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BREAST CARCINOMA

BREAST CARCINOMA. BREAST. The breast by definition is “the soft protuberant body adhering to the thorax in females in which milk is secreted for the nourishment of the infants.”. BREAST CARCINOMA :.

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BREAST CARCINOMA

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  1. BREAST CARCINOMA

  2. BREAST • The breast by definition is “the soft protuberant body adhering to the thorax in females in which milk is secreted for the nourishment of the infants.”

  3. BREAST CARCINOMA: • Cancer of the breast is an adenocarcinoma and it is the commonest cancer in women and the most common cause of death in women of the western world.

  4. ANATOMY OF BREAST • The majority of the breast parenchyma extends inferiorly from the level of the 2nd or 3rd rib to the inframammary fold, which is at about the level of the 6th or 7th rib, and laterally from the edge of sternum to the anterior axillary line. The mammary tissue extends invariably into the axilla as the glandular tail of Spence. The posterior portion of the breast rests on portions of fasciae of pectoralis major, serratus anterior, external abdominal oblique and rectus abdominis muscle.

  5. BLOOD SUPPLY • ARTERIAL SUPPLY: 1) Perforating branches of internal thoracic artery 2) Perforating branches of intercostal arteries 3) Lateral thoracic and thoracoacromial branches of axillary artery. • VENOUS DRAINAGE: Corresponds with the arteries.

  6. LYMPHATIC DRAINAGE OF BREAST • Lateral part of the gland  Axillary lymph nodes • Medial part of the gland  Internal thoracic (mammary) Lymph nodes

  7. INCIDENCE • US incidence = 1 in every 8 women • Ethnic incidence: • Caucasians  Hispanic  Asian  African Americans • African Americans  Higher stage and mortality

  8. ETIOLOGY • RISK FACTORS: • Geographical distribution • Age • Gender • Genetic predisposition • Diet • Endocrine factors a) Length of reproductive life b) Age at the birth of 1st child c) Exogenous estrogen d) Obesity • Alcohol consumption • Radiation exposure • Smoking

  9. Genetic Risk Factors for Breast Cancer • BRCA1 or BRCA 2 mutation increases risk of breast cancer by 6.0-14.0 fold • BRCA 1 and BRCA 2 are tumor suppressor genes that play a role in cellular DNA repair • Approximately 10% of breast cancer is familial and related to BRCA1 or BRCA2 • BRCA1 and BRCA2 associated cancers tend to be more aggressive, of a higher grade, and hormone receptor negative • Confer 50 to 87% lifetime risk of breast cancer • Also increase risk of ovarian cancer • Genetic testing is available for women with appropriate family history

  10. CLASSIFICATION OF BREAST CARCINOMA • A) DUCTAL (85%): a) Non-infiltrating: 1)Ductal carcinoma in situ 2)Intraductal Ca (Comedo carcinoma) 3)Intraductal papillary carcinoma b) Infiltrating: 1) Invasive ductal carcinoma (not otherwise specified [NOS] or Schirrous Ca) 2) Medullary Ca 3) Colloid (mucinous) Ca 4) Tubular Ca 5) Paget’s disease • B) LOBULAR (15%): a) Non-infiltrating: LCIS ( Lobular carcinoma insitu) b) Infiltrating: Lobular carcinoma

  11. PATHOLOGY • SITE: 1) Side: Left breast is affected slightly more often than right breast & 4-10% cases disease is bilateral 2) Quadrant: Upper outer  60% Upper inner  12% Central portion  12% 60% 12% Lower outer  10% 12% Lower inner  6% 10% 6%

  12. SPREAD OF BREAST CANCER • 1) LOCAL: a) Skin b) Pectoral muscles c) Chest wall • 2) LYMPHATIC: a) Axillary and internal mammary lymph nodes are involved early. b) Later supraclavicular lymph nodes, opposite breast and mediastinum become involved. • 3) BLOODSTREAM: a) Bones b) Liver c) Lungs d) Brain e) Adrenal glands f ) Ovaries

  13. CLINICAL FEATURES • 1) Painless lump in the breast. • 2) Occasionally painful with pricking sensation and mild aches. • 3) Distortion of breast shape and size. • 4) Nipple changes e-g deviated, displaced, elevated, retracted, ulcerated or destroyed.

  14. 5) Bloody nipple discharge • 6) Lump in axilla • 7) Swelling of arm • 8) Features of metastasis: General: Malaise and loss of weight Pulmonary: Cough, chest pain, respiratory distress. Bones: Pain, pathological fractures. Spinal cord compression: Paraplegia and paralysis. Liver: Anorexia, jaundice, abdominal swelling and pain. Brain: Mental changes and fits.

  15. MANAGEMENT • A) HISTORY: • If patient has had breast cancer before • Family history of breast or ovarian cancer • She received radiation as a child or adolescent • She have excess weight • Early first period, menopause • If she has never had children or first conceived after age 35 • Race- Caucasian women develop breast cancer more often than Black or Hispanic women • Treatment with combination hormone therapy • Smoking with a family history of cancer • Chemical exposure • Alcohol abuse

  16. EXAMINATION Local signs: Breast lump: • Site - 60% in the upper outer quadrant • Shape - roughly spherical, can grow into any shape • Size - variable • Surface - usually indistinct • Color - initially reddish purple, but becomes yellow or pearly white on complete skin infiltration. • Temperature - normal in non-vascular carcinoma • Consistency: a) Invasive duct Ca  Stony hard b) Medullary carcinoma  Soft c) Colloid carcinoma  Extremely soft d) Infiltrating lobular carcinoma  Rubbery, sometimes hard 8. Relations to surrounding structures 9. Regional lymph nodes

  17. Breast carcinoma is also associated with the following morphological features: 1) Adherence & eventually fixation to pectoral muscles & deep fascia of chest wall.

  18. 2) Adherence of overlyring skin, with retraction or dimpling of skin (peau d’orange) or nipple. 3) Infiltration into the skin of the chest results in cancer-en-curiasse.

  19. 4) Involvement of lymphatic pathways may cause localized lymphedema. 5) Inflammatory carcinoma  Sometimes, esp. in pregnancy, tumor spreads so rapidly that it excites an acute inflammatory reaction, with swelling, redness & tenderness.

  20. INVESTIGATIONS 1) Needle biopsy 2) Mammography 3)Ultrasound Breast

  21. TRIPLE ASSESSMENT: In any patient who presents with a breast lump or other symptoms suspicious of carcinoma, the diagnosis should be made by a combination of clinical assessment, radiological imaging and a tissue sample taken for either cytological or histological analysis, the so called triple assessment. Triple assessment Pathology clinical Imaging Age Examination US mammography FNAC corecut Confident diagnosis in 99.9% of cases

  22. PROGNOSTIC FACTORS Prognosis is influenced by the following variables: • Size of the primary carcinoma • Lymph node involvement and no. of lymph nodes involved by metastasis. • Distant metastases • The grade of the carcinoma • Histological types of carcinoma • The presence or absence of estrogen or progesterone receptors • The proliferative rate of cancer • Aneuploidy • Over expression of HER2/NEU

  23. GRADING AND STAGING OF CANCER • GRADING: Grading refers to the appearance of the cancer cells under the microscope. The grade gives an idea of how quickly the cancer may develop. There are three grades: grade 1 (low-grade), grade 2 (moderate or intermediate grade) and grade 3 (high-grade). • Low-grade means that the cancer cells look very like the normal cells of the breast. They are usually slow growing and are less likely to spread. • In high-grade tumors the cells look very abnormal. They are likely to grow more quickly and are more likely to spread. • Moderate-grade or grade 2 cancers fall between these two grades and have a level of activity somewhere in between. 

  24. STAGING Cancer stage is based on the size of the tumor, whether the cancer is invasive or non-invasive, whether lymph nodes are involved, and whether the cancer has spread beyond the breast. • A) MANCHESTER SYSTEM: 1. Stage-I: Growth confined to breast. 2. Stage-II: a) Growth confined to breast. b) Affected mobile lymph nodes in ipsilateralaxilla. 3. Stage-III: a) Skin involvement of peaud’orange larger than tumor but still limited to breast. b) Tumor fixed to pectoral muscles but not to chest wall. c) Ipsilateralaxillary lymph nodes matted together or fixed to chest wall, or ipsilateralsupraclavicular nodes mobile or fixed, or edema of arm 4. Stage-IV: a) Skin involvement with breast b) Complete fixation of tumor to chest wall. c) Distant metastasis. .

  25. TNM CLASSIFICATION: • Primary tumor (T) • TIS  No palpable tumor (carcinoma in situ) • T1  < 2 cm • T2  2-5 cm • T3  >5 cm • T4  Tumor (any size) invading skin or chest wall • Nodal Involvement: • N0  No nodal metastasis • N1  Mobile involved axillary lymph nodes • N2  Fixed involved axillary lymph nodes • N3  Involved ipsilateral supraclavicular nodes 3) Distant Metastasis: • M0  No known distant metastasis • M1  Known distant metastasis STAGING ACCORDING TO TNM: • STAGE-I  TIS OR T1, N0 & M0 (5 year survival rate : 87%) • STAGE-II  T2, N1 & M0 (5 year survival rate : 75%) • STAGE-III  T3 OR T4, N2 OR N3 & M0 (5 year survival rate : 46%) • STAGE-IV  Any T, Any N & M1 (5 year survival rate : 13%)

  26. TREATMENT • Two basic principles of treatment: • Reduce the chance of local recurrence • Reduce the chance of metastatic spread • Treatment of early breast cancer  usually involves surgery with or without radiotherapy. Systemic therapy such as chemo or hormone therapy is added if there are adverse prognostic factors such as involvement of lymph nodes, a high likelihood of metastasis. • At the other end of the spectrum locally advanced or metastatic disease is usually treated by systemic therapy to palliate symptoms, with surgery playing a much smaller role.

  27. INDICATIONS FOR MASTECTOMY • Large tumors in relation to the size of the breast • Central tumors beneath or involving the nipple • Multifocal disease • Local recurrence • Patient preference OPERATIVE CHOICES: • Radical (Halsted) mastectomy • Modified radical or Patey’s mastectomy • Conservative surgery (Wide local excision, lumpectomy, quadrantectomy) • Radiotherapy

  28. RADICAL (HALSTED) MASTECTOMY: Surgical removal of an entire breast; pectoral muscles; axillary lymph nodes; and all fat, fascia, and adjacent tissues as one surgical treatment for breast cancer. • No longer indicated as it causes excessive morbidity with no survival benefit. • Advantages: If confined to the breast cancer cells and nearby tissue, the tumor can be completely removed, and lymph node examination, treatment of future provide important information. • Disadvantages: remove the entire breast and chest muscles, will leave a long scar, the chest will sag and may lead to lymphedema, arm weakness, numbness, pain, and restricted shoulder movement, different conditions have different restrictions .

  29. 2. PATEY’S MASTECTOMY: The breast and associated structures are dissected and the excised mass is composed of: • The whole breast • A large portion of skin, the centre of which overlies the tumor but which always includes the nipple. • All of the fats, fascia and lymph nodes of the nipple. • Like a simple mastectomy, the procedure is performed using an elliptical incision 6 to 8 inches in length that begins on the inside of the breast, near the breast bone, and extends upward and outward toward the armpit. • The wound is drained using a wide bore suction tube. Early mobilization of the arm is encouraged and physiotherapy helps normal function to return very quickly.

  30. CONSERVATIVE SURGERY: • Involves removal of tumor plus a rim of at least 1 cm of normal breast tissue, referred as wide local excision or lumpectomy. • Quadrantectomy involves removing the entire segment of the breast which contains the tumor. • Usually combined with axillary surgery. • QUART: A quadrantectomy, axillary dissection and radiotherapy are known as QUART. • RADIOTHERAPY: • May be used alone or in combination with surgery • It is necessary to identify which patients are at higher risk of local relapse and thus would benefit most from the postoperative breast irradiation. These include patients with extensive In situ carcinoma & invasive cancer, patients under 35 years & those with multifocal disease.

  31. OTHER THERAPIES: • Anti-estrogens: Tamoxifen 20 mg daily, increasing to 40 mg daily if necessary. • Cytotoxic chemotherapy: A regimen consisting 6 monthly cycle of CMF. • Cyclophosphamide  3.5 - 5 mg/kg/d orally for 10 days • Methotrexate 10 – 60 mg/ square meter body surface area • 5- Flourouracil 400-500 mg/square meter, IV on day 1 & 8 within a cycle of 38 days. • Hormone therapy: Medroxyprogesterone acetate (farlutal depot 500)  1 – 1.5 gm orally daily. • Endocrine manipulation • Radiotherapy • Immunotherapy

  32. RECONSTRUCTION OF BREAST AND CHEST WALL • Reconstructive surgery  wound closure and breast reconstruction • In a more radical approach  a skin graft is provided for functional coverage that will tolerate the adjuvant radiation therapy. • Breast reconstruction after prophylactic mastectomy or after mastectomy for early invasive breast cancer  performed immediately after surgery. • While reconstruction following surgery for advanced breast cancer  delayed for 6 months after completion of adjuvant therapy to insure that locoregional control of disease is obtained • Breast reconstruction following mastectomy essentially consists of three surgical options : • Tissue expansion (implants) • The TRAM flap and • The latissimus dorsi flap

  33. TRAM Flap • TRAM (transverse rectus abdominis muscle) flap is a type of breast reconstruction surgery. The surgeon takes muscle and tissue from the lower belly and moves it to the chest area. This reduces the amount of fat and skin in the lower belly and results in a "tummy tuck." • TRAM may be done as either a pedicle flap (which means the tissue is pulled under the skin and attached in the chest area without cutting its blood supply) or a free flap (which means the tissue and blood vessels are cut and reattached in the chest area).

  34. Latissimus Dorsi Flap • In this flap procedure, the surgeon takes tissue from the latissimus dorsi muscle in your back, tunnels it underneath your skin to its new location and uses it to form a new breast mound. your skin to its new location and uses it to form a new breast mound.

  35. Nipple Reconstruction • A relatively simple procedure. • Tattooing of the reconstructed nipple often required • Prosthetic nipple • To achieve symmetry with the opposite side  Reduction or augmentation mammoplasty or mastopexy.

  36. FOLLOW UP • The primary goal of follow up is to detect potentially curable, new or recurrent disease. A secondary goal is to assess treatment outcome. • All breast patients should be seen for a physical examination at least every 6 months for the first five years and then annually. As well as the affected breast or mastectomy site, the chest wall, regional. The chest wall, regional lymph node drainage areas and the contralateral breast must be examined. The spine should be percussed for bony tenderness, the lungs auscultated and the abdomen examined for hepatomegaly. • Mammography every month initially. • A mammogram of the contralateral breast should be done annually. • Symptoms or signs should be investigated as indicated. • Blood work, chest x-rays and bone scans are not recommended in the absence of symptoms or signs.

  37. BREAST SELF EXAM • Breast self-examination should be instructed to all women. The postmastectomy chest wall should be examined in a similar manner. • Both the left and right side of the chest. • The skin over the chest wall. • Any incisions or scars. • Above and below the collarbone. • The armpits. • The entire chest wall, down to the bottom of the ribs.

  38. If the patient has had breast conservation treatment, careful follow up of the treated breast is required as follows: • five to six weeks after radiation is completed, the patients should be seen at an Agency or a consultative clinic to assess acute reactions. • for five years the patient should be seen every six months by a physician. Baseline, post-treatment bilateral mammograms should be performed approximately six months after all treatment has been completed and repeated annually thereafter. • after five years the patient should be seen every year by their family doctor for physical examination and bilateral mammogram.

  39. PREVENTION OF BREAST CANCER • Examine Your Breasts Every Month Beginning At Age 20 (see your doctor for self breast exam instructions). Check for: new lump (painful or not), unusual thickening of tissue, discharge from the nipples, change in the skin of nipples or breasts, or different breast size or shape than before. • Have Your Doctor Examine Your Breasts Every Year Or Two Beginning At Age 30 • Have A Mammogram Every Year After Age 40 • And lastly avoid anything that can turn out to be a risk factor for breast carcinoma such as obesity, alcohol consumption etc.

  40. CARCINOMA OF THE MALE BREAST • Accounts for less than 0.5 % of all cases of breast cancer. • PREDISPOSING CAUSE: • Gynaecomastia • Excess endogenous or exogenous estrogen • PRESENTATION: Lump (most commonly infiltrative ductal carcinoma) • TREATMENT: Same as for females and prognosis depends on the stage at presentation. Adequate local excision, because of small size of the breast, should always be with a mastectomy.

  41. THANK YOU

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