The Power of Pink: Diagnosis & Treatment of Breast Disease. Tony L. Weaver, D.O.

Transcription

1 The Power of Pink: Diagnosis & Treatment of Breast Disease Tony L. Weaver, D.O.

2 Objectives Review Anatomy & Physiology Discuss: Diagnosis Management Treatment of benign & Malignant Breast Disease It is about YOU!

3 ANATOMY AND PHYSIOLOGY Breast development Breast formed from ectoderm milk streak Estrogen duct development (double layer of columnar cells) Progesterone Lobular development Prolactin synergizes estrogen and progesterone

4 Hormones and Cyclic changes Estrogen breast swelling, growth of glandular tissue Progesterone maturation of glandular tissue; withdrawal causes menses FSH, LH surge cause ovum release After menopause, lack of estrogen and progesterone results in atrophy of breast tissue

5 Lymphatic drainage 97% is to the axillary nodes 2% is to the internal mammary nodes Any quadrant can drain to the internal mammary nodes Supraclavicular nodes considered N3 disease Primary axillary adenopathy #1 is lymphoma

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7 You ve Got a lot of Nerve Medial pectoral nerve pectoralis major and pectoralis minor Lateral pectoral nerve ---> Pectoralis Major only Intercostobrachial Nerve lateral cutaneous branch of the 2nd intercostal nerve

8 Nerve Name that Nerve

9 Long thoracic nerve innervates serratus anterior; injury results in winged scapula Important Nerves Thoracodorsal Nerve innervates latissimus dorsi; injury results in weak arm pullups and adduction

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11 Vessels Internal thoracic artery Intercostal arteries, Thoracoacromial artery lateral thoracic artery Batson s plexus valveless vein plexus direct hematogenous metastasis to spine Lateral thoracic artery supplies serratus anterior Thoracodorsal artery supplies latissimus dorsi

12 BREAST CANCER Breast CA decreased in economically poor areas Japan has lowest rate of breast CA worldwide U.S. breast CA risk 1 in 8 women (12%); 5% in women with no risk factors Screening decreases mortality by 25% Untreated breast cancer median survival 2 3 years 10% of breast CAs have negative mammogram and negative ultrasound Clinical features of breast CA distortion of normal architecture; skin/nipple distortion or retraction; hard, tethered, indistinct borders

13 Breast Cancer Risk Greatly increased risk (relative risk > 4) BRCA gene in patient with family history of breast CA 2 primary relatives with bilateral or premenopausal breast CA DCIS (ipsilateral breast at risk) and LCIS (both breasts have same high risk) Fibrocystic disease with atypical hyperplasia Moderately increased risk (relative risk 2 4) prior breast cancer, radiation exposure, first-degree relative with breast cancer, age > 35 first birth Lower increased risk (relative risk < 2) early menarche, late menopause, nulliparity, proliferative benign disease, obesity, alcohol use, hormone replacement therapy

14 What s a Mammogram?

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17 Screening Mammogram every 2 3 years after age 40, then yearly after 50 High-risk screening mammogram 10 years before the youngest age of diagnosis of breast CA in first-degree relative No mammography in patients < 40 unless high risk hard to interpret because of dense parenchyma Want to decrease radiation dose in young patients

18 Mammography Has 90% sensitivity/specificity Sensitivity increases with age as the dense parenchymal tissue is replaced with fat Mass needs to be 5 mm to be detected Suggestive of CA irregular borders; spiculated; multiple clustered, small, thin, linear, crushed-like and/or branching calcifications; ductal asymmetry, distortion of architecture

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20 What is BIRADS?

21 Nice Negative Breast Benign Please Probably Benign Show Suspicious for Malignancy Me Highly Suspicious for Malignant

22 BiRADS

23 Risk Assessment Tools Gail Model Age, menarche, age of first live birth, previous history of biopsies (benign or atypia), family history of 1 st degree relatives Calculates risk at 5 years and to age 90 of developing breast cancer Gail Pitfalls Underestimates family history (accounts for only disease in first degree relatives), no paternal FH Heavily weighted on biopsy history Not incorporate age at diagnosis Not accepted estimate for need for MRI Other alternatives: Claus tables, BRCAPRO and BOADICEA (genetic counselor) more in depth family assessment

24 Average woman risk of BRCA 1 or 2 mutation: 1/450 to 1/800 Women of Ashkenazi descent risk of BRCA mutation: 1/40 10% of women with breast cancer have a BRCA mutation

25 BRCA 1 Younger age at cancer presentation 30-45yo Premenopausal Lifetime risk for breast cancer 50-80% Risk of contralateral breast cancer 60% Breast cancers tend to be triple negative Ovarian cancer risk 40-60% BRCA2 Same age for development of breast cancer as general population Lifetime risk of BC same as BRCA1 Risk for contralateral BC is same as BRCA1 Breast cancers tend to be ER+ Ovarian cancer risk 16-30% Male breast cancer risk 6% Increased risk for prostate, pancreas, melanoma

26 85% of all breast CA Ductal Cancer Medullary smooth borders, lymphocytes, bizarre cells, more favorable prognosis Tubular small tubule formations, more favorable prognosis Mucinous (colloid) produces an abundance of mucin, more favorable prognosis Scirrhotic worse prognosis Tx: MRM or BCT with postop XRT

27 Prognostics of Invasive Breast Cancer Good Tubular Papillary Mucinous Adenoid cystic Bad Medullary squamous

28 Considered T4 disease Inflammatory Cancer Very aggressive median survival of 36 months Has dermal lymphatic invasion, which causes peau d orange lymphedema appearance on breast; erythematous and warm Tx: Neoadjuvant chemo, then MRM, then adjuvant chemo-xrt

29 Occult breast CA breast CA that presents as axillary metastases with unknown primary; Tx: MRM (70% are found to have breast CA) Almost all women with recurrence die of disease Increased recurrences and metastases occur with positive nodes, large tumors, negative receptors, unfavorable subtype Metastatic flare pain, swelling, erythema in metastatic areas; XRT can help XRT is good for bone metastases

30 What is the most important prognostic staging factor??

31 Nodes

32 Survival is directly related to the number of positive nodes 0 nodes positive 75% 5-year survival 1 3 nodes positive 60% 5-year survival 4 10 nodes positive 40% 5-year survival

33 What is the MOST COMMON Site of Distal Mets?

34 Bone most common site for distant metastasis (can also go to lung, liver, brain) Takes approximately 5 7 years to go from single malignant cell to 1-cm tumor Central and subareolar tumors have increased risk of multicentricity

35 Invasive BC treatment (all types) Excise to negative margins (no tumor at ink, most aim for >2mm margin) XRT if had successful BCT SLNB +/-ALND in all cases Chemotherapy Hormonal (antiestrogen) Chemotherapy Monoclonal antibody (trastuzumab/herceptin)

36 ALND take level I and II nodes Breast Surgery Basics Complications of MRM infection, flap necrosis, seromas Complications of ALND Infection, lymphedema, lymphangiosarcoma Axillary vein thrombosis sudden, early, postop swelling Lymphatic fibrosis slow swelling over 18 months Intercostal brachiocutaneous nerve injury hyperesthesia of inner arm and lateral chest wall; most commonly injured nerve after mastectomy; no significant sequelae Drains leave in until drainage < 40 cc/day

37 Receptors Positive receptors: better response to hormones, chemotherapy, surgery, and better overall prognosis Receptor-positive tumors are more common in postmenopausal women Progesterone receptor positive tumors have better prognosis than estrogen receptor positive tumors Tumors that are both progesterone receptor & estrogen receptor positive have the best prognosis 10% of breast CA is negative for both receptors

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39 During SLNB if no radiotracer or dye is found??

40 Fewer complications than ALND Only for malignant tumors > 1 cm SLNB Patients with clinically positive nodes; Need ALND Accuracy best when primary tumor is present (finds the right lymphatic channels) Lymphazurin blue dye or radiotracer is injected directly into tumor area Risk: Type I hypersensitivity reactions Usually find 1 3 nodes; 95% of the time, the sentinel node is found Contraindications pregnancy, multicentric disease, neoadjuvant therapy, clinically positive nodes, prior axillary surgery, inflammatory or locally advanced disease

41 Lobular Cancer 10% of all breast CAs Does not form calcifications; extensively infiltrative; bilateral, multifocal, and multicentric disease Signet ring cells confer worse prognosis Tx: MRM or BCT with postop XRT

42 Male Breast Cancer < 1% of all breast CAs; usually ductal Poorer prognosis because of late presentation Have pectoral muscle involvement Associated with steroid use, previous XRT, family history, Klinefelter s syndrome Tx: modified radical mastectomy (MRM)

43 Breast Cancer Treatment

44 What is a Name????

45 Surgical Options Lumpectomy/Partial Mastectomy/BCT Mastectomy Survival is equivalent Rates of local recurrence are higher with BCT than with Mastectomy.

46 Compared BCT vs Mastectomy Alone vs Mastectomy w/ Radiation Large Retrospective Study 132,149 pts Breast conservation therapy 70%, Mastectomy alone 27% of patients, Mastectomy with radiation 3% of patients. 5-year breast cancer specific survival rates 97%, 94%, and 90% (P <.001) 10-year breast cancer specific survival rates were 94%, 90%, and 83% (P <.001). Multivariate analysis showed that women undergoing BCT had a higher survival rate than those undergoing mastectomy alone (hazard ratio, 1.31; P <.001) or mastectomy with radiation (hazard ratio, 1.47; P <.001).

47 Breast-Conserving therapy BCT Lumpectomy Quadrectomy + ALND or SLNBcombined with Postop XRT; need 1-cm margin

48 BCT with XRT Need to have negative margins (1 cm) following BCT before starting XRT 10% chance of local recurrence, usually within 2 years of 1st operation, need to re-stage with recurrence Need salvage MRM for local recurrence

49 Radical Mastectomy

50 Radical Mastectomy

51 Modified Radical Mastectomy

52 Modified Radical Modified radical mastectomy Removes all breast tissue, including the nipple areolar complex Includes axillary node dissection level I nodes

53 Simple Mastectomy

54 Simple Mastectomy A simple mastectomy (left) removes the breast tissue, nipple, areola and skin but not all the lymph nodes

55 Subcutaneous Mastectomy

56 Subcutaneous Mastectomy

57 Chemotherapy TAC (taxanes, Adriamycin, and cyclophosphamide) for 6 12 weeks Positive nodes everyone gets chemo except postmenopausal women with positive estrogen receptors they can get hormonal therapy only witharomatase inhibitor (anastrozole) > 1 cm and negative nodes everyone gets chemoexcept patients with positive estrogen receptors they can get hormonal therapy only with tamoxifen if they are premenopausal or aromatase inhibitor (anastrozole) if they are postmenopausal < 1 cm and negative nodes no chemo; hormonal therapy as above if positive estrogen receptors After chemo, patients positive for estrogen receptorsshould receive appropriate hormonal therapy Both chemotherapy and hormonal therapy have been shown to decrease recurrence and improve survival Taxanes docetaxel, paclitaxel Tamoxifen decreases risk of breast CA by 50% 1% risk of blood clots; 0.1% risk of endometrial CA

58 10,253 eligible women enrolled, 1626 women (15.9%) who had a recurrence score of 0 to 10 were assigned to receive endocrine therapy alone without chemotherapy. 5 year Invasive disease free survival was 93.8% Rate of freedom from recurrence of breast cancer at a distant site was 99.3% The rate of freedom from recurrence of breast cancer at a distant or local regional site was 98.7% Rate of overall survival was 98.0% (95% CI, 97.1 to 98.6). Pts with hormone-receptor positive, HER2-negative, axillary node negative breast cancer with tumors that had a favorable gene-expression profile had very low rates of recurrence at 5 years with endocrine therapy alone.

59 Radiotherapy Usually consists of 5,000 rad for BCT and XRT Complications of XRT edema, erythema, rib fractures, pneumonitis, ulceration, sarcoma, contralateral breast CA Contraindications to XRT scleroderma (results in severe fibrosis and necrosis), previous XRT and would exceed recommended dose, SLE (relative), active rheumatoid arthritis (relative) Indications for XRT after mastectomy: > 4 nodes Skin or chest wall involvement Positive margins Tumor > 5 cm (T3) Extracapsular nodal invasion Inflammatory CA Fixed axillary nodes (N2) or internal mammary nodes (N3)

60 Which one of the following represents a contraindication to breast conservation therapy? A. Previous breast irradiation B. Tumors larger than 3 cm diameter C. Unifocal disease D. Ductal carcinoma in situ E. Tumors in large fatty breasts

61 In a female patient with a primary T2N0M0 breast cancer, which one of the following is correct? A. Her overall survival is unaffected whether breast conservation surgery or mastectomy is performed. B. Her risk of local recurrence is unaffected by whether breast conservation surgery or mastectomy is performed. C. Postoperative radiotherapy is required irrespective of whether breast conservation surgery or mastectomy is performed. D. She has a 95% chance of being alive at five years given her disease stage. E. Sentinel lymph node biopsy for this patient has only 65% sensitivity and specificity for breast cancer.

62 Pregnancy & Breast Cancer Tends to present late, leading to worse prognosis Mammography and ultrasound do not work as well during pregnancy Try to use ultrasound to avoid radiation If cyst, drain it and send FNA for cytology If solid, perform core needle biopsy or FNA If core needle and FNA equivocal, need to go to excisional biopsy If breast CA 1st trimester MRM 2nd trimester MRM 3rd trimester MRM or if late can perform lumpectomy with ALND and postpartum XRT No XRT while pregnant; no breastfeeding after delivery

63 Cystosarcoma Phyllodes 10% malignant, based on mitoses per high-power field (> 5 10) No nodal metastases, hematogenous spread if any (rare) Resembles giant fibroadenoma; has stromal and epithelial elements (mesenchymal tissue) Can often be large tumors Tx: WLE with negative margins; no ALND

64 Paget s Disease Scaly skin lesion on nipple; biopsy shows Paget s cells Patients have DCIS or ductal CA in breast Tx: need MRM if cancer present; otherwise simple mastectomy (need to include the nipple-areolar complex with Paget s)

65 Stewart Treves Syndrome Lymphangiosarcoma from chronic lymphedema following axillary dissection Patients present with dark purple nodule or lesion on arm 5 10 years after surgery

66 Nipple Discharge Most nipple discharge is benign All need a history, breast exam, and bilateral mammogram Try to find the trigger point or mass on exam

67 Nipple Discharge Green discharge usually due to fibrocystic disease Tx: if cyclical and nonspontaneous, reassure patient Bloody discharge most commonly intraductal papilloma; occasionally ductal CA Tx: need ductogram and excision of that ductal area Serous discharge worrisome for cancer, especially if coming from only 1 duct or spontaneous Tx: excisional biopsy of that ductal area Spontaneous discharge no matter what the color or consistency is, this is worrisome for CA all these patients need excisional biopsy of duct area causing the discharge Nonspontaneous discharge (occurs only with pressure, tight garments, exercise, etc.) not as worrisome but may still need excisional biopsy (eg if bloody) May have to do a complete subareolar resection if the area above cannot be properly identified (no trigger point or mass felt)

68 Periductal Mastitis (mammary duct ectasia or plasma cellmastitis) Symptoms: noncyclical mastodynia, erythema, nipple retraction, creamy discharge from nipple; can have sterile or infected subareolar abscess Risk factors smoking, nipple piercings Biopsy dilated mammary ducts, inspissated secretions, marked periductal inflammation Tx: if typical creamy discharge is present that is not bloody and not associated with nipple retraction, give antibiotics and reassure; if not or if it recurs, need to rule out inflammatory CA (incisional biopsy including the skin)

69 Mastodynia pain in breast; rarely represents breast CA Dx: H & P, MMG Cyclic mastodynia pain before menstrual period; most commonly from fibrocystic disease Continuous mastodynia continuous pain, most commonly represents acute or subacute infection; continuous mastodynia is more refractory to treatment than cyclic mastodynia enlarge, need excisional biopsy In patients > 40 years old excisional biopsy to ensure diagnosis Tx: Danazol, OCPs, NSAIDs, evening primrose oil, bromocriptine Discontinue caffeine, nicotine, methylxanthines

70 Poland s Syndrome 1. Hypoplasia of chest wall & Shoulder, 2. Amastia 3. no pectoralis muscle

71 Infectious Mastitis most commonly associated with breastfeeding S. aureus most common. nonlactating women think chronic inflammatory diseases (eg actinomyces) or autoimmune disease (eg SLE) may need to rule out necrotic cancer (need incisional biopsy including the skin)

72 Galactorrhea Is often associated with amenorrhea can be caused by prolactin (pituitary prolactinoma) Meds: OCPs, TCAs, phenothiazines, Reglan, alpha-methyl dopa, reserpine Look for source: Prolactin level, Thyroid work up, MRI, medications

73 Gynecomastia 2-cm pinch; MCC idiopathic Assoc. w cimetidine, spironolactone, marijuana Tx: Many regress; may need to resect if cosmetically deforming or causing social problems

74 Intraductal papilloma MCC bloody nipple discharge usually small, nonpalpable, & close to the nipple NOT premalignant contrast ductogram to find papilloma, then needle localization Tx: subareolar resection of the involved duct and papilloma

75 Mondor s Disease superficial vein thrombophlebitis of breast; feels cordlike, can be painful Associated with trauma and strenuous exercise Usually occurs in lower outer quadrant Tx: NSAIDs

76 Fibrocystic Disease Lots of types: papillomatosis, sclerosing adenosis, apocrine metaplasia, duct adenosis, epithelial hyperplasia, ductal hyperplasia, and lobular hyperplasia Symptoms: breast pain, nipple discharge (usually yellow to brown), lumpy breast tissue that varies with hormonal cycle Only cancer risk is atypical ductal or lobular hyperplasia need to resect these lesions Do not need to get negative margins with atypical hyperplasia; just remove all suspicious areas (ie calcifications) that appear on mammogram

77 Fibroadenoma Most common breast lesion in adolescents and young women; 10% multiple Usually painless, slow growing, well circumscribed, firm, and rubbery Often grows to several cm in size and then stops Can change in size with menstrual cycle and can enlarge in pregnancy Giant fibromas can be > 5 cm (treatment is the same) Can have large, coarse calcifications (popcorn lesions) on mammography from degeneration In patients < 40 years old: 1) Mass needs to feel clinically benign (firm, rubbery, rolls, not fixed) 2) Ultrasound or mammogram needs to be consistent with fibroadenoma 3) Need FNA or core needle biopsy to show fibroadenoma Need all 3 of the above to be able to observe, otherwise need excisional biopsy