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An Introduction To Breast Cancer: Biology, Pathology, and The Latest in Screening and Diagnostic Tools
An Introduction To Breast Cancer: Biology, Pathology, and The Latest in Screening and Diagnostic Tools
American Cancer Society. Cancer Facts & Figures 2008. Atlanta: American Cancer Society: 2008.
Epidemiology of Breast Cancer
• Incidence rates had been increasing from 1980-2000
– Increased use of screening mammography
– Detecting breast cancers in earlier stages of disease
American Cancer Society. Cancer Facts & Figures 2008. Atlanta: American Cancer Society: 2008.
Question #1
• What is a woman’s lifetime risk of having invasive breast
cancer?
• A) 0.5%
• B) 3.8%
• C) 6.7%
• D) 12.5%
• E) 25%
Question #1
• What is a woman’s lifetime risk of having invasive breast
cancer?
• A) 0.5%
• B) 3.8%
• C) 6.7%
• D) 12.5%
• E) 25%
American Cancer Society. Cancer Facts & Figures 2008. Atlanta: American Cancer Society: 2008.
Breast Anatomy
• Anterior chest wall
• Superficial to pectoralis major muscle
• Borders
– Medial: Midline chest wall
– Lateral: mid-axillary line
– Superior: 2nd anterior rib
– Inferior: 6th anterior rib
Halperin E, Perez C, Brady L, Ed. Perez and Brady’s Principles and Practice of Radiation Oncology: Fifth edition. Lippincott Williams
& Wilkins, Philadelphia: 2008. 1162-1317.
Breast Anatomy
• 4 Quadrants:
– Upper Inner (UI)
– Upper Outer (UO)
– Lower Inner (LI)
– Lower Outer (LO)
http://www.breastdiagnostic.com/images/anatomy1.gif.
http://www.breastdiagnostic.com/images/anatomy1.gif
Breast Anatomy
• Blood vessels
• Nerves
Lobules
• Lymphatics
Fat
http://www.breastdiagnostic.com/images/anatomy1.gif
Breast Anatomy
• Parenchyma:
– Lobules
• Produce Milk
– Ducts
• Function to transport lactation
products to the nipple
• Peripheral ducts converge into
major lactiferous ducts, which
communicate with the nipple-
areola complex
Halperin E, Perez C, Brady L, Ed. Perez and Brady’s Principles and Practice of Radiation Oncology: Fifth edition. Lippincott Williams
& Wilkins, Philadelphia: 2008. 1162-1317.
http://www.cancervic.org.au/images/content/breast_health/lcis.gif
http://www.cancervic.org.au/images/content/breast_health/lcis.gif
Breast Anatomy
• Lymphatics
– Begin in the interlobular
spaces
– Travel along the ducts
– End in the subareolar network
of lymphatics of the skin
Halperin E, Perez C, Brady L, Ed. Perez and Brady’s Principles and Practice of Radiation Oncology: Fifth edition. Lippincott Williams
& Wilkins, Philadelphia: 2008. 1162-1317.
Breast Anatomy
• Axillary lymph nodes
• 3 levels
– Based on relationship to
pectoralis minor muscle
• Level I axilla
– Caudal and lateral to
III pectoralis minor m.
II • Level II axilla
I – Beneath pectoralis minor m.
• Level III axilla
– Infraclavicular region
– Cranial and medial to
pectoralis minor m.
Halperin E, Perez C, Brady L, Ed. Perez and Brady’s Principles and Practice of Radiation Oncology: Fifth edition. Lippincott Williams
& Wilkins, Philadelphia: 2008. 1162-1317.
Breast Anatomy
• Supraclavicular (SCV) LNs
– Axillary lymph nodes continue SCV
underneath the clavicle to
become the SCV lymph nodes.
– Locally advanced cancers
Halperin E, Perez C, Brady L, Ed. Perez and Brady’s Principles and Practice of Radiation Oncology: Fifth edition. Lippincott Williams
& Wilkins, Philadelphia: 2008. 1162-1317.
www.intra-
www.intra-medical.com/lymphatic.html
Breast Anatomy
• Anatomy of the chest wall is important for staging purposes
• Chest wall:
– Ribs
– Intercostal muscles
– Serratus anterior muscle
– NOT the pectoral muscles
Halperin E, Perez C, Brady L, Ed. Perez and Brady’s Principles and Practice of Radiation Oncology: Fifth edition. Lippincott
Williams & Wilkins, Philadelphia: 2008. 1162-1317.
Question #2
• What is the most significant risk factor for developing breast
cancer (other than gender)?
Halperin E, Perez C, Brady L, Ed. Perez and Brady’s Principles and Practice of Radiation Oncology: Fifth edition. Lippincott Williams
& Wilkins, Philadelphia: 2008. 1162-1317.
Genetic and Familial Factors
• BRCA1 and BRCA2
– < 1% of the population
– < 7% of breast cancer patients
– Mediate effects of cell response to DNA damage
– BRCA1
• Lifetime risk of breast cancer 65-85%
• Lifetime risk of ovarian cancer 50%
• Increased risk of colon and prostate cancer
– BRCA2
• Lifetime risk of breast cancer 65-85%
• Increased lifetime risk of ovarian cancer, but less than that for BRCA1
• Associated with pancreatic cancer and male breast cancer
Signs and Symptoms of Breast Cancer
• Often found as an abnormality on mammogram
Giordano, SH. Update on locally advanced breast cancer. Oncologist 2003; 8:526. Copyright © 2003 AlphaMed Press.
Signs and Symptoms of Breast Cancer
• Nipple changes
– Ulceration
– Retraction, inversion
– Spontaneous discharge
Natural History of Breast Cancer
• Thought to be slow growing tumors, with an average of 5 yrs
before a tumor becomes palpable.
– Can grow through blood vessel walls and spread into the deep
lymphatics of the dermis (skin)
• Edema and dimpling of the skin (peau d’orange)
• +/- CT chest/abdomen/pelvis
– Stage II or III disease, or elevated
liver function tests
Breast Cancer Histology
• In situ carcinomas
– Confinement of malignant cells
within the basement membrane
http://www.bccancer.bc.ca/NR/rdonlyres/E74D74FF-
http://www.bccancer.bc.ca/NR/rdonlyres/E74D74FF-9D8E-
9D8E-4FF1-
4FF1-8B39-
8B39-92E61EFE5310/18064/ductal_carcinoma_range1.jpg
Breast Cancer Histology
• Invasive carcinomas
– Invasive ductal carcinoma (IDC)
• Most common type (> 50% of
cases)
• Solid cords or groups of cells
• Commonly associated with an in
situ component
– Medullary carcinoma
– Mucinous carcinoma Better prognosis
– Tubular carcinoma
• Prognostic significance:
– Grade 1 tumors tend to have a better
prognosis than grade 2 or 3 tumors
Hormone Receptor Status Testing
• Receptors are proteins on the surface of cells that can attach to
certain substances circulating in the blood stream, like
hormones.
• A) 30 y/o
• B) 35 y/o
• C) 40 y/o
• D) 45 y/o
• E) 50 y/o
Question #3
• Beginning at what age does the American Cancer Society
recommend annual mammogram screening in women of
average risk for breast cancer?
• A) 30 y/o
• B) 35 y/o
• C) 40 y/o
• D) 45 y/o
• E) 50 y/o
– Recommendations:
• Annual mammograms starting at age 40 y/o
• Should discuss the benefits and limitations of adding an annual
screening MRI
“American Cancer Society Guidelines for Early Breast Cancer Detection.
Detection.””
http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_Can_breast_cancer_be_found_early_5.asp?rnav=cri
http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_Can_breast_cancer_be_found_early_5.asp?rnav=cri.. Last revised on
09/04/2008.
Breast Cancer Screening
• Women at high risk
– > 20% lifetime risk of breast cancer
– Proven mutation in BRCA1 or BRCA2
– First-degree relative (parent, brother, sister, or child) with a BRCA1
or BRCA2 gene mutation
– Radiation therapy to the chest between the ages of 10-30 years old
– Personal history or family history in a first-degree relative of
• Li-Fraumeni syndrome
• Cowden syndrome, or
• Bannayan-Riley-Ruvalcaba syndrome
– Recommendations:
• Begin screening at age 30 y/o
• Annual mammogram and MRI
• Annual Clinical Breast Exam
• For patients who have BRCA1 or BRCA2 mutations
– Annual pelvic exams with transvaginal U/S of the ovaries, and Ca-125
“American Cancer Society Guidelines for Early Breast Cancer Detection.
Detection.””
http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_Can_breast_cancer_be_found_early_5.asp?rnav=cri
http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_Can_breast_cancer_be_found_early_5.asp?rnav=cri.. Last revised on
09/04/2008.
Question #4
• On average, screening mammograms detect what percentage of
malignancies?
• A) < 1%
• B) 4%
• C) 10%
• D) 20%
• E) 35%
Question #4
• On average, screening mammograms detect what percentage of
malignancies?
• A) < 1%
• B) 4%
• C) 10%
• D) 20%
• E) 35%
Harris J, et al. Diseases of the breast. Philadelphia: Lippincott Williams & Wilkins, 2004.
Mammogram
• Mammography has been associated with:
– Detection of earlier stage breast cancers
– Reduction in breast cancer mortality rates
Harris J, et al. Diseases of the breast. Philadelphia: Lippincott Williams & Wilkins, 2004.
http://www.med.yale.edu/intmed/cardio/imaging/anatomy/breast_anatomy/graphics/breast_anatomy.gif
http://www.med.yale.edu/intmed/cardio/imaging/anatomy/breast_anatomy/graphics/breast_anatomy.gif
Mammogram
• Screening Mammogram
– Routine images in asymptomatic women
– 2 views: craniocaudal and mediolateral obliques of each breast
Mediolateral
Craniocaudal
“American Cancer Society Guidelines for Early Breast Cancer Detection.
Detection.””
http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_Can_breast_cancer_be_found_early_5.asp?rnav=cri
http://www.cancer.org/docroot/CRI/content/CRI_2_4_3X_Can_breast_cancer_be_found_early_5.asp?rnav=cri.. Last revised on
09/04/2008.
Mammogram
• Diagnostic Mammogram
– Used to characterize abnormalities detected at screening or in
women with palpable masses
– Additional magnification views
– Generally done with the radiologist present to determine the need
for additional views and/or follow-up studies.
Kriege M, et al. “Efficacy of MRI and mammography for breast-cancer screening in women with a familial or genetic predisposition.”
N Engl J Med 2004;351:427-437.
Courtesy of Bernard J R, Mayo Clinic Jacksonville
Question #5
• Magnetic Resonance Imaging (MRI) detects what percentage of
contralateral otherwise occult malignancies?
• A) < 1%
• B) 3-4%
• C) 10-15%
• D) 20-25%
• E) 35%
Question #5
• Magnetic Resonance Imaging (MRI) detects what percentage of
otherwise occult contralateral malignancies in women of any
age, recently diagnosed with breast carcinoma?
• A) < 1%
• B) 3-4%
• C) 10-15%
• D) 20-25%
• E) 35%
Bernard J R, Vallow L A, et al. “Mammographically Occult Contralateral Breast Carcinoma Detected by Magnetic Resonance Imaging
in the Elderly.” J Clin Oncol 26:2008 (May 20 supplement; abstr 500).
Magnetic Resonance Imaging (MRI)
MRI Mammogram
Saslow D, et al. “American Cancer Society Guidelines for Breast Screening with MRI as an Adjunct to Mammography.” CA Cancer J
Clin 2007;57;75-89.
Indications for Breast MRI
• Screening for breast cancer in certain moderate to high risk
patient populations (American Cancer Society)
MRI
Post
Cycle 1
Post
Cycle 2
1 4 5
Questions?