1. Principles and Practice of Radiation Therapy
Chapter 38
Breast Cancer
Copyright © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

2. Breast Anatomy Composition Glandular system Size and shape
Factors effecting the breasts
Lymphatics

3. Composition
Glandular tissue
Adipose tissue
Connective tissue

4. Glandular System
Ducts
Nipple
Areola
Underlying musculature

5. Size and Shape Normal breast extension
Factors influencing breast shape and size

6. Factors Effecting the Breasts
Hormones
Estrogen
Progesterone
Prolactin
Age
Menstruation
Menopause

7. Lymphatics
Axillary
Internal mammary
Subclavian
Supraclavicular (SCV)

8. Breast Cancer Epidemiology Etiology Prevention Clinical presentation
Detection and diagnosis
Pattern of spread
Disease classification
Treatment
Survival

9. Epidemiology Incidence Deaths Worldwide
178,500 new cases of invasive cancer
62,000 new cases of carcinoma in situ (CIS)
Deaths
40,000 deaths
Worldwide
Appears to be increasing

10. Etiology Causes Risk factors BRCA genes Gender Aging Genetics BRCA ATM
CHEK-2
p53 tumor suppressor
Li-Fraumeni syndrome

11. Etiology Family history
Two or more relatives with breast or ovarian cancer
Relatives with both breast and ovarian cancer
One or more relatives with two cancers
A male relative with breast cancer
A family history of breast or ovarian cancer and Ashkenazi Jewish heritage
Family history of diseases associated with hereditary breast cancer

12. Etiology
Personal history of breast cancer
Race

13. Etiology History of abnormal breast biopsy Nonproliferative lesions
Proliferative lesions without atypia
Proliferative lesions with atypia

14. Etiology Radiation Menstrual history Diethylstilbestrol (DES)
Nulliparity
Oral contraceptives (OC)

15. Etiology Hormone replacement therapy Breastfeeding Alcohol Obesity
Combination vs. estrogen replacement therapy (ERT)
Breastfeeding
Alcohol
Obesity
Physical activity

16. Etiology Unproven or controversial risk factors Antiperspirants
Underwire bras
Abortion
Breast implants
Pollution
Smoking
Secondhand smoke
Night work

17. Prevention Genetic Testing
Not of Ashkenazi Jewish heritage
Two first-degree relatives with breast cancer
Three or more first- or second-degree relatives diagnosed with breast cancer
A first-degree relative diagnosed with cancer in both breasts
Two or more first- or second-degree relatives diagnosed with breast cancer
A male relative with breast cancer

18. Prevention Genetic Testing
Women of Ashkenazi Jewish heritage
A first-degree relative with breast or ovarian cancer
Two second-degree relatives on the same side of the family with breast or ovarian cancer

19. Prevention Chemoprevention Tamoxifen Raloxifene Aromatase inhibitors
Nonsteroidal antiinflammatory drugs (NSAIDs)
Cyclooxygenase-2 (COX-2) inhibitors

20. Prevention Prophylactic mastectomy Indications Oophorectomy
Mutated BRCA genes
Previous breast cancer
Strong family history
Biopsy specimens showing lobular carcinoma in situ (LCIS)
Oophorectomy

21. Clinical Presentation
Screening
American Cancer Society (ACS) recommendations
Mammography
Clinical breast examination (CBE)
Breast self-examination (BSE)
Breast magnetic resonance imaging (MRI)

22. Clinical Presentation
Location
Quadrant
Upper outermost common
Clock dial
Right vs. left

23. Clinical Presentation
Symptoms
Asymptomatic
Lump or mass
Swelling
Skin dimpling
Nipple retraction
Discharge

24. Detection and Diagnosis
Types
Adenocarcinoma
Ductal carcinoma in situ (DCIS)
Comedocarcinoma
Lobular carcinoma in situ (LCIS)
Invasive ductal carcinoma (IDC)
Most common
Invasive lobular carcinoma (ILC)

25. Detection and Diagnosis
Types
Inflammatory
Uncommon
Always stage III or higher
Mixed tumor
Medullary

26. Detection and Diagnosis
Types
Metaplastic
Mucinous
Paget’s disease of the nipple

27. Detection and Diagnosis
Types
Phyllodes tumor
Benign vs. malignant
Tubular carcinoma
Angiosarcoma

28. Detection and Diagnosis
Imaging
Mammography
Screening vs. diagnostic
Potential findings
Calcification
Mass
Cyst
Concerns

29. Detection and Diagnosis
Imaging
Ultrasound
MRI
Ductogram

30. Pattern of Spread DCIS LCIS IDC Intraluminal growth Lymphatic routes
Axillary nodes
Level I
Level II
Level III

31. Pattern of Spread
Metastatic disease
Bone
Lung
Liver
Other sites

32. Disease Classification
Tumor Node Metastasis (TNM) TX T0
Tis T1 T2 T3 T4

33. Disease Classification
TNM NX N0 N1 N2 N3

34. Disease Classification
Stage 0
Stage I
Stage IIA
Stage IIB

35. Disease Classification
Stage IIIA
Stage IIIB
Stage IIIC
Stage IV

36. Disease Classification
Grade
Histologic tumor grade
Grade 1
Grade 2
Grade 3
Nuclear grade
DCIS

37. Disease Classification
Other factors
Estrogen and progesterone receptors
HER2/neu
Herceptin

38. Treatment Surgery Breast conservation Ductal excision Lumpectomy
Quadrantectomy

39. Treatment
Surgery
Mastectomy
Simple
Modified radical
Radical

40. Treatment Surgery Sentinel node biopsy
Completion lymph node dissection
Axillary dissection

41. Treatment Surgery Reconstruction Prosthesis Immediate vs. delayed
Implants

42. Treatment Surgery Reconstruction Tissue flaps
Transverse rectus abdominis myocutaneous (TRAM)
Latissimus dorsi
Deep inferior epigastric perforator (DIEP)

43. Treatment
Surgery
Reconstruction
Nipple and areola

44. Treatment
Surgery
Contraindications
Breast conservation
Mastectomy

45. Treatment
Chemotherapy
Neoadjuvant

46. Treatment Hormone therapy Tamoxifen Toremifene Fulvestrant Pill form
5 years following treatment
Toremifene
Fulvestrant

47. Treatment Hormone therapy Aromatase inhibitors Ovarian ablation
Megestrol acetate
Androgens

48. Treatment Radiation therapy Whole breast vs. partial breast
Indications
Breast conservation
Sterilize remaining breast tissue

49. Treatment Radiation therapy Patient position Supine Arm(s) Head
Both up vs. one up
Head
Turned away

50. Treatment Radiation therapy Immobilization Breast board Wing board
Alpha cradle/Vac-Loc
Prone breast board

51. Treatment Radiation therapy Immobilization Large-breasted women
Aquaplast
Treatment brassiere
Decubitus position

52. Treatment Radiation therapy Treatment fields Tangents Borders
Beam arrangement
Blocking
Energy
Dose

53. Treatment Radiation therapy Treatment fields SCV Indications Borders
Beam arrangement
Blocking
Energy
Dose

54. Treatment Radiation therapy Treatment fields PAB Indications Borders
Beam arrangement
Blocking
Energy
Dose

55. Treatment Radiation therapy Treatment fields IMC Indications Borders
Beam arrangement
Blocking
Energy
Dose

56. Treatment Radiation therapy Treatment fields Boost Borders
Beam arrangement
Blocking
Energy
Dose

57. Treatment Radiation therapy External beam Side effects Skin changes
Fatigue
Pulmonary effects
Lymphedema

58. Treatment
Radiation therapy
Brachytherapy
Interstitial

59. Treatment
Radiation therapy
Brachytherapy
MammoSite

60. Survival Factors Overall survival Race Genetics Tumor size
Nodal status
Overall survival
85% after 5 years
71% after 10 years
57% after 15 years
52% after 20 years

61. Survival 5-year survival Stage 0 – 100% Stage I – 100% Stage IIA – 92%
Stage IIB – 81%
Stage IIIA – 67%
Stage IIIB – 54%
Stage IV – 20%