Lindsey 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.
Etiology:
Lindsey - Environmental factors1 - 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
Signs & Symptoms:
Kevin T. Most patients with carcinoma in situ, T1 or T2 breast cancers present with a painless or slightly tender breast mass or have an abnormal screening mammogram. •Approximately 40% to 50% of these lesions are detected by mammography only; approximately 35% of tumors detected by mammography and physical examination are invasive carcinomas smaller than 1cm.2 Occasionally, enlargement of an axillary lymph node can be the first sign of detection.3
Diagnostic Procedures:
Kevin T. Dianoistic procedures include: •complete clinical and family history •physical examination including breasts, axilla, supraclavicular area, abdomen and pelvis •tests including needle aspiration, biopsy, evaluation for hormone receptors •imaging before biopsy includes mammography or xeromammograhy, chest radiographs •imaging after biopsy includes bone scan, liver and spleen scan (if bone scan is positive), internal mammary lymphoscintigraphy (as indicated), skeletal studies •labs include complete CBC, chemistry (with liver function tests when indicated), urinalysis •optional tests would be growth factor, DNA index and oncogene assays (BRCA1, BRAC2, her B-2, etc)2
Histology:
Jenn 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.4 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.4 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.4
Lymph node drainage:
Jenn 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.1 10% to 40% of T1 and T2 show axillary involvement.5
Figure 1. Reprinted from Radiation Oncololgy Management Decisions.5
Metastatic spread:
Rachel
As breast cancer grows, it can travel along the ducts, eventually invade adjacent lobules, ducts, mammary fat and skin. It can then spread into the breast lymphatics , then into peripheral lymphatics. The tumor can also invade blood vessels.6
10 -40% of newly diagnosed T1 and T2 breast cancers have pathologic evidence of axillary nodal metastases.
Metastases to the internal mammary nodes are more likely from inner quadrant and central lesions. It is more likely to occur when there is axillary node involvement. Supraclavicular nodes are involved occasionally.
Vascular invasion and hematogenous metastases to the lungs, pleura, bone, brain, eyes, liver, ovaries, and pituitary glands can occur even with small tumors.
Grading:
Rachel
Grading refers to how the cancer cells look under the microscope compared with normal breast cells.7
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.
Grade 3 (high grade): The cancer cells look very different from normal cells and tend to grow quickly.
Staging:
Brandon 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.8 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
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.9 The main radiation side effects of radiation therapy alone include:9
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.9
Prognosis:
Ashley There prognosis of a breast cancer diagnosis is largely dependent on tumor size and clinical stage.10 Patients diagnosed with carcinoma in situ, ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS) and Paget’s disease differ are considered to have a noninvasive form of breast cancer and the prognosis is largely dependent on the probability of developing an invasive form of breast cancer. If treated when detected, patients have a very promising prognosis. However, reports suggest that patients diagnosed with DCIS have a 30%-50% chance of developing an invasive breast cancer if left untreated within 10 years.10 In addition, patient’s with a mass greater than 2.5cm is more likely to develop invasive disease, impacting prognosis.10 Similarly, patients who are untreated for LCIS also have an increased risk (35%-45%) of developing invasive cancer in 10-20 years.9 The overall 5 year survival rate for patient’s diagnosed with this particular stage is 93%. For patients with stage T1 or T2 disease, the prognosis is not only dependent on tumor size but also the status of lymph node involvement and metastasis. It is estimated that the 5 year survival rate for patients with Stage I, Stage IIA and Stage IIB is 88%, 81% and 74% respectively.11
Treatments:
Ashley The treatment of Tis, TI, TII staged breast cancer is dependent of the history of the disease, tumor extent, histologic features and patient preference.10 Specifically with DCIS, treatment options include total mastectomy or breast-conserving therapy (lumpectomy).10 Some patients are also given radiation therapy. Patients diagnosed with LCIS are closely monitored and their treatment options include follow-up, bilateral mastectomies, and hormonal manipulation.10 The use of radiation therapy in these patients is not supported. For patients with Stage I or II disease, breast conservation therapy is preferred. Post-operative radiation is an option for some patients as well. The combination of surgery and radiation therapy provides the same survival possibilities as patients that have a total mastectomy and axillary dissection.10 Patients that undergo radiation therapy can be given treatment via 3 protocols; whole breast, accelerated whole breast and accelerated partial breast. The total dose for the whole breast treatment is 4,500-5,040cGy, the total dose for the accelerated whole breast treatment is 4,250cGy and the accelerated partial breast is 3,400-3,850cGy.10 The figure below demonstrates a typical treatment field for a patient undergoing radiation treatments after breast conserving therapy.12
Figure 2. Reprinted from Mayo Clinic Web site.11
TD 5/5:
Amanuel Tissue dose associated with 5% injury rate within 5 years13
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 factors1 - 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
Most patients with carcinoma in situ, T1 or T2 breast cancers present with a painless or slightly tender breast mass or have an abnormal screening mammogram.
•Approximately 40% to 50% of these lesions are detected by mammography only; approximately 35% of tumors detected by mammography and physical examination are invasive carcinomas smaller than 1cm.2
Occasionally, enlargement of an axillary lymph node can be the first sign of detection.3
Dianoistic procedures include:
•complete clinical and family history
•physical examination including breasts, axilla, supraclavicular area, abdomen and pelvis
•tests including needle aspiration, biopsy, evaluation for hormone receptors
•imaging before biopsy includes mammography or xeromammograhy, chest radiographs
•imaging after biopsy includes bone scan, liver and spleen scan (if bone scan is positive), internal mammary lymphoscintigraphy (as indicated), skeletal studies
•labs include complete CBC, chemistry (with liver function tests when indicated), urinalysis
•optional tests would be growth factor, DNA index and oncogene assays (BRCA1, BRAC2, her B-2, etc)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.4 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.4 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.4
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.1 10% to 40% of T1 and T2 show axillary involvement.5
Grading refers to how the cancer cells look under the microscope compared with normal breast cells.7
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.8
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)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.9 The main radiation side effects of radiation therapy alone include:9
Other side effects include: fatigue, cardiac effects, pulmonary effects, lymphedema, brachia plexopathy (with supraclavicular nodal involvement), myelopathy, and osteoradionecrosis.9
There prognosis of a breast cancer diagnosis is largely dependent on tumor size and clinical stage.10 Patients diagnosed with carcinoma in situ, ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS) and Paget’s disease differ are considered to have a noninvasive form of breast cancer and the prognosis is largely dependent on the probability of developing an invasive form of breast cancer. If treated when detected, patients have a very promising prognosis. However, reports suggest that patients diagnosed with DCIS have a 30%-50% chance of developing an invasive breast cancer if left untreated within 10 years.10 In addition, patient’s with a mass greater than 2.5cm is more likely to develop invasive disease, impacting prognosis.10 Similarly, patients who are untreated for LCIS also have an increased risk (35%-45%) of developing invasive cancer in 10-20 years.9 The overall 5 year survival rate for patient’s diagnosed with this particular stage is 93%. For patients with stage T1 or T2 disease, the prognosis is not only dependent on tumor size but also the status of lymph node involvement and metastasis. It is estimated that the 5 year survival rate for patients with Stage I, Stage IIA and Stage IIB is 88%, 81% and 74% respectively.11
The treatment of Tis, TI, TII staged breast cancer is dependent of the history of the disease, tumor extent, histologic features and patient preference.10 Specifically with DCIS, treatment options include total mastectomy or breast-conserving therapy (lumpectomy).10 Some patients are also given radiation therapy. Patients diagnosed with LCIS are closely monitored and their treatment options include follow-up, bilateral mastectomies, and hormonal manipulation.10 The use of radiation therapy in these patients is not supported. For patients with Stage I or II disease, breast conservation therapy is preferred. Post-operative radiation is an option for some patients as well. The combination of surgery and radiation therapy provides the same survival possibilities as patients that have a total mastectomy and axillary dissection.10 Patients that undergo radiation therapy can be given treatment via 3 protocols; whole breast, accelerated whole breast and accelerated partial breast. The total dose for the whole breast treatment is 4,500-5,040cGy, the total dose for the accelerated whole breast treatment is 4,250cGy and the accelerated partial breast is 3,400-3,850cGy.10 The figure below demonstrates a typical treatment field for a patient undergoing radiation treatments after breast conserving therapy.12
Tissue dose associated with 5% injury rate within 5 years13
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