Breast Cancer: from bedside and grossing room to diagnoses and beyond. Adriana Corben, M.D.

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1 Breast Cancer: from bedside and grossing room to diagnoses and beyond Adriana Corben, M.D.

2 About breast anatomy Breasts are special organs that develop in women during puberty when female hormones are produced Men have breast tissue too, does not change during puberty because men do not have female hormones

3 Two types of breast tissue Lobular tissue: groups of cells that make the breast milk Ductal tissue: drains milk from the glands where it is made, and carries it to the nipple

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6 Secretory changes

7 Developmental Disorders Congenital: Supernumerary nipple(s) (next figure) Accessory axillary breast tissue (next figure) Congenital inversion nipple Acquired changes: Macromastia (female) Gynecomastia (male)

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9 Acute Mastitis

10 Fibrocystic Changes Most common disorder years Hormonal imbalance; excess estrogen Asymtomatic or present with large cysts (lumpy breasts)

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12 Most common benign breast tumor years Fibroadenoma

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15 Intraductal Papilloma Benign Arises in a lactiferous duct Serous or bloody discharge Careful: cancer!

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17 What is Breast Cancer? Cancer is caused by abnormal cells that grow and multiply without control Cancer that begins in any part of the breast Most common malignancy in women Male breast cancer makes up less than 1% of all breast cancer cases

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20 Breast Carcinoma - Risks Family history 5-10% are hereditary (BRCA1-BRCA2, others) Increasing age Proliferative breast disease Cancer of breast or uterus Parity, reproductive life length, age of 1 st child Obesity, diet

21 What are the symptoms of breast cancer? Sometimes breast cancer does not form a lump, but other changes in the breast can occur: Thickening of breast tissue Lumps under the arm (enlarged lymph nodes in the armpit) Change in the size or shape of the breast Rash, ridges or swelling of the breast skin Nipple discharge, tenderness, or the nipple being pulled inward

22 Breast Cancers

23 E-cadherin: Ductal vs Lobular

24 Ductal Carcinoma in Situ Very early (or beginning) stage of breast cancer In situ in Latin means in that place and not anywhere else

25 Clinical Case Screening mammography: 1.6 cm mass (R breast) Chest X-ray: lung nodules Family history of breast cancer (1 st and 2 nd generation)

26 Invasive Ductal Carcinoma Ductal cancer cells that grow beyond the ducts in the supporting stromal tissues or lymphatics or blood vessels Stage: T tumor N lymph nodes M metastasis

27 Invasive Ductal Carcinoma Stage Measured by Tumor size (T), which is important when planning each patient's treatment 0.1 cm = T1mi > cm = T1a cm = T1b cm = T1c (our patient) cm = T2 > 5.1 cm = T3

28 Invasive Ductal Carcinoma Stage It also means the cells can or not spread from the original tumor to nearby lymph Nodes (N) All negative = pn0 (our pt.) pn0(i+) = tumor cells <0.2 mm (H&E or IHC) pn1mi = micromets >0.2 mm 2 mm / >200 ITC) pn1 = macromets >2 mm pn1 = 1-3 positive lymph nodes pn2 = 4-9 positive lymph nodes pn3 = > 10 positive lymph nodes

29 Invasive Ductal Carcinoma Stage When breast cancer spreads to other organs, for example the lungs (liver, bones, brain...) it is still breast cancer and does not become lung cancer Cancer spread is called Metastasis (M) Stage = T-N-M Our patient T1c N0 M1 (1.6 cm breast mass, lung mets)

30 Stage I T = less than 2 cm N = no mets M = no mets

31 Stage II T = any size N = no mets M = no mets Or T = < 5 cm N = 1-3 lymph nodes involved M = no mets

32 Stage IV T = any size N = any nodes M = distant metastasis

33 Lobular Carcinoma Lobular tissue is the milkproducing gland tissue of the breast It is arranged in clusters or rings of cells Each cluster is called a gland The glands produce the breast milk that goes into the ducts

34 Other Breast Cancers Unusual types of breast cancer that affect women and do not fit into the ductal or lobular categories Inflammatory Breast Cancer starts as a rash in the skin of the breast; uncommon and aggressive

35 Other Breast Cancers Paget's disease of the nipple

36 Male Breast Cancer At any age, but found between 60 and 70 yrs of age (< 1% all breast cases) Same type of cancers: ductal, lobular, Paget s disease of the nipple Male risk factors Radiation exposure High levels of estrogen (genetic disorders, cirrhosis..) Family history of breast cancer (mother or sister with BRCA2 mutation) or inherited mutations

37 Screening for Breast Cancer Screening for cancer means testing for something abnormal before it makes a person sick The earlier a cancer is found, the smaller it is likely to be and more likely to be curable Screening means doing mammograms and self breast exams A mammogram is a set of breast x-rays

38 Who should have a mammogram? 40 yrs and older, every other year until 50 and then every year In combination with a good breast self-exam!!

39 Breast X-ray The mammogram x-rays can show small white spots of calcium or lumps in the breast tissue These spots can show that there are breast cancer cells in the tissue even when the cancer is too small to feel

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41 Ca++ in DCIS

42 Fine Needle Aspiration (FNA) Thin needle used to draw out cells Done in dr. office or radiology room With /without ultrasound guidance Cells placed on slide Benign or malignant NOT in situ or invasive

43 Needle is thicker Removal of portion of a lesion (not cells) Done in dr. office or radiology room With /without ultrasound guidance Cells placed on slide Benign or malignant In situ or invasive Core biopsy

44 Needle localization biopsy Places a tiny wire strand (hardly bigger than a hair) into the breast tissue Done by radiologist Then, once in place, surgeon removes tissue around needle Then checked again by x- ray

45 Excision Complete removal of lesion Short surgery in day surgery center Can represent either a diagnostic or a therapeutic procedure

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48 At the grossing bench Appropriate orientation Precise inking of the entire surface with different color Thin sectioning Careful description (matched with radiograph) Recording critical data (tumor size, margin distances, dissection of lymph nodes..)

49 Simple mastectomy (our pt had) Removal of entire breast (with occasional one or two axillary nodes) For DCIS, invasive carcinoma with negative sentinel lymph nodes or prophylactically (in high risk patients) Nipple sparing (FS)

50 Modified radical mastectomy Removal of entire breast with all lymph nodes All cancers with positive nodes

51 Radical mastectomy (rare) Removal of entire breast with all lymph nodes and chest muscles All cancers with positive nodes

52 Sentinel node biopsy By injecting radioactive or colored fluid near the breast tumor The fluid will flow away from the breast in the lymph channels to the nearby lymph nodes The surgeon removes one or a few lymph nodes that collected the radioactive fluid The nodes are tested for cancer cells by the pathologist in the Frozen Section lab

53 MSK Breast Cancer Center Highly collaborative care, involving a multidisciplinary team of cancer specialists Newly diagnosed patients are seen by a surgical, radiation, and medical oncologist in a single visit, which is usually scheduled as soon as possible A multidisciplinary team develops each patient s treatment plan, which includes radiology and pathology review, as well as eligibility for clinical research trials Before the patient leaves the hospital they know what their treatment will entail and has discussed it in detail with their physician

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