Cancer breast

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					BREAST CANCER
The Breast
        A ducts
        B lobules
        C dilated section of duct to
         hold milk
        D nipple
        E fat
        F pectoralis major muscle
        G chest wall/rib cage
        Enlargement:
        A normal duct cells
        B basement membrane
        C lumen (center of duct)
Breast Carcinoma Incidence
          20% of all cancers in
           women
          Commonest cause of
           death - 35-55y
          In UK 1 in 10-12 chances
          1 in 8 women in US
          Less incidence in Asia
          Majority of cancers arise in
           the ducts.
          Very rare before age 25
                Risk Factors:
   Female sex..!, Age, Obesity, high fat diet
   Maternal relative with breast cancer.
   Longer reproductive span.
   Nulliparity, Oral contraceptives
   Later age at first pregnancy.
   Atypical epithelial hyperplasia.
   Previous breast cancer/Endometrial Ca.
   Geographic factors - country
   BRCA1 and BRCA2 genes
 Breast Cancer Risk Factors
      that cannot be changed
           Age
                           GENDER - All        Reproductive
                            women are            History
Family/Personal
                              at risk
    History

                                                       Menstrual
            Race                                        History
                                 Radiation
          Treatment with                     Genetic
               DES                           Factors
Breast Cancer Risk Factors
            that can be controlled
            Obesity
                                   All              Not having
 Exercise                       women are             children
                                  at risk

  Breastfeeding
                                                    Birth Control
                                       Hormone           Pills
                      Alcohol         Replacement
                                        Therapy
    Pathology ( WHO classification)
   Epithelial (mammary tissue)
      Non invasive
         DCIS
         LCIS
      Invasive
         Ductal 85 %
         Lobular 9 %
         Mucinous 5 %
         Papillary < 5 %
         Medullary < 5 %
   Mixed Ct & epithelial
   Miscellaneous
      Paget’s disease
      IBC
        Pathology (Foot& Stewart
             classification)
   Neoplasm of mammary tissue proper
       Neoplasm of lobular epithelium 9- 10 %
          LCIS 50 %
          Lobular carcinoma invasive 50 %
       Neoplasm of ductal epithelium 85 %
          DCIS
          Ductal carcinoma Invasive ( IDC)
              NOS ( simple type)
              Special types ( scirrhous, medullary, mucinous,
               papillary, cribriform, comedo, tubular, secretory
               with metaplasia)
            Unusual presentations
                 Paget’s disease
                 IBC
      Pathology (Foot& Stewart
           classification)
   Malignant mesenchymal neoplasm
      Sarcoma
      Lymphomas
      Myeloid leukemia
   Miscellaneous malignancies
      Skin
         SCC
         BCC
      Skin adenxa ( carcinoma of sweat glands or
       sebaceous glands)
   Undifferentiated carcinoma
   Metastatic
      Female ( other breast, lung, MM)
      Male (prostate)
            Carcinoma in situ
It is a spectrum of pre invasive neoplastic changes
   in the breast includes;
 DCIS 4 % symptomatic 25 % screen detected

 LCIS <1 % symptomatic 1% screen detected

 Hyper plastic appearance ( ductal or lobular)
        Ductal Carcinoma in Situ
   It is the group of
    neoplasm arising from
    ductal epithelium &
    confined by basement
    membrane
   Ducts expanded by
    large irregular cells
    with lage irregular
    nuclei
   Malignant cells are
    confined by basement
    membrane
           Ductal Carcinoma in Situ
               (classification)
   Comedo DCIS
                              Non Comedo DCIS
       High grade cytology
                              •Low grade cytology
       Extensive necrosis
                              •Lack necrosis
        Branched
    
                              •Lack calcification
        calcification
                                        • Cribribriform
                                        • Solid
                                        • micropapillary

                              Intermediate histology
         Ductal Carcinoma in Situ

   Clinical presentation
       Asymptomatic > 50 % in screening programs
        as abnormal mamographic finding
       Nipple discharge
       Paget’s disease
   Risk of invasive BC is 40 % over 30 y
   Multicentricity in 50 %
           Ductal Carcinoma in Situ
                 (Diagnosis)
   Sterotactic CNB
   U/S guided CNB
   Wire or ink guided excisional biopsy which is a
    must if;
       Atypical ductal hyperplasia
       Radial scar
       Non specific diagnosis
       Lack correlation with mammogram
   Wedge biopsy if paget’s
               Ductal Carcinoma in Situ
                     (Treatment)
        Depend on Van Nuys Prognostic Index
         which classify patients into 3 groups
               Depending on 3 factors

                           1- Tumor size
                        2- Histological grade

                       3- Surgical free margin


    Low risk          Intermediate risk                 High risk

Wide local excision     BCS & irradiation        Mastectomy    SSM
   (BCS)
         Lobular Carcinoma In Situ
   It constitute 25 % of CIS
   The risk of invasive cancer is 20 – 30 % life time
    and bilateral
   It is multicentric in 80 %
   Never palpable mass
   Treatment
       Follow up by
            C/E every 4 months
            Mammography yearly
       Chemoprevention by Tamoxafen or raloxifene
       Mastectomy which is rarely used
Non Invasive (Carcinoma in Situ)

    Feature              DCIS                LCIS

   Incidence          75 % of CIS         25% of CIS
Risk of invasive   30-40 %, mostly in    20 % lifetime,
    cancer          location of DCIS        bilateral
 Multi-centric            50 %               80 %
   Palpable              Rarely              Never

Mammography             Mass or             Occult
                   microcalcifications
     Invasive Breast Cancer

   Epithelial Invasive BC
        Ductal 85 %
        Lobular 9 %

        Mucinous 5 %

        Papillary < 5 %

        Medullary < 5 %

   Mixed Ct & epithelial
   Miscellaneous
     Paget’s disease

     IBC
     Infiltrating Duct Carcinoma: small hard
                (Atrophic scirrhous)
   5%
   post menopausal with
    shriveled breast
   NEA
      Small size
      Irregular in shape
      Very hard in consistency
   MP
      ++++ FT
      + islads of malignant
       spheroidal cells
      Infrequant mititic figures
   Very slowly progress 10 Y
   Very late metastases
   Best prognosis
    Infiltrating Duct Carcinoma: Fibrosis
                  (Scirrhous)
   75 %
   Middle aged 40 – 60 Y
   NEA
      Small size
      Irregular in shape
      hard in consistency
   MP
      +++ FT
      ++ scanty as finger like
       processes
   slowly progress
   late metastases
   Good prognosis
         Medullary Carcinoma: Large soft
   3- 5 %
   Well developed breast of young
    woman
   NEA
      Largr fleshy in size
      Brain like cut section in
        shape
       with hge & necrosis
      Soft in consistency
   MP
      ++ delicate FT
      ++ + highly malignant cells
   Rapidly progress
   Moderate metastases
   Good prognosis
        Rapid increase lead to early
         presentation
        Fungate more than infilttrate
        Late LN affection dt large cell
         size
    Mucoid or Colloid Carcinoma
   It form a bulky mass with mucoid
    degeneration & necrosis
   It grow slowly & disseminate late & may
    reach huge sizes so have good prognosis
    after surgery
   Signet ring shaped cells dt mucoid
    materials
               Lobular Carcinoma
   It constitute 9 %
   Arise in the terminal
    lobules
   It could take different
    presentation as ductal
    carcinoma
                  Paget’s Disease
   It is a chronic eczematoid
    malignant eruption of the
    nipple
   1 % in middle aged and old
    woman
   Etiology
      Old theory ( skin tumor
        with secondary breast
        mass
      New theory ( tumor in
        terminal ducts as in situ
        cancer then spread
           Outward to nipple
            and skin
           Inward breast mass
                 Paget’s Disease
   Hyper plastic changes
    in all layers of
    epidermis (epidermal
    hypertrophy)
   Characteristic paget’s
    cells
      Large vaculated cells

      Deeply stained
       eccentric nucleus
   Subdermal round cell
    infiltration
                 Paget’s Disease
                ( Clinical picture)
   Persistent eczema like
    condition that affect old
    female 50 Y which does
    not respond to topical
    treatment
   Unilateral erosion of the
    nipple which is red,
    thick, scaly & crusted
    without vesicles or
    itching
   Serosangious discharge
   Mass in the breast in 2
    Years
Paget’s                  Eczema

   Menopause               Lactation
   Unilateral              Bilateral
   No vesicles or          Vesicles and
    itching                  itching
   Sub areolar mass        No mass
    after 2 years
   Not respond to          Respond to topical
    topical treatment        treatment
   Biopsy paget cells      No paget cells
                   Paget’s Disease
                     Diagnosis
   Mammography is a must
       Detect sub clinical mass
       Detect micro calcification
       Detect multi centricity
   Biopsy ( full thickness nipple biopsy) is
    diagnostic where there are 3 different types
       Paget’s disease with DCIS ( high grade comedo)
       Paget’s disease with invasive cancer ( commonest)
       Paget’s disease confined to epidermis of nipple &
        areola ( rarest)
                  Paget’s Disease
                   ( Treatment)
   The standard treatment is mastectomy
   Recently BCS is used with segmentectomy of nipple &
    areola & radiotherapy
     Paget’s disease                 Paget’s disease
                                     with mass or with
     with no mass                    invasive cancer
     Or with DCIS
                                    Segmentectomy
     Segmentectomy                       Of N & A
        Of N & A                   & Axillary dissection

             -Ve margins      + Ve margins
           -No multicentric   multicentric

          Radiotherapy            Mastectomy
              Paget’s Disease
               ( Treatment)
Use of chemotherapy based on 5 prognostic
   indication of chemotherapy
  1.   Age < 35 year
  2.   Tumor > 1 cm
  3.   Tumor high grade
  4.   + ve LN
  5.   - ve ER
    IBC( Inflammatory breast cancer
   Very rare
   Well developed breast of
    young woman during
    pregnancy and lactation
    should be DD of abscess
   NEA
      Diffuse swollen, hot on
       palpation ,with dilated
       vein
      Soft in consistency
   MP
      + very little FT
      ++ + + highly
       malignant anaplastic
       cells
   Rapidly progress
   Very early metastases
    IBC( Inflammatory breast cancer
   It is very similar to acute breast abscess
    with the following differences
       It is a diffuse lesion
       No pyrexia
       LN not tender
       Progressive in nature
       No lecucytosis
       No respond to antibiotic
        Spread of Breast Carcinoma:
   Methods of spread
     Direct

     Lymphatic

     Blood

     Trans- celomic

   Theories of spread
     Loco-regional
      theory
     Systemic theory
Tumor
                        TNM Staging
 Tx  primary tumor can not be assessed
   Tis In situ carcinoma & paget’s disease
   T0 no palpable mass
   T1 tumor < or = 2 cm
                   T1a < or = 0.5 cm no deep fixation
                   T2b   0.5 – 1 cm + deep fixation
                   T3c  1 – 2 cm + deep fixation
   T2 tumor 2 – 5 cm
                   T2a  no deep fixation
                   T2b    deep fixation
   T3 tumor 5 – 10 cm
                   T3a no deep fixation
                   T3b deep fixation
   T4 tumor of any size
                   T4a   direct chest extension
                   T4b skin ( Peau d’orange, skin nodule & ulceration)
                   T4c T 4a + T4b
                   T4d inflammatory breast cnacer
Nodes
                     TNM Staging
   N   x can not be assessed
   N   0 not palpable LN
   N   1 palpable homo-lateral axillary LN and mobile
   N   2 palpable homo-lateral axillary LN and fixed
   N   3 ipsilateral internal mammary LN

Metastases
   M X can not be assessed
   M 0 no known metastases
   M 1 distant metastases including supra-clavicular LN
                TNM staging
        T0        T1        T2    T3   T4
N0      Stage I T1 N0 M0

N1
N2
N3

 Stage II a T1 N1, T2 N0, T0 N1
 Stage II b T2 N1, T3 N0
              TNM staging
     T0            T1      T2         T3         T4
N0
N1
N2   Stage III a    any N2 any T3 except T3 N0

N3        Stage III b any N3 any T4
St                                            5-year     7-year
                  Definition
ag                                            Surv (%)   Surv (%)

I    Tumor 2 cm or less without spread           96         92


     Tumor 2-5cm with regional lymph
     node involvement but without distant
II                                               81         71
     metastases, OR > 5 cm in diameter
     without spread

    Any size with skin/chest wall fixation,
    & axillary or internal mammary
III                                              52         39
    nodal involvement, without distant
    metastases
    Tumor of any size with or without
IV regional spread but with evidence of          18         11
    distant metastases
          Manchester classification
   Stage I ( 85%)
      Mobile tumor
      Free axilla
      Paget’s
   Stage II ( 66 %)
      Mobile tumor
      Mobile axillary LN
   Stage III ( 41 %)
      Tumor fixed
      LN fixed
   Stage IV ( 10%)
      Wide dissemination
      suprac;lavicular LN
                        Prognosis
   Clinical factors
       Age
       Sex
       Site
       Stage
       Grade
       Pregnancy
   Pathological factors
       Tumor type
       Grade
       Axillary LN
   Biological factors
       Receptors ER, Pg R
       Tumor markers
       DNA ploidy
       S phase fraction
    Nottingham Prognostic Index (NPI)
   Axillary LN involvement
          1 no node
          2 1-3 node
          3 4 or more node
   Grade (1, 2, 3)
   Tumor size in cm x 0.2
    Prognostic group             NPI       10 Y survival
        Excellent             < or = 2.4        94
            Good              < or = 3.4        83
       Moderate I             < or = 4.4        70
      Moderate II             < or = 5.4        31
            Poor                > 5.4           20
Breast self examination for early
            detection
        Clinical Features: (symptoms)
   Main symptoms
       Lump
       Discharge ( blood stained)
       Pain ( late)
   Symptoms of spread
       Direct ( skin, nipple, Areola)
       Lymphatic LN
       Blood
            Lung ( respiratory distress & hemoptsis)
            Bone ( aches & patholgical fracture)
            Malignant ascites
            Met static nodules any where
           Clinical Features: (signs)
1.   Breast a whole
        Examination while
         sitting ( puckered or
         displaced
        Raising the arms
         above the head
         (pulled upward)
        Patient leaning
         forward ( not
         protrude freely)
                 Clinical Features: (signs)
2.   Nipple changes
        Recent retraction
            dt neoplastic fibrosis &
             lactiferous ducts invasion
            Should be DD from
                Congenital
                Chronic inflammation
        Nipple erosion (should be
         DD of eczema)
        Discharge which could be
         serous or bloody
                Clinical Features: (signs)
3.   Skin manifestations
     1.   Peau d’ orange dt
          obstruction of skin
          lymphatic
     2.   Cancerous nodule or
          satellites
     3.   Ulceration or fungation dt
          skin invasion
Clinical Features: (signs)
Clinical Features: (signs)
Clinical Features: (signs)
         Clinical Features: (signs)
4.   Dimpling and
     puckering dt pull on
     cooper ligaments
5.   Dilated veins
6.   Skin lymphoedema
7.   Tumor fixation to
     the skin
8.   Inflammatory signs
     as in IBC
9.   Nipple and areola
     changes
             Clinical Features: (signs)

10.   Cancer en cuirasse
      1.   Atrophic breast
      2.   Hard
      3.   Pigmented
      4.   Fixed to chest wall
      5.   Studded with nodules
           Clinical Features: (signs)
4.    Breast lump
        Mostly in UOQ in 60 %
        Irregular in shape
        Hard in consistancy
        Ill deined borders
        Fixed within the breast
         my be fixed to skin or
         chest wall
5.    Opposite breast
     examined first before
      the diseased one to
      exclude metastases
        Clinical Features: (signs)
6- lymph nodes should be examined




                                    Central and apical groups




 Pectoral or anterior group
                                    Lateral or brachial groups
       Clinical Features: (signs)




Posterior or subscapular group   Supraclavicular group
          Clinical Features: (signs)
7- general examination
     Chest effusion, deposites , mediastinal
      LN
     Abdomen ascites, hepatomegally
     Pelvis by PR and PV
       Krukenberg
       Plummer shelf

     Bones tenderness , weakness,
      deformity and fractures
                             Diagnosis:
   Laboratory
       General
       Liver function
       Kidney function
       Cytological examination of nipple discharge
       Tumor markers
   Radiological
       Plain x ray
       Breast imaging
            Mammography
            Thermo graphy
            Galactography
            Ultrasound
            CT
            MRI
            Light spectroscopy
       Radioactive isotope scanning of LN
                     Diagnosis:
   Biopsy
       Fine Needle Aspiration Biopsy
       Core Biopsy
       Excision Biopsy
       Frozen section
       Drill biopsy
       Sentinal node biopsy
   Immunoperoxidase,
   Molecular techniques – Gene detection.
         History of Mammography
   Used in clinical practice since
    1927 in diagnosis of breast
    abnormalities.
   In the 50’s and 60’s it was
    developed to the point that
    benign and malignant tumors
    could be differentiated.
   1963-1967 screening program
    for the detection of breast
    cancer conducted by the
    Health Insurance Plan of New
    York (60,000 women
    screened).
   1973 Breast Cancer Detection
    Demonstration Project
    (B.C.D.D.P.) – 15 annual
    screenings of 270,000 women.
               Low Dose X-rays
   Electrons originating
    at the cathode are
    accelerated towards
    the rotating anode.
   Upon contact the
    kinetic energy of the
    electron is converted
    into x-rays and heat
    (0.5% x-rays)
   Collimator system,
    composed of lead for
    complete absorption,
    focuses the x-ray
    beam
        X-ray/ Breast Interaction
   As with most x-ray images greater contrast
    occurs when there is a large difference in
    attenuation between tissues.
   The breast is compressed and the x-ray beam is
    applied.
   Contrast is best seen between fatty tissue and
    functional glandular tissue, but contrast is poor
    between glandular tissue and cancerous tissues.
   Thus, in older women, post-menopause, the
    reduction in functional glandular tissue provides
    for a distinct contrast between cancerous
    masses and fatty tissues.
    Two Types of Mammograms
   A screening mammogram is an x-ray examination of
    the breast in a woman who has no breast complaints
    (asymptomatic). The goal of screening
    mammography is to find cancer when it is still too
    small to be felt by her doctor or the woman.
   A screening mammogram usually takes 2 x-ray
    pictures (views) of each breast.
   A diagnostic mammogram is an x-ray examination of
    the breast in a woman who either has a breast
    complaint (for example, a breast mass, nipple
    discharge, etc.) or has had an abnormality found
    during a screening mammogram. During a diagnostic
    mammogram, more pictures will be taken to carefully
    study the breast condition.
        Two Methods of Mammograms
   Ordinary film
   Xero or zeno
    mammography
       over selinium plates gave
        different colors blue and
        white
Mammogram Equipment
             A mammography unit is a
              rectangular box that
              houses a tube in which x-
              rays are produced.
              Attached to the unit is a
              device that holds and
              compresses the breast
              and positions it so images
              can be obtained at
              different angles.
             Modern technique uses a
              special machine
              exclusively for breast x-
              rays to produce studies
              that are high quality but
              have a low radiation dose
              (usually about 0.1 to 0.2
              rad dose per picture).
Mammogram Equipment Cont.

                A mammogram device
                 has special accessories
                 that allow only the breast
                 to be exposed to the x-
                 rays.
                x-rays do not penetrate
                 tissue as easily as the x-
                 ray used for routine chest
                 films or x-rays of the arms
                 or legs.
            Mammogram Procedure
    The breast is first placed on a platform
     and squeezed between 2 plates
    Breast compression is necessary to:
1)   even out the breast thickness so all
     tissue can be visualized
2)    spread out tissue so small
     abnormalities won't be obscured by
     overlying breast tissue
3)   allow the use of a lower x-ray dose
     since a thinner amount of breast
     tissue is being imaged
4)   hold the breast still to eliminate
     blurring of image caused by motion
5)    reduce x-ray scatter to increase
     sharpness of picture.
    Indications of Mammography
                                     1- Breast with mass
    4- Evaluation of               2- Breast with discharge
  contralateral breast                  3- Follow up of
                                         breast lesions




5 - Screening of BC               Follow up is needed in the following
                                  Premalignant lesions, papillomatoso
6 - breast that is difficult to   cystic lesions ,
be examined                       atypia, lobular neoplasia

7 – work up of met static         Patient at high risk of cancer
Aden carcinoma                    breast
                                  Patients with previous BC
       Reading the Mammogram
   Best if read by radiologist specializing in mammography
   Important to recognize even the smallest abnormalities
   Multiple films and angles are often necessary
   Sometimes two physicians will read the same film for the most
    thorough assessment
   Computer based digital mammography is used to get
    maximum information from each mammogram taken
   Comparison with older films is also extremely useful
Mammography

       Average-size lump found by woman practicing
       occasional breast self-exam (BSE)



      Average-size lump found by woman practicing
      regular breast self-exam (BSE)



      Average-size lump found by first
      mammogram


      Average-size lump found by getting regular
      mammograms
Abnormal Mammographic findings
                                         Micro calcifications


                Speculated
Circumscribed                Satellite
                  lesion
    lesion                   lesion


                                         Linear    Rounded
                                         branching punctuate

    Mammographic signs of malignancy
    1. Breast lump
    2. Linear or branching micrcalcification
    3. Skin or nipple thickening
    4. Mammary duct distortion or asymmetry
                  Ultrasound
   It is the intial
    investigation in a
    woman < 35 yeaers
   DD solid and cystic
    lesions
   Positive predictive
    value is 92 % with
    palpable mass
            Sentinel Node Biopsy
   An evolving technique to
    identify node status
    without formal axillary
    dissection
   A radioactive tracer
    and/or blue dye is
    identified in the first
    draining node
   Potentially gives accurate
    staging with decreased
    morbidity
   Sensitivity exceeds 90%
    and accuracy exceeds
    95% for experienced
    surgeons
        Breast Cancer Treatment

  Treatment of early BC          Treatment of advanced BC
     ( stage I& II a)               •(stage II b, III& IV)
                                     •Metastatic disease
                                      •Local recuurence


                                   Neoadjuvant chemotherapy

 Surgery&        Surgery&
observation   Adjuvant therapy
                                 Surgery either Mastectomy or BCS



                                        + or - Radiotherapy


                                        + or - Chemotherapy
             Treatment of early BC
   Surgery & Observation
       Indication
          T1 N0
          ER + ve

          Patient under willing close observation

       Surgery
          MRM
          MRM + breast reconstruction

       Observation
          Monthly C/ E
          Chest x ray, U/S abdomen every 6 months
              Treatment of early BC
   Surgery & Adjuvant therapy
       Why use of adjuvant therapy
            Decrease local recurrence ( Radiotherapy)
            Decrease distant metastases as Radiotherapy) micro
             metastases are present in 50 % of cases at diagnosis
             (chemotherapy)
            Good response to adjuvant therapy
       Types of adjuvant therapy
            Radiotherapy
            Chemotherapy
            Hormonal treatment
           Breast Cancer Treatment (Surgery)
   Old operation that lost popularity (Radical Mastectomy)
      Remove the whole breast, P Major & minor, axillary LN and wide
       margin of skin & soft tissue
      Its rationale is loco regional theory of spread


   Obsolete operations
      Extended Radical Mastectomy ( RM + internal mammary LN
       removal)
         Used with medial lesions, +ve Axillary Ln & M0
      Supra Radical Mastectomy ( RM + clavicle excision and
       supaclavicular LN removal)
   Operations that recently gained popularity
      Modified Radical Mastectomy             70 % in USA
      Simple mastectomy (Total Mastectomy) 70 % in UK
   Breast Conservative procedures
      Lumpectomy
      Partial Mastectomy (Quadrantectomy)
      Segmental mastectomy
      Tylectomy
      QUART (Quadrantectomy +Axillary clearance + RT)
          Conservation Therapy (BCT)
       Indications for Use:
1.     Tumor size
        2 cm in small breast
        4 cm in large breast
2.     Tumor location favorable for good aesthetic
       result (peripheral location)
3.     Unifocal single tumor with negative margins
4.     Patient’s preference for breast conservation
5.     Patient’s inability to tolerate general anesthesia
     Advantages of BCS
 • Better cosmetics
 • Not affect survival
 • Not affect local recuurence which if occur not in the chest
   wall and MRM could be done
Contraindications to Conservation
1.   Tumor size > 5 cm
2.   Tumor multi centric (Two or more primary
     tumors in separate quadrants)
3.   Diffuse tumors ( Diffuse malignant appearing
     micro calcifications)
4.   High grade tumors
5.   Distant metastases

6.     Any contraindication to irradiation
        Previous breast irradiation
        Pregnancy (unless radiation is provided
         after delivery)
        Collagen vascular disease (relative
         contraindication)
        Large breast size
       Standard Axillary Dissection
Method
   Levels I and II axillary
     dissection
Aim of axillary surgery
    Provides staging
     information
    Provides local control if
     node positive
    Provide prognostic
     information
    No reliable imaging
     technique
Complications
    Wound infection

    Arm lymphoedema

    Arm morbidity
    Sentinel Lymph Node Biopsy (SLNB)
                Surgical Treatment Options


   Procedure is still under investigation to
    determine if patients’ survival will not be
    affected if lymph nodes that may have cancer in
    them are left behind and untreated
   Not the standard of care for breast cancer at
    this point
   Success rate of about 92 %
            Indications of MRM
   Tumor size > 5 cm
   Tumor multi centric (Two or more primary
    tumors in separate quadrants)
   Diffuse tumors ( Diffuse malignant appearing
    micro calcifications)
   High grade tumors
   Distant metastases

   Any contraindication to irradiation
      Previous breast irradiation
      Pregnancy (unless radiation is provided
       after delivery)
      Collagen vascular disease (relative
       contraindication)
      Large breast size
               Ductal Carcinoma in Situ
                     (Treatment)
        Depend on Van Nuys Prognostic Index
         which classify patients into 3 groups
               Depending on 3 factors

                           1- Tumor size
                        2- Histological grade

                       3- Surgical free margin


    Low risk          Intermediate risk                 High risk

Wide local excision     BCS & irradiation        Mastectomy    SSM
   (BCS)
         Lobular Carcinoma In Situ
   It constitute 25 % of CIS
   The risk of invasive cancer is 20 – 30 % life time
    and bilateral
   It is multicentric in 80 %
   Never palpable mass
   Treatment
       Follow up by
            C/E every 4 months
            Mammography yearly
       Chemoprevention by Tamoxafen or raloxifene
       Mastectomy which is rarely used
                  Paget’s Disease
                   ( Treatment)
   The standard treatment is mastectomy
   Recently BCS is used with segmentectomy of nipple &
    areola & radiotherapy
     Paget’s disease                 Paget’s disease
                                     with mass or with
     with no mass                    invasive cancer
     Or with DCIS
                                    Segmentectomy
     Segmentectomy                       Of N & A
        Of N & A                   & Axillary dissection

             -Ve margins      + Ve margins
           -No multicentric   multicentric

          Radiotherapy            Mastectomy
              Paget’s Disease
               ( Treatment)
Use of chemotherapy based on 5 prognostic
   indication of chemotherapy
  1.   Age < 35 year
  2.   Tumor > 1 cm
  3.   Tumor high grade
  4.   + ve LN
  5.   - ve ER
  Post-Treatment Follow-up of the Patient
  with Early Stage (I and II) Breast Cancer

Study      Year 1-2    Year 3-5    Year > 5
Exam       3-6 mos.    6 mos.      12 mos.
Mammo      6-12 mos.   6-12 mos.   12 mos.
CXR        prn         prn         prn
CT, bone   prn         prn         prn
scan
             Infiltrating Cancer
           Surgical treatment Options

Breast Conservation (followed by RT)
and Axillary Lymph Node Dissection

   Modified Radical Mastectomy
    (with/without reconstruction)
      Long Term Side Effects of
      Surgery for Breast Cancer
   Loss of part or of the whole the breast-
    change of self image and sexuality
   Nerve Function Deficits/Neuropathy
   Lymphedema
   Motor (Muscle) Function Deficits
   Pain
         Breast Reconstruction
   Indicated in women undergoing
    mastectomy who desire reconstruction
   Radiation after reconstruction may
    produce less desirable results
   Autogenous tissue vs. prosthetic     vs.
    combination
   Immediate vs. delayed- no survival
    difference
Prosthetic Silicon implants
Latissmus Dorsi Mycutaneus flap
TRAM Flap
TRAM Flap
   Most women with breast cancer may be
    treated with breast conservation if they so
    desire
   Most women requiring/choosing
    mastectomy may undergo immediate
    breast reconstruction
   Optimal treatment involves multimodality
    therapy provided by multidisciplinary
    teams
                         Radiotherapy
      Aim to destruction of local micro metastases to
       decrease local recurrence
      Indications

    Radiotherapy to breast area             Radiotherapy to Axilla



                                                    Used only if
After all BCS       After mastectomy             1. 4 or more + ve
                  1. 4 or more + ve LN               Axillary LN
                2. Extracapsular invasion        2. Extra capsular
                 3. + ve or close margin              invasion

          T3 , T4 & pectoral fascia affection
                       All ABC
                          Radiotherapy
    When ?
        2- 3 weeks after mastectomy
    Dose
        40 – 50 Gy delivered at 15 –
         25 fraction
    Complications
1.   T1 N0 it decrease 5 y survival
2.   Lymphatic destruction
3.   Increase cancer in contra-
     lateral breast
4.   Local complications
        Skin burn
        Arm lymph-oedema
        Interfere with breast
         reconstruction
        Increase interstitial
         pulmonary fibrosis
                    Hormonal therapy
   Anti-estrogen (Tamoxifen) First line
       Mechanism
            Decrease estrogen uptake by tissue
            Increase TGF inhibitor
       Advantages
            Decrease annual recurrence by 25 %
            Decrease annual mortality by 17%
            Decrease risk of CB in contra-lateral breast by 40 %
            Benefits observed in pre & post menopausal
            Great benefit in ER + ve but also in ER – ve
       Dose
            20 mg/ day for 2- 5 years
       Side effects
            Hyper-calcemia
            Bone pains
            Hot flashs
            phlebitis
               Hormonal therapy
   Aromatase Inhibitor Second line
       It block conversion of androgen to
        estrogen
   Progestin Third line
       Megestrol acetate 40 mg 4 times daily
   LHRH agonists
       Reversible ovarian suppression in pre-
        menopausal female
                  Chemotherapy
   Aim to
       killing of malignant micro-metastases any where in
        the body
   Indications 5 major
       Age < 35 years
       Tumor > 1 cm
       Tumor high grade
       ER + ve
       LN + ve of metastases
   Methods
       given 6 cycles post operative in early CB
               Chemotherapy
                   Classic
                             CMF CA       FAC
                   CMF
Cyclo-             100       600   600   400-500
phosphamide                              (day 1)
Methotrexate       40        40

5 FU               600       600         400-500

A ( Doxorubicin)                   60    40-50

Cyclic frequency   4 weeks   3w    3w    4 weeks
        Breast Cancer Treatment

  Treatment of early BC          Treatment of advanced BC
     ( stage I& II a)               •(stage II b, III& IV)
                                     •Metastatic disease
                                      •Local recuurence


                                   Neoadjuvant chemotherapy

 Surgery&        Surgery&
observation   Adjuvant therapy
                                 Surgery either Mastectomy or BCS



                                        + or - Radiotherapy


                                        + or - Chemotherapy
         Neo-adjuvant Chemotherapy
    Advantages
    1.   Assessment of tumor response
    2.   70 % of tumors show clinical response
            20- 30 % complete response
            80% still have histological evidence of the tumor
            Surgery is required even with complete response
    3.   Increase incidence of BCS
    4.   Improve cosmetic results
    Disadvantages
    1.   Delayed local treatment
    2.   Loss of prognostic information of LN and tumor size
    3.   Induction of drug resistance
         Neo-adjuvant Chemotherapy
   What to give
        CMF
        VAP
        CHOP
   When to give
        3 months pre-operative
        9 months post-operative
   SE
        BM suppression
        Alopecia
        Cystitis
        Cardio-toxic
        Neuro-toxic
        GIT disturbance
                       Treatment of ABC

                Neo-adjuvant chemotherapy




         No response                          Complete response
                        Partial response

                                                      Radio alone then
                                                      Chemo for a year
                 Stop treat     MRM
Change
        RT until               +/- RT
regimen the tumor             + Chemo      BCS with PALND
        Is operable                        Then Radio
                                           Then Chemo for a year
                Treatment of ABC
   Hormonal treatment
       used in all patients regardless age
       Given continuously until relapse occur
   Postoperative chemotherapy
       Life threatening disease
          Rapidly growing tumor
          Liver metastases

          Lung metastases

       ER – ve
       Failure of hormonal treatment
             Treatment of ABC

                 Radiotherapy




If No response                         Complete response
                 Partial response

                                               Radio alone then
                                               Chemo for a year
                        MRM
   RT until            +/- RT
   the tumor          + Chemo       BCS with PALND
   Is operable                      Then Radio
                                    Then Chemo for a year
               Treatment of ABC

   Palliative Radiotherapy
       Single brain metastases
       Chest wall recurrence
       Multiple metastases
          Bone
          Spinal cord

          Liver

          Brachial plexus
                      Male BC
   4 quadrant from the
    start
   Absent pad of fat
   Lymphatic spread in 4
    directions
   Rapid blood spread
   Radical surgery is
    difficult due to lack of
    soft tissue
   Recently male and
    females are equal
    except male with + ve
    LN

				
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