00:01
The clinical presentation.
00:03
Most breast tumors occur
in the upper outer quadrant.
00:06
The superior lateral quadrant,
that's actually where you
have the most breast tissue.
00:11
The inner lower quadrant.
00:14
So, the medial inferior quadrant has
the least amount of breast cancers.
00:19
What you'll see is a palpable mass,
usually firm.
00:23
Although it doesn't have to be.
00:25
And you may then see associated
changes in the overlying skin
with dimpling, erythema,
induration the
nipple retraction
and/or discharge tends
to indicate that you have a
larger ductular involvement.
00:40
And especially
in lobular carcinoma,
the contralateral
breast can be affected
even though you may not
have detected anything.
00:47
So, a diagnosis of lobular carcinoma
really mandates that you look very
carefully at the other breast.
00:55
This is just an example
of some of the gross
and then the microscopic
manifestations.
00:59
Paget's disease typically involves
the more distal ducts
and into the nipple,
and we see kind of an erythematous
mass like lesion
involving the nipple.
01:12
When you look at the histology,
there are tumor cells
percolating through
all the way up into the skin.
01:20
Inflammatory carcinoma,
it's not so much inflammatory
is that we have invasion
of the lymphatics by tumor,
and it gives that the skin
a very indurated appearance
because of the subcutaneous
lymphatic filling with tumor
and that the peau
d'orange appearance.
01:38
This is the
Phyllodes tumor, they can,
as I've already said,
be quite dramatic.
01:43
And this particular one,
although it looks
incredibly large, is benign.
The epithelium is totally normal.
01:53
It's actually kind of
an afterthought,
and we have this
stromal proliferation.
01:57
But this was not
a malignant version,
so, size does not necessarily
equate to malignant potential.
02:06
Making the diagnosis.
02:08
It's a combination of
imaging and pathology.
02:12
A breast exam is
clearly also indicated
before you progress to
any of the other things.
02:17
A discrete mass
with irregular borders
that is firmly fixed to the chest
wall or to the overlying skin,
typically indicates
that we have a malignancy.
02:29
We can do a variety
of other imaging,
including ultrasonography,
and Magnetic Resonance Imaging.
02:35
The final gold standard, however,
is going to be a biopsy,
and it can be an excisional biopsy,
it can be a core biopsy,
it depends on the practice within
the particular oncologic service.
02:49
It's really important, that when
we do a biopsy, or an excision
that we also look
at tumor biomarkers.
02:57
And it's not just
because we're curious,
but because that
will impact and instruck
exactly how we're going
to treat the patient.
03:05
So, we will want to look for the
presence of hormone receptors.
03:09
We want to see if there's estrogen
or progesterone receptors.
03:11
And if there are,
then we can give antagonists
that will in many
cases will provide
very good medical therapy
for the tumors.
03:20
If the tumor’s overexpressing the
epidermal growth factor receptor,
there's very intense
immunohistochemical staining
for HER2/neu,
then these tumors are going to
respond to monoclonal antibodies
that block that receptor.
03:32
So, we will always on
breast cancers look
for estrogen and progesterone
receptor and HER2/neu overexpression.
03:39
Other tumor markers in the blood
can be helpful
for following disease,
such as carcinoembryonic antigen and
some of the other cancer antigens,
although they are
somewhat nonspecific,
and are useful only in
following response to therapy.
03:57
So, if you know that your
tumor has a high level of CEA
that you can detect in
the bloodstream,
you may be able to do
follow on CEAs after therapy
and make sure the tumor
is not recurring.
04:09
Or if it is,
then you can go looking for
where it may be re established.
04:15
The Treatment.
Depends on what we have.
04:18
If it's carcinoma in situ,
surgery is usually completely curative.
04:22
We may do radiation therapy,
and certainly would do
endocrine therapy
if it's estrogen or
progesterone receptor positive.
04:31
For early stage invasive cancer.
04:33
So for infiltrative ductal,
infiltrative lobular carcinoma,
we clearly have to excise that
with wide margins.
04:41
We will probably also do
lymph node dissections.
04:44
We'll do radiotherapy
to the original site of the tumor,
as well as to the
draining nodal tissue.
04:51
And we may do neoadjuvant
or adjuvant therapy
with either endocrine blockers.
04:58
So, if it's estrogen and
progesterone receptor positive,
or HER2 monoclonal antibodies.
05:05
Chemotherapy may also be indicated.
Although in most of the cases
endocrine or HER2 therapies
are more than sufficient.
05:14
For locally advanced
invasive carcinoma.
05:16
So large tumors infiltrating
into the chest wall,
or infiltrating into
the overlying skin.
05:22
We have to do surgery. We will do
adjuvant therapy for sure
that may involve
immunotherapy, radiotherapy,
chemotherapy, hormonal therapy.
05:33
And then for metastatic cancer.
05:35
In many cases, we will
still do a primary excision,
but then we're going
to follow that up
with any of a variety
of ways to treat this.
05:43
Metastatic cancer has
the worst overall prognosis.
05:46
But we are getting better
at treating that.
05:49
And again, for all comers
in cancer of the breast,
only 1 in 39 will die
of her breast cancer.
05:57
With that, a rather long talk
about a very important topic
that occurs quite frequently
in women as well as
occasionally in men,
breast cancer.