Breast+(T3-T4)

In the U.S., breast cancer is the most common non-skin cancer and 2nd leading cause of cancer related death in women. 1 A small number of men are also diagnosed with, and die from, breast cancer. Breast cancer incidence is highest in white women for most age groups, but African American women have higher incidence rates before age 40, and have higher breast cancer mortality rates than women of any other racial/ethnic groups in the U.S. Women in rural areas have lower breast cancer rates than women in urban areas. Breast cancer is more common in Western countries than in Asian countries. Breast cancer is diagnosed more in women 55 years of age and older. || - Environmental factors 1 - diet - endocrine factors - family history - radiation exposure - reproductive and menstrual history - certain genetic changes - long term use of menopausal/hormone therapy - increased breast density - obesity - lack of exercise || Breast cancer is often 1st detected as an abnormality on a mammogram before it is felt by the patient or health care provider. Mammographic features suggestive of malignancy include asymmetry, microcalcifications, a mass or architectural distortion. Breast ultrasound guided biopsy and or MR are the next studies in the workup. Only 5% of patients with a malignant mass present with breast pain. Other symptons include immobility, skin changes (thickening, swelling, redness) or nipple abnormalities (ulceration, retraction, spontaneous discharge). 2 || Diagnoistic Procedures include: •physical examination with special attention given to locoregional extent of tumor and checking potiential sites of spread •lab studies include a complete CBC, serum chemistry profile and full liver function tests •if liver function values are abnormal, CT of the abdomen •if anemia, leukopenia or thrombocytopenia is present, bone marrow biopsy is necessary •imaging to include chest x-ray, bone scans, CT of chest and abdomen. 2 || Most breast cancers arise in the terminal ductal lobular units of the breast and are classified as ductal or lobular, depending on the specific site of origin. 3  Ductal carcinoma forms in the lining of a milk duct within the breast. Ducts carry breast milk from the lobules, to the nipple. Lobular carcinoma starts in the lobules of the breast, where breast milk is produced. Infiltrating ductal carcinoma is breast cancer that has spread outside the membrane that lines the duct. This type of breast malignancy is the most common, accounting for 70% to 80% of all breast cancer. 4  Infiltrating lobular carcinoma is the next most common type, comprising about 5% to 10% of breast cancer. 3  There are several other types of relatively rare types of infiltrating breast cancer, such as mucinous or collid, tubular, and papillary carcinoma. These lesions have distinct histologic characteristics and tend to yield a more favorable prognosis. 3 || The most common sites of regional lymph nodes involvement in breast cancer are the axillary, IMN and supraclavicular regions. More than 75% of lymph from the breast passes to the axillary nodes. 4  Lymphatic spread frequently occurs for T3 and T4 lesions. 4
 * **Epidemiolgy:** || Lindsey
 * **Etiology:** || Lindsey
 * **Signs & Symptoms:** || Kevin T
 * **Diagnostic Procedures:** || Kevin T
 * **Histology:** || Jenn
 * **Lymph node drainage:** || Jenn

||
 * **Metastatic spread:** || Rachel

Grading refers to how the cancer cells look under the microscope compared with normal breast cells. 6
 * Metastatic spread can occur through lymphatic or hematogenous spread. Metastatic spread involves the axillary, internal mammary or supraclavicular nodes. Hematogenous spread involves bone, lung, pleura, liver and brain. 5 ||
 * **Grading:** || Rachel
 * Grade 1 (Low Grade): The cancer cells look similar to normal cells and grow very slowly.


 * Grade 2 (moderate or intermediate grade): The cancer cells look more abnormal and are slightly faster growing.

Note: definitions for classifying the primary tumor (T) are the same for clinical and pathologic classification. If the measurement is made by physical examination, the examiner will use the major headings (T1, T2, or T3). If other measurements, such as mammographic or pathologic, are used, the telescoped subset of T1 can be used. 7 With any radiation therapy treatment there is a chance of radiation side effects. In breast cancer, these side effects increase with the combination of chemotherapy as well, especially with Doxorubicin. 8 The main radiation side effects of radiation therapy alone include: 7
 * Grade 3 (high grade): The cancer cells look very different from normal cells and tend to grow quickly. ||
 * **Staging:** || Brandon
 * Primary Tumor (T) **
 * TX: Primary Tumor cannot be assessed
 * T0: No Evidence of Primary Tumor
 * Tis Carcinoma in situ: Intraductal carcinoma, lobular carcinoma in situ, or Paget’s disease of the nipple with no tumor
 * T1: Tumor ≤ 2 centimeters (cm) in greatest dimension
 * T1mic: Microinvasion ≤ 0.1cm in greatest dimension
 * T1a: Tumor > 0.1 cm but not > 0.5 cm in the greatest dimension
 * T1b: Tumor > 0.5 cm but not >1.0 cm in the greatest dimension
 * T1c: Tumor > 1.0 cm but not > 2.0 cm in the greatest dimension
 * T2: Tumor > 2 cm but not > 5 cm in greatest dimension
 * T3: Tumor > 5 cm in greatest dimension
 * T4: Tumor of any size with direst extension to (a) chest wall or (b) skin
 * T4a: Extension to chest wall
 * T4b: Edema or ulceration of the skin of the breast
 * T4c: Both (T4a and T4b)
 * T4d: Inflammatory Carcinoma
 * Regional Lymph Node (N) **
 * NX: Regional lymph nodes cannot be assessed
 * N0: No regional lymph node metastasis
 * N1: Metastasis to moveable lymph ipsilateral axillary lymph node(s)
 * N2: Metastasis to ipsilateral axillary lymph node(s) fixed to one another or other structures
 * N3: Metastasis to ipsilateral internal mammary lymph node(s)
 * Distant Metastasis (M) **
 * MX: Distant metastasis cannot be assessed
 * M0: No distant metastasis
 * M1: Distant metastasis (includes metastasis to ipsilateral supraclavicular lymph node(s) ||
 * **Radiation side effects:** || Brandon
 * Erythema (dryness and redness) - about 3000 centiGray (cGy)
 * Dry Desquamation (involves dry flaking of the skin) - about 4000 cGy
 * Moist Desquamation (loss of superficial and deep epithelial cells) - about 5000 cGy
 * Telangiectasia (permanent dilation of blood vessels, producing small, red lesions)

Other side effects include: fatigue, cardiac effects, pulmonary effects, lymphedema, brachia plexopathy (with supraclavicular nodal involvement), myelopathy, and osteoradionecrosis. 8 || The prognosis of people who are diagnosed with Stage 3 or 4 breast cancer can vary largely based on factors such as tumor size, nodal involvement and distant metastases. Typically, patients with involvement of the axillary nodes have a lower survival rate then patients of the stage without nodal involvement. 9 Also, patients that test positive for mutated genes such as the p53 gene or breast cancer gene 1 or 2 (BRCA 1/2 ) typically have a lower survival rate then patients without these mutations. 9 It is difficult to ascertain the exact prognosis for patients diagnosed with Stage 3 or 4 disease because lymphatic involvement is probable and variable. Other variables include the involvement of skin or chest wall and possible metastases. The 5 year survival rate for patients diagnosed with stage 3A, 3B, 3C, or 4 are 67%, 41%, 49% and 15% respectively. 10 || Most patients who are diagnosed with stage 3 or 4 breast cancer undergo a mastectomy and post-operative radiation to the chest wall and nodal regions. Evidence supports that for these patients, mastectomy improves survival irrespective of tumor size, histopathologic grade or positive lymph nodes. 9 The recommended radiation dose for these patients is 50Gy with approximately 1.8Gy/fraction to the ipsilateral chest wall, mastectomy scar and drain sites. 11 A boost of 5 fractions may also be administered to the surgical scar before the patient concludes treatment. If lymph nodes are involved, 50Gy is also administered at 1.8-2Gy per fraction to the nodal areas. 11 In many of these patients, hormonal therapy such as tamoxifen citrate or selective estrogen receptor (ER) modifiers are also recommended. 9 Figure 1 indicates a traditional supraclavicular nodal field. 12
 * **Prognosis:** || Ashley
 * **Treatments:** || Ashley

|| Tissue dose associated with 5% injury rate within 5 years 13
 * **TD 5/5:** || Amanuel
 * Breast (adult): 6000cGy [Atrophy]
 * Lung [Pneumonitis]
 * 1/3 of the Lung: 4500cGy
 * 2/3 of the Lung: 3000cGy
 * The whole Lung: 1750cGy
 * Heart: 4000cGy [Pericarditis and Pancarditis]
 * Brachial plexus: 6000cGy [Clinically apparent nerve damage] ||
 * **References:** || Amanuel
 * 1) <span style="color: #800080; font-family: Arial,sans-serif;">National Cancer Institute Web Site. <span style="color: #0000ff; font-family: Arial,sans-serif;">[] <span style="color: #800080; font-family: Arial,sans-serif;">. Accessed June 12, 2013.
 * 2) <span style="background-color: #ffffff; color: #ff0000; font-family: Arial,sans-serif;">Chao KS, Perez CA, Brady LW. Radiation Oncology Management Decisions. 3rd ed. Philadelphia, PA: Lippincott, Williams, and Wilkins; 2011: 376-386.
 * 3) <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 3nd ed. St. Louis, MO: Mosbey-Elsevier; 2010: 869-876.
 * 4) <span style="color: #0000ff; font-family: Arial,Helvetica,sans-serif;">Chao KS, Perez CA, Brady LW. Radiation Oncology Management Decisions. 3rd . Philadelphia, PA: Lippincott, Williams & Wilkins; 2002: 373-376.
 * 5) Chao KS, Perez CA, Brady LW. Radiation Oncology Management Decisions. 3rd ed. Philadelphia, PA: Lippincott, Williams, and Wilkins; 2011: 405.
 * 6) Staging and grading of Breast Cancer. Macmillan Cancer Support Web Site. []. Accessed June 13, 2013.
 * 7) <span style="background-color: #ffffff; color: #800000; font-family: Arial,sans-serif; line-height: 1.5;">Chao K, Perez C, Brady L. //<span style="background-color: #ffffff; color: #800000; font-family: Arial,sans-serif; line-height: 1.5;">Radiation Oncology Management Decisions //<span style="background-color: #ffffff; color: #800000; font-family: Arial,sans-serif; line-height: 1.5;">. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2002: 348.
 * 8) <span style="background-color: #ffffff; color: #800000; font-family: Arial,sans-serif; line-height: 1.5;">Washington C, Leaver D. //<span style="background-color: #ffffff; color: #800000; font-family: Arial,sans-serif; line-height: 1.5;">Principles and Practice of Radiation Oncology. //<span style="background-color: #ffffff; color: #800000; font-family: Arial,sans-serif; line-height: 1.5;"> 3rd ed. St. Louis, MO: Mosby Elsevier; 2010:891-892.
 * 9) <span style="background-color: #ffffff; color: #008000; font-family: Arial,sans-serif; line-height: 1.5;">Chao KS, Perez CA, Brady LW. Radiation Oncology Management Decisions. 3rd ed. Philadelphia, PA: Lippincott, Williams, and Wilkins; 2011: 376-386.
 * 10) <span style="background-color: #ffffff; color: #008000; font-family: Arial,sans-serif; line-height: 1.5;">Chances for Survival Based on Cancer Stage. Susan G. Komen Foundation Web site. <span style="background-color: #ffffff; color: #0000ff; font-family: Arial,sans-serif; line-height: 1.5;">[] <span style="background-color: #ffffff; color: #008000; font-family: Arial,sans-serif; line-height: 1.5;">. Updated December 4, 2012. Accessed June 10, 2013.
 * 11) <span style="background-color: #ffffff; color: #008000; font-family: Arial,sans-serif; line-height: 1.5;">Standard 2.1 Post-Mastectomy Radiation Therapy. St. John Health Breast Care Program Web site. <span style="background-color: #ffffff; color: #0000ff; font-family: Arial,sans-serif; line-height: 1.5;">[] <span style="background-color: #ffffff; color: #008000; font-family: Arial,sans-serif; line-height: 1.5;">. Updated June 16, 2009. Accessed June 10, 2013.
 * 12) <span style="color: #008000; font-family: Arial,sans-serif; line-height: 1.5;">Radiation Therapy Techniques for Breast Cancer. UC San Diego Moores Cancer Center. <span style="color: #0000ff; font-family: Arial,sans-serif; line-height: 1.5;">[] <span style="color: #008000; font-family: Arial,sans-serif; line-height: 1.5;">. Updated 2013. Accessed June 10, 2013.
 * 13) <span style="background-color: #ffffff; color: #ff7100; font-family: Arial,sans-serif; line-height: 1.5;">Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 3rd ed. St. Louis, MO: Mosby-Elsevier; 2010 ||

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