breast cancer presentation final copy

7/31/2019 Breast Cancer Presentation Final Copy

1/69

Akinpelu, Angela; Espinosa, Frankie; Lawson, Chatriece


2/69

#1 cause of cancer death in women world wide

2nd most common cause of cancer death in the

US

Most common female malignancy

In the US, there is a 1/8 chance a woman will

develop breast cancer if she lives to be 90 y/o Surgery is the primary treatment

Early-stage is often cured with surgery alone


3/69

Incidence and mortality rates are 5 times higher

in North America and Northern Europe thanAsian and African countries

230,480 new cases of invasive breast cancer

were expected to be diagnosed in women in the

US


4/69

Risk Factor Relative Risk

Age (50 vs


5/69

Milk producingsebaceous glands

Rest on pectoralismajor

Attached to muscle wallvia Coopers ligaments

15-20 lobes in circulararrangement

Fat gives size andshape


6/69

Glands at the ends oflobules produce milk

Lobes, lobules, and bulbsare linked by a network of

ducts Ducts carry milk from

bulbs toward areola

Ducts join together into

larger ducts ending at thenipple, where milk isdelivered

Network of lymphaticsrun through the breasts


7/69

The external structure of the breast can be divided into 4

quadrants:

the upper inner quadrant

the lower inner quadrant

the lower outer quadrant

the upper outer quadrant

The upper-outer quadrant of the breast is thicker than the

remainder of the breast.

Contains a greater bulk of mammary tissue than the

other quadrants

Both benign and malignant tumors occur most

frequently there

The breast borders

The upper border of breast tissue begins at the

collarbone

The lower border is at the base of a properly fitted bra

The inner border is the edge of the sternum

the outer border is the anterior axillary line which is the

underarm or arm pit

Some women have tails or axillary projections of breast

tissue that extend further than the anterior axillary lines

into the armpit. It is important this this area be

included in the breast self-examination.


8/69

Fibrocystic changes

Hyperplasia Fibroadenomas

Intraductal papillomas

Galactocele


9/69

Three Histologic Categories

Nonproliferative lesions

Proliferative lesions (hyperplasia) without

atypia Atypical hyperplasia


10/69

Most common benign breast disorder

Present in ~50% of women May involve any or all breast tissues

Caused by decrease in progesterone or

increase in estrogen

Improves in pregnancy and lactation

Can be painful, especially premenstrually


11/69

Most common benign tumor

Composed of both fibrous and glandular tissue

Well circumscribed, freely mobile

Usually solitary

Common before the age of 30

Has malignant potential

Excised for definitive diagnosis and cure


12/69

Neoplastic growths within ducts

Common before or during menopause

Rarely palpable

Presents as bloody, serous, or turbid discharge

from nipple

Excisional biopsy of lesion is the treatment ofchoice

May have invasive tendency


13/69

Cyst of dilation of duct

Filled with thick, inspissated, milky fluid

Presents during or shortly after lactation

Represents ductal obstruction (i.e., inflammation,

hpyerplasia, neoplasia)

Multiple cysts often present Can 2 acute mastitis or abscess

Tx: needle aspiration; excisional biopsy if bloody


14/69

Carcinoma

begins in the epithelial cells of organs (i.e. breast) Nearly all breast cancers are carcinomas (either

ductal carcinomas or lobular carcinomas)

Adenocarcinoma

carcinoma that starts in glandular tissue, i.e. ductsand lobules


15/69

Invasive (infiltrating) carcinoma

An invasive cancer is one that has already grown beyondthe layer of cells where it started

Sarcoma start in connective tissues such as muscle tissue, fat

tissue, or blood vessels


16/69

Carcinoma in situ

Early stage of cancer

It is confined to the layer of cells where it began Lobular carcinoma in situ(LCIS)

Ductal carcinoma in situ(DCIS)

Cells have not invaded into deeper breast tissues or

spread to other organs Referred to non-invasive or pre-invasive breast

cancer because it may develop into an invasive breast

cancer if left untreated


17/69


18/69

Arises from terminal duct apparatus

Has diffuse distribution, usually non-palpable

Incidence is 2.8 per 100,000 women

Peak incidence at 40 50 years


19/69

If LCIS becomes invasive

it is termed as infiltrating

lobular carcinoma < 15% of invasive breast

cancer

Metastasizes to axillary

lymph nodes 1st

Tends to become multi-

focal


20/69

Most common type of non-invasive breast cancer

DCIS is notlife-threatening

DCIS can increase the risk of developing an

invasive breast cancer

High risk for cancer reoccurrence

At a higher risk for developing a new onset of

breast cancer than a person who has never had

breast cancer


21/69

~80% of all breastcancers

DCIS initiallymicroinvades the ductwall

Eventually, cancerouscells invade breast tissue

Can spread to lymph

nodes, then to otherareas of the body

2/3 of women are > 55 y/owhen diagnosed

Also affects men


22/69

Uncommon, 1 2% of all breast cancers

Histology: single layer epithelial cells, low-

grade nuclei and apical cytoplasmic snoutings(extrusions) arranged in well-formed tubules

and glands

Has low incidence of lymph node involvement

Very high overall survival rate

Treatment is often only breast-conserving

surgery and local radiation


23/69

Uncommon, 1 2% of all breast cancers

Two common types:

cystic (noninvasive); low mitotic activity, indolent,good prognosis

micropapillary (invasive); centrally located; can

present as bloody nipple d/c; strongly ER+ and

PR+; more aggressive; frequent lymph nodemetastasis; correlates with survival

Usually in women > 60 y/o


24/69

Relatively uncommon, < 5%

Occurs in younger women

Typically presents as a bulky palpable

mass with axillary lymphadenopathy (30%)

DCIS sometimes observed in surrounding

normal tissue

Usually ER, PR, and HER2 negative

TP53commonly mutated


25/69

Relatively uncommon, < 5% of invasive

breast cancers

Women typically > 70 y/o at presentation Presents as palpable mass or

mammographically as poorly defined with

rare calcifications

Excellent prognosis; > 80% 10-year survival

Histologic: types A, B, and AB; mucin

production > in type A


26/69

Associated with underlying breastcancer in 75% of cases

Occurs in ~3% of all breastcancers

Arises from excretory ducts skinof nipple and areola

Eczematoid appearance

Palpable lesion in 2/3

Poor prognosis associated withpalpable tumor, lymph nodeinvolvement, age < 60

Overall 5- and 10-year survivalrates 59% and 44%, respectively


27/69

Rare, 1 4%

Often seen in pregnancy

Develops rapidly, making the affectedbreast red, swollen and tender; classicpeau dorange appearance

Cancer cells block the lymphatic vessels inthe breast, causing the characteristicappearance of the breast.

Considered a locally advanced cancerithas spread from its point of origin tonearby tissue and possibly to nearbylymph nodes

Easily confused with a breast infection Seek medical attention promptly if younotice skin changes on your breast

Typically is advanced with mets by time ofdiagnosis


28/69

Carcinoma

Painless and freely mobile

Tumor

Fixed into deep fascia

extension to the skin causes retraction and dimpling

of the skin

Ductal involvement nipple retraction

Blockage of skin lymphatic's causes lymphedema

and thickening of the skin referred to as peaud

organge


29/69


30/69

Tumors spread by:

Local Infiltration

Directly into parenchyma

Lymphatic Spread Mainly into the axillary nodes

Occurs in up to 50% of patients with systematic breast cancer

Internal mammary nodes are the 2nd most common affected

site

Supraclavicular nodes are only involved after axillary nodes 10%-20% of patients screened have detected breast cancers

Hematogenous Spread

Metastasizes mainly to the lungs and liver

Other sites include: bone, pleura, adrenals, ovaries and brain


31/69

Scale of 0 (describing non-invasive cancers ) to IV (describing

invasive cancers )

Stage 0: non-invasive cancers

Stage I: invasive, the tumor measures


32/69

IIB the tumor is >2 cm 5 cm but not metastasized to the axillary lymph nodes

Stage III IIIA

no tumor is found, but cancer is found in axillary lymph nodes, or cancer may

metastasized to lymph nodes near the breastbone OR the cancer is any size and metastasized to axillary lymph nodes

IIIB the cancer may be any size and metastasized to the chest wall and/or skin of the

breast AND may metastasized to axillary lymph nodes, or cancer may have spreadto lymph nodes near the breastbone

Inflammatory breast cancer

IIIC there may be no sign of cancer in the breast or, if there is a tumor, it may be any

size and may have spread to the chest wall and/or the skin of the breast AND

the cancer has spread to lymph nodes above or below the collarbone AND

the cancer may have spread to axillary lymph nodes or to lymph nodes near thebreastbone


33/69

Stage IV

Metastasized to other organs


34/69


35/69

Screening begins for asymptomatic women

The Physician - Physician Assistant has to befamiliar with common Benign and Malignant

disorders of the breasts along with their therapeuticoptions

The screening process all begins with the patientThe Breast Self-Exam (BSE)

This means that the MD PA should give the patientpertinent health information tailored to anyabnormalities, as well as properly training andeducating the patient on how to properly do theBSE


36/69

There is no documented proof that performing a

Breast Self-Examination directly reduces

mortality, but all health professionals agree that ithelps lead to an earlier diagnosis, which in turn

will indirectly increase mortality

A rule of thumb: It is best to perform a monthlyBreast Self-Examination after menses has

ceased


37/69

Proper Technique is KEY

Begin in the Upright Positionwith the arms to the

side


38/69

After Inspection with the arms to the side then

arms in the raised position


39/69

Have the patient palpate 2 key areas

1. Supraclavicular

2. Axillae

Assessing for any nodes

Then, have the patient lie supine, palpating

each quadrant against the chest wall using the

flat of the hands Next, have patient palpate their areola

Finally, decompress the nipples for any

evidence of discharge


40/69

To be done annuallyat the minimum

Begin upright and use observation, checkingfor:

a) Symmetryb) Contour

c) Skin Changes/Retractions Due to thetethering of skin to an underlying malignancy

d) Nipple Retractions Have patient raise theirhands above their head to accentuate anyabnormalities


41/69

Be sure to palpate in the following order

1. Breast

2. Areola

3. Nipple If any mass is palpated, check if it is fixated to deep

tissues by having the patient put her hands on her hipsand contracting the pectoralis muscles while she isdoing this palpate the:

a) Axillab) Supraclavicular fossa

After completing the exam upright, repeat theexam with the patient supine


42/69

Mammogram

A veryimportantcomponent of the screening

process, especially in asymptomaticwomen


43/69

The Mammogram should be done in conjunction with thePhysical Examination

Able to detect malignancies


44/69

Ultrasound

Helps differentiate a cystic vs. solid mass

May also show any solid tissue that is

potentially malignant

Good diagnostic tool for women


45/69

MRI Magnetic Resonance Imaging Before using this diagnostic the healthcare professional

must distinguish whether the nodules or tenderness iscaused by normal hormone function or whether it iscaused from benign or malignant changes

Nuclear Imaging Not usually indicated for the detection of breast cancer

Plays a very useful role in the detection of breast cancer

Detection rate of 85%

Specificity rate of 89% 3 radiotracers are commonly used

Tc sestamibi

Tc tetrofosmin

Tc methylene diphosphonate


46/69

Positron Emission Tomography Scanning

PET Scan

Most sensitive and specific of all the imaging

modalities for breast disease

One of the most expensive and least widely

used modalities available

Utilizes labeled metabolites for detectionfluorinated glucose

Main use is to help detect recurrences


47/69

For definitive diagnosis of neoplasms:

1. Fine Needle Aspiration FNA

2. Open Biopsy


48/69

Fine Needle Aspiration FNA

Can be performed on an out-patient basis

It is bothsensitive & specific

Remember!

Neveraccept a negative biopsy result as a definitive

when a mammogram indicates a malignancy


49/69

Open Breast Biopsy

Smaller Masses = Excisional Biopsy

Larger Masses = Incisional Biopsy

Indications for open biopsy:

A mass that exists through out menses

Cystic masses that does not decompress with

aspiration or has blood in the aspirate

Spontaneous serous nipple discharge

No mass with a trigger point


50/69

Open breast biopsy (contd)

Can be done as an in-patient or out-patient In an out-patient setting use local anesthesia

In an in-patient setting use general anesthesia

Do Not use open breast biopsy for:

Women with large breast and a small deep mass

Non-palpable lesions detected on a mammogram


51/69

There is a trend towards conservative

surgical approaches to breast cancer with

adjuvant radiation and, if necessary

chemotherapy or hormonal therapy


52/69

Surgery For many years radical mastectomy was the standard of treatment for

breast cancer

Survival rates of conservative therapy are equal to those of radicalmastectomy

Routine axillary lymph node dissection has progressively been replaced

by lymphatic mapping and sentinel lymph node resection Breast reconstruction after a mastectomy is an integral part of the

treatment of breast cancer, which can be done at the time ofmastectomy

Radiation Therapy Conservative surgery is always performed in conjunction with radiation

therapy to the breast

This approach gives equivalent outcomes to radical mastectomy, andfunctional and cosmetic results are improved

External beam therapy is used with this modality, by giving 4,500 to5,000 cGy to the entire breast

The axilla is not routinely irradiated due to the occurrence oflymphedema


53/69

Used in cases of early breast cancer, regardlessof lymph node involvement

Reduces the risk of relapse by about 33%

Reduces the risk of death by about 25%

Pre-menopausal women with ER-negativetumors should receive adjuvant therapy

Pre-menopausal women with ER-positive tumorsshould receive adjuvant therapy in addition to

chemo therapy The use of Tamoxifen shows a 70% reduction inthe risk of cancer in the contralateral breast

In patients with proven metastases, symptomsmay be palliated with combination chemotherapy


54/69

3% breast cancer occur in pregnancy Complicating ~ 1/3000 pregnancies

Diagnosis is usually delayed because ofhypertrophied breast

If a mass is suspected, a needle aspiration oropen biopsy needs to be performed promptly

Surgical treatment is the same as a non-pregnant patient

With nodal metastases abortion is advisable inthe first trimester with tx of adjuvantchemotherapy because of teratogenic risk,during the 3rd trimester should wait until afterdelivery


55/69

Is related to the stage of the disease and age

Older age has better prognosis

Status of axillary lymph nodes is the single most

important prognosticator

Patients with negative lymph nodes had an

actuarial 5-year survival rate of 83%

Pregnant patients has a worse prognosis thannon-pregnant patients


56/69

BreastCancerStage

5-YearSurvivalRate forWomen

0 93%

I 88%

IIA 81%

IIB 74%

IIIA 67%IIIB 41%

IIIC 49%

IV 15%


57/69

Which of the following is a benign breast

disorder?

a) Fibroadenoma

b) DCIS

c) Padgets

d) LCIS


58/69

Which of the following is a benign breast

disorder?

a) Fibroadenoma

b) DCIS

c) Padgets

d) LCIS


59/69

What is the #1 cause of female cancer death

worldwide?

a) Lung

b) Breast

c) Cervical

d) Ovarian


60/69

What is the #1 cause of female cancer death

worldwide?

a) Lung

b) Breast

c) Cervical

d) Ovarian


61/69

Which quadrant has the highest occurrence of

benign tumors?

a) Upper Inner

b) Lower Outer

c) Upper Outer

d) Lower Inner


62/69


benign tumors?

a) Upper Inner

b) Lower Outer

c) Upper Outer

d) Lower Inner


63/69


malignant tumors?

a) Upper Inner

b) Lower Outer

c) Upper Outer

d) Lower Inner


64/69


malignant tumors?

a) Upper Inner

b) Lower Outer

c) Upper Outer

d) Lower Inner


65/69

What is the most effective treatment modality?

a) Radiation

b) Acupuncture

c) Chemotherapy

d) Surgery


66/69

What is the most effective treatment modality?

a) Radiation

b) Acupuncture

c) Chemotherapy

d) Surgery


67/69


68/69

DCIS

Ductal Carcinoma In Situ

IDC Invasive Ductal Carcinoma


69/69

IDC - Less Common Types

ILC Invasive Lobular Carcinoma

Inflammatory Breast Cancer

LCIS Lobular Carcinoma In Situ

Male Breast Cancer

Paget's Disease of the Nipple

Phyllodes Tumors of the Breast

Recurrent and Metastatic Breast Cancer

http://www.cancer.org/Cancer/BreastCancer/DetailedGuide/breast-cancer-what-is-breast-cancer

Hacker, Neville F., Joseph C. Gambone, and Calvin J. Hobel. "Breast Disease: A Gynecologic Perspective." Hacker and Moore's

Essentials of Obstetrics and Gynecology. 5th ed. Philadelphia, PA: Saunders/Elsevier, 2010. Print.

"Types of Breast Cancer." BreastCancer.org - Breast Cancer Treatment Information and Pictures. 17 Sept. 2010. Web. 01 Dec.

2011. .

"What Is Breast Cancer?"American Cancer Society :: Information and Resources for Cancer: Breast, Colon, Prostate, Lung and

Other Forms. 29 Sept. 2011. Web. 1 Dec. 2011. .

[PPT]

For Breast Cancer

www.uams.edu/cop/Rxforbreastcancer/low_res.ppt

File Format: Microsoft Powerpoint - Quick View

For Breast Cancer. A program of the. UAMS College of Pharmacy. Funded through unrestricted educational grants. by Susan

breast cancer presentation final copy

Documents