Tara PowerPoint An In Depth Look At Breast Cancers

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An In-Depth Look
at Breast Cancer
Tara Sorg, M.H.A., B.S. R.T.(R) (M) (BD)
tara.sorg@unitypoint.org

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• Identify breast cancers diagnosed among
women in the U.S.
• Demonstrate the diagnostic imaging
appearance of breast cancers
• Diagnosis, prognosis and treatment of breast
cancers
Objectives
An In-Depth Look at Breast Cancer

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Breast cancer can be classified in many ways. Microscopic evidence can
tell us what type of breast cancer we are dealing with and how aggressive
the cancer is.
• Epithelial cells line the organs and tissues of the breast. This is where a
majority of BrCA’s develop.
• Adenocarcinoma is a carcinoma that begins in the glandular tissue.
• BrCA’s can occur in the cells contained within muscle, fat or connective
tissue.
• Cancerous tumors can be a combination of invasive and in situ cancer
(BrCA’s do not always present as a tumor).
• BrCA’s can be classified based on proteins of the cancer cells; hormone
receptors or triple-negative.
Classifying Breast Cancer

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• A person’s genetic make-up is what directs the
body’s proteins within a cell to stay healthy and
function correctly. Proteins are influenced by those
genes and directs their response to change or
treatment.
• Cancer cells from a tissue sample can be tested to
see which genes are normal or abnormal. The
proteins they make can also be tested.
How genes affect the behavior of
breast cancer

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High grade vs low grade cancer (Histology)

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• There may be an element found by researchers from the University of
California, helping to explain why some cancers spread faster than others.
• A protein has been identified that seems to act like a switch responsible
for regulating the metastasis of cancer from the primary tumor to other
areas of the body.
• This protein is used by embryo cells during early development and
disappears from the body after birth.
• According to researchers, this protein was only found in people with
metastatic cancer.
• It’s believed that regulation of this protein could potentially stop the
dangerous progression of this fatal disease.
Our body’s proteins and the affects of
BrCA

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“The protein seems to get turned off (after embryonic development), and we’ve only
identified a small sub-population of cells that can turn it on,” lead investigator, Dr. Thomas
Kipps, Evelyn and Edwin Tasch Chair in Cancer Research at UC San Diego, told
FoxNews.com. “By and large, we looked at the brain, lungs, heart, kidney and other
organs, and it wasn’t there. Then we looked at a variety of cancers – breast, ovarian,
prostate – and it seems to be a common theme to express this embryonic protein.”

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• A woman’s lifetime risk of developing breast cancer is
greatly increased if she inherits a harmful mutation in
BRCA1 or BRCA2.
• Approx. 12% of women in the general pop. will develop
breast cancer sometime during their lives.
• According to the most recent estimates, 55-65% of
women who inherit a harmful BRCA1 mutation and
around 45% of women who inherit a harmful BRCA2
mutation, will develop breast cancer by age 70.
How much does having a BRCA1 or BRCA2
gene mutation increase a woman’s risk of
breast cancer?

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Grading of Breast Cancer
The grade of a breast cancer is representative of how “aggressive” the
tumor’s potential is.
-For example: A “low-grade” cancer is less aggressive than “high-
grade” cancers. Determining the grade is important to healthcare
providers as they use this information to guide the patient’s
treatment options.
-There are different “scoring systems” available for determining the
grade. Scoring systems consider three factors:
1. Glandular formation- How well the tumor cells attempt to recreate
normal glands
2. Nuclear features- “Pleomorphism” or how ugly the tumor cells look
3. Mitoses- Rate of cellular division

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Grading Scores
Total Feature Score Tumor Grade Cellular Appearance
3-5 Grade 1 Tumor Well-differentiated (appear
normal, growing slowly, non-
aggressive)
6-7 Grade 2 Tumor Moderately-differentiated (semi-
normal, growing moderately fast)
8-9 Grade 3 Tumor Poorly-differentiated (abnormal,
growing quickly, aggressive)

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BIRADS System
The BIRADS system is a tool that is used to assess a
patient’s risk of developing breast cancer. This is
rated from zero to six, zero being incomplete and in
need of further imaging and six being a known
malignancy. The BIRADS system takes into account
the patient’s breast density and risk factors.

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1.IDC
2.DCIS
3.Inflammatory BrCA
4.Triple-Negative BrCA
5.Paget’s Disease
Identifying the following:

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• The most common type of breast
cancer among both males and
females is invasive ductal
carcinoma.
• Ductal carcinoma refers to cancers
that develop within origins of the
ducts (tubular structures).
• Infiltrating (invasive) means the
cancer cells have spread beyond
the ducts into the surrounding
tissue.
• Approx. 80% of all breast cancers
are invasive ductal carcinomas.
IDC- Invasive Ductal Carcinoma
Invasive Ductal Carcinoma (IDC)

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IDC- Signs and Symptoms
• IDC does not always present with symptoms; an
abnormal mammogram may find it first
• Palpable lump felt by patient or provider
• Swelling of entire breast or single quadrant
• Skin irritation, redness, thickening or dimpling
• Discharge
• Axillary lump
• Breast pain

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• 70 y/o patient
• Bilateral yearly screening mammogram
• Small focal asymmetry in the posterior breast slightly
medial to the plane of the nipple
• 1 cm in size
• Well-defined abnormality is not seen on MLO view
• Focal compression views and ultrasound recommended
IDC Case Study

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IDC Case Study

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IDC Case Study
• Left 3D focal compression views were performed
• Images confirmed a subtle mass was present at
12:00
• Measures 1.0 x 1.5 x 1.2 cm
• Ultrasound was performed to follow focal views
• U/S concordant with mammographic findings
• BIRADS 5- highly suggestive of malignancy
• US guided breast biopsy recommended

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IDC Case Study
Patient underwent
U/S guided biopsy.
Findings came
back as Invasive
Ductal Carcinoma.
Patient was
referred to
oncology.

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• Most common type of non-invasive breast cancer
• Ductal means that the cancer starts inside the milk ducts, carcinoma refers to
any cancer that begins in the skin or other tissues (including breast tissue) that
cover or line the internal organs
• In situ means "in its original place"
• DCIS is called "non-invasive" because it hasn’t spread beyond the milk duct
into any surrounding breast tissue
• DCIS isn’t life-threatening, but having DCIS can increase the risk of developing
an invasive breast cancer later
• There’s a greater risk for reoccurrence or developing a new BrCA or for
developing a new breast cancer than a person who has never had breast
cancer before
• Most recurrences happen within the 5-10 years after initial diagnosis
• The chances of a recurrence are under 30%
DCIS

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• DCIS generally has no signs or symptoms
• Few patients may feel a lump or experience
nipple discharge
• According to the National Cancer Institute,
approx. 80% of DCIS cases are found by
mammography
DCIS- Signs and Symptoms

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• 71 y/o
• Calcifications found on
screening mammogram
• Upper outer middle
depth of left breast
• Spot magnification
views recommended
DCIS Case Study

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MAG VIEWSDCIS Case Study

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• Magnification views demonstrate a group of
pleomorphic microcalcifications in the upper outer
middle depth left breast
• Extend anterolateral over 2 cm
• Biopsy is recommended
• Options include stereotactic core biopsy and surgical
excisional biopsy
• Results discussed with the patient
DCIS Case Study

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• Patient underwent stereotactic core biopsy
• Specimen positive for DCIS
• Patient referred to oncologist and surgeon for
follow-up
• Lumpectomy recommended
• Clean margins
DCIS Findings

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• Rare and aggressive form of breast cancer
• According to the National Cancer Institute, about 1-5% of all breast cancer cases in the
United States are inflammatory breast cancers
• Capable of growing and spreading quickly; symptoms worsening within days or hours
• Immediate treatment is recommended
• Inflammatory breast cancer is either stage III or IV at diagnosis, dependent on
metastasis to surrounding tissue and/or lymph nodes
*The average age at diagnosis for inflammatory breast cancer in the United States is 57
for white women and 52 for African American women; 5 years younger than the average
diagnosis ages for other forms of breast cancer. According to the American Cancer Society,
inflammatory breast cancer is more common in African American women. A 2008 study
found that being overweight makes a person more likely to develop IBC. Like other forms
of breast cancer, IBC can also affect men.
*breastcancer.org
Inflammatory Breast Cancer (IBC)

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• Reddening
• Swelling
• Skin thickening
• Does not present as a lump
• Orange-peel appearance
• Breast feels “hot”
• Flattening or nipple inversion
• Lymph node swelling
• Aching
• Burning sensation
IBC- Signs and Symptoms

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• 40 y/o
• Baseline exam
• Presents with right lump x 4-5 months
• Orange-peel appearance x 4-5 months (peau d'orange)
• Bilateral mammogram accomplished, including a right
ML
• Ultrasound f/u recommended
IBC Case Study

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IBC Case Study

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IBC Case Study

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• Mammogram demonstrates a 5 x 3 cm spiculated
mass
• Ultrasound demonstrates a 6 cm abnormality in the
12:00 position
• This area appears to extend to the skin’s surface
• Ultrasound core needle biopsy is recommended
• No suspicious lymph nodes found
IBC Case Study

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• The three most common types of receptors known to fuel most
breast cancer growth–estrogen, progesterone, and the HER-2/neu
gene– are not present in the cancer tumor. This means that the
breast cancer cells have tested negative for hormone epidermal
growth factor receptor 2 (HER-2), estrogen receptors (ER), and
progesterone receptors (PR)
• Due to this, common treatments for BrCA such as hormone therapy
and drugs that target estrogen, progesterone, and HER-2 are not an
option
• Chemo can be used to treat triple negative breast cancer (may
respond better to chemo in the earlier stages than many other forms
of cancer).
Triple-Negative BrCA

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• TNBC tends to be more aggressive that other BrCA’s. Studies show this type
is more likely to metastasize and is also more likely to reoccur than other
BrCA’s. Like others, the chance for it to reoccur is at it’s highest the first few
years following treatment.
• Five-year survival rates are lower compared to other cancers. Studies show
77% of women with TNBC survived at least 5 years, versus 93% of women
with other types of breast cancer.
• Another study of more than 1,600 women published in 2007 found that
women with triple-negative breast cancer had a higher risk of death within 5
years of diagnosis, but not after that time period. This study, however,
depends on the woman’s stage at diagnosis.
• Tends to be at a higher grade at time of diagnosis when compared to other
BrCA’s.
Triple-Negative BrCA Facts and Statistics

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• Luminal cells line the
apical surface of the
normal breast duct and
have secretory
properties. Most breast
cancers arise from
luminal cells. Most cells
affiliated with TRBC are
described as “basal-
like”.
• “Basal-like” means that
the cells resemble the
basal cells that line the
breast ducts. This is a
new subtype of breast
cancer that researchers
have identified using
gene analysis
technology.

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Paget Disease
• Rare cancer involving the skin of the nipple and the areola
• Most patients with Paget’s have one or more tumors found within
the same breast; DCIS or IBC
• Malignant cells called Paget cells are the first sign of this disease
• They are most often found in the epidermis (surface) of the skin on
the nipple and areola
• Paget cells often have a large, round appearance under a
microscope
-May be diagnosed as single or small groups of cells within the
epidermis

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• The cause of Paget Disease of the breast is unknown
• One theory is that cancer cells from a tumor found inside the breast travel through the milk
ducts to the nipple and areola (this theory goes along with why Paget disease of the breast
and tumors inside the same breast are almost always found together)
• A second theory is cells in the nipple or areola abnormally form and divide, turning into
cancer on their own; no spread from elsewhere within the breast
Symptoms include:
• Itching, tingling, or redness in the nipple and/or areola
• Flaking, crusty, or thickened skin on or around the nipple
• A flattened nipple
• Discharge from the nipple that may be yellowish or bloody
• Because the early symptoms of Paget disease of the breast may suggest a benign skin
condition, and because the disease is rare, it may be misdiagnosed at first. People with
Paget disease of the breast have often had symptoms for several months before being
correctly diagnosed
Paget Disease- Origin and Symptoms

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• 67 y/o
• Saw her dermatologist for changes of her left nipple
• Mammogram showed sub-areola density and changes
from prior imaging
• Breast MRI recommended
• MRI showing an asymmetric linear type enhancement at
the base of the left nipple
• Beyond this point, no morphologic or kinetic feature of
malignancy bilaterally is noted
Paget Disease Case Study

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• Biopsy of left nipple is recommended
• Incidental finding seen in the right axilla; U/S
recommended
• U/S biopsy recommended for right abnormal
appearing lymph node
• Results conclude there is no evidence of non-
Hodgkin’s lymphoma or metastatic disease
• Paget’s diagnosed following surgical consult for left
nipple

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Conclusion
• According to the American Cancer Society (ACS), second to skin cancer,
breast cancer is the most-commonly diagnosed cancer in women in the
United States.
• Breast cancer is cancer that begins with the malignant cells forming in the
breast.
• A malignant tumor or cellular make-up is a group of cancer cells that can
grow into nearby tissues or spread (metastasize) to other areas of the body.
• There are several lifestyle-related, environmental, and hormonal factors may
increase your risk of developing breast cancer.
• However, many women who develop the disease have no known risk factors.
• Certain traits are known to increase the risk of breast cancer, such as obesity,
personal or family history of breast cancer, and genetic mutations such as
BRCA1 and BRCA2 gene mutations.
• Breast cancer is most likely caused by a complex interaction of your genetic
makeup, your behavior, and your environment.

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References
BREASTCANCER.ORG (2015). HER2 status. Retrieved November 16, 2015 from
http://www.breastcancer.org/symptoms/diagnosis/her2
BREASTCANCER.ORG (2015). Signs and symptoms of IDC. Retrieved October 27, 2015 from
http://www.breastcancer.org/symptoms/types/idc/symptoms
Grush, Loren (2013). Stopping cancer’s spread: New protein found to control deadly cancer metastasis.
Retrieved December 23, 2015 from http://www.foxnews.com/health/2013/06/15/stopping-cancer-
spread-researchers-identify-protein-that-regulates-cancer.html
NATIONALBREASTCANCER.ORG (2015). Triple negative breast cancer. Retrieved October 28, 2015 from
http://www.nationalbreastcancer.org/triple-negative-breast-cancer
National Cancer Institute (2015). BRCA1 and BRCA2: Cancer Risk and Genetic Testing. Retrieved
December 23, 2015 from http://www.cancer.gov/about-cancer/causes-prevention/genetics/brca-fact-
sheet#q2
National Cancer Institute (2015). Inflammatory breast cancer. Retrieved October 27, 2015 from
http://www.cancer.gov/types/breast/ibc-fact-sheet

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National Cancer Institute (2015). Paget disease of the breast. Retrieved November 13, 2015 from
http://www.cancer.gov/types/breast/paget-breast-fact-sheet
NATIONALBREASTCANCER.ORG (2015). Triple negative breast cancer. Retrieved October 28, 2015 from
http://www.nationalbreastcancer.org/triple-negative-breast-cancer
ZenBio (2015). Human mammary cells. Retrieved October 28, 2015 from
http://www.zen-bio.com/products/cells/human-mammary-cells.php
References Cont’d

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