7/25/2019 Breast Cancer Class Dr Varun

1/42

Breast Cancer

Dr Varun Kumar Singh

7/25/2019 Breast Cancer Class Dr Varun

2/42

IMAGING

Breast Cancer

1/14/16 Breast Cancer 2

7/25/2019 Breast Cancer Class Dr Varun

3/42

Mammography: Views

Screening Craniocaudal (CC)

Mediolateral oli!ue (M"#)

Diagnostic Craniocaudal (CC) and Mediolateral oli!ue (M"#)

$%aggerated CC (a%illary tail)

&olled CC

Clea'age 'iew (medial reast)

degree oli!ue (a%illa) * degree lateral

Magni+cation 'iew

,pot compression

1/14/16 Breast Cancer

7/25/2019 Breast Cancer Class Dr Varun

4/42

Mammography: -uidelines

For screening (USPSTF 2009) B/w 4 and 4*: should e decided on indi'idual

asis (earlier iennial)

B/w . and 4: iennial (earlier annual) 0o recommendation or .

34: special circumstances (0C) 5re'ious h/o "C, or reast cancer: annual

/o premenopausal reast cancer in 1stdegree relati'e:

annual starting 1 years younger

/o mantle irradiation or 7: 8 years younger

B&C9 1 and 2: rom 2.. years (indi'idualpreerences)

1/14/16 Breast Cancer 4

7/25/2019 Breast Cancer Class Dr Varun

5/42

Mammography: &eporting (B&97,)

1. Breast co!osition

4 types: $%tremely at

,cattered +roglandular tissue

eterogenously dense

$%tremely dense

igher density: lower sensiti'ity

1/14/16 Breast Cancer .

7/25/2019 Breast Cancer Class Dr Varun

6/42

Mammography: &eporting (B&97,)

2. Breast ass" Must e seen in two di;erent pro

7/25/2019 Breast Cancer Class Dr Varun

7/42

Mammography: &eporting (B&97,)

Margins: Circumscried

Microloulated

#scured

ndistinct/ illde+ned

,piculated/ in'ading

,pecial cases: ,olitary dilated ducts

ntramammary lymph nodes (reniorm shape=radiolucent notch d/t at in hilum)

9symmetrical reast tissue

>ocal asymmetrical density

1/14/16 Breast Cancer

7/25/2019 Breast Cancer Class Dr Varun

8/42

Mammography: &eporting (B&97,)

7ensity: yperdense

sodense ypodense

&adiolucent: at/ oil #il cyst

-alactocele

"ipoma

hamartoma

1/14/16 Breast Cancer 8

7/25/2019 Breast Cancer Class Dr Varun

9/42

Mammography: &eporting (B&97,)

#. Ca$ci%cations

Benign: "ucent centered (s?in)

5arallel trac?s ('ascular)

Coarse/ popcorn (+roadenoma)

"arge/ rod li?e (secretory anormalities)

&ound (acini o loules)

5unctate (3@. mm)

$gg shell/ rim (at necrosis) Mil? o calcium (tiny cysts)

,uture

7ystrophic (trauma/ radiation)

1/14/16 Breast Cancer *

7/25/2019 Breast Cancer Class Dr Varun

10/42

Mammography: &eporting (B&97,)

ntermediate:

9morphous/ indistinct

&ound or Aa?e shaped

,mall or hay ighly proale:

5leomorphic or heterogenous/ granular (3@.mm)

>ine linear >ine ranching (casting)

"inear ut discontinuous (s/o +lling o duct lumenwith cancerous cells)

1/14/16 Breast Cancer 1

7/25/2019 Breast Cancer Class Dr Varun

11/42

Mammography: &eporting (B&97,)

&. Ca$ci%cation 'istrition -rouped or clustered (multiple

calci+cation in 32 cc o tissue multiplemeans D2 groups with similarmorphology)

"inear with or without ranching

,egmental (s/o multiocality)

&egional (scattered in a large 'olume)

7i;use/ scattered (random)

1/14/16 Breast Cancer 11

7/25/2019 Breast Cancer Class Dr Varun

12/42

Mammography: &eporting (B&97,)

*. Associate' %n'ings ,?in or nipple retraction

,?in or traecular thic?ening

,?in lesions 9%illary adenopathy

9rchitectural distortion

+. ,ocation &ight or let or oth

9nterior or middle or posterior 1/

&elation to nipple

1/14/16 Breast Cancer 12

7/25/2019 Breast Cancer Class Dr Varun

13/42

Mammography: &eporting (B&97,)

Categor- Assessent ecoen'ation

ncomplete 0eed additionalimaging

1 Complete=negati'e(0ormal)

9nnual mammography

2 Complete= enign (0omammographic e/o

malignancy)

9nnual mammography

Complete= proaly enign ,hort inter'al ollowup

6 month: /" reast1= 2= years: B/"

reasts

4 Complete= suspicious Biopsy

. Complete= highly

suggesti'e

9ppropriate action

1/14/16 Breast Cancer 1

7/25/2019 Breast Cancer Class Dr Varun

14/42

M& (9C,)

9nnual M& (ased on e'idence) B&C9 mutation

Entested +rst degree relati'e o B&C9 carrier

"ietime ris? o reast cancer 22.F 9nnual M& (ased on e%pert opinion)

&adiation to chest /w 1 years

"i>raumeni syndrome and 1stdegree relati'es

Cowden syndrome and 1stdegree relati'es

Bannayan &iley &u'alcaa syndrome and 1stdegree relati'es

1/14/16 Breast Cancer 14

7/25/2019 Breast Cancer Class Dr Varun

15/42

M& (9C,)

nsuGcient e'idence to recommendor or against M& "ietime reast cancer ris? 1.2F

"C,

97= 9"

$%tremely or heterogeneously dense

reasts on mammogram 5ersonal history o reast cancer

including 7C,

1/14/16 Breast Cancer 1.

7/25/2019 Breast Cancer Class Dr Varun

16/42

STAGING

Breast Cancer

1/14/16 Breast Cancer 16

7/25/2019 Breast Cancer Class Dr Varun

17/42

5rimary tumorT Tor

H% Humor canIt e assessed

H 0o tumor

His 7C,= "C,= 5agetIs

H1 J2 mm

mi: J1 mma: 1J. mm: .J1 mmc: 1J2 mm

H2 2J. mm

H D. mm

H4 $%tension to chest wall or s?in (ulceration/ nodule) (in'asion o s?inalone does not !ualiy as H4)

a: chest wall (eyond pect ma

7/25/2019 Breast Cancer Class Dr Varun

18/42

"ymph node

N No'e

0% &egional "0 canIt e assessed

0 0o regional "0

01 /"= moile= le'el = 9"0

02 /"= +%ed= le'el = 9"0 or /" M"0a: /"= +%ed= le'el = 9"0: /" M"0 in asence o 02a

0 /" C"0 or /" le'el = 9"0 and /" M"0 or /" ,C"0a: /" C"0 (le'el )

: /" 9"0 K /" M"0 (01/2aK 02)c: /" ,C"0

1/14/16 Breast Cancer 18

7/25/2019 Breast Cancer Class Dr Varun

19/42

"ymph node (5)

A,N IM,N

0i L$ and Cnegati'e

0iK L$ and Cpositi'e (incHC)0ot D@2 mm

0mol L$= C and&H5C& negati'e

0molK L$ and C

negati'e&H5C& positi'e

1/14/16 Breast Cancer 1*

7/25/2019 Breast Cancer Class Dr Varun

20/42

7/25/2019 Breast Cancer Class Dr Varun

21/42

,taging

T/N T0 Tis T1 T2 T# T&

N0 9 9 B B

N1i B B

N1 9 9 B 9 B

N2 9 9 9 9 B

N# C C C C C

M1 V V V V V V

1/14/16 Breast Cancer 21

7/25/2019 Breast Cancer Class Dr Varun

22/42

,taging

T/N T0 T1 T2 T# T&

0 9 9 B B

01 9 9 B 9 B

02 9 9 9 9 B

0 C C C C C

M1 V V V V V

1/14/16 Breast Cancer 22

7/25/2019 Breast Cancer Class Dr Varun

23/42

MANAGMNT

Breast Cancer

1/14/16 Breast Cancer 2

7/25/2019 Breast Cancer Class Dr Varun

24/42

1/14/16 Breast Cancer 24

Breast Cancer

5ure nonin'asi'e "ocoregional in'asi'e Metastatic/ &ecurrent

,tage

#perale

,tage 4

0onoperale

,tage 1= 2= 9 ,tage 9= B= C

"C,= 7C, $arly in'asi'e "ocally ad'anced in'asi'e

H01 is operale= $%cept H01

7/25/2019 Breast Cancer Class Dr Varun

25/42

1/14/16 Breast Cancer 2.

"C,

%/ $%/ 7M/ 5% re'iew

$%cisional iopsy i initial iopsy was not a surgical iopsy

7C,= n'asi'e cancer "C,

Counselling regarding ris? reduction,ur'eillance

9s per 7C,

7/25/2019 Breast Cancer Class Dr Varun

26/42

"C,: special considerations

0egati'e margin is not a consideration while treating

"C,

5leomorphic "C,: complete e%cision with negati'e

margins may e considered= howe'er e'idence are

lac?ing to recommend the same@

Multiocal/ e%tensi'e "C, in'ol'ing D4 terminal ductalloar units on a core iopsy may e associated with

increased ris? o in'asi'e cancer on surgical e%cision@

1/14/16 Breast Cancer 26

7/25/2019 Breast Cancer Class Dr Varun

27/42

1/14/16 Breast Cancer 2

7C,

%/ $%/ 7M/ 5% re'iew$&/ -enetic counsellingM& (optional)

BCH(lumpectomyK whole reast &H)

&is? reduction therapy

igher oost dose &H

Margins 31 mm

5$

Hotal mastectomyK/ &HK/ &econstruction"umpectomy alone

7/25/2019 Breast Cancer Class Dr Varun

28/42

1/14/16 Breast Cancer 28

&is? reduction therapy

>or /" reastHamo%ien or . years

BCH with $& positi'e$%cision alone with $& positi'e

$& negati'e: ene+ts are uncertain

>or C/" reastCounselling regarding ris? reduction

>ollow up

%/ $%: 6/12 monthly or . years= then annuallyMammography annually (6/12 monthly i &H)Hamo%ien: standard monitoring

7/25/2019 Breast Cancer Class Dr Varun

29/42

7C,: special considerations

M& has not een shown to increase li?elihood o

negati'e margins or decrease con'ersion to

mastectomy@

&eresection may e perormed in an e;ort to

otain negati'e margins in patients desiring BC,@

5atients not amenale to margin ree

lumpectomy should ha'e total mastectomy@

1/14/16 Breast Cancer 2*

7/25/2019 Breast Cancer Class Dr Varun

30/42

7C,: special considerations

Complete 9"07 should not e perormed

in asence o e/o in'asi'e or metastatic

cancer in women with pure 7C,@

,"0B should e strongly considered in

pure 7C, i the lesion is in an anatomical

location to compromise the perormance

o ,"0B@

1/14/16 Breast Cancer

7/25/2019 Breast Cancer Class Dr Varun

31/42

7C,: special considerations

Nhole reast &H ollowing lumpectomy reducesrecurrences y aout .F@

9ppro%imately hal o recurrences are in'asi'e

and hal 7C,@

>actors determining local recurrence:

5alpale mass/ "arger sie

igher grade

Close or positi'e margins

9ge 3. years1/14/16 Breast Cancer 1

7/25/2019 Breast Cancer Class Dr Varun

32/42

7C,: special considerations

Margins D1 mm: negati'e (may e

e%cessi'e rom cosmetic point o

'iew) Margins 31 mm: close (do not

mandate surgical e%cision ut !ualiyor higher oost dose radiation to

in'ol'ed site@1/14/16 Breast Cancer 2

7/25/2019 Breast Cancer Class Dr Varun

33/42

1/14/16 Breast Cancer

$arly Breast Cancer(#perale n'asi'e Breast Cancer)

,tage = (9 L B)= 9 (only H01)

%/ $%/ CBC/ 5C/ ">HsE,- (i indicated)

5% re'iew/ $&/ 5&/ $& 2-enetic counselling (i hereditaryreast ca)>ertility counselling (consider)M& (optional)9"5/ Bone scan (i symptomatic or

9"5 is O)9dominal K/ pel'ic CH/ M& (i O9"5/ an ">H/ symptomatic/ anormale%amination H01 (9)

Chest diagnostic CH

9dominal K/ pel'ic CH/ M&Bone scan/ 0a> 5$HCH>7- 5$HCH

Nor?up

# categories"1@ BC, K ,9,2@ HM K ,9, K/ &

@ 5reop systemic &%(i H2/H and ul+lscriteria or BC,e%cept or sie)

7/25/2019 Breast Cancer Class Dr Varun

34/42

1/14/16 Breast Cancer 4

BC, K ,9,

9"0

0o 1 4

NB&H K/ HBB#& 5B (selectedpatients)

NB&H K/ HBB,trongly consider oostto C"0= ,C"0= M"0

NB&H K/ HBB= C"0L ,C"0 oost,trongly consideroost to M"0

7/25/2019 Breast Cancer Class Dr Varun

35/42

1/14/16 Breast Cancer .

9"0HM K ,9, K/ &

Margins 31 mm

Humor D. cm#r Margin positi'e

0o

Humor J. cm 1

4

Consider &H to CN0o &H

Consider &H to CNK/ C"0 K/ ,C"0,trongly consider &H to M"0

Margins 1 mm

,trongly consider &H to CN= C"0= ,C"0K/ M"0

&H to CN= C"0= ,C"0,trongly consider &H to M"0

7/25/2019 Breast Cancer Class Dr Varun

36/42

1/14/16 Breast Cancer 6

BC, K ,9,HM K ,9, K/ &

istology

$&/ 5& 907 $& 2

7uctal/ "oular/ Mi%ed/ Metaplastic #& Huular/ Mucinou

"ymph 0odes

Humor ,ie

"ymph 0odes

21 gene &H 5C&

&eceptor ,tatus

J2 mm/ D2 mm

J. mm/ D. mm/ D1 mm

0/ 01mic

0ot done/ "ow/ ntermediate/ igh

7/25/2019 Breast Cancer Class Dr Varun

37/42

1/14/16 Breast Cancer

/P 2 No'e Tor No'

e

21 gene T

PC

K'e K'e J2 mm J. mm 0 P $H

01mic

$H P H

61

mm

$H P H

D1mm

$H K H

D2 mm $H K H

'e J2 mm J. mm 0 P $H

01mic

$H P CH

D. mm 0ot done $H P CH

"ow &, (318) $H

ntermediate $H P CH

Esual histology: 7uctal/ "oular/ Mi%ed/ Metaplastic

7/25/2019 Breast Cancer Class Dr Varun

38/42

1/14/16 Breast Cancer 8

/P 2 No'e Tor No'e 21geneT PC

'e K'e J2 mm J. mm 0 0o

01mic P H

61mm

P H

D1 mm H

D2 mm H

'e J2 mm J. mm 0 0o01mic P CH

61mm

P CH

D1 mm CH

D2 mm CH

Esual histology: 7uctal/ "oular/ Mi%ed/ Metaplastic

7/25/2019 Breast Cancer Class Dr Varun

39/42

1/14/16 Breast Cancer *

>a'ourale histology: Huular/ Mucinous

/P 2 No'e Tor No'e 21geneT PC

K'e J2 mm 31 mm 0o

12*

mm

P $H

mm $H

D2 mm $H P CH

'e 9s usual

% aterrepeatdetermination

7/25/2019 Breast Cancer Class Dr Varun

40/42

1/14/16 Breast Cancer 4

5reop systemic &% (i H2/H and ul+ls criteria or BC, e%cept or sie)

9%illary e'aluation

Core iopsy o tumor K localiation o tumor ed

9"0 clinically negati'e9"0 clinically positi'e

,"0B9%illary E,-

>09/ Core iopsy

negati'e: ,"0B

7/25/2019 Breast Cancer Class Dr Varun

41/42

1/14/16 Breast Cancer 41

5reop systemic &% (i H2/H and ul+ls criteria or BC, e%cept or sie)

09CH (4 cycles)

P $H i $& positi'e post menopausal

0o response 5artial response Complete response

"umpectomy not possile "umpectomy possile

9lternati'e CH

0& 5& C&

"umpectomy not possile

7/25/2019 Breast Cancer Class Dr Varun

42/42

"umpectomy not possile "umpectomy possile

Mastectomy "umpectomy

,"0B done eore 09CH

Qes and negati'e 0o

HM P & HM K ,9, P &

sider additional CHu'ant &H as per preCH stageu'ant $H i $&/5& positi'eu'ant Hrastuuma % 1 year i $& positi'e

,"0B done eore 09CH

Qes and negati'e 0o

"umpectomy alone"umpectomy K ,9,

Consider additional CH9d