tubal.tuliao.umag.uy.valencia.verde.villanueva.vizconde.wee.wylengco.zapanta

1

Breast Cancer
the case of a 53 year old menopausal female from
novaliches, quezon city
tubal.tuliao.umag.uy.valencia.verde.villanueva.viz
conde.wee.wylengco.zapanta
2
HISTORY
3
CC

• Solitary, hard, non-tender breast mass, Right
  Lower Outer Quadrant
• Non-Neoplastic
• Fat Necrosis
• Fibroadenoma
• Chronic Breast
• Abscess
• Neoplastic

Breast Mass, Right
HISTORY
Breast Mass, Right
HPI
1 Month PTA
Patient palpated a mass on her right breast about
the size of a small marble located on the Lower
Outer Quadrant (-) tenderness, discharge or
erythema
Patient palpated a mass on her right breast about
the size of a small marble located on the Lower
Outer Quadrant (-) tenderness, discharge or
erythema
4
HISTORY
In the Review of Systems, try to elicit the
following SSx of Metastasis Bone
pain Shortness of breath Lack of
appetite Weight loss Neurological pain or
weakness, headaches
On Examination of the Breast, take note of the
following Mass Size Consistency Mobility Di
scharge Skin changes Erythema
Induration Skin Dimpling Nipple
Retraction
5
HISTORY
ROS
No weight loss, loss of appetite No headache,
vomiting No dyspnea, difficulty of breathing No
chest pain, orthopnea No palpitations, PND No
abdominal pain, diarrhea, constipation No
dysuria, frequency, urgency No edema, cyanosis
PMHx
(-) DM, HTN, PTB, Asthma No previous surgery
FMHx
(-) History of Breast Cancer
PSHx
Non-smoker, non-alcoholic drinker
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PHYSICAL EXAMINATION
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Findings
Conscious, coherent, ambulatory Pink
palbebral conjunctivae, anicteric sclerae (-)
NAD, TPC, CLAD Right Breast Pendulous breast
with 2x2cm mass, non-tender, fixed, hard, (-)
discharge, orange-peel (-) palpable right
axillary lymph nodes Left Breast Unremarkable
PHYSICAL EXAMINATION
BP 100/70 mmHG Normotensive
CR 89 beats/min Normal
RR 14 breaths/min Normal
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PHYSICAL EXAMINATION
Findings
SCE, (-) retractions, resonant, CBS, (-)
crackles, wheezes AP, NRRR, no murmur, AB at 5th
ICS, LMCL Flabby abdomen, NABS, soft, non-tender,
liver and spleen not enlarged (-) pallor,
cyanosis, edema DRE unremarkable
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PHYSICAL EXAMINATION
Rule In Rule Out
Fat Necrosis Solitary nontender firm mass (-) Hx of Trauma, Scar, Hematoma R/O through Excisional Biopsy
Fibroadenoma Solitary nontender firm mass Usually found in a young woman with large breasts R/O
Chronic Breast Abscess Solitary nontender firm mass (-) Fever Biopsy to distinguish from carcinoma
Breast Carcinoma Dominant solitary nontender mass (-) Involvement of the Suspensory Ligaments - retraction, revealed by dimpling, deviation of the nipples, fixation to the pectoral muscles (-) Involvement of the Lactiferous Tubules - Flattening of the nipple, bloody or clear discharge (-) Lymphatic obstruction edema of the skin, peau dorange (-) Lymphatic spread Regional lymphadenopathy
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IMPRESSION
Breast Mass, Right, Probably Malignant
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WORK-UP
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Resource Allocation for Diagnosis and Pathology Resource Allocation for Diagnosis and Pathology Resource Allocation for Diagnosis and Pathology Resource Allocation for Diagnosis and Pathology
Level of Resources Clinical Pathology Imaging and Laboratory Tests
Basic History Physical examination Clinical breast examination Fine-needle aspiration biopsy (1) Surgical biopsy (Incision/Excision) (2) Interpretation of biopsies Cytology report categorizing cells as malignant, benign or not diagnostic Surgical or pathology report categorizing lesion as malignant vs. benign, invasive vs. in situ and describing tumor size, lymph node status, histologic type, tumor grade and margin status  
Limited Core needle biopsy Image-guided sampling (ultrasonographic mammographic) Determination and reporting of ER and PR status Determination and reporting of margin status Diagnostic breast ultrasound /- diagnostic mammography Plain chest radiography Liver ultrasound Blood chemistry profile/CBC
Enhanced Preoperative needle localization under mammographic or ultrasound guidance Onsite cytopathologist Diagnostic mammography Bone scan
Maximal Stereotactic biopsy Sentinel node biopsy HER-2/neu status IHC staining of sentinel nodes for cytokeratin to detect micrometastases CT scanning, PET scan, MIBI scan, breast MRI
WORK-UP
Shyyan R, Masood S, Badwe RA, Errico KM, Liberman
L, Ozmen V, Stalsberg H, Vargas H, Vass L. Breast
cancer in limited-resource countries diagnosis
and pathology. Breast J 2006 Jan-Feb12 Suppl
1S27-37. 45 references
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WORK-UP
Comparison of Paraclinical Diagnostic Procedures
in Patients with a Palpable Breast Lump in which
a More Definitive Diagnosis is Needed in a
Patient Suspected to have a Breast Cancer (Goal
to be more definite on the diagnosis of a
palpable breast lump suspected of cancer)
Procedures Benefit Risk Cost
FNAB Direct examination and Sampling Diagnostic yield and accuracy rate of more than 90 Pain Hematoma No Scar Php 1,500
Open Biopsy Direct examination and sampling Diagnostic yield and accuracy rate of more than 98 Pain Hematoma Side effects of Anesthetic agents Scar Php 8,000
Lecture Dr. Reynaldo Joson, September 25, 2006
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WORK-UP
Excision Biopsy Invasive Ductal Carcinoma
August 23, 2006 (s/p Excision) Invasive Ductal
Carcinoma, Right breast mass, grade
II Measuring 2x1x1cm Modified Radical
Mastectomy (after 2 wks) September 14, 2006
(s/p MRM) No residual tumor seen Skin, nipple,
and basal line of resection are negative for
malignant cells All (0/12) lymph nodes are
negative for malignant cells T2NOMx
Actual Procedures Done on the Patient ? CBC,
Blood Chemistry Normal ? Estrogen and
Progesterone Receptor - Positive () ? Her2-neu
IHC 2 ? Her2neu FISH Negative
Actual Procedures Done on the Patient ? CBC,
Blood Chemistry Normal ? Excision Biopsy
Invasive Ductal Carcinoma ? August 23,
2006 (s/p Excision) Invasive Ductal Carcinoma,
Right breast mass, grade II Measuring 2x1x1cm ?
Modified Radical Mastectomy (after 2 weeks)
?September 14, 2006 (s/p MRM) No residual
tumor seen Skin, nipple, and basal line of
resection are negative for malignant
cells All (0/12) lymph nodes are negative for
malignant cells T2NOMx ? Estrogen and
Progesterone Receptor Positive () ? Her2-neu
IHC 2 ? Her2neu FISH Negative
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STAGING
Primary Tumor (T) Primary Tumor (T) Regional Lymph Nodes (N) Regional Lymph Nodes (N)
Tx Cannot be assessed Nx Cannot be assessed
T0 No evidence of primary tumor N0 No regional lymph nodes
TIS Carcinoma in situ N1 Metastasis to movable ipsilateral nodes
T1 Tumor 2cm N2 Metastasis to matted or fixed ipsilateral nodes
T2 Tumor gt 2cm but 5cm N3 Metastasis to ipsilateral internal mammary nodes
T3 Tumor gt 5 cm Distant Metastasis (M) Distant Metastasis (M)
T4 Extension to chest wall, inflammation, satellite lesions, ulcerations Mx Cannot be assessed
M0 No distant metastasis
M1 Distant Metastasis (includes spread to ipsilateral supraclavicular nodes)
HPIM 16th ed
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STAGING
Stage Grouping
Stage 0 TIS N0 M0
Stage I T1 N0 M0
Stage II A T0 N1 M0 T1 N1 M0 T2 N0 M0
Stage II B T2 N1 M0 T3 N0 M0
Stage IIIA T0 N2 M0 T1 N2 M0 T2 N2 M0 T3 N1,N2 M0
Stage III B T4 Any N M0 Any T N3 M0
Stage IV Any T Any N M1
HPIM 16th ed
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Histopathologic Grading
Scarff, Bloom and Richardson grade Grade I -
well differentiated (3-5) Grade II - moderately
differentiated (6-7) Grade III - poorly
differentiated (8-9)
HPIM 16th ed
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Metastasis Prognostic Markers
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WORK-UP
Diagnostic tests to rule out metastasis
Stage I, II

• Complete Blood Count
• Liver Function Tests
• Chest X-Ray

Bigger, More Advanced
? Bone Scan ? Liver Scan
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WORK-UP
Diagnosing Nodal Metastasis in Invasive Ductal
Carcinoma
ALND

• Axillary Lymph Node Dissection
• - traditional procedure to detect lymph node
  metastasis, and potentially therapeutic for the
  regional control of axillary metastases
• - most women with early-stage breast cancer are
  node negative, and axillary dissection in these
  women exposes them to the complications of this
  procedure, with no benefit
• - associated with significant long-term morbidity.

Axillary Lymph Node Dissection
SLNB

• Sentinel Lymph Node (SLN) Biopsy
• minimally invasive alternative to stage breast
  cancer in clinically node-negative patients
• yields metastasis-free SLN in 6570 of patients
  
• if SLNs are histologically negative, no further
  axillary surgery would be performed
• associated with reduced arm morbidity and better
  quality of life
• treatment of choice for patients who have
  early-stage breast cancer with clinically
  negative nodes

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TREATMENT
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Local/regional treatments 1. Mastectomy
radiation therapy 2. Breast-conserving surgery
Lumpectomy (also called "wide resection,"
"partial mastectomy," or "quadrantectomy")
radiation therapy to the remainder of the breast
tissue Women who didn't get radiation after
lumpectomy were shown to have a 40 greater risk
of the cancer coming back in the same
breast These two options are considered equally
effective for women with a breast cancer
measuring about four centimeters or less. For
women with a single tumor larger than about four
centimeters, breast preservation therapy may
still be an option if chemotherapy is able to
shrink the cancer substantially BEFORE surgery.
TREATMENT
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TREATMENT
Suggested Approaches to Adjuvant Therapy
Check Serum Tumor Markers
Age Group Lymph Node Status Endocrine Receptor (ER) Status Tumor Recommendations
Pre-menopausal Positive Any Any Multidrug chemotherapy Tamoxifen if ER()
Pre-menopausal Negative Any gt2 cm, or 1-2 cm with other poor prognostic variables Multidrug chemotherapy Tamoxifen if ER()
Post Menopausal Positive Negative Any Multidrug chemotherapy
Post Menopausal Positive Positive Any Tamoxifen with or without chemotherapy
Post Menopausal Negative Positive gt2 cm, or 1-2 cm with other poor prognostic variables Tamoxifen
Post Menopausal Negative Negative gt2 cm, or 1-2 cm with other poor prognostic variables Consider multidrug chemotherapy
HPIM 16th ed, p.521
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TREATMENT

• For years, tamoxifen was the hormonal medicine of
  choice for all women with hormone-receptor-positiv
  e breast cancer
• In 2005, the results of several major worldwide
  clinical trials showed that aromatase inhibitors
  worked better than tamoxifen in post-menopausal
  women with hormone-receptive-positive breast
  cancer
• Aromatase inhibitors are now considered the
  standard of care for post-menopausal women with
  hormone-receptor-positive breast cancer
• Tamoxifen remains the hormonal treatment of
  choice for pre-menopausal women

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PROGNOSIS
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The patient underwent modified radical
mastectomy. Histopathology results showed the
patient to be on T2NOMx. The patient is at Stage
IIA.
PROGNOSIS
Disease Stage 5-year Survival Rate
Stage 0 99
Stage I 85-95
Stage II 65-75
Stage III (locally advanced) 45-50
Stage IV (metastatic) 20-30
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PROGNOSIS

• Modified radical mastectomy continues to be
  appropriate for some patients, but breast
  conservation therapy is now regarded as the
  optimal treatment for most. Six prospective
  randomized trials have shown no difference in
  survival when mastectomy is compared with
  conservative surgery plus radiation for Stage I
  and Stage II breast cancer (Table 1).

Adapted from Winchester DP, Cox JD. Standards for
diagnosis and management of invasive breast
carcinoma. CA Cancer J Clin 19984885.
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PROGNOSIS

• Recurrence
• ? Most recurrences occur in the first three to
  five years after initial treatment.
• Breast cancer can come back as a local
  recurrence (in the treated breast or near the
  mastectomy scar) or as a distant recurrence
  somewhere else in the body.
• The most common regions that breast cancer may
  spread to in order of frequency are Bone, Lung
  and Liver.
• Approximately 25 of breast cancers spread first
  to the bone. The bones of the spine, ribs,
  pelvis, skull, and long bones of the arms and
  legs are most often affected.
• Between 60 and 70 of women who die from breast
  cancer have eventually had it spread to their
  lungs.
• In 21 of cases, the lung is the only site of
  metastasis (spread)

The most common signs of lung metastases are
shortness of breath and dry cough. In some
cases, women will not experience any symptoms
cancer will only be detected by chest X-ray or CT
scan.
http//www.imaginis.com/breasthealth/bcrecurrence.
asp
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PROGNOSIS

• Recurrence
• Chest wall recurrence (CWR) after mastectomy
  occurs in 5 to 40 of breast cancer patients and
  is generally believed to forecast a grim outcome.
  These recurrences are often followed by distant
  metastasis and death
• Patients with initial node-negative disease who
  develop CWR after 24 months have an optimistic
  prognosis, especially if they are treated with
  radiation
• Presence of estrogen and progesterone receptors
  in the cancer cell is another important
  prognostic factor, and may guide treatment
• Hormone receptor positive breast cancer is
  usually associated with much better prognosis
  compared to hormone negative breast cancer
• HER2/neu status has also been described as a
  prognostic factor. Patients whose cancer cells
  are positive for HER2/neu have more aggressive
  disease

Annals of Surgical Oncology, 10(6)628634
www.emedicine.com
30
PROGNOSIS
Metastasis should be assessed since breast
cancer can spread to the lungs. The patients
chest x-ray showed a pulmonary nodule which maybe
a sign of metastasis. In addition the patient is
already taking anti-metastasis medication.
However histopathologic studies showed no nodal
involvement. Thus a biopsy of the pulmonary
nodule is needed for definitive staging. The
presence of metastasis will classify the patient
as Stage 4.
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SURVEILLANCE
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CXR - Pulmonary nodule at the right lung
base CT Scan Pulmonary nodule on the Right
Lower Lobe, 1x1cm Advised chemotherapy Enrolled
at RIBBON Study, receiving Xeloda and Avastin
SURVEILLANCE
33
SURVEILLANCE
Solitary Pulmonary Nodule in the Patient with
Breast Cancer Similarly, in a study assessing the
role of surgery in the diagnosis and treatment of
an SPN among post-surgery breast cancer patients,
results showed that histology of SPN was primary
lung cancer in 38 patients (n79), pulmonary
metastasis of breast cancer in 27, and benign
condition in 14. In a patient with a known
extrathoracic malignancy and a solitary pulmonary
nodule on the CT scan, the following scenarios
have been proposed Malignant lesions
account for 3-10 of CT scandetected pulmonary
nodules. In an older patient, a solitary nodule
is more likely to be malignant (lung cancer, in
particular) in a younger patient, multiple
nodules are more likely to be metastases
European Journal of Surgical Oncology, Volume 33,
Issue 5, June 2007, pp 546-550
With a history of sarcoma or melanoma, the
pulmonary nodule is more likely to be a
metastasis In the case of underlying head and
neck cancer or breast cancer, a second primary
cancer in the lung is more likely With other
malignancies, the nodule is equally likely to be
a primary lung cancer or metastatic disease
Bascom, R. (2006). Secondary Lung Tumors.
www.emedicine.com
34
SURVEILLANCE
Solitary Pulmonary Nodule in the Patient with
Breast Cancer A solitary pulmonary nodule (SPN)
appearing in a patient with breast cancer, either
past or present, is most likely to be a second
primary cancer originating in the lung rather
than a metastasis from the breast cancer.
Patients with breast cancer with SPNs should have
a diagnostic workup appropriate for lung cancer
(In a study conducted among 1416 breast cancer
patients, 42 had a solitary pulmonary nodule
either at the time of presentation of their
breast cancer or during the follow-up period,
Fifty-two percent of the solitary pulmonary
nodules proved to be a primary lung tumor, 5
proved to be benign lesions, and only 43 proved
to be metastatic breast cancer.). Since
adenocarcinoma has become the most common lung
cancer cell type, the usual diagnostic tests may
not allow a firm differentiation between primary
lung and secondary breast cancer. Therefore if
malignancy is proved or suspected, thoracotomy
with appropriate resection is the treatment of
choice in most patients with breast cancer, even
at the initial appearance of the breast cancer.
www.emedicine.com
35
BioPsychoSocial Aspect
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• Stress
• Uncertainty of the future
• Unpredictability of the cancer
• Disability
• Financial difficulties
• Physical appearance
• - after mastectomy
• - hair loss due to chemotherapy
• - skin changes due to radiotherapy

• Reduce Stress
• Keep a positive attitude
• Be assertive instead of aggressive - "Assert"
  feelings, opinions, or beliefs instead of
  becoming angry, combative, or passive
• Exercise regularly
• Eat well-balanced meals
• Keep Track of Medical Information
• Make use of resources and support services
  offered by the hospital and community
• Learn more about breast cancer to help patient
  feel more comfortable with treatment

BioPsychoSocial Aspect
37
Thank you!
tubal.tuliao.umag.uy.valencia.verde.villanueva.viz
conde.wee.wylengco.zapanta hLPS
38
RIBBON STUDY
The Ribbon 1 Study is seeking approximately 1000
patients over age 18 with metastatic breast
cancer who have not previously received
chemotherapy for this disease. Individuals who
have received chemotherapy prior to being
diagnosed with metastatic breast cancer may be
eligible for the study as long as they have not
been treated with chemotherapy since that
diagnosis of metastatic breast cancer. The study
will evaluate the safety and effectiveness of
bevacizumab, an investigational compound, when
combined with chemotherapy, compared to
chemotherapy alone, in individuals who have not
been previously treated with chemotherapy for
metastatic breast cancer. Individuals
participating in the study will be randomly
assigned to one of two treatment groups One
group will receive bevacizumab in combination
with the standard of care chemotherapy treatment.
One group will receive placebo in combination
with the standard of care chemotherapy treatment.
Note The chemotherapy treatment used in both
groups is considered the standard of care for
metastatic breast cancer. Study participants will
be given bevacizumab or placebo once every three
weeks until their disease progresses or they
experience unacceptable toxicity. The maximum
treatment period with bevacizumab is 24 months.