MANAGEMENT OF BREAST CANCER

1. MANAGEMENT OF BREAST CANCER

2. DIAGNOSES TRIPLE ASSESSMENT • Clinical examination • Radiological • Pathological

3. CLINICAL EXAMINATION • History and physical examination. • Irregular margins, attached to skin, ulcerating lump, nipple retraction, Lymph node enlargement.

4. RADIOLOGICAL MAMMOGRAMS BENIGN • Rounded • Smaller over time, oval, large, smooth & uniform coarse calcification. MALIGNANT • Irregular shape & margins. • Distorted breast architecture. • Larger overtime • Fine clustur calcification.

5. MAMMOGRAM Advantages • Use during pregnancy. • Best for impalpable region. • Used to get different biopsies. • Shown to decrease mortality.

6. MAMMOGRAM (CONT--) Disadvantages • Can not be used before age 35 except high risk cases. • 10-15% negative despite cancer esp in premenopausal. • A normal mammogram in presence of palpable lump does not exclude cancer.

8. ULTRASOUND Advantages • Differentiate between solid and cystic. • Accurately assess size, counter and internal texture. • Get biopsies. • Less invasive and cost effective. • Can be used before age 35.

9. ULTRASOUND CONTI---- Disadvantages • Can not be used for screening. • High false positive & negative. • Cannot detect calcification.

10. MRI • Still experimental • As adjuvent to mammogram in detecting multicentring disease. • Cannot differentiate b/w breast cancer & breast abscess. • Cannot detect micro calcification. • Useful in breast implants pt with Ca.

11. PATHOLOGICAL For palpable lesions • FNAC • Core biopsy • Excisional biopsy • Incisional biopsy

12. PATHOLOGICAL FNAC Advantages • Out patient, minimally invasive, quick. • > 90 % sensetive. • Decrease local complications. • Can differentiate b/w benign & malig. • Harmonal status can be measure.

13. FNAC Disadvantages • Risk of inadequate specimen. • Cannot differentiate b/w INSITU and invasive cancer.

14. CORE BIOPSY Advantages • Can differentiate b/w insitu and invasive. • Tumour grading. • Harmonal status. • Accurate histological diagnosis. Disadvantages • More invasive • Time consuming • Decrease local complications.

15. NON PALPABLE LESIONS. • Stereotactic core biopsy. • Vaccum assisted biopsies. • Needle localization.

17. TREATMENT DCIS • Local excision with radiotherapy. < 3cm in periphery of breast. • Simple mastectomy in multicentric lesions: • Axillary lymph node sampling not needed. • Chemotherapy not needed. • Tamoxifen. Decrease recurrence by 37% over five years and also decrease risk in contralateral breast.

18. TREATMENT LCIS • Not pre cancerous lesion. • Carefull examination every six months by physician. • Yearly mammograms. • Monthly self examination. • Bilateral mastectomy + reconstruction-positive family history.

19. INVASIVE BREAST CA TREATMENT Local Disease (stage1&2) • Breast conservative surgery with radiotherapy ± ALNS. Indications • Small ca in breast periphery. • Patient desire.

20. BREAST CONSERVATIVE SURGERY (CONTI--) Advantages • Breast conservative. • Less psychological problems. • DISADVANTAGES: • Increase local recurrences. • Decrease 30-70% over five yrs by post op radiation.

21. CONTRA INDICATION • Multicenteric tumor. • Persistently positive margins after multiple attempts. • Pregnency • Unavailability of radiation. • Collagen vascular disease.

22. MASTECTOMY Indications • Large tumour in small breast. • Central tumour beneath or invading nipple. • Multi focal disease. • Local recurrences after bcs. • Pt preference.

23. TYPES • Radical halstead. • Modified radical. • Simple mastectomy. • Often followed by radiotherapy to axilla. Follow Up • Physical examinations every 3 to 4 months for 2-3 yrs & every 6 months for next 2-3 yrs. • Mammogram of contralateral breast annualy.

24. CHEMOTHERAPY Indications • Early breast cancer with L/nodes +ve. • Early breast cancer with L/nodes –ve usually does not need chemo, but needed in. • Mod/poorly differentiated tumor • > 1 cm. • Hormonal receptor –ve.

25. CHEMOTHERAPY Locally advanced breast ca • Usually needed pre op. • + ve L/nodes in LABC have 70% relapse at 10 yrs and >90% relapse if > 10 L/nodes are involved. • Adjuvant chemo decrease relapses by 37% in premen and 22 % post menop. Metastatic carcinoma Inflamatory breast cancer (pre op)

26. No chemotherapy • <1cm tumour. • ER +ve. • L/N –ve. • Pregnancy.

27. RADIOTHERAPY. Indications • After BCS. • 3 weeks to chest wall + SC fossa after mastectomy with increase local recurrence chances. • >4cm. • Extensive lymphovascular invasion. • Pect muscle involvement. • > 4 L/N involve. • +ve surgical margins • Internal mammory nodes +ve. • Residual tumour on axillary vein. • Inadequate or no ALND Metastatic for paliation

28. LOCALLY ADVANCED CA (STAGE3) • Usually required neo advunant chemo therapy before surgery. • Radiation to chest wall, SCF and axilla post surgery. • 20% have distant metastasis. • CBC, metabolic profile, bone scan, CT chest abd before neo advunant chemotherapy. Follow up • Every three months by all specialists involved in their care, because of increase risk of recurrence.

29. METASTATIC CA (STAGE4) • Involved bone, lungs, liver, brain etc. Routine Inv • CBC, LFT’s, bone scan, CEA, C-Xray, U/S Abd. Selective inv • CT Abd, Chest & Head. • MRI Spine, biopsy of metastatic area. • Aspiration of ascities or pleural effusion.

30. TREATMENT Systemic therapy • ENDOCRINE. • Ovarian ablation (medical/surgical) for premenopasal women. • Tamoxifen. • Aromatase inhibitors for post menopausal. • Progesterone etc. • CHEMOTHERAPY. • IMMUN THERAPY. • RADIATION.

32. TREATMENT OF LOCO REGIONAL RECURRENCES • After BCT: Salvage mastectomy • In Axilla: Surgery followed by radiation to axilla and systemic therapy. • Chest after mastectomy: 1/3 have distant metastasis at recurrence time. • Isolated recurrence: excision + radio. • Multiple recurrence: Radical chest resection with flap cover.

33. AXILLARY DISECTION • Indications • Positive node metastasis. • All patients with stage1 & stage 2 disease • For staging purposes & control of axilla. • As a component of MRM/BCS. • LEVEL 1 L/NODE: lateral to pect minor. • LEVEL 2 L/NODE: Post to pect minor. • LEVEL 3 L/NODE: Medial to pect minor.

34. RECOMMENDATION OF ALN MANAGEMENT IN OPERABLE CASES. • Impalpable or <2cm: Node sampling or sentinal L/nd biopsy or level 1,2,3 dissection. • All other operable cases: level 1,2,3 dissection.

35. STAGING OF AXILLA By 3 methods • LEVEL 1 DISSECTION: Four or more L/N should be removed. • SENTINAL L/N BIOPSY: False negative rate, difficult to interpretate. • L/N SAMPLING

36. TAMOXIFEN • Selective estrogen receptors modulator. • Agonist at endometrium. • Agonist at bone. • Antagonist at breast. • Decrease recurrence of cancer by 47% and also in contralateral breast but no decrease in mortality. • Highly effective in ER +ve pt.

37. TRUSTOZUMAB • 25-30% of breast ca pt are HER 2 +ve. • Monoclonal anti body against HER 2+ve receptors. INDICATIONS • With taxane for metastaic ca in HER 2 +ve pt with no chemotherpay for ca. • Alone in pt with at least two chemotherapy regimen. • Is cardiotoxic.

38. RECENT ADVANCES ANNUAL MRI INDICATIONS: • Chest radiation b/w 10-30 yrs. • Life long risk of 20% or more of Ca. • Strong family history of breast / ovarian Ca. BEVACIZUMAB: • Monoclonal antibodies against blood vessels in tumor. • Use for metastatic Ca

39. POOR PROGNOSTIC FACTORS • +ve lymph nodes. • Increase tumor size. • ER receptors –ve. • Age <35 • HER 2 receptor +ve. • Poorly differentiated Ca.

40. RECENT ADVANCES (CONTI----) LAPATINIB: • Monoclonal antibodies against HER2 receptors. • For metastaic Ca only in conjunction with chemo. FULVESTRANT: • Anti estogen. • Metastatic Ca in post menopasal as second line after tamoxafen / anastrozole. • Used in tamoxafen resistant cases with +ve ER.

43. SCREENING