`

the case of a 53 year old menopausal female from

novaliches, quezon city
 CC
Breast Mass, Right
Breast Mass, Right  Solitary, hard, non-tender
HPI breast mass, Right Lower
Outer Quadrant
1 Month PTA
Non-Neoplastic
Patient palpated a mass
Patient palpated a mass on her right breast about
Fat the size of a
Necrosis
on her right breast about
small marble located on the Lower OuterFibroadenoma
Quadrant
the size of a small marble
(-) tenderness, discharge or erythema
Chronic Breast
located on the Lower
Abscess
Outer Quadrant
Neoplastic
(-) tenderness, discharge
or erythema
 On Examination of the Breast,
In the Review of Systems, try to
take note of the following:
elicit the following:
Mass
SSx of Metastasis
Size
Bone pain
Consistency
Shortness of breath
Mobility
Lack of appetite
Discharge
Weight loss
Skin changes
Neurological pain or
Erythema
weakness,
Induration
headaches
Skin Dimpling
Nipple Retraction
ROS No weight loss, loss of appetite
No headache, vomiting
No dyspnea, difficulty of breathing
No chest pain, orthopnea
No palpitations, PND
No abdominal pain, diarrhea, constipation
No dysuria, frequency, urgency
No edema, cyanosis
PMHx
(-) DM, HTN, PTB, Asthma
No previous surgery
FMHx
(-) History of Breast Cancer
PSHx
Non-smoker, non-alcoholic drinker
Findings
Conscious, coherent, ambulatory
BP 100/70 mmHG Normotensive

CR 89 beats/min Normal

RR 14 breaths/min Normal

Pink palbebral conjunctivae, anicteric sclerae

(-) NAD, TPC, CLAD
Right Breast: Pendulous breast with 2x2cm mass, non-tender,
fixed, hard, (-) discharge, orange-peel
(-) palpable right axillary lymph nodes
Left Breast: Unremarkable
Findings
SCE, (-) retractions, resonant, CBS, (-) crackles, wheezes
AP, NRRR, no murmur, AB at 5th ICS, LMCL
Flabby abdomen, NABS, soft, non-tender, liver and spleen not enlarged
(-) pallor, cyanosis, edema
DRE unremarkable
 Rule In Rule Out
Fat Necrosis Solitary nontender (-) Hx of Trauma, Scar, Hematoma
firm mass ** R/O through Excisional Biopsy
Fibroadenoma Solitary nontender ** Usually found in a young woman with large
firm mass breasts
** R/O
Chronic Breast Solitary nontender (-) Fever
Abscess firm mass ** Biopsy to distinguish from carcinoma
Breast Carcinoma Dominant solitary (-) Involvement of the Suspensory Ligaments
nontender mass - retraction, revealed by dimpling, deviation
of the nipples, fixation to the pectoral
muscles
(-) Involvement of the Lactiferous Tubules -
Flattening of the nipple, bloody or clear
discharge
(-) Lymphatic obstruction – edema of the
skin, peau d’orange
(-) Lymphatic spread – Regional
lymphadenopathy
Breast Mass, Right,
Probably Malignant
 Resource Allocation for Diagnosis and Pathology
Level of Resources Clinical
Basic • History
• Physical examination
• Clinical breast
examination
• Fine-needle aspiration
biopsy (1)
• Surgical biopsy
(Incision/Excision) (2)
Limited • Core needle biopsy
• Image-guided sampling
(ultrasonographic +
mammographic)
Enhanced • Preoperative needle
localization under
mammographic or
ultrasound guidance
Maximal • Stereotactic biopsy
• Sentinel node biopsy
Shyyan R, Masood S, Badwe RA, Errico KM, Liberman L, Ozmen V, Stalsberg H, Vargas H, Vass L. Breast cancer in limited-resource countries: diagnosis and
pathology. Breast J 2006 Jan-Feb;12 Suppl 1:S27-37. [45 references]
Pathology Imaging and Laboratory Tests
• Interpretation of biopsies
• Cytology report
categorizing cells as
malignant, benign or not
diagnostic
• Surgical or pathology
report categorizing lesion
as malignant vs. benign,
invasive vs. in situ and
describing tumor size,
lymph node status,
histologic type, tumor
grade and margin status
• Determination and • Diagnostic breast
reporting of ER and PR ultrasound +/- diagnostic
status mammography
• Determination and • Plain chest radiography
reporting of margin status • Liver ultrasound
• Blood chemistry
profile/CBC
• Onsite cytopathologist • Diagnostic mammography
• Bone scan
• HER-2/neu status • CT scanning, PET scan,
• IHC staining of sentinel MIBI scan, breast MRI
nodes for cytokeratin to
detect micrometastases
Comparison of Paraclinical Diagnostic Procedures in Patients with a
Palpable Breast Lump in which a More Definitive Diagnosis is Needed
in a Patient Suspected to have a Breast Cancer
(Goal: to be more definite on the diagnosis of a palpable breast lump suspected of cancer)

Procedures Benefit Risk Cost

FNAB Direct examination and Sampling Pain Php

•Diagnostic yield and accuracy rate •Hematoma 1,500
of more than 90% •No Scar

Open Direct examination and sampling Pain Php

Biopsy •Diagnostic yield and accuracy rate •Hematoma 8,000
of more than 98% •Side effects of
Anesthetic agents
•Scar

Lecture: Dr. Reynaldo Joson, September 25, 2006

Actual Procedures Done on Excision Biopsy – Invasive Ductal
the Patient Carcinoma
CBC, Blood Chemistry – August 23, 2006 (s/p Excision)
Normal Invasive Ductal Carcinoma,
Estrogen and Progesterone Right breast mass,
Receptor - Positive (+) grade II
Her2-neu – IHC 2+ Measuring 2x1x1cm
Her2neu – FISH Negative
Modified Radical Mastectomy
(after 2 wks)
September 14, 2006 (s/p MRM)
No residual tumor seen
Skin, nipple, and basal line of
resection are
negative for
malignant cells
All (0/12) lymph nodes are
 Primary Tumor (T) Regional Lymph Nodes (N)
Tx Cannot be assessed Nx Cannot be assessed

T0 No evidence of primary tumor N0 No regional lymph nodes

TIS Carcinoma in situ N1 Metastasis to movable ipsilateral nodes

T1 Tumor ≤ 2cm N2 Metastasis to matted or fixed ipsilateral nodes

T2 Tumor > 2cm but ≤ 5cm N3 Metastasis to ipsilateral internal mammary

nodes
T3 Tumor > 5 cm Distant Metastasis (M)
T4 Extension to chest wall, inflammation, Mx Cannot be assessed
satellite lesions, ulcerations
M0 No distant metastasis

M1 Distant Metastasis (includes spread to ipsilateral

supraclavicular nodes)

HPIM 16th ed
 Stage Grouping
Stage 0 TIS N0 M0
Stage I T1 N0 M0
Stage II A T0 N1 M0
T1 N1 M0
T2 N0 M0
Stage II B T2 N1 M0
T3 N0 M0
Stage IIIA T0 N2 M0
T1 N2 M0
T2 N2 M0
T3 N1,N2 M0
Stage III B T4 Any N M0
Any T N3 M0
Stage IV Any T Any N M1
HPIM 16th ed
Scarff, Bloom and Richardson grade

Grade I - well differentiated (3-5)

Grade II - moderately differentiated (6-7)
Grade III - poorly differentiated (8-9)

HPIM 16th ed
Diagnostic tests to rule out metastasis

Stage I, II
Complete Blood Count
Liver Function Tests
Chest X-Ray

Bigger,
More Advanced
Bone Scan
Liver Scan
Diagnosing Nodal Metastasis in Invasive Ductal Carcinoma

ALND Axillary Lymph Node Dissection

- traditional
Axillary procedure
Lymph Nodeto detect lymph node metastasis,
Dissection
and potentially therapeutic for the regional control of
axillary metastases
SLNB Sentinel Lymph Node (SLN) Biopsy
- most women with early-stage breast cancer are node
- negative,
minimallyand
invasive alternative
axillary dissection to in
stage
thesebreast
womencancer in
exposes
clinically
them to thenode-negative
complications patients
of this procedure, with no
- benefit
yields metastasis-free SLN in 65–70% of patients
-- associated
if SLNs are histologically
with negative, no
significant long-term further axillary
morbidity.
surgery would be performed
- associated with reduced arm morbidity and better quality
of life
- treatment of choice for patients who have early-stage
breast cancer with clinically negative nodes
Local/regional treatments:
1. Mastectomy + radiation therapy
2. Breast-conserving surgery
Lumpectomy (also called "wide resection," "partial mastectomy," or
"quadrantectomy") + radiation therapy to the remainder of the
breast tissue

Women who didn't get radiation after lumpectomy were shown to have a
40% greater risk of the cancer coming back in the same breast

These two options are considered equally effective for women with a
breast cancer measuring about four centimeters or less. For women
with a single tumor larger than about four centimeters, breast
preservation therapy may still be an option if chemotherapy is able to
shrink the cancer substantially BEFORE surgery.
Suggested Approaches to Adjuvant Therapy
Age Group Lymph Endocrine Tumor Recommendations
Node Receptor (ER)
Status Status
Check Serum
Pre-menopausal Positive Any Any
TumorMultidrug
Markers chemotherapy
+ Tamoxifen if ER(+)
Negative Any >2 cm, or 1-2 cm with other Multidrug chemotherapy
poor prognostic variables + Tamoxifen if ER(+)

Post Menopausal Positive Negative Any Multidrug chemotherapy

Positive Positive Any Tamoxifen with or
without chemotherapy
Negative Positive >2 cm, or 1-2 cm with other Tamoxifen
poor prognostic variables

Negative Negative >2 cm, or 1-2 cm with other Consider multidrug

poor prognostic variables chemotherapy

HPIM 16th ed, p.521

For years, tamoxifen was the hormonal medicine of choice for all women
with hormone-receptor-positive breast cancer

In 2005, the results of several major worldwide clinical trials showed that
aromatase inhibitors worked better than tamoxifen in post-menopausal
women with hormone-receptive-positive breast cancer

Aromatase inhibitors are now considered the standard of care for

post-menopausal women with hormone-receptor-positive breast
cancer

Tamoxifen remains the hormonal treatment of choice for pre-menopausal

women
The patient underwent modified radical mastectomy. Histopathology
results showed the patient to be on T2NOMx. The patient is at Stage
IIA.
Disease Stage 5-year Survival Rate
Stage 0 99%

Stage I 85-95%

Stage II 65-75%

Stage III 45-50%

(locally advanced)
Stage IV 20-30%
(metastatic)
Modified radical mastectomy continues to be appropriate for some
patients, but breast conservation therapy is now regarded as the optimal
treatment for most. Six prospective randomized trials have shown no
difference in survival when mastectomy is compared with
conservative surgery plus radiation for Stage I and Stage II breast
cancer (Table 1).

Adapted from Winchester DP, Cox JD. Standards for diagnosis and management of invasive breast carcinoma.
Recurrence
Most recurrences occur in the first three to five years after initial treatment.
Breast cancer can come back as a local recurrence (in the treated
breast or near the mastectomy scar) or as a distant recurrence
somewhere else in the body.
The most common regions that breast cancer may spread to in order of
frequency are: Bone, Lung and Liver.
Approximately 25% of breast cancers spread first to the bone. The
bones of the spine, ribs, pelvis, skull, and long bones of the arms
and legs are most often affected.
Between 60% and 70% of women who die from breast cancer have
eventually had it spread to their lungs.
In 21% of cases, the lung is the only site of metastasis (spread)
The most common signs of lung metastases are: shortness of breath and dry
cough.
In some cases, women will not experience any symptoms; cancer will only be
detected by chest X-ray or CT scan.
http://www.imaginis.com/breasthealth/bcrecurrence.asp
Recurrence
Chest wall recurrence (CWR) after mastectomy occurs in 5% to 40%
of breast cancer patients and is generally believed to forecast a grim
outcome. These recurrences are often followed by distant metastasis
and death

Patients with initial node-negative disease who develop CWR after 24

months have an optimistic prognosis, especially ifAnnals
theyof are treated with
Surgical Oncology, 10(6):628–634

radiation

Presence of estrogen and progesterone receptors in the cancer cell is

another important prognostic factor, and may guide treatment

Hormone receptor positive breast cancer is usually associated with

much better prognosis compared to hormone negative breast cancer

HER2/neu status has also been described as a prognostic factor. Patients

whose cancer cells are positive for HER2/neu have more aggressive www.emedicine.com
Metastasis should be assessed since breast cancer can spread to the lungs.
The patient’s chest x-ray showed a pulmonary nodule which maybe a
sign of metastasis. In addition the patient is already taking anti-
metastasis medication. However histopathologic studies showed no
nodal involvement.
Thus a biopsy of the pulmonary nodule is needed for definitive staging.

The presence of metastasis will classify the patient as Stage 4.

 CXR - Pulmonary nodule at the right lung base
CT Scan – Pulmonary nodule on the Right Lower Lobe, 1x1cm
Advised chemotherapy
Enrolled at RIBBON Study, receiving Xeloda and Avastin
Solitary Pulmonary Nodule in the Patient with Breast Cancer
Similarly, in a study assessing the role of surgery in the diagnosis and
treatment of an SPN among post-surgery breast cancer patients, results
showed that histology of SPN was primary lung cancer in 38 patients
(n=79), pulmonary metastasis of breast cancer in 27, and benign
condition in 14. European Journal of Surgical Oncology, Volume 33, Issue 5, June 2007, pp 546-550

In a patient with a known extrathoracic malignancy and a solitary pulmonary

nodule
With onofthe
a history CT scan,
sarcoma the following
or melanoma, scenarios
the pulmonary nodule have
is morebeen proposed:
likely to be a metastasis
In the case of underlying head and neck cancer or breast cancer, a second primary cancer
in the lung is more likely
With other malignancies, the nodule is equally likely to be a primary lung cancer or metastatic
disease

Malignant lesions account for 3-10% of CT scan–detected pulmonary

nodules. In an older patient, a solitary nodule is more likely to be
malignant (lung cancer, in particular); in a younger patient, multiple
nodules are more likely to be metastasesBascom, R. (2006). Secondary Lung Tumors. www.emedicine.com
Solitary Pulmonary Nodule in the Patient with Breast Cancer
A solitary pulmonary nodule (SPN) appearing in a patient with breast cancer,
either past or present, is most likely to be a second primary cancer
originating in the lung rather than a metastasis from the breast cancer.
Patients with breast cancer with SPNs should have a diagnostic workup
appropriate for lung cancer (In a study conducted among 1416 breast cancer
patients, 42 had a solitary pulmonary nodule either at the time of presentation
of their breast cancer or during the follow-up period, Fifty-two percent of the
solitary pulmonary nodules proved to be a primary lung tumor, 5% proved to
be benign lesions, and only 43% proved to be metastatic breast cancer.).

Since adenocarcinoma has become the most common lung cancer cell type, the
usual diagnostic tests may not allow a firm differentiation between primary lung and
secondary breast cancer. Therefore if malignancy is proved or suspected,
thoracotomy with appropriate resection is the treatment of choice in most patients
with breast cancer, even at the initial appearance of the breast cancer.

www.emedicine.com
Reduce Stress
- Keep a positive attitude
- Be assertive instead of aggressive -
"Assert" feelings, opinions, or beliefs
Stress
instead of becoming angry, combative,
- or
Uncertainty
passive of the future
- Unpredictability
Exercise regularly
of the cancer
- Disability
Eat well-balanced meals
- Financial difficulties
- Physical
Keep Trackappearance
of Medical Information
- Make- after
use mastectomy
of resources and support
services
- hairoffered
loss duebytothe
chemotherapy
hospital and
community
- skin changes due to radiotherapy
- Learn more about breast cancer to
help patient feel more comfortable with
treatment
 Thank
you!
tubal.tuliao.umag.uy.valencia.verde.villanueva.vizconde.wee.wylengco.zapanta || hLPS
 The Ribbon 1 Study is seeking approximately 1000 patients over age 18 with
metastatic breast cancer who have not previously received chemotherapy for this
disease. Individuals who have received chemotherapy prior to being diagnosed with
metastatic breast cancer may be eligible for the study as long as they have not been
treated with chemotherapy since that diagnosis of metastatic breast cancer. The study
will evaluate the safety and effectiveness of bevacizumab, an investigational
compound, when combined with chemotherapy, compared to chemotherapy
alone, in individuals who have not been previously treated with chemotherapy for
metastatic breast cancer.
Individuals participating in the study will be randomly assigned to one of two treatment
groups:

* One group will receive bevacizumab in combination with the standard of care
chemotherapy treatment.
* One group will receive placebo in combination with the standard of care
chemotherapy treatment.

Note: The chemotherapy treatment used in both groups is considered the standard of
care for metastatic breast cancer.
Study participants will be given bevacizumab or placebo once every three weeks until
their disease progresses or they experience unacceptable toxicity. The maximum
treatment period with bevacizumab is 24 months.