breast cancer awatif
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BREAST CANCER
By WAN AWATIF
OUTLINE
• Introduction• Risk factors• Clinical features• Staging• Investigation• Management
INTRODUCTION
• The common cause of death in middle-aged women in Western countries.
• in women amongst all races from the age of 20 years in Malaysia for 2003 to 2005.* Breast cancer is most common in the Chinese, followed by the Indians and then, Malays.* Breast cancer formed 31.1% of newly diagnosed cancer cases in women in 2003-2005.
RISK FACTORS
BREAST CARCINOMA – RISK FACTORS
BREAST CARCINOMA – RISK FACTORS
BREAST CARCINOMA – RISK FACTORS
CLINICAL FEATURES
• Breast lump• Dry scaling / red weeping.• Blood stained nipple discharge• Painless• Site : commonly in the upper outer quadrant• Tumour fixation : - -Breast distortion-flattening of contour-dimpling or puckering of the overlying skin-Nipple retraction• Nipple eczema in Paget’s disease
• Firm to hard in consistency• Irregular and indistinct edge • Mobile, softer and well circumscribed (esp in
mucoid and medullary ca)• In advanced :Skin ulcerationInfiltrationOedema
Must palpate axillae and supraclavicular
areas
BREAST - SKIN CHANGES
• Retracted nipple• Asymmetry• Skin changes
BREAST – SKIN CHANGES
• Swelling• Skin necrosing• Inflammation
CLASSIFICATION – BREAST CARCINOMA
NON-INVASIVE/IN SITU CARCINOMA
Intraductal carcinoma Lobular carcinoma in situ
INVASIVE CARCINOMA Infiltrating ( invasive )
duct carcinoma – NOS Infiltrating ( invasive )
lobular carcinoma Medullary carcinoma
Colloid (mucinous) carcinoma Papillary carcinoma Tubular carcinoma Adenoid cystic carcinoma Secretory carcinoma Inflammatory carcinoma Carcinoma with metaplasia
PAGET’S DISEASE OF THE NIPPLE
DUCTAL CARCINOMA IN SITU• Most DCIS detected by calcifications
on mammography/mammographic density - periductal fibrosis surrounding a DCIS/rarely palpable mass/ nipple discharge/incidental finding on a biopsy for another lesion.
• Spreads through ducts & lobules extensive lesions entire sector of a breast.
• DCIS – involves lobules – acini distorted, unfolded appear as small ducts.
PAGET’S DISEASE OF NIPPLE
INVESTIGATION- TRIPLE ASSESSMENT
54. NICE guidelines 2009; 55. KCE Belgian guideline, 2007
Triple Assessment
• All patients presenting with breast symptom should have a full clinical examination
• If a localised abnormality is present, >>> mammography and /or ultrasound examination
• >>>>core and /or FNAC depending on the clinician’s, radiologist’s and pathologist’s experience.
55. Belgian Guideline 2007
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• In young women (< 40 years old), ultrasound should be the initial imaging modality as part of the triple assessment
• a screening tool• Detects:- Lumps- changes in breast tissue - calcifications too small to be found in a physical exam.• Soft tissue radiographs are taken by -placing the breast in direct contact with ultrasensitive film• Very safe investigation -expose to low-voltage.• Sensitivity increases with age (breast become less dense)• Screening procedure
– monitoring patients at high risk for breast ca– Women > 40 years
• 5% of Br Ca can be missed.• Mammogram: does not exclude Br Ca.
MAMMOGRAPHY
• Useful in young women with dense breast.• Distinguish cysts from solid lession• Localise impalpable areas of breast pathology• Not useful as a screening tool
ULTRASOUND
• 3 ways– Fine needle aspiration– Core needle biopsy– Incisional / excisional open biopsy
• Microscopic examination
BIOPSY
Core Biopsy (CB) in combination with Fine Needle
Aspiration Cytology (FNAC)
Core biopsy in combination with FNAC may be used where facility and expertise are available
27
Others
• Baseline investigation• detection of metastatic disease:
– liver function tests – serum calcium – chest radiograph – isotope bone scan – liver ultrasound scan – CT brain - in cases where suspicion is great clinically
TNM CLASSIFICATION
Stage I : T1 N0 M0Stage II A : T1 N1 M0 / T2 N0 M0Stage II B : T2 N1 M0 / T3 N0 M0Stage III A : T1 N2 M0 / T2 N2 M0 /
T3 N1 M0 / T3 N2 M0Stage III B : T4 any N M0 / any T N3 M0Stage IV : any T any N M1
MANCHESTER SYSTEM
•distant metastases other than the axillary nodes or •satellite nodules on breast or •supraclavicular nodal involvement
EARLY BREAST CA
Stage I : T1 N0 M0 Stage IIA :
• T0 N1 M0 • T1 N1 M0 • T2 N0 M0
Stage IIB - T2 N1 M0
Breast conservation is appropriate. It is an
alternative to Mastectomy
Breast conservation
• Removal of the tumour only• tumour should be <4cm in size for BCT.• >>>> radiotherapy. • Patient should be willing to take radiotherapy and come for
regular follow up. • Absolute contraindications: Pt’s wish to avoid radiotherapy Multifocal invasive breast breast cancer Large tumour in a small breast Widespread of ductal carcinoma in situ. (DCIS)• Then pt needs to do a mastectomy.
RADIOTHERAPY
• Improving local control• After BCT for early invasive BC
MASTECTOMY1. Radical Mastectomy (Halsted)
• Stage III, IV• Excision of pectoralis major muscle, excision of
breast, axillary LN, pect. major & minor• no longer indicated
2. Simple mastectomy - – removes breast only, with no dissection of axilla
(except for axillary tail - usually attached to a few LN in the anterior group)
MASTECTOMY
Indications:large tumour ( in relation to breast size)central tumours beneath or involved the nipplelocal recurrenceabsolute C/I to radiotherapypt’s preference skin/ collagen vascular disease that may be complicated by radiotherapyinavailability of radiotherapy facilities or non-compliance with radiotherapy
Indications:large tumour ( in relation to breast size)central tumours beneath or involved the nipplelocal recurrenceabsolute C/I to radiotherapypt’s preference skin/ collagen vascular disease that may be complicated by radiotherapyinavailability of radiotherapy facilities or non-compliance with radiotherapy
3. Modified Radical Mastectomy:1. Patey • the whole breast• large portion of skin, the centre of which overlies the tumour,
but always include the nipple• all of the fat, fascia, LN of axilla• preservation of axillary vein & nerves to serratus anterior,
pectoralis major & latissimus dorsi
4 Total mastectomy w/ or w/o radiation:1. Crile – Total mastectomy2. Mc Whirter – Total mastectomy and radiation (Axilla, • supraclavicular and
internal mammary nodes)
5. Subcutaneous Mastectomy:• Nipple is retained / for T1s
6. Quandrantectomy, axillary, radiotherapy (QUART)
• Quadrant of the breast that has the CA is resected• (quadrant of breast tissue, skin
and superficial pectoralis fascia)• Unacceptable cosmetic result
AXILLARY TREATMENT• At least 4 of LN from axillary fat for analysis.• Can be done w or w/o the removal of pectoralis minor muscle.• Axillary sample- removal of 4/> LN from proximal ant/ pectoral
& central gp of draining LN in axilla• Axillary dissection: dissecting the axilla to various anatomical
levels-– level I: removal of LN lateral to inferior border of pec.
Minor– level II : removal of level I LN & those behind & in front of
pec. Minor– level III : removal of all the lymphatic tissue
• Axillary clearance ; level III axillary dissection
complications of axillary treatment:intraoperative- damage to nervespostoperative- wound complications, lymphoedema
BREAST RECONSTRUCTION
• By plastic surgeons or specialist breast surgeons.• Method is depend on shape of contralateral
breast and chest wall.• Can be made either of a silicone implant or
autologous material or both methods.• Indicated for;
– < 55 yrs old– DCIS, LCIS & Stage I & II BC– pt who are undergoing prophylactic mastectomy
47
• Chemotherapy:– Cyclophosphamide, metrotrexate , 5-fluorouracil (CMF) = gold
standard. – combination of chemotherapeutic agent containing
doxorubicin can be used– Administration of chemotherapy ( 2/> agents) improves
survival rate– Side effect: nausea, vomiting, myelosuppression, alopecia,
thrombocytopenia, exercise intolerance
48
• Hormonal Therapy:Anti-estrogen:
a. Tamoxifen – a non-steroidal anti-estrogenic compound that compete w/ estrogen at receptor site. – Estrogen receptor assay should be
determined; if negative chance of success is very low
49
Mechanism of action of tamoxifenas an antitumor agent
Local effects - independent of oestrogen receptor
+
-
stromalcell
Increase TGFβ
Anti-estrogen effects - blockage of estrogen receptor
Decrease TGF TGFαα
50
Aromatase inhibition withinthe breast tumour cell
ANDROGENS OESTROGENS
P-450 Aromatase+ NADPH-cytochrome P-450 reductase
(Testosterone, androstenedione,16-OH-testosterone)
(Oestradiol, oestrone)
Aromatase Inhibitors
tumourgrowth
51
Therapeutic Approach for Breast Cancer
A. Carcinoma in Situ:1. DCIS:
a. Breast conserving surgery + radiation therapy w/ or w/o tamoxifenb. Total mastectomy w/ or w/o tamoxifenc. Breast-conserving surgery w/o radiation therapy
2. Lobular Carcinoma in Situ:a. Observation after diagnostic biopsyb. Tamoxifen to decrease the incidence of subsequent breast cancerc. Bilateral prophylactic total mastectomy, w/o axillary dissection
Follow - up
• ALL pts with BC should be F/U• Objectives of F/U:
– support & counselling– detect potentially curable conditions ( such as
local recurrence of cancer in the breast following BCT & to detect new cancers in opposite breast)
– manage pts in whom metastatic develops, & to determine outcome
• During F/U:– history, P/E– advise pt to do BSE monthly– annual mammography after therapy for primary
BC– after BCT, the first mammogram should be
performed 6 months after completion of radiotherapy
THANK YOU
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