New Treatments for Early Breast Cancer
This is just to review the anatomy of the breast, of course there is the nipple, and then multiple, multiple ducts which strand into the nipple, so the highest concentration of ducts is right behind the nipple and then deeper to the breasts are the lobules. The number of lymph nodes at this point in time continues to determine the prognosis of the tumor. So a patient with one positive axillary node does not have the same prognosis as a patient with 10 positive axillary nodes. Internal mammary nodes can sometimes be clinically affected but usually only with medial tumors in which a patient already has documented positive axillary nodes. Supraclavicular nodes indicate distant disease and by definition are metastatic disease in the staging system. Metastases most commonly occurs to the bone, brain, liver and lung. History is important in a patient who may have a breast cancer, especially their family history, what age the family member was at their diagnosis, was it bilateral, was there any history of ovarian, uterine or colon cancer which may either indicate a BRCA one or two family or a Lynch syndrome family. Did they have radiation, especially if you’re from Chicago because many, many women were radiated for acne or thymic problems and those women later had thyroid cancers and we’re now seeing those women develop a breast cancer, or lymphoma as a child and then as a radiation oncologist we need to know, does the patient have a history of collagen vascular disease because that may not allow them to receive radiation therapy. We need to know if the patient had breast implants, where they are, are they subpectoral, we need to know the date of their last period, and never forget a pregnancy test because women can be pregnant when they have breast cancer. Many women come using estrogen replacement therapy, it’s a reminder to stop it at the time of the diagnosis, you need to know if there is nipple discharge, either unilateral, bilateral, if it’s bloody or guaiac positive, and then if they have any symptoms of distant disease, most commonly bone pain.
Physical exam should be a careful one and you can gain a lot of information by just the classic careful physical exam, you can tell the tumor size, if it’s fixed to the skin or the chest wall, if you’re considering breast preservation you look at the ratio of the breast to the tumor size, is the breast a huge breast with a tiny tumor or is this a medium sized tumor in a small breast which may prevent breast preservation. You want to find out if there are palpable tumors in other parts of the breast or in the other breast, and of course you would check for regional node enlargement. You want to make sure there is not locally advanced disease like skin ulcerations, satellite nodules, peau de orange which is that sort of dimply texture of the skin from dermal lymphatic invasion, inflammatory skin changes which are commonly misdiagnosed in young woman, you think it’s a mastitis when it turns out to be an inflammatory carcinoma or lymphedema of the arm. Diagnostic workup is important to include bilateral mammograms. Unless the woman has had a mammogram of the contralateral breast within the last several months, both breasts should be evaluated. Ultrasound, especially the new 3-D ultrasound is becoming increasingly important to characterize tumors, something can be solid on the mammogram but a simple cyst on ultrasound. Chest x-ray is a standard diagnostic evaluation. CBC, liver functions and alkaline phosphatase are routinely performed. We don’t need to get a bone scan or a CT scan of the liver for early disease, unless there is pain or elevation of the alkaline phosphatase. Staging system is based primarily on surgical staging and it just is broken down by tumor size. I just want to show you that in the staging system, ductal carcinoma and lobular carcinoma in situ are both as TIS which is a stage 0 tumor. The nodal disease is based on whether they are movable fixed, and where they are, and notice that supraclavicular nodes are considered distant disease.