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Breast Cancer I.

Definition/General Considerations * Breast cancer is the most common cancer of women Incidence is 216,000/year * Breast cancer is the second leading cause of cancer death in women after lung cancer 40,000/year * Women have 10 chance of getting !reast cancer in their life * "is# factors for !reast cancer$ %ender & age & young 1st menarche '(11), old 1st *regnancy '&+0), late meno*ause '&,0), nulli*arity, *rior history of !reast cancer, -. of !reast cancer in 1st degree relative / young age, 012 * 3ost common !reast cancer are$ Invasive ductal carcinoma & invasive lo!ular and inflammatory carcinoma * 4creening for normal, healthy women 5) &,0$ 5nnual mammogram and 1B6 B) 40748$ 4hared decision with *atient and 39 * 4creening for those with 1st degree relatives having cancer at young age 5) Begin screening and 1B6 10 years earlier than diagnosis of youngest family mem!er II. Clinical Findings * 5ny *al*a!le !reast lum*, asymmetric thic#ening, or focal *ain * 3ost develo* in u**er right :uadrant and the ma;ority of asym*tomatic * 3alignant traits 1) -i<ed mass that does not change si=e with menstruation 2) 9im*ling of s#in overlying !reast +) "ecent onset, unilateral ni**le inversion 4) 4*ontaneous ni**le discharge, es*> if clear or !loody ,) 4caly lesions on ni**le 6) -ailure of !reast inflammation to res*ond to 5!< ?) 2ersistent, focal !reast *ain III-IV. Workup/Laboratory Findings * %eneral 5) 3ammogram of @4 in women over +0 B) -A5 of a *al*a!le lum* 1) 1ore needle !io*sy for nondiagnostic -A5 9) Aeedle as*iration of a *al*a!le cystic lesion 6) 0*en e<cisional !io*sy is definitive -) 9uctogra*hy and cytology for ni**le discharge * 5lgorithm 5) Aon7sus*icious mass, ( +, -A5 1) Bloody fluid go to sus*icious mass algorithm 2) Aormal fluid drain and reassureB routine -/@ +) Ao fluid a) 5ge (+, 9iscuss with *atient, reassure 7 If reassured, f/u in 1 mo and closely after that 7 If want !io*sy 91I4/15 or negative and reassure !) 5ge & +, 1ore or e<cisional !io*sy, mammorgra*hy 7 91I4/15 or negative reassure B) 4us*icious mass, & +, 1ore or e<cisional !io*sy, mammogra*hy 7 91I4/15 or negative reassure * Cri*le test findings$ Aegative -A5, negative mammorgram, low7sus*icion 1B6 V. Differential Diagnosis 5) Benign mass$ Well circumscri!ed, mo!ile, tender, and changes in si=e with cycle 1) -i!rocystic change 'most fre:uent !reast lesion)$ 2ainful !efore menses, fluctuation in si=e, multi*le/!ilateral 7 Increase ris# of B1 with ductal/aty*ical hy*er*lasia 7 1an arise overnight 7 C<$ 9rainage 2) -i!roadenoma 'most common !reast mass in women (+0)$ -irm, round, mo!ile, and nontender

7 C<$ Ao treatment re:uired +) Intraductal *a*illoma$ 3ost common cause of !loody ni**le discharge 4) 0ther$ Di*oma, a!scess, fat necrosis, mastitis B) 3alignant mass$ .ard, irregular, fi<ed, ni**le retraction, dim*ling, edema, lym*hadeno*athy 1) Invasive ductal carcinoma 'mid +0s7late ,0s)$ 3ost common !reast malignancyB tumor si=e is greatest *rognosis indicator 7 C< E 5d;uvant tamo<ifen to *revent mets 2) Invasive lo!ar carcinoma '4,7,6 yo)$ F710 of casesB increased fre:uency of !ilateral 15 7 C< E 6ither **< !/l mastectomy or mastectomy *lus very close -/@ +) 2agetGs carcinoma$ Infiltrating ductal carcinoma in !reast 7 4/4 E itching/!urning of ni**le with su*erficial ulceration or erosion 7 C< E e<cision H radiation 4) Inflammatory carcinoma$ 3ost aggressive, *oorly differentiated, ra*idly lethal 7 4/4 E diffuse induration, signs of inflammation 'warmth, erythema, *ain), edema, I a<illary D59 7 1hemo H radiation VI. reat!ent * %eneral 5) 3odified radical mastectomy$ "emoval of the !reast and ni**le with a<illary node dissection 7 4*ares chest wall muscles B) Dum*ectomy 'wide local e<cision) *lus radiation$ 1om*lete e<cision with margins and a<illary node dissection followed !y radiothera*y 1) 4im*le mastectomy$ "emoval of !reast and ni**le only> 0nly can !e used **< 9) 5d;uvant thera*y$ 6liminate micrometastases 1) 6strogen7rece*tor status$ Camo<ifen for estrogen7sensitive tumors and com!o chemo for non7 estrogen7rece*tive tumors 2) Aodal involvement$ 1om!ine chemo if *ositive nodes * 3ets go to !one, !rain, and liver 7 1hemo is only o*tion if 6" negativeB hormonal mani*ulation if 6" *ositive 7 0o*hrectomy if *remeno*ausalB tamo<ifen if *ostmeno*ausal