1. Diagnosis and Staging JoAnne Zujewski, MD
Head, Breast Cancer Therapeutics
Clinical Investigations Branch
Cancer Therapy Evaluation Program
Division of Cancer Diagnostics and Treatment
May 2011

2. NEJM, November 23, 2000

3. Early Detections reduces the risk of dying from breast cancer.
New slide

4. Cancer Diagnosis: Defining the Cancer
The first step in designing the treatment plan is carefully defining the cancer
Clinical examination
Radiology tests
Pathology tests
Blood tests

5. Breast Cancer Signs and Symptoms
Skin redness
Asymmetry
Enlargement
Nipple retraction
Dimpling
Mass in axilla (armpit)
Warmth
None
Lump or mass
Pain in breast
Tenderness
Thickening
Firmness
Nipple discharge
Fix the symmetry of this slide. The second column and the first do not match even though both have 7 entries.

8. BREAST CANCER 18. Breast Cancer
This patient has breast cancer. The “peau d’orange” or dimpling effect of the skin is apparent.

10. Defining the Cancer: Radiology
Radiologic imaging can help determine the location and spread of the cancer
Local extent
Regional lymph nodes
Distant spread (metastases)

11. Mammography Technique

12. Mammography

13. Mammography Sensitivity in Younger Women
Screening mammograms miss up to 25% of breast cancers in women in their 40s, compared to 10% of cancers for older women

14. Right breast 12 o’clock invasive ductal carcinoma 11 mm on mammo and US, has US bx. Multiple MRI masses and non-mass-like enhancement at 12 o’clock spanning 40 mm. Invasive ductal carcinoma and ductal carcinoma in situ by MRI guided core needle biopsy, breast conservation candidate due to breast size.
Ultrasound

15. Breast MRI Important new tool for imaging the breast High sensitivity
Detection and characterization of otherwise-occult breast carcinoma

16. Breast Cancer Diagnosis
Any breast change or lump needs to be evaluated
Breast cancer needs to be diagnosed by biopsy
Fine needle aspiration
Core needle biopsy
Surgical biopsy
Change to
Fine needle aspiration
Remove “Stereotactic”
Change to surgical BIOPSY

17. Mammotone & Minimally Invasive Breast Biopsy (MIBB)
The Mammotone and MIBB are different from the core needle biopsy in that a needle is inserted once and multiple specimens are removed through contiguous sampling. Core needle biopsies require the needle to be inserted multiple times.
Both the Mammotone and MIBB biopsy utilize a vacuum system. A probe is inserted and samples of tissue are collected in a chamber. Tissue samples are removed by action of a gentle vacuum.

18. Advantages of Needle Biopsies
Simple procedure – does not require surgery
Accurate
Quick – only takes a few minutes
Not painful
Inexpensive
Quick results

19. Disadvantages of Needle Biopsies
Entire lump is not removed
Open biopsy may be necessary
For Fine Needle Only:
Specialist needed to read results
In situ cancer not distinguishable from invasive cancer

20. Image Guided Biopsy in Clinical Practice
Allows treatment planning
Better cosmesis
Can mark site with clip
Less costly
Needs specialized equipment
May still require confirmatory pathology in minority of cases
Advantages are..
Now standard

21. Breast Biopsy Non-Surgical Surgical
A core needle biopsy of the area is recommended
Non-Surgical
Surgical

22. Ultrasound-Guided Breast Biopsy

23. Right breast 12 o’clock invasive ductal carcinoma 11 mm on mammo and US, has US bx. Multiple MRI masses and non-mass-like enhancement at 12 o’clock spanning 40 mm. Invasive ductal carcinoma and ductal carcinoma in situ by MRI guided core needle biopsy, breast conservation candidate due to breast size.
Ultrasound

24. Image Guided Biopsy
Image guided biopsy developed that can be done in radiation suite- abnormalities on mammogram- such as these calcs shown on left can be imaged and bx. Exceeding impt in era of mammo screening with more lesions detected before any lump can be detected.

25. Wire Localization: Example

26. Inking the Tumor Specimen in the O.R.

27. Needle Biopsies
Fine Needle – A thin, hollow needle is used to remove a sample of tissue. The procedure is quick and can be done in a doctor’s office.
Core Needle – A larger needle is inserted through a small incision in the skin, and a small core of tissue is removed. This type of needle biopsy is done with the assistance of mammography or ultrasound imaging using stereotactic techniques with the aid of the computer, which calculates the precise location of the lump.

28. Incisional Biopsy
A surgical procedure where only a portion of a tumor is removed
Generally reserved for lumps that are larger
Performed under local anesthesia in a hospital or outpatient clinic

29. Excisional Biopsy
A surgical procedure that removes the entire suspected area plus some surrounding normal tissue.
Standard procedure for lumps that are smaller than an inch or so in diameter
Similar to a lumpectomy
Performed under local anesthetic or general anesthesia in a hospital or outpatient clinic

30. Advantages of Open Biopsies
Quick – takes only one hour
More accurate than a needle biopsy
Larger samples provide information for treatment plan
Excisional Only:
Removes entire lump
May be the only surgical treatment needed

31. Disadvantages of Open Biopsies
Surgical procedure
Expensive
Side effects such as infection or blood collection under the skin
Excisional Only:
Removing tissue can change the look and feel of the breast

32. Cancer is diagnosed in 1 of 5 breast biopsies
Diagnosis

33. Staging

35. Breast cancer Spread to lymph nodes
Supraclavicular
Subclavicular
Distal (upper)
axillary
Central (middle)
Proximal (lower)
Mediastinal
Internal mammary
Interpectoral
(Rotter’s)
31. Breast Cancer: Spread to Lymph Nodes
Axillary lymph nodes are most commonly involved in breast cancer. Internal mammary nodes can be involved if the tumor affects the internal part of the breast. Supraclavicular metastasis is rare unless axillary or internal mammary metastases are present.

36. Breast Cancer: Stage I T1 N0 M0 T1a: T  0.5 cm
T1b: 0.5 cm < T  1 cm
T1c: 1 cm < T  2 cm T1
T  2 cm
35. Breast Cancer: Stage I
Stage I disease T1 N0 M0 is common. T1 tumors are 2 cm in dimension. T1a tumors are 0.5 cm. T1b tumors are >0.5 cm, but 1 cm in greatest dimension. T1c tumors are 1 cm, but no more than 2 cm in greatest dimension. This early breast cancer is often diagnosed on screening mammograms.
N0 = no regional lymph node metastasis M0 = no distant metastasis

37. Breast Cancer: Stage IIA} T0 T1
N1 M0
T2 N0 M0 T0
No evidence
of tumor
36. Breast Cancer: Stage IIA
Stage IIA is also common. It is T0 N1 M0, T1 N1 M0, or T2 N0 M0. T2 lesions are over 2 cm and up to 5 cm. T2
2 cm < T < 5 cm
N1 = metastasis to movable ipsilateral axillary lymph node(s) M0 = no distant metastasis

38. Breast Cancer: Stage IIB
T2 N1 M0
T3 N0 M0 T3
37. Breast Cancer: Stage IIB
Stage IIB lesions are either T2 N1 M0 or T3 N0 M0 tumors. T3 tumors are >5 cm. The prognosis of these cancers is intermediate. Pathologic confirmation of the diagnosis is mandatory (N1a is micrometastasis 0.2 cm; N1b is metastasis to lymph nodes >0.2 cm).
T > 5 cm
N1 = metastasis to movable ipsilateral axillary lymph node(s) (p) N1a, N1b M0 = no distant metastasis

39. Breast Cancer: Stage IIIA
T3 N1 M0 T0 T1 T2 T3
N2 M0
38. Breast Cancer: Stage IIIA
Stage IIIA tumors are T0-3 N2 M0 or T3 N1 M0. N2 lesions are fixed to one another or to other structures. The prognosis for this stage is not good. Chemotherapy is usually used for treatment.
Metastasis to ipsilateral axillary lymph node(s)
N1 = movable
N2 = fixed to one another or to other structures
M0 = no distant metastasis

40. Breast Cancer: Stage IIIB
T4 any N M0
Any T N3 M0 T4
Tumor of any size
with direct extension
to chest wall or skin
T4d = inflammatory
carcinoma
39. Breast Cancer: Stage IIIB
Stage IIIB disease is either T4 any N M0 or any T N3 M0. T4 lesions are tumors of any size with extension to chest wall or skin. T4a involves only extension to the chest wall, while T4b presents as edema, skin ulceration on the breast, or satellite skin nodules to the same breast. T4c involves both T4a and T4b.
N3 = metastasis to ipsilateral internal mammary lymph node(s)
M0 = no distant metastasis

41. Breast Cancer: Stage IV
Any T any N M1
40. Breast Cancer: Stage IV
Stage IV, or metastatic, breast cancer is a lethal disease. The most common sites of metastases are soft tissue (skin or draining lymph nodes), bone, and viscera (eg, liver, lung).
M1 = distant metastasis (including metastases to cervical, or contralateral internal mammary lymph nodes)

42. Staging for Distant Disease: Breast Cancer
FDG PET scan
Bone Scan
Patient A
Patient B
Multiple bone metastases
Tumor in the breast, but not elsewhere
The most common sites of distant disease in breast cancer are the bones, liver and lungs

43. BREAST CANCER 5-year survival: Number of positive axillary lymph nodes0%
20%
40%
60%
80%
5-Year Survival 1 2 3 4 5
6-10
11-15
16-20
>20
Number of Positive Nodes
42. Breast Cancer: 5-year Survival as Function of the Number of Positive Axillary Lymph Nodes
As the number of involved lymph nodes increases, 5-year survival rates decrease.
Harris J, et al. Cancer: Principles & Practice of Oncology. 5th ed. 1997;

44. How effective is therapy for breast cancer?
Relative 5 Year Survival (%)
Site
1974-
1976
1983-
1985
1992-
1997
1996-
2003
Breast 75 78 86
89.8
Progress last few decades-screening and systemic therapy.
SEER, , DCP, NCI, 2009

45. BHGI-DIAGNOSTICS