Snapshot A 46-year-old woman presents to her primary care physician after discovering a lump in her left breast. She denies any breast pain or nipple discharge. Physical exam reveals a 2 cm firm, fixed mass in the left breast in the upper outer quadrant with no axillary lymphadenopathy. Introduction Overview second most common cancer (after lung cancer) most common cause of cancer-related death in adult women 12% lifetime risk Epidemiology Incidence 260,000 cases per year most common in the elderly 50% of all breast cancer occurs in woman > 65 years of age 20% among women < 50 years of age 2% in women < 30 of age Risk factors increasing age breast cancer in first-degree relatives or mother with breast cancer a low fiber, high fat diet obesity history of contralateral breast cancer a history of endometrial cancer which is also a estrogen induced cancer prior radiation increased number of menstrual cycles or exposure to estrogen nulliparity early menarche (< 11 years of age) late menopause (> 50 years of age) late first pregnancy (> 30 years of age) hormone replacement therapy physical/anatomic risk factors include (CHAFED LIPS) Cancer in breast Hyperplasia Atypical hyperplasia Female Elderly DCIS LCIS Inherited genes Papilloma Sclerosing adenitis Prevention smoking cessation alcohol cessation exercise breastfeeding ETIOLOGY Genetics BRCA1 and BRCA2 mutations associated with multiple/early onset breast and ovarian cancer Classification Benign breast tumors intraductal papilloma bloody nipple discharge Carcinoma in situ LCIS not a premalignant lesion but considered a risk factor for breast cancer DCIS a premalignancy 50% develop into invasive ductal carcinoma Paget disease breast itching, crusting, and scaling > 80% associated with underlying breast cancer spreads lymphatically often transforms into invasive ductal carcinoma within 1 year Invasive carcinoma invasive lobular carcinoma invasive ductal carcinoma inflammatory carcinoma phylloides tumor 85-90% are benign may grow aggressively and recur locally Presentation History asymptomatic with recent screening mammography felt a breast lump Symptoms asymptomatic breast lump nipple discharge especially bloody, unilateral Physical exam firm immobile, painless lump most often in upper/outer quadrant skin changes (redness, ulcerations, edema, and nodularity) skin retraction indicates involvement of Cooper ligament axillary lymohadenopathy more advanced cases breast skin edema with dimpling (peau d'orange) represents obstruction of the lymphatics cancer poorer prognosis Imaging Mammography indications screening login to view 7 more bullets diagnosis login to view 5 more bullets findings login to view 4 more bullets Magnetic resonance imaging (MRI) indications high risk women login to view 2 more bullets findings breast mass Ultrasound indications patients < 30 years of age cystic mass login to view 1 more bullet Tumor, Node, Metastasis (TNM) Staging Staging is done with the TNM system and imaging (CT/bone scan) Most important prognostic factor TNM Staging Nodes None Mobile Axillary Fixed Axillary Distant Mets Size > 5 cm Stage IIB Stage IIIA Stage IIIA Stage IV 2-5 cm Stage IIA Stage IIB Stage IIIA Stage IV < 2 cm Stage I Stage IIA Stage IIIA Stage IV Studies Serum calcium level may be elevated Alkaline phosphatase elevation may indicate metastasis Hormone receptor tests estrogen progesterone Her-2/neu Differential Benign breast mass fibroadenoma most common mass especially common in younger women fat necrosis injury hardening of breast tisue secondary to injury to the breast intraductal papilloma bloody discharge Other cancer breast sarcoma lymphoma painless unilateral breast mass in an older woman Treatment Medical chemotherapy indications login to view 6 more bullets endocrine therapy indications login to view 1 more bullet radiation indications login to view 2 more bullets Surgical lumpectomy indications login to view 2 more bullets followed by radiation therapy mastectomy indications login to view 3 more bullets risk of nerve injury login to view 7 more bullets Prognosis Dependent on stage and type triple negative (estrogen receptor (ER)/progesterone receptor (PR)-negative, HER2-neu-negative) has worse prognosis 40,000 deaths per year