1 / 55

BREAST

BREAST. INCIDENCE. Second most common type of cancer after lung cancer (10.4% of all cancer incidence, both sexes counted) Fifth most common cause of cancer death Hundred times more common in female Lower in less-developed countries and greatest in the more-developed countries.

mbeaman
Download Presentation

BREAST

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. BREAST

  2. INCIDENCE • Second most common type of cancer after lung cancer (10.4% of all cancer incidence, both sexes counted) • Fifth most common cause of cancer death • Hundred times more common in female • Lower in less-developed countries and greatest in the more-developed countries

  3. CLASSIFICATION • Pathology • Tumor Grade • well-differentiated (low grade) • moderately differentiated (intermediate grade) • poorly differentiated (high grade) • Protein and Gene expression • Tumor Stage

  4. CLINICAL FEATURES • Lump breast • Palpable L nodes (axilla,supraclavicular) • skin dimpling • nipple inversion • spontaneous single-nipple discharge • Pain (unreliable) • Inflammatory Breast Ca (pain, swelling, warmth and redness, Peau d orange)

  5. Paget’s disease of breast (tingling, itching, increased sensitivity, burning, nipple disch, pain) • Metastasis (bone, liver, lung and brain) • Unexplained weight loss • fevers or chills • Bone or joint pains • jaundice or neurological symptoms

  6. EPIDEMIOLOGY/ETIOLOGY • Genetic mutations • Abnormal growth factors • Failure of immune surveillance • Inhertited defects in DNA repair genes (BRCA1, BRCA2, p53)

  7. RISK FACTORS • Sex • Age • Childbearing • Hormones • high-fat diet • alcohol intake, tobacco use • Obesity • radiation

  8. Hereditary syndromes (5%) • carriers of the breast cancer susceptibility genes, BRCA1 and BRCA2, are at a 30-40% increased risk for breast and ovarian cancer

  9. PREVENTION • Lower age of first childbirth (less than 24 years maternal age) • having more children (about 7% lowered risk per child) • breastfeeding (4% per breastfeeding year, with an average relative risk around 0.7)

  10. Phytoestrogens (soy) • Folate • Oophorectomy / (mastectomy) • Hormonal therapy • SERM’s (Tamoxifen, Raloxifene)

  11. SCREENING • self and clinical breast exams • x-ray mammography • breast MRI • Genetic testing (BRCA mutations)

  12. DIAGNOSIS • TRIPPLE ASSESMENT • Clinical Assesment • Radiology (Mammography, USS) • Tissue Dx (FNAC, Trucut)

  13. STAGING • TX: Primary tumor cannot be assessed. T0: No evidence of tumor. Tis: Carcinoma in situ, no invasion T1: Tumor is 2 cm or less T2: Tumor is more than 2 cm but not more than 5 cm T3: Tumor is more than 5 cm T4: Tumor of any size growing into the chest wall or skin, or inflammatory breast cancer

  14. NX: Nearby lymph nodes cannot be assessed N0: Cancer has not spread to regional lymph nodes. N1: Cancer has spread to 1 to 3 axillary or one internal mammary lymph node N2: Cancer has spread to 4 to 9 axillary lymph nodes or multiple internal mammary lymph nodes N3: Cancer has spread to 10 or more axillary lymph nodes, ,OR supra/subclavicular nodes or axillary lymph nodes and has enlarged the internal mammary lymph nodes, or Cancer involves 4 or more axillary lymph nodes

  15. MX: Presence of distant spread (metastasis) cannot be assessed. M0: No distant spread. M1: Spread to distant organs, not including the supraclavicular lymph node, has occurred

  16. TUMOR MARKERS • Ca 15.3 (carbohydrate antigen 15.3, epithelial mucin) is a tumor marker determined in blood which can be used to follow disease activity over time after definitive treatment

  17. Mammogram(Breast Cancer)

  18. STAGES • Stage 0 - Carcinoma in situ (DCIS) • Stage I - Tumor (T) does not involve axillary lymph nodes (N). • Stage IIA – T 2-5 cm, N negative, or T <2 cm and N positive. • Stage IIB – T > 5 cm, N negative, or T 2-5 cm and N positive (< 4 axillary nodes). • Stage IIIA – T > 5 cm, N positive, or T 2-5 cm with 4 or more axillary nodes • --------------------------------------------------------------------- • Stage IIIB – T has penetrated chest wall or skin, and may have spread to < 10 axillary N • Stage IIIC – T has > 10 axillary N, 1 or more supraclavicular or infraclavicular N, or internal mammary N. • Stage IV – Distant metastasis (M)

  19. HORMONE RECEPTORS • Breast lesions are examined for certain markers, notably sex steroid hormone receptors. About two thirds of postmenopausal breast cancers are estrogen receptor positive (ER+) and progesterone receptor positive (PR+). Receptor status modifies the treatment as, for instance, only ER-positive tumors, not ER-negative tumors, are sensitive to hormonal therapy

  20. HER 2 • The breast cancer is also usually tested for the presence of human epidermal growth factor receptor 2, a protein also known as HER2, neu or erbB2. • HER2 accelerates tumor formation. About 20-30% of breast cancers overexpress HER2. • Those patients may be candidates for the drug trastuzumab(Herceptin), both in the postsurgical setting (so-called "adjuvant" therapy), and in the metastatic setting

  21. Surgery • D.C.I.S. • Operable breast cancer. • Locally advanced disease.

  22. Non surgical treatment • Adjuvant chemotherapy. • Adjuvant hormone treatment. • Adjuvant Radiotherapy. • Neo-adjuvant Chemotherapy.

  23. Surgery for early breast cancer • Non invasive breast cancer (DCIS): - No absolute consensus. - Lesions < 4cm: WLE with 1cm safety margin. No axillary surgery. - Lesions > 4cm or multifocal consider mastectomy. - Axillary node sampling if extensive multifocality (1-5% lymph node involvement) ( Dixon 1998) - DXT: beneficial - Hormonal treatment: less certain ( Lancet IBIS trial 2003). • Lobular carcinoma in situ (LCIS): a marker lesion for increased risk of invasive cancer/close surveillance.

  24. WLE

  25. WLE+ Augmentation Mammoplasty

  26. Invasive Breast Cancer (Early) • Breast Conservative Tumour (BCT): solitary <3cm, or selected cases with > 3cm in large breast (MDM). • Contraindications: - multifocal, - recurrent disease after BCT, - patient choice, - tumour > 3cm, - centrally placed tumors, or - if DXT is contraindicated, - pregnancy, - age< 35 years( MDM).

  27. Breast Conservative Surgery (BCS) • A cylinder of breast tissue from skin to deep fascia is removed. • No skin is removed unless superficial tumor. • Macroscopic radial margins should be at least 10-20mm and microscopic margins at least 5mm. • Radiopaque clips: 1( anterior surface),2(medial surface), 3(inferior surface). • Silk suture on tissues closest to nipple.

  28. Breast conservative surgery

  29. What’s next • Specimen x ray for all cases with a detectable mammographic abnormality. • If close margin: immediate re-excision at same operation. • 4 axillary node sampling if axillary clearance is not indicated. • ER and PR status in all patients. • Mark the cavity with 4 clips on the pectoral fascia for DXT( superior, inferior, medial and lateral).

  30. Treatment of axilla • Incidence: 1%(DCIS),5%-28%(T1), 48%(T2), 68%(T3), 88%(T4). • Axillary sampling (4 node): - if clinically N0 • Axillary clearance: if N1 or +FNAC and if mastectomy is indicated for recurrent disease. • Not indicated if previously treated with radiotherapy.

  31. Locally advanced Breast Cancer • large cancer(T3-4), skin or muscle or chest wall infiltration, matted L.N. • Full screen for metastasis( bone scan, liver US, possible CT chest). • MDM: select cases for adjuvant chemotherapy and hormonal ttt (Cancer;98:1150-60, 2003).

  32. Locally advanced Breast Cancer • Hormonal: slowly growing, ER PR+, unfit patients for chemotherapy. • Chemotherapy: inflammatory carcinoma, ER, PR –ve, young patient <35. • Value: down staging, • Definitive surgery will entirely depend on the tumor response.

  33. Chemotherapy • Adjuvant( in addition)/Neo-adjuvant (in advance/instead) of surgery. • Details pathology: tumour size, grade, nodal, receptor status, margins of excision and the presence or absence of vascular or lymph-vascular invasion. • Indications (risk factors): +ve nodes, grade 2-3, size>2cm,vascular invasion and receptor –ve tumors. • Anthracycline based e.g. 6 cycles of Epirubicin,5FU, Cyclophosphamide. Other combinations Epirubicin, Cyclophosphamide and Taxane.

  34. Chemotherapy continued • HER2 receptor status is becoming increasingly important particularly in relapse patients who are candidates for Trastuzumab (Herceptin). • The benefits of chemotherapy in postmenopausal patients is increasingly appreciated making the traditional classification of patients into pre and post menopausal less crucial. • Chemotherapy is not routinely offered to patients>65years.

  35. Hormonal therapy • All patients with estrogen/ progesterone receptors positive. • Tamoxifen 20mg/day for 5 years. • Exceptions: previous tamoxifen therapy or history of thrombo-embolism. • Should not simultaneously prescribed with DXT for fear of increased risk of pulmonary fibrosis. (Radiother Oncol 2002,Br J Cancer 2004). • Should not simultaneously prescribed with chemotherapy as it reduce its effect and significantly increase the incidence of thromboembolism. • ATTOM trial 5 more years of tamoxifen after finishing a 5 year treatment. Provided that the patients are disease free and had a complete resection of tumors.

  36. Arimidex (Anastrozole) • A non steroidal aromatase inhibitor. • ATTAC trial suggests: it is stronger with better prognosis and lesser side effects than tamoxifen. • Nevertheless more arthralgia and fractures complication (Lancet 2005). • Receptor +ve postmenopausal.

  37. Adjuvant Radiotherapy • Post BCS: DXT is given to the breast and the lower axilla in the tangential glancing fields. • DXT should be considered for all patients with completely excised DCIS who had undergone BCS. • Only those with lesions <10mm should be discussed at the MDM. • 4500-5000 cGY in 20-25 fractions daily. Options to give boost in younger patients. • DXT to supraclav. L.N: Should be considered with 4 or more pathologically involved axillary L.Ns, apical nodes involvement and with extra nodal spread of tumor.

  38. Post-mastectomy Radiotherapy • Chest wall: - 4 or more pathologically involved axillary nodes, - primary tumor >5cm(large breast) - and tumor 3-5cm( small breast), - narrow deep margin <0.5cm, - evidence of lymph vascular invasion. • Irradiation to the axilla is only for those who have not had axillary clearance.

  39. Follow up • Access to breast care nurse/unscheduled outpatient review and for post 5 years follow ups. • Patients are seen for 5years in the breasts cancer follow up clinic starting from 2 weeks postoperative where the results are conducted. • Alternating appointment every 3months between the oncologist and the surgeon for 2 years, then very 6 months for 3years. • Clinical examination to the breast and the lymph nodes.

  40. Follow UP • Mammography is requested annually for 5 years. • After 5 years if < 50years, arrange biennial mammography until 50years. • if>50years then discharge to NHSBSP for 3yearly screening. • IF>70years self referral for 3yearly screening. • All patients diagnosed with distant metastasis should stop mammography surveillance. • Other investigations are only requested if symptoms develop e.g. back pain, lump, rash etc

  41. Breast reconstruction • Patients should be aware prior to surgery for the possibility of breast reconstruction. • Primary? Delayed? • All patients should be offered the opportunity to meet another patient who underwent BR.

  42. Breast Reconstruction

  43. Breast reconstruction

  44. Outcome of breast cancer • 60% of patients will develop some form of recurrence, 2/3(40%) will develop within 5 years. • 50% will eventually present with distant metastasis and die from the disease. • Nottingham prognostic index (NPI): Grade(1-3)+ N Stage (N 0-2)(1-3)+ (0.2xsize of tumor in cm)

  45. Outcome of breast cancer • No (negative axilla), N1 (low axilla}, N2 (high axilla). • Good (score<3.4)(80% 10 year survival ),moderate (score 3.4-5.4)(40% 10 year survival) , poor (score >5.4) (15%10 year survival). • Example: 2cm,G2,N1= 0.4+2+2= 4.4 =moderate

  46. PROGNOSIS • Stage • Grade • Age (younger women worse prognosis) • ER, PR • HER2

  47. Breast Pain (cyclical or not) • No mass, mild pain: - <35 years: reassure and discharge. - > 35 years: mammography • No mass, moderate to severe pain: - < 35: ultrasound - > 35: mammography • Good support bra night and day, reduce caffeine intake, discontinue smoking, low fat diet, change the type of contraceptive pills and • Evening primrose capsules: - Gamolenic acid 240-300mg - 3-4 months at least - Danazol 100mg daily, assess after one month and continue for 6 months if response.

  48. Cystic disease ( fibrocystic or not) • Palpable cysts, 7% of western women. • U/S, Mammography according to the age group. • Aspirate (free hand or ultrasound): - No blood, no residual lump, not re-accumulating: discharge - Rapidly recurrent, or blood: re-image, FNAC ?excision? • Multidisciplinary meeting (MDM).

  49. Diagnosis • Breast lump, asymmetric thickening, nodularity, nipple discharge. • Triple assessment: clinical examination, radiological (ultrasound, mammography), Biopsy( wide bore needle, FNAC). • P value, U value, R value: 1-5(normal, benign, uncertain, suspicious, malignant). • Any P3,U3, R3 should be biopsied. • One stop clinic: patient will be given another appointment for the results if P3,U3,R3. • FNAC is only used with too small or inaccessible lesions and with nipple discharge. • All discordant results should be discussed in the MDM.

  50. Ultrasound/Mammography • Ultrasound: breast abnormalities in ages <35 years, however, • It should not used in pain, and not as screening tool. • Mammography: - Breast abnormalities in ages >35 years. - National screening programme >50 years. - Early Screening (age < 50years,+family). - Nipple discharge. - Follow up in diagnosed breast cancer.

More Related