BREAST CANCER

KAYLA TACKETT

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PATIENT SOCIAL/MEDICAL HISTORY-4138

• Female • 1995 Premarin –Estrogen Replacement after

• 75 years old menopause

• Widow with 1 adopted child • Tubular Carcinoma of the Left Breast 1999

• Retired • Hypertension
• Never smoker • Cardiac Stent- Coronary Artery Bypass Surgery
• 1 glass of wine every other night for heart attack 8/13/2015
• Very active- Pilates/Yoga • Cardiac issues for Mother and Father
• Gardener • 2 Sisters and 1 Aunt with Breast CA

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RISK FACTORS

• Gender – female has higher risk than male • Postmenopausal hormone replacement
• Increasing age 50 and above therapy (estrogen)
• History of breast cancer
• Higher alcohol consumption
• Early menarche, late menopause
• Low amounts of exercise
• Increasing age at first birth
• Lack of breast feeding
• Nulliparity
• Oral contraceptives

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SCREENING DETECTION

• Self-exams • Painless mass in breast

• Generally recommend mammogram screening • Skin dimpling

beginning at age 50 • Peau d’orange-edema of skin caused
• Patient began getting her screening done at 40 by infiltration of dermal lymphatics
due to family history
• Lymphadenopathy
• Yearly Check By physician
• Mammographic abnormality
• MRI or Ultrasound
• Nipple Discharge

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EPIDEMIOLOGY

• What Rate of incidence is breast cancer?

• Most common cancer among women, disregarding skin cancer
• Where does breast cancer fall on cause of cancer deaths in women?
• Second
• Today most frequently we will test the first lymph node that drains the tumor, how do we
figure out which lymph node to remove? Bonus piece for who can name this lymph node
• A radioactive tracer Tc 99m or isosulfan blue dye is injected into the tumor bed during
surgery which helps us find the Sentinel Lymph node

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 HISTOPATHOLOGY
• Intraductal CA or Ductal Carcinoma in situ (DCIS) – • Papillary
15-20% of Breast CA
• Adenocystic
• Lobular Carcinoma in situ- 2%
• Paget’s Disease
• Non Invasive Proliferation of abnormal epithelial
cells in lobules of the breast •Tubular Carcinoma

• Invasive Ductal Carcinoma – more than 60-80% of • Composed of tubular structure

all cases lined in single layer of well-
• Medullary Carcinoma differentiated epithelium
• Lobular Invasive • Non-aggressive
• Mucinous
• Good Prognosis

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LYMPH DRAINAGE AND METASTASIS

• Lung
• Supraclavicular • Pleura
• Axilla • Bone
• Level 1 Lateral-Near armpit • Brain

• Level 2 Directly Under • Eyes

• Level 3 Superior • Liver

• Internal Mammary Chain • Ovaries

• Intramammary Nodes • Adrenal Gland

• Pituitary Gland
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 ANATOMY
• 2nd rib to the 7th
• Edge of the sternum to anterior axillary line
• Axilla extension known as tail of spence
• Lies over the pectoralis muscles
• Coopers ligament connective tissue attaches to chest wall

• 15-20 lobes contain 15-20 lobules

• 15-20 lobes feed into 15-20 ducts which go into 8-9
lactiferous sinus’
• Bulk of breast tissue is adipose tissue
Traditional Tangential Borders

Medial- Mid sternum

Lateral-2cm past palpable tissue
Superior-1st or 2nd intercostal space
Inferior-2cm from inframammary fold 8

1-2cm of lung included in treatment field

 PREVIOUS TREATMENT

• 1999-Patient would have been 56 years old

• Stage 1A Tubular Carcinoma of the Left breast
• .9cm mass
• ER/PR Positive
• Lumpectomy
• 0 Positive Lymph nodes out of 27 tested
• Whole Breast Irradiation 50.4 Gy/ 28 fx at with 4 mv photons
• Boost 10 Gy/ 5 fx with 9 MeV electrons to depth of dmax
• Patient declined Tamoxifen
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• Patients field size was 7cm by 16cm
• We know that increasing the field size does what to skin dose?

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COURSE OF TREATMENT

• 12/19/17 Bilateral Screen Mammogram

• 12/29/17 Right Breast Ultra Sound Biopsy-Clip placed
• 1//11/18 Began Endocrine therapy
• 5/08/18 Pt. come in for right axilla fullness and breast pain
• 6/07/18 Increase in size from original mammogram
• 6/26/18 Lumpectomy with Sentinel Node Biopsy
• Radiation Therapy-hyper fractionated Right breast tangents

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 DIAGNOSTIC STUDIES 12-29-17

Patient originally presented with a .8cm mass on

12-19-2017
mammogram that was found to be ER/PR+ on 12

the US biopsy
 ENDOCRINE THERAPY 1-11-18

• 6 months of Aromatase inhibitor-Anaztrozole

• Patient received AI starting 1/11/18
• Given post-menopausal
• Cardiac Risk so opted to try this to avoid
• Lowers levels of estrogen available to receptors surgery
• Ineffective in premenopausal patients with functioning ovaries • Treatment plan from here was AI
for 6 months, surgery, and then AI
• Optional strategy of doing tamoxifen 5 years, AI 5 years
for 5 years
• 5 years is standard as of now

5-8-18 Patient come in for right axilla fullness and breast pain

6-7-18 Mass increase in size from .8cm to 2cm

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SURGERY OPTIONS
• Breast Conservation Surgery-Lumpectomy and Axillary node dissection or SLNB
• Totally Mastectomy- Removal of entire breast, not including axillary lymph or muscle below breast
• Radical mastectomy-Removal of entire breast, all axillary nodes would be removed, as well as pectoralis
major and minor
• Modified Radical Mastectomy- Removal of entire breast with axillary dissection of levels I and II

Patients tumor was small enough (2cm) that they were not concerned
with invasion of chest wall so they went with breast conservation
surgery followed by EBRT

They removed a 2cm mass that had LCIS and Tubular structures; the
SLNB was negative 14
TNM STAGING
• Carcinoma in situ-no evidence of invasive component
• T1- Tumor 2cm or less in greatest dimension
• T2- Tumor more than 2cm but not more than 5cm in greatest dimension
• T3-Tumor more than 5cm in greatest dimension
• T4- Tumor of any size with direct extension to the chest wall or skin
• Nx- Not assessed
• N0-No Nodes The patients stage was
• N1- Nodal Involvement considered a IIA ER/PR+
mass
• Mx- Not assessed
• M1- Mets
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INDICATIONS FOR RADIATION THERAPY

• Removal of Stage I and II masses will leave cancer in the breast 25% of the time
• DCIS-lumpectomy with RT
• I-IIB-Lumpectomy and surgical axillary staging with RT
• IIB-Neoadjuvant Chemo, Surgery and axilla staging with RT
• IIIB-IIIC-Neoadjuvant chemo, surgery and axilla staging with RT and adjuvant chemo

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PRONE VS SUPINE

• Previous Breast Irradiation

• Supine- large breast patient with pendulous breast gives all these folds that you have to deal with
• Lung and heart would be overtreated, long term complication because of folds
• Patients can be cut off in 3D sim if supine and large
• Prone-benefit small breast and left side good for lung dose or heart
• Lung miss because smoker or COPD
• Better dose homogeneity due to smaller separation
• Reduces skin fold dose

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PATIENT SETUP

• Prone Breast Board

• Handbar 1-left arm holding vac bag
• Arms raised in Vac loc bag
• Sponge for head- head turned left
• Pink Sternal Sponge and Rib Sponge
• Laser line Mid-Nipple
• Board Number 6.5
• Foot on bed pillow

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TREATMENT PLAN

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FIELD DESIGN ARRANGEMENT

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 21

What type of DVH is this?

CRITICAL ORGANS WITH THEIR TD 5/5

• Heart 4000 cGy

• Lung 1750 cGy
• Liver 3000cGy
• Contralateral breast >5000cGy

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DAILY SETUP AND IMAGING

• First 3 days KV orthogonal pair and CBCT

• If daily CBCT shifts from orthogonal pair greater than or equal to 3mm
• Weekly CBCT if shifts less than 3mm KV orthogonal pair and alternating medial/lateral ports daily
Her Imaging Order
• KV orthogonal pair and alternating medial/lateral ports daily
• Weekly CBCT
• Alignment Structure; Lump GTV, watch sternum and be aware of contralateral breast position

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SETUP TROUBLES

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SIDE EFFECTS/MANAGEMENT
Short Term Long Term
• Residual Hyperpigmentation or
• Fatigue Hypopigmentation
• Skin Irritation • Skin Telangiectasias
• Radiation Pneumonitis
• Breast Swelling • Scarring/Fibrosis
• Diffuse Tenderness • Radiation Induced Heart Disease
• Lymphedema
• Anxiety • Rib Fraction
• Radiation Induced Malignancy

Patient worked on staying active as doctors suggested

Pressure held on right breast was relieving 25

DISEASE SURVIVAL RATES

• Our patient is considered a stage IIA

because of the 2cm mass
• What is IIA vs IIB?

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PATIENT EXPERIENCE
• Overall positive
• Massages
• Continued exercise classes
• Very anxious with lots of questions
• Thankful for her being so open with me about her experience

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REFERENCES

• Griffin, Haley. Breast Introduction. Present at: RADSCI 3574 - Applied Radiation Oncology 2; March
2018; Columbus, Ohio
• Griffin, Haley. Breast CA. Present at: RADSCI 3574 - Applied Radiation Oncology 2; March 2018;
Columbus, Ohio
• Griffin, Haley. Breast Treatment. Present at: RADSCI 3574 - Applied Radiation Oncology 2; March 2018;
Columbus, Ohio
• Kuhn, Karla. Present at: RADSCI 3389 – Rad Therapy Practicum; Spring 2018; Columbus, Ohio
• Washington, CM & Leaver, D. Principles and Practice of Radiation Therapy. 4th Edition. St. Louis, MO:
Elsevier, Inc; 2016:822-836.

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