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Joseph A. Lucci III, M.D.
Department of Obstetrics and Gynecology
Division of Gynecologic Oncology

  
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 {eproductive Health
 Diagnosis
 Treatment
 Cancer Screening

 
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 Skin
 Fat
 Gland
 Connective Tissue
 Vessels

 
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 aody
 Tail
 Nipple Complex

 
 

 ± 2 Ducts 
Duct Drains Lobe 
Lobe Contains 2 ± 4 Lobules 
Lobule Contains  ±  Alveoli

  
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Camper¶s Fascia 
Pectoral Fascia 
Cooper¶s Ligaments

  
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 A{TE{IAL
½ Internal Mammary
½ Lateral Thoracic
 LYMPHATICS
½ Drainage
½ Nodal Levels

 
  

Level I ± Lateral Pectoralis Minor 
Level II ± Deep Pectoralis Minor 
Level III ± Medial Pectoralis Minor

  
  
  


   

 

Professional Physical Examination 
areast Self Examination (aSE) 
Mammography

!  

 OaSE{VE
½ Mass Effect
½ Arm Position
 PALPATE
½ areast
½ Nodes

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 Positioning
 Palpation
 Discharge

   
  
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 aenign 88%
 Malignant 2%
   

. Galactorrhea
2. Intraductal papilloma
3. Duct ectasia
4. Carcinoma   

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Age Physical Exam

2 ± 4 yrs Every 3 years

> 4 yrs Annually   

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{ecommended monthly for all
women over the age of 2

  
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MAMMOG{APHY
½ 2 Views
½ Magnification 

ULT{ASOUND 
 

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Mortality
Age ACS NCI {eduction

4 ± 49 Q  yr Q 
2 yrs %

5 ± 69 Q  yr Q  yr 25 ± 3 %

  Q  yr Q  yr ?
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aiopsy any suspicious palpable
lesions. 

aiopsy any suspicious area seen on
mammogram, but not palpable

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 5 ± 8 % of all women
 Etiology
 Diagnosis
 Treatment 
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 Palpation
 Mammography
 Ultrasound
 Aspiration
 aiopsy 
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 OCP¶S
 Methylxanthines
 Nicotine
 Vitamin E
 Hormones
 aromocriptine
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Extent of Proliferative Changes 
Variable   

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Hyperplasia .9

Atypical Hyperplasia 4.5

AH  FM HX 

Cysts .5

Cysts  FM HX 3.    

 Fibrocystic Changes
 Small, Irregular
 {esembles CA
 DX: FNA
 TX: Excision   

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Age: 2 ± 3 yrs 
Groups
½ Tubular
½ Lactating 
DX: FNA 
TX: Observe, Excision 
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Age 2 ± 49 yrs 
Firm, Painless 
ailateral 5 ± 25% 
DX: FNA 
TX: Observe, Excise 
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Age: 3 ± 55 yrs 
Slow Growing 
Epithelial and Stromal 
 % Sarcoma 
DX: FNA 
TX: Excision
  
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Age: 45 ± 5 yrs 
aloody Discharge 
Unilateral, small 
TX: Excision 
CA {isk: {are, Multiple Lesions

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Age: Perimenopausal 
ailateral 
Sticky, Thick, Green Discharge 
DX: Exam 
TX: AaX, Excision 
CA {isk: {are

 

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 82,8 new cases in women
 4 ,8 deaths in women
 :8 women will develop breast
cancer in lifetime

Greenlee et al, CA Cancer J Clin 2000, 50:7-33
  
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New Death
areast 8 ,3 43,5
Lung 83,3 68,4
Colon 68,9 28,9
Endometrium 36, 6,3
Ovary 25,4 4,5
Cervix 3, 4,9

Cancer Facts and Figures ± ACS, 1998

  

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, , '0121-13(

Localized 9%

{egional 8%

Distant 22%

Overall 86%

Greenlee et al, CA Cancer J Clin 2000, 50:7-33

  

Incidence has plateaued since 98 
Mortality rates have been stable or declining 
5 year survival for localized disease has improved

94 8%
993 93%
99 9%   

  
 

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Sex 
Parity 
Menses 
Socioeconomic 
{ace 
Diet 
Weight

  
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|&  & |&
 Age
 Family history of breast cancer
 Age at first live birth, if any
 Number of breast biopsies
 History of atypical hyperplasia
 Age at menarche
 {ace

 

    

{elative {isk
of areast Calculated
Family History Cancer Lifetime {isk
Unilateral

Premenopausal 3. 2.%

Postmenopausal .5  .5%

ailateral 5.4 3.8%

Premenopausal 8.8 6.6%

Postmenopausal 4. 28. %

  

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{{
First Pregnancy (>3 yrs) .48
aody mass index (>29.68 kg/m2) .48
College graduate .36
Alcohol use (>5 g/d) .6
Delayed menopause .4 (5 yrs)
H{T (current) .2 (5 yrs)*

* ased on data from Colla orative Group on Hormonal Factors in Breast Cancer. Lancer. 1997; 350-1047.

  

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Early Pregnancy 
Castration 
Exercise 
Avoid ETOH
  
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Fisher et al. J Natl Cancer Inst 1998; 90:1371-1388.
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 Primary End Point
 Incidence of invasive breast cancer
 Secondary End Points
 areast cancer mortality
 Incidence of cardiovascular events
 Incidence of bone fractures

Fisher et al. J Natl Cancer Inst 1998. 90:1371-1388
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Fisher et al. J Natl Cancer Inst 1998; 90:1371-1388
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*Not statistically significant
Fisher et al. J Natl Cancer Inst 1998;90:1371-1388
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Hip Fracture .84 .46
Total Fracture 5.28 4.29
Cardiac Ischemia 2.3 2.3
DVT .84 .34
PE .23 .69
CVA .92 .45
TIA .96 .3
Cateracts 2.2 24.82
Cateract Surgery 3. 4.2

Fisher et al. J Natl Cancer Inst 1998; 90:1371-1388.
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Invasive Ca 5 36 .9 2.3
 49 yrs 8 9 . 9 .32
> 49 yrs  2 .6 3. 5
Stage I 4 36
Stage IV 
Deaths 
Ca in situ 3  . 6 .35

Fisher et al. J Natl Cancer Inst 1998; 90:1371-1388.
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% {isk
Symptom Tamoxifen Placebo {atio
Vaginal discharge 55 34 .6

Cold sweats 2 5 .45

Genital itching 4 38 .23

Night sweats 6 55 .22

Hot flashes 8 65 .9

Day et al. J Clin Oncol 1999. 17(9):2659-2669
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Cummings SR et al. Proc Am Soc Clin Oncol. 1998;17-2a
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, 

 MO{E Trial
½ areast Cancer risk not specifically
addressed at entry
½  % reduction at 33 months
 9 trials ±  ,55 patients
½ Mean follow
followup = 4 months
½ 6 breast cancer events
½ 55% reduction in relative risk 
 

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 Evaluation
½ H&P
½ CX{
½ aone Scan
½ Labs
 TNM

 

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 Surgery
 {adiation
 Chemotherapy
 Hormones

  

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In SITU 
Location 
Tumor Size 
areast Size 
Patient Age 
Patient Preference 
Mammographic Appearance

 

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areast Conservation
½ Lumpectomy
½ Sentinal Node(s) 

Modified {adical Mastectomy
and Papillary Node Disection

  

{{
 Size
 Nodes
 Stage
 Grade
 Ploidy
 S ± Phase
 Necrosis
 HE{2/neu
HE{

 

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Premenopausal ± Chemo 
Postmenopausal ± Hormones

  

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 {egimens
½ CMF
½ CAF
½ AC
 6 ± 2 Cycles

 

{ { 
All areast Concerving Surgical Therapies 
High {isk Patients 
When
½ After Chemo
½ Middle of Chemo

  

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Tamoxifen x 5 years 
All Patients 
Ovarian Ablation

  
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