPY

• Breast Conservation
• Lumpectomy
• Sentinal Node(s)
• Modified Radical Mastectomy and Papillary Node
  Disection

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Breast Cancer
PROGNOSTIC FACTORS

• Size
• Nodes
• Stage
• Grade
• Ploidy
• S Phase
• Necrosis
• HER-2/neu

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Breast Cancer
ADJUVANT THERAPY

• Premenopausal Chemo
• Postmenopausal Hormones

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Breast Cancer
CHEMOTHERAPY

• Regimens
• CMF
• CAF
• AC
• 6 12 Cycles

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Breast Cancer
RADIOTHERAPY

• All Breast Concerving Surgical Therapies
• High Risk Patients
• When
• After Chemo
• Middle of Chemo

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Breast Cancer
HORMONE THERAPY

• Tamoxifen x 5 years
• All Patients
• Ovarian Ablation

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Breast Cancer Survival Rate According to AJCC
Stage