clinical pharmacology breast cancer by dr.waleed elnahas lecturer of surgical oncology hosam...
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Clinical Clinical PharmacologyPharmacologybreast cancer breast cancer byby
DrWaleed ElnahasDrWaleed ElnahasLecturer of surgical oncologyLecturer of surgical oncology
Hosam ElghadbanHosam ElghadbanAssistant Lecturer of surgeryAssistant Lecturer of surgery
IncidenceIncidence Age- Age- 40-50 yr 40-50 yr
NO age is immuneNO age is immune after puberty after puberty
Sex- Sex-
= 991 = 991 (the commonest tumor in female)(the commonest tumor in female)
Side- Side-
Left gt right Left gt right
Bilateral-----raquo Simultaneous Bilateral-----raquo Simultaneous 11
-----raquo Metachronous -----raquo Metachronous 55
Site- Site-
Upper outer quadrant 60 -----raquo most of mammary Upper outer quadrant 60 -----raquo most of mammary tissue tissue
Geographic- Geographic-
West West gt east gt east
Developed gt Developed gt developing developing
Etiology Etiology (predisposing factors)(predisposing factors)
1-Genetic1-Genetic
A-Young age lt 30 yrA-Young age lt 30 yr
b- Mostly Bilateralb- Mostly Bilateral
c- Multiple relatives with cancer breast (gt3) c- Multiple relatives with cancer breast (gt3)
-Hereditary breast cancer 5ndash10-Hereditary breast cancer 5ndash10 BRCA-1 BRCA-1 Long arm of chromosome 17qLong arm of chromosome 17q BRCA-2 BRCA-2 Long arm of chromosome 13qLong arm of chromosome 13q Li-Fraumeni syndrome P53 Li-Fraumeni syndrome P53 Short arm chromosome Short arm chromosome
17p17p
2- Endocrinal (Hormonal)2- Endocrinal (Hormonal)
- Not married null Para elderly primigravida - Not married null Para elderly primigravida (gt 35 yr) and non-lactating female (gt 35 yr) and non-lactating female
- Early menarche or late menopause due to - Early menarche or late menopause due to prolonged exposure to estrogenprolonged exposure to estrogen
3- Exposure to radiation3- Exposure to radiation
- Nuclear war - Nuclear war
- Medical purposes (diagnostic or therapeutic - Medical purposes (diagnostic or therapeutic being greater for exposures in childhood and being greater for exposures in childhood and adolescence than after age of 40 years)adolescence than after age of 40 years)
4-drugs estrogen contraceptive pills more 4-drugs estrogen contraceptive pills more than 10 years (uncertain)than 10 years (uncertain)
pathologypathology World Health Organization Classification of World Health Organization Classification of
Carcinoma of the Breast Carcinoma of the Breast Noninvasive carcinomaNoninvasive carcinoma
-Ductal carcinoma -Ductal carcinoma in situin situ -Lobular carcinoma -Lobular carcinoma in situin situ Invasive carcinomaInvasive carcinoma
-Invasive ductal carcinoma -- 80-Invasive ductal carcinoma -- 80
-Invasive lobular carcinoma ndash 10-Invasive lobular carcinoma ndash 10
-Mucinous carcinoma -- 2-Mucinous carcinoma -- 2
-Medullary carcinoma ndash 5-Medullary carcinoma ndash 5
-Papillary carcinoma -- 1-Papillary carcinoma -- 1
-Tubular carcinoma ndash 1-Tubular carcinoma ndash 1
-Adenoid cystic carcinoma-Adenoid cystic carcinoma
-Secretory (juvenile) carcinoma-Secretory (juvenile) carcinoma
-Apocrine carcinoma-Apocrine carcinoma
-Carcinoma with metaplasia (metaplastic carcinoma)-Carcinoma with metaplasia (metaplastic carcinoma)
-Inflammatory carcinoma-Inflammatory carcinoma
-Other sarcoma lymphoma and melanoma-Other sarcoma lymphoma and melanoma Pagets disease of the nipplePagets disease of the nipple
SpreadSpreadDirect spread-Direct spread-
11 Intrinsic Intrinsic to surrounding breast tissue to surrounding breast tissue
2 2 ExtrinsicExtrinsic
To the skin causing ulceration amp To the skin causing ulceration amp fungation fungation
To deep structures Pectoral fascia To deep structures Pectoral fascia pectoral muscles amp chest wallpectoral muscles amp chest wall
Lymphatic spread-Lymphatic spread-
Haematogenous spread- Haematogenous spread-
Transcoelomic spread-Transcoelomic spread-
Clinical pictureClinical picture Symptoms Symptoms
A- AsymptomaticA- Asymptomatic- - discovered discovered accidentally during screening programs accidentally during screening programs
B- SymptomaticB- Symptomatic- -
1 Mass 1 Mass ((commonest presentationcommonest presentation) )
2 Pain2 Pain ( (Very Rare 10Very Rare 10))
3 Nipple discharge 3 Nipple discharge - Bloody discharge - Bloody discharge in duct carcinoma in duct carcinoma
4 Skin amp nipple manifestations4 Skin amp nipple manifestations
5 Manifestations of metastasis- 5 Manifestations of metastasis-
Signs Signs
A) General examinationsA) General examinations
1 Chest signs of pleural effusion or 1 Chest signs of pleural effusion or mediastinal LNmediastinal LN
2 Abdominal examination2 Abdominal examination
- Hepatomegaly - Ascites- Hepatomegaly - Ascites
3 PR or PV nodules in the 3 PR or PV nodules in the Douglasrsquo pouch or Krukenbergrsquos Douglasrsquo pouch or Krukenbergrsquos tumortumor
4 Bone for tenderness swelling amp 4 Bone for tenderness swelling amp pathological fracturepathological fracture
B) Local examinationB) Local examination
1- inspection1- inspection
BreastBreast compared to healthy side compared to healthy side
Nipple amp areola Nipple amp areola may showmay show
the skinthe skin
1) Skin dimpling Tethering amp Puckering1) Skin dimpling Tethering amp Puckering
2) ulceration amp fungation 2) ulceration amp fungation
3) Peau drsquoorange (Pitted edema) 3) Peau drsquoorange (Pitted edema)
4) Cancerous satellite nodules (late sign) 4) Cancerous satellite nodules (late sign)
5) Cancer en cuirasse5) Cancer en cuirasse
The massThe mass the axillathe axilla The armThe arm
2- palpation2- palpation palpate breasts with both the flat of your palpate breasts with both the flat of your
hand and fingers hand and fingers with flat fingers compress breast tissue with flat fingers compress breast tissue follow systematically in a circular follow systematically in a circular
pattern around the nipple or along the pattern around the nipple or along the radial lines (simulate a clock) or vertical radial lines (simulate a clock) or vertical segments and feel the entire breast segments and feel the entire breast including the tail near the axillaincluding the tail near the axilla
Examine criteria of the mass site size shape consistency
Examine axillary lymph nodes
American Joint Committee on Cancer TNM Staging System for Breast American Joint Committee on Cancer TNM Staging System for Breast Cancer Cancer
Primary Tumor (T)Primary Tumor (T) TX Primary tumor cannot be assessedTX Primary tumor cannot be assessed T0 No evidence of primary tumorT0 No evidence of primary tumor Tis Carcinoma Tis Carcinoma in situin situ
Note Pagets disease associated with a tumor is classified according Note Pagets disease associated with a tumor is classified according to the size of the tumor to the size of the tumor
T1 Tumor 2 cm or less in greatest dimensionT1 Tumor 2 cm or less in greatest dimension
T1mic Microinvasion 01 cm or less in greatest dimensionT1mic Microinvasion 01 cm or less in greatest dimension
T1a Tumor more than 01 cm but not more than 05 cm in greatest T1a Tumor more than 01 cm but not more than 05 cm in greatest dimension dimension
T1b Tumor more than 05 cm but not more than 1 cm in greatest T1b Tumor more than 05 cm but not more than 1 cm in greatest dimension dimension
T1c Tumor more than 1 cm but not more than 2 cm in greatest T1c Tumor more than 1 cm but not more than 2 cm in greatest dimensiondimension
T2 Tumor more than 2 cm but not more than 5 cm in greatest T2 Tumor more than 2 cm but not more than 5 cm in greatest dimensiondimension
T3 Tumor more than 5 cm in greatest dimensionT3 Tumor more than 5 cm in greatest dimension T4a Extension to chest wall not including pectoralis muscleT4a Extension to chest wall not including pectoralis muscle
T4b Edema (including peau dorange) or ulceration of the skin of the T4b Edema (including peau dorange) or ulceration of the skin of the breast or satellite skin nodules confined to the same breast breast or satellite skin nodules confined to the same breast
T4c Both T4a and T4bT4c Both T4a and T4b
T4d Inflammatory carcinomaT4d Inflammatory carcinoma
Regional Lymph Nodes (N) Regional Lymph Nodes (N) NX Regional lymph nodes cannot be assessed (eg NX Regional lymph nodes cannot be assessed (eg
previously removed) previously removed) N0 No regional lymph node metastasisN0 No regional lymph node metastasis N1 Metastasis to movable ipsilateral axillary lymph N1 Metastasis to movable ipsilateral axillary lymph
node(s)node(s) N2 N2
N2a Metastases in ipsilateral axillary lymph nodes N2a Metastases in ipsilateral axillary lymph nodes fixed to one another (matted) or to other structures fixed to one another (matted) or to other structures
N2b Metastasis only in N2b Metastasis only in clinically apparentclinically apparent ipsilateral ipsilateral internal mammary nodes and in theinternal mammary nodes and in the absence absence of of clinically evident axillary lymph node metastasis clinically evident axillary lymph node metastasis
N3N3
N3a Metastasis in ipsilateral infraclavicular lymph N3a Metastasis in ipsilateral infraclavicular lymph node(s)node(s)
N3b Metastasis in ipsilateral internal mammary N3b Metastasis in ipsilateral internal mammary lymph node(s) and axillary lymph node(s) lymph node(s) and axillary lymph node(s)
N3c Metastasis in ipsilateral supraclavicular lymph N3c Metastasis in ipsilateral supraclavicular lymph node(s)node(s)
M ( METASTASIS)M ( METASTASIS)
MX metastasis can no be assessedMX metastasis can no be assessed
M0 no metastasisM0 no metastasis
M1 metastasisM1 metastasis
American Cancer SocietyAmerican Cancer SocietyScreening RecommendationsScreening Recommendations
Annual mammogramsAnnual mammograms starting at starting at age 40age 40
Clinical breast examsClinical breast examsndash every year starting at age 40every year starting at age 40ndash every 3 years for women age every 3 years for women age 20-3920-39
Self-breast examsSelf-breast exams monthly starting monthly starting at age 20at age 20
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 11 Begin by looking at your breasts in the mirror Begin by looking at your breasts in the mirror
with your shoulders straight and yourwith your shoulders straight and your
arms on your hipsarms on your hips Heres what you should look forHeres what you should look for
Breasts that are their usual size shape and colorBreasts that are their usual size shape and color
--Breasts that are evenly shaped without visible --Breasts that are evenly shaped without visible distortion or swellingdistortion or swelling
If you see any of the following changes bring If you see any of the following changes bring them to your doctors attentionthem to your doctors attention
--Dimpling puckering or bulging of the skin--Dimpling puckering or bulging of the skin
--A nipple that has changed position or become --A nipple that has changed position or become inverted (pushed inward instead ofinverted (pushed inward instead of
sticking out)sticking out) --Redness soreness rash or swelling--Redness soreness rash or swelling
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 22
Raise your arms and look for the Raise your arms and look for the
samesame
changeschanges
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 33 Feel your breasts while lying down using Feel your breasts while lying down using
your right hand to feel your left breast and your right hand to feel your left breast and then your left hand to feel your right breast then your left hand to feel your right breast Use a firm smooth touch with the first few Use a firm smooth touch with the first few fingers of your hand keeping the fingersfingers of your hand keeping the fingers
flat and togetherflat and together
Cover the entire breast from top to Cover the entire breast from top to bottom side to sidemdashfrom your bottom side to sidemdashfrom your collarbone to the top of your abdomen collarbone to the top of your abdomen and from your armpit to your cleavageand from your armpit to your cleavage
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 44
Finally feel your breasts while you are Finally feel your breasts while you are standing or sitting Many women find standing or sitting Many women find that the easiest way to feel their breasts that the easiest way to feel their breasts is when their skin is wet and slippery is when their skin is wet and slippery so they like to do this step in the so they like to do this step in the shower Cover your entire breast using shower Cover your entire breast using the same hand movements described in the same hand movements described in Step 3Step 3
InvestigationsInvestigations
Mammography (conrsquot)Mammography (conrsquot) 1048698 1048698 Standard mammography Standard mammography depends on depends on
density of the tissue and its ability to stop density of the tissue and its ability to stop xrayxray
beam from exposing film placed on the other beam from exposing film placed on the other side of the breastside of the breast
Digital mammography Digital mammography works on the same works on the same principle but there is also some ability to principle but there is also some ability to manipulate the image by computer Main manipulate the image by computer Main advantage is storage of the filmsadvantage is storage of the films
UltrasoundUltrasound
Since solid tissue andSince solid tissue and collections of fluid look thecollections of fluid look the same on mammographysame on mammography ultrasound is very useful in ultrasound is very useful in telling whether a mass istelling whether a mass is solid or fluid and if solid ifsolid or fluid and if solid if characteristics arecharacteristics are suspicioussuspicious CystCyst
MRIMRI MRI relies on completely different type of MRI relies on completely different type of
wavewave
energy a strong magnet that affects the energy a strong magnet that affects the charge incharge in
the nuclei As magnetic force is applied and the nuclei As magnetic force is applied and thenthen
released different types of tissue send back released different types of tissue send back different types of radio wavesdifferent types of radio waves
MRI can be extremely useful in very denseMRI can be extremely useful in very dense
breasts hereditary casesbreasts hereditary cases
Fine needle aspiration of a palpable mass
1048698 Fine needle aspiration takes individual cells out ofmass Can be done for palpable or non-palpablemasses Does not show architecture especially wallof duct so best used to confirm strong suspicions
Fine Needle Aspiration
C0 No epithelial cellsC1 InadequateC2 BenignC3 AtypiaC4 SuspiciousC5 Malignant
1048698 Core biopsy can also bedone on palpable and non palpableabnormalities and on microcalcifications
Core Biopsy
B1 Normal tissue unsatisfactoryB2 BenignB3 Lesion uncertain malignant potentialB4 Suspicion of malignancyB5a In situ malignancyB5b Invasive malignancy
Investigations for Investigations for metastasismetastasis
1- abdominal ultrasound1- abdominal ultrasound
2- chest x ray or CT2- chest x ray or CT
3- bone survey or bone scan3- bone survey or bone scan
Established prognostic Established prognostic factorsfactors
bull Nodal status Nodal status bull Tumor size Tumor size bull Lymph node Lymph node bull Grade Grade bull ERPR StatusERPR Statusbull Age Age bull Lymphatic invasionLymphatic invasionbull Histological tumor typeHistological tumor type bull Perinodular infiltrationPerinodular infiltration
TREATMENT OPTIONS FOR PRIMARY OPERABLE BREAST CANCER Objective Options
Local control Lumpectomy Lumpectomy with breast irradiation Mastectomy
Regional control Axillary lymph node dissection Regional irradiation
Control of occult Chemotherapymicrometastatic disease Hormone therapy
Improved function and cosmesis Breast-conserving therapy Reconstruction (immediate or delayed)
Localized breast cancer Surgery is mainstay Halsted 1882 radical mastectomy
John Hopkins
Metastatic breast cancer Systemic treatment
Radical mastectomy A Entire breast and a
chest wall muscle is removed
LNs in the level 1 (B) and level 2 (C ) and even sometimes more distant lymph node groups (D E and F) were also removed
Modified radical mastectomy (MRM)
A Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed called an axillary lymph node dissection
MRM = simple mastectomy + ALND
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
IncidenceIncidence Age- Age- 40-50 yr 40-50 yr
NO age is immuneNO age is immune after puberty after puberty
Sex- Sex-
= 991 = 991 (the commonest tumor in female)(the commonest tumor in female)
Side- Side-
Left gt right Left gt right
Bilateral-----raquo Simultaneous Bilateral-----raquo Simultaneous 11
-----raquo Metachronous -----raquo Metachronous 55
Site- Site-
Upper outer quadrant 60 -----raquo most of mammary Upper outer quadrant 60 -----raquo most of mammary tissue tissue
Geographic- Geographic-
West West gt east gt east
Developed gt Developed gt developing developing
Etiology Etiology (predisposing factors)(predisposing factors)
1-Genetic1-Genetic
A-Young age lt 30 yrA-Young age lt 30 yr
b- Mostly Bilateralb- Mostly Bilateral
c- Multiple relatives with cancer breast (gt3) c- Multiple relatives with cancer breast (gt3)
-Hereditary breast cancer 5ndash10-Hereditary breast cancer 5ndash10 BRCA-1 BRCA-1 Long arm of chromosome 17qLong arm of chromosome 17q BRCA-2 BRCA-2 Long arm of chromosome 13qLong arm of chromosome 13q Li-Fraumeni syndrome P53 Li-Fraumeni syndrome P53 Short arm chromosome Short arm chromosome
17p17p
2- Endocrinal (Hormonal)2- Endocrinal (Hormonal)
- Not married null Para elderly primigravida - Not married null Para elderly primigravida (gt 35 yr) and non-lactating female (gt 35 yr) and non-lactating female
- Early menarche or late menopause due to - Early menarche or late menopause due to prolonged exposure to estrogenprolonged exposure to estrogen
3- Exposure to radiation3- Exposure to radiation
- Nuclear war - Nuclear war
- Medical purposes (diagnostic or therapeutic - Medical purposes (diagnostic or therapeutic being greater for exposures in childhood and being greater for exposures in childhood and adolescence than after age of 40 years)adolescence than after age of 40 years)
4-drugs estrogen contraceptive pills more 4-drugs estrogen contraceptive pills more than 10 years (uncertain)than 10 years (uncertain)
pathologypathology World Health Organization Classification of World Health Organization Classification of
Carcinoma of the Breast Carcinoma of the Breast Noninvasive carcinomaNoninvasive carcinoma
-Ductal carcinoma -Ductal carcinoma in situin situ -Lobular carcinoma -Lobular carcinoma in situin situ Invasive carcinomaInvasive carcinoma
-Invasive ductal carcinoma -- 80-Invasive ductal carcinoma -- 80
-Invasive lobular carcinoma ndash 10-Invasive lobular carcinoma ndash 10
-Mucinous carcinoma -- 2-Mucinous carcinoma -- 2
-Medullary carcinoma ndash 5-Medullary carcinoma ndash 5
-Papillary carcinoma -- 1-Papillary carcinoma -- 1
-Tubular carcinoma ndash 1-Tubular carcinoma ndash 1
-Adenoid cystic carcinoma-Adenoid cystic carcinoma
-Secretory (juvenile) carcinoma-Secretory (juvenile) carcinoma
-Apocrine carcinoma-Apocrine carcinoma
-Carcinoma with metaplasia (metaplastic carcinoma)-Carcinoma with metaplasia (metaplastic carcinoma)
-Inflammatory carcinoma-Inflammatory carcinoma
-Other sarcoma lymphoma and melanoma-Other sarcoma lymphoma and melanoma Pagets disease of the nipplePagets disease of the nipple
SpreadSpreadDirect spread-Direct spread-
11 Intrinsic Intrinsic to surrounding breast tissue to surrounding breast tissue
2 2 ExtrinsicExtrinsic
To the skin causing ulceration amp To the skin causing ulceration amp fungation fungation
To deep structures Pectoral fascia To deep structures Pectoral fascia pectoral muscles amp chest wallpectoral muscles amp chest wall
Lymphatic spread-Lymphatic spread-
Haematogenous spread- Haematogenous spread-
Transcoelomic spread-Transcoelomic spread-
Clinical pictureClinical picture Symptoms Symptoms
A- AsymptomaticA- Asymptomatic- - discovered discovered accidentally during screening programs accidentally during screening programs
B- SymptomaticB- Symptomatic- -
1 Mass 1 Mass ((commonest presentationcommonest presentation) )
2 Pain2 Pain ( (Very Rare 10Very Rare 10))
3 Nipple discharge 3 Nipple discharge - Bloody discharge - Bloody discharge in duct carcinoma in duct carcinoma
4 Skin amp nipple manifestations4 Skin amp nipple manifestations
5 Manifestations of metastasis- 5 Manifestations of metastasis-
Signs Signs
A) General examinationsA) General examinations
1 Chest signs of pleural effusion or 1 Chest signs of pleural effusion or mediastinal LNmediastinal LN
2 Abdominal examination2 Abdominal examination
- Hepatomegaly - Ascites- Hepatomegaly - Ascites
3 PR or PV nodules in the 3 PR or PV nodules in the Douglasrsquo pouch or Krukenbergrsquos Douglasrsquo pouch or Krukenbergrsquos tumortumor
4 Bone for tenderness swelling amp 4 Bone for tenderness swelling amp pathological fracturepathological fracture
B) Local examinationB) Local examination
1- inspection1- inspection
BreastBreast compared to healthy side compared to healthy side
Nipple amp areola Nipple amp areola may showmay show
the skinthe skin
1) Skin dimpling Tethering amp Puckering1) Skin dimpling Tethering amp Puckering
2) ulceration amp fungation 2) ulceration amp fungation
3) Peau drsquoorange (Pitted edema) 3) Peau drsquoorange (Pitted edema)
4) Cancerous satellite nodules (late sign) 4) Cancerous satellite nodules (late sign)
5) Cancer en cuirasse5) Cancer en cuirasse
The massThe mass the axillathe axilla The armThe arm
2- palpation2- palpation palpate breasts with both the flat of your palpate breasts with both the flat of your
hand and fingers hand and fingers with flat fingers compress breast tissue with flat fingers compress breast tissue follow systematically in a circular follow systematically in a circular
pattern around the nipple or along the pattern around the nipple or along the radial lines (simulate a clock) or vertical radial lines (simulate a clock) or vertical segments and feel the entire breast segments and feel the entire breast including the tail near the axillaincluding the tail near the axilla
Examine criteria of the mass site size shape consistency
Examine axillary lymph nodes
American Joint Committee on Cancer TNM Staging System for Breast American Joint Committee on Cancer TNM Staging System for Breast Cancer Cancer
Primary Tumor (T)Primary Tumor (T) TX Primary tumor cannot be assessedTX Primary tumor cannot be assessed T0 No evidence of primary tumorT0 No evidence of primary tumor Tis Carcinoma Tis Carcinoma in situin situ
Note Pagets disease associated with a tumor is classified according Note Pagets disease associated with a tumor is classified according to the size of the tumor to the size of the tumor
T1 Tumor 2 cm or less in greatest dimensionT1 Tumor 2 cm or less in greatest dimension
T1mic Microinvasion 01 cm or less in greatest dimensionT1mic Microinvasion 01 cm or less in greatest dimension
T1a Tumor more than 01 cm but not more than 05 cm in greatest T1a Tumor more than 01 cm but not more than 05 cm in greatest dimension dimension
T1b Tumor more than 05 cm but not more than 1 cm in greatest T1b Tumor more than 05 cm but not more than 1 cm in greatest dimension dimension
T1c Tumor more than 1 cm but not more than 2 cm in greatest T1c Tumor more than 1 cm but not more than 2 cm in greatest dimensiondimension
T2 Tumor more than 2 cm but not more than 5 cm in greatest T2 Tumor more than 2 cm but not more than 5 cm in greatest dimensiondimension
T3 Tumor more than 5 cm in greatest dimensionT3 Tumor more than 5 cm in greatest dimension T4a Extension to chest wall not including pectoralis muscleT4a Extension to chest wall not including pectoralis muscle
T4b Edema (including peau dorange) or ulceration of the skin of the T4b Edema (including peau dorange) or ulceration of the skin of the breast or satellite skin nodules confined to the same breast breast or satellite skin nodules confined to the same breast
T4c Both T4a and T4bT4c Both T4a and T4b
T4d Inflammatory carcinomaT4d Inflammatory carcinoma
Regional Lymph Nodes (N) Regional Lymph Nodes (N) NX Regional lymph nodes cannot be assessed (eg NX Regional lymph nodes cannot be assessed (eg
previously removed) previously removed) N0 No regional lymph node metastasisN0 No regional lymph node metastasis N1 Metastasis to movable ipsilateral axillary lymph N1 Metastasis to movable ipsilateral axillary lymph
node(s)node(s) N2 N2
N2a Metastases in ipsilateral axillary lymph nodes N2a Metastases in ipsilateral axillary lymph nodes fixed to one another (matted) or to other structures fixed to one another (matted) or to other structures
N2b Metastasis only in N2b Metastasis only in clinically apparentclinically apparent ipsilateral ipsilateral internal mammary nodes and in theinternal mammary nodes and in the absence absence of of clinically evident axillary lymph node metastasis clinically evident axillary lymph node metastasis
N3N3
N3a Metastasis in ipsilateral infraclavicular lymph N3a Metastasis in ipsilateral infraclavicular lymph node(s)node(s)
N3b Metastasis in ipsilateral internal mammary N3b Metastasis in ipsilateral internal mammary lymph node(s) and axillary lymph node(s) lymph node(s) and axillary lymph node(s)
N3c Metastasis in ipsilateral supraclavicular lymph N3c Metastasis in ipsilateral supraclavicular lymph node(s)node(s)
M ( METASTASIS)M ( METASTASIS)
MX metastasis can no be assessedMX metastasis can no be assessed
M0 no metastasisM0 no metastasis
M1 metastasisM1 metastasis
American Cancer SocietyAmerican Cancer SocietyScreening RecommendationsScreening Recommendations
Annual mammogramsAnnual mammograms starting at starting at age 40age 40
Clinical breast examsClinical breast examsndash every year starting at age 40every year starting at age 40ndash every 3 years for women age every 3 years for women age 20-3920-39
Self-breast examsSelf-breast exams monthly starting monthly starting at age 20at age 20
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 11 Begin by looking at your breasts in the mirror Begin by looking at your breasts in the mirror
with your shoulders straight and yourwith your shoulders straight and your
arms on your hipsarms on your hips Heres what you should look forHeres what you should look for
Breasts that are their usual size shape and colorBreasts that are their usual size shape and color
--Breasts that are evenly shaped without visible --Breasts that are evenly shaped without visible distortion or swellingdistortion or swelling
If you see any of the following changes bring If you see any of the following changes bring them to your doctors attentionthem to your doctors attention
--Dimpling puckering or bulging of the skin--Dimpling puckering or bulging of the skin
--A nipple that has changed position or become --A nipple that has changed position or become inverted (pushed inward instead ofinverted (pushed inward instead of
sticking out)sticking out) --Redness soreness rash or swelling--Redness soreness rash or swelling
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 22
Raise your arms and look for the Raise your arms and look for the
samesame
changeschanges
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 33 Feel your breasts while lying down using Feel your breasts while lying down using
your right hand to feel your left breast and your right hand to feel your left breast and then your left hand to feel your right breast then your left hand to feel your right breast Use a firm smooth touch with the first few Use a firm smooth touch with the first few fingers of your hand keeping the fingersfingers of your hand keeping the fingers
flat and togetherflat and together
Cover the entire breast from top to Cover the entire breast from top to bottom side to sidemdashfrom your bottom side to sidemdashfrom your collarbone to the top of your abdomen collarbone to the top of your abdomen and from your armpit to your cleavageand from your armpit to your cleavage
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 44
Finally feel your breasts while you are Finally feel your breasts while you are standing or sitting Many women find standing or sitting Many women find that the easiest way to feel their breasts that the easiest way to feel their breasts is when their skin is wet and slippery is when their skin is wet and slippery so they like to do this step in the so they like to do this step in the shower Cover your entire breast using shower Cover your entire breast using the same hand movements described in the same hand movements described in Step 3Step 3
InvestigationsInvestigations
Mammography (conrsquot)Mammography (conrsquot) 1048698 1048698 Standard mammography Standard mammography depends on depends on
density of the tissue and its ability to stop density of the tissue and its ability to stop xrayxray
beam from exposing film placed on the other beam from exposing film placed on the other side of the breastside of the breast
Digital mammography Digital mammography works on the same works on the same principle but there is also some ability to principle but there is also some ability to manipulate the image by computer Main manipulate the image by computer Main advantage is storage of the filmsadvantage is storage of the films
UltrasoundUltrasound
Since solid tissue andSince solid tissue and collections of fluid look thecollections of fluid look the same on mammographysame on mammography ultrasound is very useful in ultrasound is very useful in telling whether a mass istelling whether a mass is solid or fluid and if solid ifsolid or fluid and if solid if characteristics arecharacteristics are suspicioussuspicious CystCyst
MRIMRI MRI relies on completely different type of MRI relies on completely different type of
wavewave
energy a strong magnet that affects the energy a strong magnet that affects the charge incharge in
the nuclei As magnetic force is applied and the nuclei As magnetic force is applied and thenthen
released different types of tissue send back released different types of tissue send back different types of radio wavesdifferent types of radio waves
MRI can be extremely useful in very denseMRI can be extremely useful in very dense
breasts hereditary casesbreasts hereditary cases
Fine needle aspiration of a palpable mass
1048698 Fine needle aspiration takes individual cells out ofmass Can be done for palpable or non-palpablemasses Does not show architecture especially wallof duct so best used to confirm strong suspicions
Fine Needle Aspiration
C0 No epithelial cellsC1 InadequateC2 BenignC3 AtypiaC4 SuspiciousC5 Malignant
1048698 Core biopsy can also bedone on palpable and non palpableabnormalities and on microcalcifications
Core Biopsy
B1 Normal tissue unsatisfactoryB2 BenignB3 Lesion uncertain malignant potentialB4 Suspicion of malignancyB5a In situ malignancyB5b Invasive malignancy
Investigations for Investigations for metastasismetastasis
1- abdominal ultrasound1- abdominal ultrasound
2- chest x ray or CT2- chest x ray or CT
3- bone survey or bone scan3- bone survey or bone scan
Established prognostic Established prognostic factorsfactors
bull Nodal status Nodal status bull Tumor size Tumor size bull Lymph node Lymph node bull Grade Grade bull ERPR StatusERPR Statusbull Age Age bull Lymphatic invasionLymphatic invasionbull Histological tumor typeHistological tumor type bull Perinodular infiltrationPerinodular infiltration
TREATMENT OPTIONS FOR PRIMARY OPERABLE BREAST CANCER Objective Options
Local control Lumpectomy Lumpectomy with breast irradiation Mastectomy
Regional control Axillary lymph node dissection Regional irradiation
Control of occult Chemotherapymicrometastatic disease Hormone therapy
Improved function and cosmesis Breast-conserving therapy Reconstruction (immediate or delayed)
Localized breast cancer Surgery is mainstay Halsted 1882 radical mastectomy
John Hopkins
Metastatic breast cancer Systemic treatment
Radical mastectomy A Entire breast and a
chest wall muscle is removed
LNs in the level 1 (B) and level 2 (C ) and even sometimes more distant lymph node groups (D E and F) were also removed
Modified radical mastectomy (MRM)
A Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed called an axillary lymph node dissection
MRM = simple mastectomy + ALND
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
Etiology Etiology (predisposing factors)(predisposing factors)
1-Genetic1-Genetic
A-Young age lt 30 yrA-Young age lt 30 yr
b- Mostly Bilateralb- Mostly Bilateral
c- Multiple relatives with cancer breast (gt3) c- Multiple relatives with cancer breast (gt3)
-Hereditary breast cancer 5ndash10-Hereditary breast cancer 5ndash10 BRCA-1 BRCA-1 Long arm of chromosome 17qLong arm of chromosome 17q BRCA-2 BRCA-2 Long arm of chromosome 13qLong arm of chromosome 13q Li-Fraumeni syndrome P53 Li-Fraumeni syndrome P53 Short arm chromosome Short arm chromosome
17p17p
2- Endocrinal (Hormonal)2- Endocrinal (Hormonal)
- Not married null Para elderly primigravida - Not married null Para elderly primigravida (gt 35 yr) and non-lactating female (gt 35 yr) and non-lactating female
- Early menarche or late menopause due to - Early menarche or late menopause due to prolonged exposure to estrogenprolonged exposure to estrogen
3- Exposure to radiation3- Exposure to radiation
- Nuclear war - Nuclear war
- Medical purposes (diagnostic or therapeutic - Medical purposes (diagnostic or therapeutic being greater for exposures in childhood and being greater for exposures in childhood and adolescence than after age of 40 years)adolescence than after age of 40 years)
4-drugs estrogen contraceptive pills more 4-drugs estrogen contraceptive pills more than 10 years (uncertain)than 10 years (uncertain)
pathologypathology World Health Organization Classification of World Health Organization Classification of
Carcinoma of the Breast Carcinoma of the Breast Noninvasive carcinomaNoninvasive carcinoma
-Ductal carcinoma -Ductal carcinoma in situin situ -Lobular carcinoma -Lobular carcinoma in situin situ Invasive carcinomaInvasive carcinoma
-Invasive ductal carcinoma -- 80-Invasive ductal carcinoma -- 80
-Invasive lobular carcinoma ndash 10-Invasive lobular carcinoma ndash 10
-Mucinous carcinoma -- 2-Mucinous carcinoma -- 2
-Medullary carcinoma ndash 5-Medullary carcinoma ndash 5
-Papillary carcinoma -- 1-Papillary carcinoma -- 1
-Tubular carcinoma ndash 1-Tubular carcinoma ndash 1
-Adenoid cystic carcinoma-Adenoid cystic carcinoma
-Secretory (juvenile) carcinoma-Secretory (juvenile) carcinoma
-Apocrine carcinoma-Apocrine carcinoma
-Carcinoma with metaplasia (metaplastic carcinoma)-Carcinoma with metaplasia (metaplastic carcinoma)
-Inflammatory carcinoma-Inflammatory carcinoma
-Other sarcoma lymphoma and melanoma-Other sarcoma lymphoma and melanoma Pagets disease of the nipplePagets disease of the nipple
SpreadSpreadDirect spread-Direct spread-
11 Intrinsic Intrinsic to surrounding breast tissue to surrounding breast tissue
2 2 ExtrinsicExtrinsic
To the skin causing ulceration amp To the skin causing ulceration amp fungation fungation
To deep structures Pectoral fascia To deep structures Pectoral fascia pectoral muscles amp chest wallpectoral muscles amp chest wall
Lymphatic spread-Lymphatic spread-
Haematogenous spread- Haematogenous spread-
Transcoelomic spread-Transcoelomic spread-
Clinical pictureClinical picture Symptoms Symptoms
A- AsymptomaticA- Asymptomatic- - discovered discovered accidentally during screening programs accidentally during screening programs
B- SymptomaticB- Symptomatic- -
1 Mass 1 Mass ((commonest presentationcommonest presentation) )
2 Pain2 Pain ( (Very Rare 10Very Rare 10))
3 Nipple discharge 3 Nipple discharge - Bloody discharge - Bloody discharge in duct carcinoma in duct carcinoma
4 Skin amp nipple manifestations4 Skin amp nipple manifestations
5 Manifestations of metastasis- 5 Manifestations of metastasis-
Signs Signs
A) General examinationsA) General examinations
1 Chest signs of pleural effusion or 1 Chest signs of pleural effusion or mediastinal LNmediastinal LN
2 Abdominal examination2 Abdominal examination
- Hepatomegaly - Ascites- Hepatomegaly - Ascites
3 PR or PV nodules in the 3 PR or PV nodules in the Douglasrsquo pouch or Krukenbergrsquos Douglasrsquo pouch or Krukenbergrsquos tumortumor
4 Bone for tenderness swelling amp 4 Bone for tenderness swelling amp pathological fracturepathological fracture
B) Local examinationB) Local examination
1- inspection1- inspection
BreastBreast compared to healthy side compared to healthy side
Nipple amp areola Nipple amp areola may showmay show
the skinthe skin
1) Skin dimpling Tethering amp Puckering1) Skin dimpling Tethering amp Puckering
2) ulceration amp fungation 2) ulceration amp fungation
3) Peau drsquoorange (Pitted edema) 3) Peau drsquoorange (Pitted edema)
4) Cancerous satellite nodules (late sign) 4) Cancerous satellite nodules (late sign)
5) Cancer en cuirasse5) Cancer en cuirasse
The massThe mass the axillathe axilla The armThe arm
2- palpation2- palpation palpate breasts with both the flat of your palpate breasts with both the flat of your
hand and fingers hand and fingers with flat fingers compress breast tissue with flat fingers compress breast tissue follow systematically in a circular follow systematically in a circular
pattern around the nipple or along the pattern around the nipple or along the radial lines (simulate a clock) or vertical radial lines (simulate a clock) or vertical segments and feel the entire breast segments and feel the entire breast including the tail near the axillaincluding the tail near the axilla
Examine criteria of the mass site size shape consistency
Examine axillary lymph nodes
American Joint Committee on Cancer TNM Staging System for Breast American Joint Committee on Cancer TNM Staging System for Breast Cancer Cancer
Primary Tumor (T)Primary Tumor (T) TX Primary tumor cannot be assessedTX Primary tumor cannot be assessed T0 No evidence of primary tumorT0 No evidence of primary tumor Tis Carcinoma Tis Carcinoma in situin situ
Note Pagets disease associated with a tumor is classified according Note Pagets disease associated with a tumor is classified according to the size of the tumor to the size of the tumor
T1 Tumor 2 cm or less in greatest dimensionT1 Tumor 2 cm or less in greatest dimension
T1mic Microinvasion 01 cm or less in greatest dimensionT1mic Microinvasion 01 cm or less in greatest dimension
T1a Tumor more than 01 cm but not more than 05 cm in greatest T1a Tumor more than 01 cm but not more than 05 cm in greatest dimension dimension
T1b Tumor more than 05 cm but not more than 1 cm in greatest T1b Tumor more than 05 cm but not more than 1 cm in greatest dimension dimension
T1c Tumor more than 1 cm but not more than 2 cm in greatest T1c Tumor more than 1 cm but not more than 2 cm in greatest dimensiondimension
T2 Tumor more than 2 cm but not more than 5 cm in greatest T2 Tumor more than 2 cm but not more than 5 cm in greatest dimensiondimension
T3 Tumor more than 5 cm in greatest dimensionT3 Tumor more than 5 cm in greatest dimension T4a Extension to chest wall not including pectoralis muscleT4a Extension to chest wall not including pectoralis muscle
T4b Edema (including peau dorange) or ulceration of the skin of the T4b Edema (including peau dorange) or ulceration of the skin of the breast or satellite skin nodules confined to the same breast breast or satellite skin nodules confined to the same breast
T4c Both T4a and T4bT4c Both T4a and T4b
T4d Inflammatory carcinomaT4d Inflammatory carcinoma
Regional Lymph Nodes (N) Regional Lymph Nodes (N) NX Regional lymph nodes cannot be assessed (eg NX Regional lymph nodes cannot be assessed (eg
previously removed) previously removed) N0 No regional lymph node metastasisN0 No regional lymph node metastasis N1 Metastasis to movable ipsilateral axillary lymph N1 Metastasis to movable ipsilateral axillary lymph
node(s)node(s) N2 N2
N2a Metastases in ipsilateral axillary lymph nodes N2a Metastases in ipsilateral axillary lymph nodes fixed to one another (matted) or to other structures fixed to one another (matted) or to other structures
N2b Metastasis only in N2b Metastasis only in clinically apparentclinically apparent ipsilateral ipsilateral internal mammary nodes and in theinternal mammary nodes and in the absence absence of of clinically evident axillary lymph node metastasis clinically evident axillary lymph node metastasis
N3N3
N3a Metastasis in ipsilateral infraclavicular lymph N3a Metastasis in ipsilateral infraclavicular lymph node(s)node(s)
N3b Metastasis in ipsilateral internal mammary N3b Metastasis in ipsilateral internal mammary lymph node(s) and axillary lymph node(s) lymph node(s) and axillary lymph node(s)
N3c Metastasis in ipsilateral supraclavicular lymph N3c Metastasis in ipsilateral supraclavicular lymph node(s)node(s)
M ( METASTASIS)M ( METASTASIS)
MX metastasis can no be assessedMX metastasis can no be assessed
M0 no metastasisM0 no metastasis
M1 metastasisM1 metastasis
American Cancer SocietyAmerican Cancer SocietyScreening RecommendationsScreening Recommendations
Annual mammogramsAnnual mammograms starting at starting at age 40age 40
Clinical breast examsClinical breast examsndash every year starting at age 40every year starting at age 40ndash every 3 years for women age every 3 years for women age 20-3920-39
Self-breast examsSelf-breast exams monthly starting monthly starting at age 20at age 20
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 11 Begin by looking at your breasts in the mirror Begin by looking at your breasts in the mirror
with your shoulders straight and yourwith your shoulders straight and your
arms on your hipsarms on your hips Heres what you should look forHeres what you should look for
Breasts that are their usual size shape and colorBreasts that are their usual size shape and color
--Breasts that are evenly shaped without visible --Breasts that are evenly shaped without visible distortion or swellingdistortion or swelling
If you see any of the following changes bring If you see any of the following changes bring them to your doctors attentionthem to your doctors attention
--Dimpling puckering or bulging of the skin--Dimpling puckering or bulging of the skin
--A nipple that has changed position or become --A nipple that has changed position or become inverted (pushed inward instead ofinverted (pushed inward instead of
sticking out)sticking out) --Redness soreness rash or swelling--Redness soreness rash or swelling
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 22
Raise your arms and look for the Raise your arms and look for the
samesame
changeschanges
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 33 Feel your breasts while lying down using Feel your breasts while lying down using
your right hand to feel your left breast and your right hand to feel your left breast and then your left hand to feel your right breast then your left hand to feel your right breast Use a firm smooth touch with the first few Use a firm smooth touch with the first few fingers of your hand keeping the fingersfingers of your hand keeping the fingers
flat and togetherflat and together
Cover the entire breast from top to Cover the entire breast from top to bottom side to sidemdashfrom your bottom side to sidemdashfrom your collarbone to the top of your abdomen collarbone to the top of your abdomen and from your armpit to your cleavageand from your armpit to your cleavage
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 44
Finally feel your breasts while you are Finally feel your breasts while you are standing or sitting Many women find standing or sitting Many women find that the easiest way to feel their breasts that the easiest way to feel their breasts is when their skin is wet and slippery is when their skin is wet and slippery so they like to do this step in the so they like to do this step in the shower Cover your entire breast using shower Cover your entire breast using the same hand movements described in the same hand movements described in Step 3Step 3
InvestigationsInvestigations
Mammography (conrsquot)Mammography (conrsquot) 1048698 1048698 Standard mammography Standard mammography depends on depends on
density of the tissue and its ability to stop density of the tissue and its ability to stop xrayxray
beam from exposing film placed on the other beam from exposing film placed on the other side of the breastside of the breast
Digital mammography Digital mammography works on the same works on the same principle but there is also some ability to principle but there is also some ability to manipulate the image by computer Main manipulate the image by computer Main advantage is storage of the filmsadvantage is storage of the films
UltrasoundUltrasound
Since solid tissue andSince solid tissue and collections of fluid look thecollections of fluid look the same on mammographysame on mammography ultrasound is very useful in ultrasound is very useful in telling whether a mass istelling whether a mass is solid or fluid and if solid ifsolid or fluid and if solid if characteristics arecharacteristics are suspicioussuspicious CystCyst
MRIMRI MRI relies on completely different type of MRI relies on completely different type of
wavewave
energy a strong magnet that affects the energy a strong magnet that affects the charge incharge in
the nuclei As magnetic force is applied and the nuclei As magnetic force is applied and thenthen
released different types of tissue send back released different types of tissue send back different types of radio wavesdifferent types of radio waves
MRI can be extremely useful in very denseMRI can be extremely useful in very dense
breasts hereditary casesbreasts hereditary cases
Fine needle aspiration of a palpable mass
1048698 Fine needle aspiration takes individual cells out ofmass Can be done for palpable or non-palpablemasses Does not show architecture especially wallof duct so best used to confirm strong suspicions
Fine Needle Aspiration
C0 No epithelial cellsC1 InadequateC2 BenignC3 AtypiaC4 SuspiciousC5 Malignant
1048698 Core biopsy can also bedone on palpable and non palpableabnormalities and on microcalcifications
Core Biopsy
B1 Normal tissue unsatisfactoryB2 BenignB3 Lesion uncertain malignant potentialB4 Suspicion of malignancyB5a In situ malignancyB5b Invasive malignancy
Investigations for Investigations for metastasismetastasis
1- abdominal ultrasound1- abdominal ultrasound
2- chest x ray or CT2- chest x ray or CT
3- bone survey or bone scan3- bone survey or bone scan
Established prognostic Established prognostic factorsfactors
bull Nodal status Nodal status bull Tumor size Tumor size bull Lymph node Lymph node bull Grade Grade bull ERPR StatusERPR Statusbull Age Age bull Lymphatic invasionLymphatic invasionbull Histological tumor typeHistological tumor type bull Perinodular infiltrationPerinodular infiltration
TREATMENT OPTIONS FOR PRIMARY OPERABLE BREAST CANCER Objective Options
Local control Lumpectomy Lumpectomy with breast irradiation Mastectomy
Regional control Axillary lymph node dissection Regional irradiation
Control of occult Chemotherapymicrometastatic disease Hormone therapy
Improved function and cosmesis Breast-conserving therapy Reconstruction (immediate or delayed)
Localized breast cancer Surgery is mainstay Halsted 1882 radical mastectomy
John Hopkins
Metastatic breast cancer Systemic treatment
Radical mastectomy A Entire breast and a
chest wall muscle is removed
LNs in the level 1 (B) and level 2 (C ) and even sometimes more distant lymph node groups (D E and F) were also removed
Modified radical mastectomy (MRM)
A Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed called an axillary lymph node dissection
MRM = simple mastectomy + ALND
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
2- Endocrinal (Hormonal)2- Endocrinal (Hormonal)
- Not married null Para elderly primigravida - Not married null Para elderly primigravida (gt 35 yr) and non-lactating female (gt 35 yr) and non-lactating female
- Early menarche or late menopause due to - Early menarche or late menopause due to prolonged exposure to estrogenprolonged exposure to estrogen
3- Exposure to radiation3- Exposure to radiation
- Nuclear war - Nuclear war
- Medical purposes (diagnostic or therapeutic - Medical purposes (diagnostic or therapeutic being greater for exposures in childhood and being greater for exposures in childhood and adolescence than after age of 40 years)adolescence than after age of 40 years)
4-drugs estrogen contraceptive pills more 4-drugs estrogen contraceptive pills more than 10 years (uncertain)than 10 years (uncertain)
pathologypathology World Health Organization Classification of World Health Organization Classification of
Carcinoma of the Breast Carcinoma of the Breast Noninvasive carcinomaNoninvasive carcinoma
-Ductal carcinoma -Ductal carcinoma in situin situ -Lobular carcinoma -Lobular carcinoma in situin situ Invasive carcinomaInvasive carcinoma
-Invasive ductal carcinoma -- 80-Invasive ductal carcinoma -- 80
-Invasive lobular carcinoma ndash 10-Invasive lobular carcinoma ndash 10
-Mucinous carcinoma -- 2-Mucinous carcinoma -- 2
-Medullary carcinoma ndash 5-Medullary carcinoma ndash 5
-Papillary carcinoma -- 1-Papillary carcinoma -- 1
-Tubular carcinoma ndash 1-Tubular carcinoma ndash 1
-Adenoid cystic carcinoma-Adenoid cystic carcinoma
-Secretory (juvenile) carcinoma-Secretory (juvenile) carcinoma
-Apocrine carcinoma-Apocrine carcinoma
-Carcinoma with metaplasia (metaplastic carcinoma)-Carcinoma with metaplasia (metaplastic carcinoma)
-Inflammatory carcinoma-Inflammatory carcinoma
-Other sarcoma lymphoma and melanoma-Other sarcoma lymphoma and melanoma Pagets disease of the nipplePagets disease of the nipple
SpreadSpreadDirect spread-Direct spread-
11 Intrinsic Intrinsic to surrounding breast tissue to surrounding breast tissue
2 2 ExtrinsicExtrinsic
To the skin causing ulceration amp To the skin causing ulceration amp fungation fungation
To deep structures Pectoral fascia To deep structures Pectoral fascia pectoral muscles amp chest wallpectoral muscles amp chest wall
Lymphatic spread-Lymphatic spread-
Haematogenous spread- Haematogenous spread-
Transcoelomic spread-Transcoelomic spread-
Clinical pictureClinical picture Symptoms Symptoms
A- AsymptomaticA- Asymptomatic- - discovered discovered accidentally during screening programs accidentally during screening programs
B- SymptomaticB- Symptomatic- -
1 Mass 1 Mass ((commonest presentationcommonest presentation) )
2 Pain2 Pain ( (Very Rare 10Very Rare 10))
3 Nipple discharge 3 Nipple discharge - Bloody discharge - Bloody discharge in duct carcinoma in duct carcinoma
4 Skin amp nipple manifestations4 Skin amp nipple manifestations
5 Manifestations of metastasis- 5 Manifestations of metastasis-
Signs Signs
A) General examinationsA) General examinations
1 Chest signs of pleural effusion or 1 Chest signs of pleural effusion or mediastinal LNmediastinal LN
2 Abdominal examination2 Abdominal examination
- Hepatomegaly - Ascites- Hepatomegaly - Ascites
3 PR or PV nodules in the 3 PR or PV nodules in the Douglasrsquo pouch or Krukenbergrsquos Douglasrsquo pouch or Krukenbergrsquos tumortumor
4 Bone for tenderness swelling amp 4 Bone for tenderness swelling amp pathological fracturepathological fracture
B) Local examinationB) Local examination
1- inspection1- inspection
BreastBreast compared to healthy side compared to healthy side
Nipple amp areola Nipple amp areola may showmay show
the skinthe skin
1) Skin dimpling Tethering amp Puckering1) Skin dimpling Tethering amp Puckering
2) ulceration amp fungation 2) ulceration amp fungation
3) Peau drsquoorange (Pitted edema) 3) Peau drsquoorange (Pitted edema)
4) Cancerous satellite nodules (late sign) 4) Cancerous satellite nodules (late sign)
5) Cancer en cuirasse5) Cancer en cuirasse
The massThe mass the axillathe axilla The armThe arm
2- palpation2- palpation palpate breasts with both the flat of your palpate breasts with both the flat of your
hand and fingers hand and fingers with flat fingers compress breast tissue with flat fingers compress breast tissue follow systematically in a circular follow systematically in a circular
pattern around the nipple or along the pattern around the nipple or along the radial lines (simulate a clock) or vertical radial lines (simulate a clock) or vertical segments and feel the entire breast segments and feel the entire breast including the tail near the axillaincluding the tail near the axilla
Examine criteria of the mass site size shape consistency
Examine axillary lymph nodes
American Joint Committee on Cancer TNM Staging System for Breast American Joint Committee on Cancer TNM Staging System for Breast Cancer Cancer
Primary Tumor (T)Primary Tumor (T) TX Primary tumor cannot be assessedTX Primary tumor cannot be assessed T0 No evidence of primary tumorT0 No evidence of primary tumor Tis Carcinoma Tis Carcinoma in situin situ
Note Pagets disease associated with a tumor is classified according Note Pagets disease associated with a tumor is classified according to the size of the tumor to the size of the tumor
T1 Tumor 2 cm or less in greatest dimensionT1 Tumor 2 cm or less in greatest dimension
T1mic Microinvasion 01 cm or less in greatest dimensionT1mic Microinvasion 01 cm or less in greatest dimension
T1a Tumor more than 01 cm but not more than 05 cm in greatest T1a Tumor more than 01 cm but not more than 05 cm in greatest dimension dimension
T1b Tumor more than 05 cm but not more than 1 cm in greatest T1b Tumor more than 05 cm but not more than 1 cm in greatest dimension dimension
T1c Tumor more than 1 cm but not more than 2 cm in greatest T1c Tumor more than 1 cm but not more than 2 cm in greatest dimensiondimension
T2 Tumor more than 2 cm but not more than 5 cm in greatest T2 Tumor more than 2 cm but not more than 5 cm in greatest dimensiondimension
T3 Tumor more than 5 cm in greatest dimensionT3 Tumor more than 5 cm in greatest dimension T4a Extension to chest wall not including pectoralis muscleT4a Extension to chest wall not including pectoralis muscle
T4b Edema (including peau dorange) or ulceration of the skin of the T4b Edema (including peau dorange) or ulceration of the skin of the breast or satellite skin nodules confined to the same breast breast or satellite skin nodules confined to the same breast
T4c Both T4a and T4bT4c Both T4a and T4b
T4d Inflammatory carcinomaT4d Inflammatory carcinoma
Regional Lymph Nodes (N) Regional Lymph Nodes (N) NX Regional lymph nodes cannot be assessed (eg NX Regional lymph nodes cannot be assessed (eg
previously removed) previously removed) N0 No regional lymph node metastasisN0 No regional lymph node metastasis N1 Metastasis to movable ipsilateral axillary lymph N1 Metastasis to movable ipsilateral axillary lymph
node(s)node(s) N2 N2
N2a Metastases in ipsilateral axillary lymph nodes N2a Metastases in ipsilateral axillary lymph nodes fixed to one another (matted) or to other structures fixed to one another (matted) or to other structures
N2b Metastasis only in N2b Metastasis only in clinically apparentclinically apparent ipsilateral ipsilateral internal mammary nodes and in theinternal mammary nodes and in the absence absence of of clinically evident axillary lymph node metastasis clinically evident axillary lymph node metastasis
N3N3
N3a Metastasis in ipsilateral infraclavicular lymph N3a Metastasis in ipsilateral infraclavicular lymph node(s)node(s)
N3b Metastasis in ipsilateral internal mammary N3b Metastasis in ipsilateral internal mammary lymph node(s) and axillary lymph node(s) lymph node(s) and axillary lymph node(s)
N3c Metastasis in ipsilateral supraclavicular lymph N3c Metastasis in ipsilateral supraclavicular lymph node(s)node(s)
M ( METASTASIS)M ( METASTASIS)
MX metastasis can no be assessedMX metastasis can no be assessed
M0 no metastasisM0 no metastasis
M1 metastasisM1 metastasis
American Cancer SocietyAmerican Cancer SocietyScreening RecommendationsScreening Recommendations
Annual mammogramsAnnual mammograms starting at starting at age 40age 40
Clinical breast examsClinical breast examsndash every year starting at age 40every year starting at age 40ndash every 3 years for women age every 3 years for women age 20-3920-39
Self-breast examsSelf-breast exams monthly starting monthly starting at age 20at age 20
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 11 Begin by looking at your breasts in the mirror Begin by looking at your breasts in the mirror
with your shoulders straight and yourwith your shoulders straight and your
arms on your hipsarms on your hips Heres what you should look forHeres what you should look for
Breasts that are their usual size shape and colorBreasts that are their usual size shape and color
--Breasts that are evenly shaped without visible --Breasts that are evenly shaped without visible distortion or swellingdistortion or swelling
If you see any of the following changes bring If you see any of the following changes bring them to your doctors attentionthem to your doctors attention
--Dimpling puckering or bulging of the skin--Dimpling puckering or bulging of the skin
--A nipple that has changed position or become --A nipple that has changed position or become inverted (pushed inward instead ofinverted (pushed inward instead of
sticking out)sticking out) --Redness soreness rash or swelling--Redness soreness rash or swelling
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 22
Raise your arms and look for the Raise your arms and look for the
samesame
changeschanges
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 33 Feel your breasts while lying down using Feel your breasts while lying down using
your right hand to feel your left breast and your right hand to feel your left breast and then your left hand to feel your right breast then your left hand to feel your right breast Use a firm smooth touch with the first few Use a firm smooth touch with the first few fingers of your hand keeping the fingersfingers of your hand keeping the fingers
flat and togetherflat and together
Cover the entire breast from top to Cover the entire breast from top to bottom side to sidemdashfrom your bottom side to sidemdashfrom your collarbone to the top of your abdomen collarbone to the top of your abdomen and from your armpit to your cleavageand from your armpit to your cleavage
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 44
Finally feel your breasts while you are Finally feel your breasts while you are standing or sitting Many women find standing or sitting Many women find that the easiest way to feel their breasts that the easiest way to feel their breasts is when their skin is wet and slippery is when their skin is wet and slippery so they like to do this step in the so they like to do this step in the shower Cover your entire breast using shower Cover your entire breast using the same hand movements described in the same hand movements described in Step 3Step 3
InvestigationsInvestigations
Mammography (conrsquot)Mammography (conrsquot) 1048698 1048698 Standard mammography Standard mammography depends on depends on
density of the tissue and its ability to stop density of the tissue and its ability to stop xrayxray
beam from exposing film placed on the other beam from exposing film placed on the other side of the breastside of the breast
Digital mammography Digital mammography works on the same works on the same principle but there is also some ability to principle but there is also some ability to manipulate the image by computer Main manipulate the image by computer Main advantage is storage of the filmsadvantage is storage of the films
UltrasoundUltrasound
Since solid tissue andSince solid tissue and collections of fluid look thecollections of fluid look the same on mammographysame on mammography ultrasound is very useful in ultrasound is very useful in telling whether a mass istelling whether a mass is solid or fluid and if solid ifsolid or fluid and if solid if characteristics arecharacteristics are suspicioussuspicious CystCyst
MRIMRI MRI relies on completely different type of MRI relies on completely different type of
wavewave
energy a strong magnet that affects the energy a strong magnet that affects the charge incharge in
the nuclei As magnetic force is applied and the nuclei As magnetic force is applied and thenthen
released different types of tissue send back released different types of tissue send back different types of radio wavesdifferent types of radio waves
MRI can be extremely useful in very denseMRI can be extremely useful in very dense
breasts hereditary casesbreasts hereditary cases
Fine needle aspiration of a palpable mass
1048698 Fine needle aspiration takes individual cells out ofmass Can be done for palpable or non-palpablemasses Does not show architecture especially wallof duct so best used to confirm strong suspicions
Fine Needle Aspiration
C0 No epithelial cellsC1 InadequateC2 BenignC3 AtypiaC4 SuspiciousC5 Malignant
1048698 Core biopsy can also bedone on palpable and non palpableabnormalities and on microcalcifications
Core Biopsy
B1 Normal tissue unsatisfactoryB2 BenignB3 Lesion uncertain malignant potentialB4 Suspicion of malignancyB5a In situ malignancyB5b Invasive malignancy
Investigations for Investigations for metastasismetastasis
1- abdominal ultrasound1- abdominal ultrasound
2- chest x ray or CT2- chest x ray or CT
3- bone survey or bone scan3- bone survey or bone scan
Established prognostic Established prognostic factorsfactors
bull Nodal status Nodal status bull Tumor size Tumor size bull Lymph node Lymph node bull Grade Grade bull ERPR StatusERPR Statusbull Age Age bull Lymphatic invasionLymphatic invasionbull Histological tumor typeHistological tumor type bull Perinodular infiltrationPerinodular infiltration
TREATMENT OPTIONS FOR PRIMARY OPERABLE BREAST CANCER Objective Options
Local control Lumpectomy Lumpectomy with breast irradiation Mastectomy
Regional control Axillary lymph node dissection Regional irradiation
Control of occult Chemotherapymicrometastatic disease Hormone therapy
Improved function and cosmesis Breast-conserving therapy Reconstruction (immediate or delayed)
Localized breast cancer Surgery is mainstay Halsted 1882 radical mastectomy
John Hopkins
Metastatic breast cancer Systemic treatment
Radical mastectomy A Entire breast and a
chest wall muscle is removed
LNs in the level 1 (B) and level 2 (C ) and even sometimes more distant lymph node groups (D E and F) were also removed
Modified radical mastectomy (MRM)
A Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed called an axillary lymph node dissection
MRM = simple mastectomy + ALND
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
pathologypathology World Health Organization Classification of World Health Organization Classification of
Carcinoma of the Breast Carcinoma of the Breast Noninvasive carcinomaNoninvasive carcinoma
-Ductal carcinoma -Ductal carcinoma in situin situ -Lobular carcinoma -Lobular carcinoma in situin situ Invasive carcinomaInvasive carcinoma
-Invasive ductal carcinoma -- 80-Invasive ductal carcinoma -- 80
-Invasive lobular carcinoma ndash 10-Invasive lobular carcinoma ndash 10
-Mucinous carcinoma -- 2-Mucinous carcinoma -- 2
-Medullary carcinoma ndash 5-Medullary carcinoma ndash 5
-Papillary carcinoma -- 1-Papillary carcinoma -- 1
-Tubular carcinoma ndash 1-Tubular carcinoma ndash 1
-Adenoid cystic carcinoma-Adenoid cystic carcinoma
-Secretory (juvenile) carcinoma-Secretory (juvenile) carcinoma
-Apocrine carcinoma-Apocrine carcinoma
-Carcinoma with metaplasia (metaplastic carcinoma)-Carcinoma with metaplasia (metaplastic carcinoma)
-Inflammatory carcinoma-Inflammatory carcinoma
-Other sarcoma lymphoma and melanoma-Other sarcoma lymphoma and melanoma Pagets disease of the nipplePagets disease of the nipple
SpreadSpreadDirect spread-Direct spread-
11 Intrinsic Intrinsic to surrounding breast tissue to surrounding breast tissue
2 2 ExtrinsicExtrinsic
To the skin causing ulceration amp To the skin causing ulceration amp fungation fungation
To deep structures Pectoral fascia To deep structures Pectoral fascia pectoral muscles amp chest wallpectoral muscles amp chest wall
Lymphatic spread-Lymphatic spread-
Haematogenous spread- Haematogenous spread-
Transcoelomic spread-Transcoelomic spread-
Clinical pictureClinical picture Symptoms Symptoms
A- AsymptomaticA- Asymptomatic- - discovered discovered accidentally during screening programs accidentally during screening programs
B- SymptomaticB- Symptomatic- -
1 Mass 1 Mass ((commonest presentationcommonest presentation) )
2 Pain2 Pain ( (Very Rare 10Very Rare 10))
3 Nipple discharge 3 Nipple discharge - Bloody discharge - Bloody discharge in duct carcinoma in duct carcinoma
4 Skin amp nipple manifestations4 Skin amp nipple manifestations
5 Manifestations of metastasis- 5 Manifestations of metastasis-
Signs Signs
A) General examinationsA) General examinations
1 Chest signs of pleural effusion or 1 Chest signs of pleural effusion or mediastinal LNmediastinal LN
2 Abdominal examination2 Abdominal examination
- Hepatomegaly - Ascites- Hepatomegaly - Ascites
3 PR or PV nodules in the 3 PR or PV nodules in the Douglasrsquo pouch or Krukenbergrsquos Douglasrsquo pouch or Krukenbergrsquos tumortumor
4 Bone for tenderness swelling amp 4 Bone for tenderness swelling amp pathological fracturepathological fracture
B) Local examinationB) Local examination
1- inspection1- inspection
BreastBreast compared to healthy side compared to healthy side
Nipple amp areola Nipple amp areola may showmay show
the skinthe skin
1) Skin dimpling Tethering amp Puckering1) Skin dimpling Tethering amp Puckering
2) ulceration amp fungation 2) ulceration amp fungation
3) Peau drsquoorange (Pitted edema) 3) Peau drsquoorange (Pitted edema)
4) Cancerous satellite nodules (late sign) 4) Cancerous satellite nodules (late sign)
5) Cancer en cuirasse5) Cancer en cuirasse
The massThe mass the axillathe axilla The armThe arm
2- palpation2- palpation palpate breasts with both the flat of your palpate breasts with both the flat of your
hand and fingers hand and fingers with flat fingers compress breast tissue with flat fingers compress breast tissue follow systematically in a circular follow systematically in a circular
pattern around the nipple or along the pattern around the nipple or along the radial lines (simulate a clock) or vertical radial lines (simulate a clock) or vertical segments and feel the entire breast segments and feel the entire breast including the tail near the axillaincluding the tail near the axilla
Examine criteria of the mass site size shape consistency
Examine axillary lymph nodes
American Joint Committee on Cancer TNM Staging System for Breast American Joint Committee on Cancer TNM Staging System for Breast Cancer Cancer
Primary Tumor (T)Primary Tumor (T) TX Primary tumor cannot be assessedTX Primary tumor cannot be assessed T0 No evidence of primary tumorT0 No evidence of primary tumor Tis Carcinoma Tis Carcinoma in situin situ
Note Pagets disease associated with a tumor is classified according Note Pagets disease associated with a tumor is classified according to the size of the tumor to the size of the tumor
T1 Tumor 2 cm or less in greatest dimensionT1 Tumor 2 cm or less in greatest dimension
T1mic Microinvasion 01 cm or less in greatest dimensionT1mic Microinvasion 01 cm or less in greatest dimension
T1a Tumor more than 01 cm but not more than 05 cm in greatest T1a Tumor more than 01 cm but not more than 05 cm in greatest dimension dimension
T1b Tumor more than 05 cm but not more than 1 cm in greatest T1b Tumor more than 05 cm but not more than 1 cm in greatest dimension dimension
T1c Tumor more than 1 cm but not more than 2 cm in greatest T1c Tumor more than 1 cm but not more than 2 cm in greatest dimensiondimension
T2 Tumor more than 2 cm but not more than 5 cm in greatest T2 Tumor more than 2 cm but not more than 5 cm in greatest dimensiondimension
T3 Tumor more than 5 cm in greatest dimensionT3 Tumor more than 5 cm in greatest dimension T4a Extension to chest wall not including pectoralis muscleT4a Extension to chest wall not including pectoralis muscle
T4b Edema (including peau dorange) or ulceration of the skin of the T4b Edema (including peau dorange) or ulceration of the skin of the breast or satellite skin nodules confined to the same breast breast or satellite skin nodules confined to the same breast
T4c Both T4a and T4bT4c Both T4a and T4b
T4d Inflammatory carcinomaT4d Inflammatory carcinoma
Regional Lymph Nodes (N) Regional Lymph Nodes (N) NX Regional lymph nodes cannot be assessed (eg NX Regional lymph nodes cannot be assessed (eg
previously removed) previously removed) N0 No regional lymph node metastasisN0 No regional lymph node metastasis N1 Metastasis to movable ipsilateral axillary lymph N1 Metastasis to movable ipsilateral axillary lymph
node(s)node(s) N2 N2
N2a Metastases in ipsilateral axillary lymph nodes N2a Metastases in ipsilateral axillary lymph nodes fixed to one another (matted) or to other structures fixed to one another (matted) or to other structures
N2b Metastasis only in N2b Metastasis only in clinically apparentclinically apparent ipsilateral ipsilateral internal mammary nodes and in theinternal mammary nodes and in the absence absence of of clinically evident axillary lymph node metastasis clinically evident axillary lymph node metastasis
N3N3
N3a Metastasis in ipsilateral infraclavicular lymph N3a Metastasis in ipsilateral infraclavicular lymph node(s)node(s)
N3b Metastasis in ipsilateral internal mammary N3b Metastasis in ipsilateral internal mammary lymph node(s) and axillary lymph node(s) lymph node(s) and axillary lymph node(s)
N3c Metastasis in ipsilateral supraclavicular lymph N3c Metastasis in ipsilateral supraclavicular lymph node(s)node(s)
M ( METASTASIS)M ( METASTASIS)
MX metastasis can no be assessedMX metastasis can no be assessed
M0 no metastasisM0 no metastasis
M1 metastasisM1 metastasis
American Cancer SocietyAmerican Cancer SocietyScreening RecommendationsScreening Recommendations
Annual mammogramsAnnual mammograms starting at starting at age 40age 40
Clinical breast examsClinical breast examsndash every year starting at age 40every year starting at age 40ndash every 3 years for women age every 3 years for women age 20-3920-39
Self-breast examsSelf-breast exams monthly starting monthly starting at age 20at age 20
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 11 Begin by looking at your breasts in the mirror Begin by looking at your breasts in the mirror
with your shoulders straight and yourwith your shoulders straight and your
arms on your hipsarms on your hips Heres what you should look forHeres what you should look for
Breasts that are their usual size shape and colorBreasts that are their usual size shape and color
--Breasts that are evenly shaped without visible --Breasts that are evenly shaped without visible distortion or swellingdistortion or swelling
If you see any of the following changes bring If you see any of the following changes bring them to your doctors attentionthem to your doctors attention
--Dimpling puckering or bulging of the skin--Dimpling puckering or bulging of the skin
--A nipple that has changed position or become --A nipple that has changed position or become inverted (pushed inward instead ofinverted (pushed inward instead of
sticking out)sticking out) --Redness soreness rash or swelling--Redness soreness rash or swelling
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 22
Raise your arms and look for the Raise your arms and look for the
samesame
changeschanges
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 33 Feel your breasts while lying down using Feel your breasts while lying down using
your right hand to feel your left breast and your right hand to feel your left breast and then your left hand to feel your right breast then your left hand to feel your right breast Use a firm smooth touch with the first few Use a firm smooth touch with the first few fingers of your hand keeping the fingersfingers of your hand keeping the fingers
flat and togetherflat and together
Cover the entire breast from top to Cover the entire breast from top to bottom side to sidemdashfrom your bottom side to sidemdashfrom your collarbone to the top of your abdomen collarbone to the top of your abdomen and from your armpit to your cleavageand from your armpit to your cleavage
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 44
Finally feel your breasts while you are Finally feel your breasts while you are standing or sitting Many women find standing or sitting Many women find that the easiest way to feel their breasts that the easiest way to feel their breasts is when their skin is wet and slippery is when their skin is wet and slippery so they like to do this step in the so they like to do this step in the shower Cover your entire breast using shower Cover your entire breast using the same hand movements described in the same hand movements described in Step 3Step 3
InvestigationsInvestigations
Mammography (conrsquot)Mammography (conrsquot) 1048698 1048698 Standard mammography Standard mammography depends on depends on
density of the tissue and its ability to stop density of the tissue and its ability to stop xrayxray
beam from exposing film placed on the other beam from exposing film placed on the other side of the breastside of the breast
Digital mammography Digital mammography works on the same works on the same principle but there is also some ability to principle but there is also some ability to manipulate the image by computer Main manipulate the image by computer Main advantage is storage of the filmsadvantage is storage of the films
UltrasoundUltrasound
Since solid tissue andSince solid tissue and collections of fluid look thecollections of fluid look the same on mammographysame on mammography ultrasound is very useful in ultrasound is very useful in telling whether a mass istelling whether a mass is solid or fluid and if solid ifsolid or fluid and if solid if characteristics arecharacteristics are suspicioussuspicious CystCyst
MRIMRI MRI relies on completely different type of MRI relies on completely different type of
wavewave
energy a strong magnet that affects the energy a strong magnet that affects the charge incharge in
the nuclei As magnetic force is applied and the nuclei As magnetic force is applied and thenthen
released different types of tissue send back released different types of tissue send back different types of radio wavesdifferent types of radio waves
MRI can be extremely useful in very denseMRI can be extremely useful in very dense
breasts hereditary casesbreasts hereditary cases
Fine needle aspiration of a palpable mass
1048698 Fine needle aspiration takes individual cells out ofmass Can be done for palpable or non-palpablemasses Does not show architecture especially wallof duct so best used to confirm strong suspicions
Fine Needle Aspiration
C0 No epithelial cellsC1 InadequateC2 BenignC3 AtypiaC4 SuspiciousC5 Malignant
1048698 Core biopsy can also bedone on palpable and non palpableabnormalities and on microcalcifications
Core Biopsy
B1 Normal tissue unsatisfactoryB2 BenignB3 Lesion uncertain malignant potentialB4 Suspicion of malignancyB5a In situ malignancyB5b Invasive malignancy
Investigations for Investigations for metastasismetastasis
1- abdominal ultrasound1- abdominal ultrasound
2- chest x ray or CT2- chest x ray or CT
3- bone survey or bone scan3- bone survey or bone scan
Established prognostic Established prognostic factorsfactors
bull Nodal status Nodal status bull Tumor size Tumor size bull Lymph node Lymph node bull Grade Grade bull ERPR StatusERPR Statusbull Age Age bull Lymphatic invasionLymphatic invasionbull Histological tumor typeHistological tumor type bull Perinodular infiltrationPerinodular infiltration
TREATMENT OPTIONS FOR PRIMARY OPERABLE BREAST CANCER Objective Options
Local control Lumpectomy Lumpectomy with breast irradiation Mastectomy
Regional control Axillary lymph node dissection Regional irradiation
Control of occult Chemotherapymicrometastatic disease Hormone therapy
Improved function and cosmesis Breast-conserving therapy Reconstruction (immediate or delayed)
Localized breast cancer Surgery is mainstay Halsted 1882 radical mastectomy
John Hopkins
Metastatic breast cancer Systemic treatment
Radical mastectomy A Entire breast and a
chest wall muscle is removed
LNs in the level 1 (B) and level 2 (C ) and even sometimes more distant lymph node groups (D E and F) were also removed
Modified radical mastectomy (MRM)
A Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed called an axillary lymph node dissection
MRM = simple mastectomy + ALND
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
SpreadSpreadDirect spread-Direct spread-
11 Intrinsic Intrinsic to surrounding breast tissue to surrounding breast tissue
2 2 ExtrinsicExtrinsic
To the skin causing ulceration amp To the skin causing ulceration amp fungation fungation
To deep structures Pectoral fascia To deep structures Pectoral fascia pectoral muscles amp chest wallpectoral muscles amp chest wall
Lymphatic spread-Lymphatic spread-
Haematogenous spread- Haematogenous spread-
Transcoelomic spread-Transcoelomic spread-
Clinical pictureClinical picture Symptoms Symptoms
A- AsymptomaticA- Asymptomatic- - discovered discovered accidentally during screening programs accidentally during screening programs
B- SymptomaticB- Symptomatic- -
1 Mass 1 Mass ((commonest presentationcommonest presentation) )
2 Pain2 Pain ( (Very Rare 10Very Rare 10))
3 Nipple discharge 3 Nipple discharge - Bloody discharge - Bloody discharge in duct carcinoma in duct carcinoma
4 Skin amp nipple manifestations4 Skin amp nipple manifestations
5 Manifestations of metastasis- 5 Manifestations of metastasis-
Signs Signs
A) General examinationsA) General examinations
1 Chest signs of pleural effusion or 1 Chest signs of pleural effusion or mediastinal LNmediastinal LN
2 Abdominal examination2 Abdominal examination
- Hepatomegaly - Ascites- Hepatomegaly - Ascites
3 PR or PV nodules in the 3 PR or PV nodules in the Douglasrsquo pouch or Krukenbergrsquos Douglasrsquo pouch or Krukenbergrsquos tumortumor
4 Bone for tenderness swelling amp 4 Bone for tenderness swelling amp pathological fracturepathological fracture
B) Local examinationB) Local examination
1- inspection1- inspection
BreastBreast compared to healthy side compared to healthy side
Nipple amp areola Nipple amp areola may showmay show
the skinthe skin
1) Skin dimpling Tethering amp Puckering1) Skin dimpling Tethering amp Puckering
2) ulceration amp fungation 2) ulceration amp fungation
3) Peau drsquoorange (Pitted edema) 3) Peau drsquoorange (Pitted edema)
4) Cancerous satellite nodules (late sign) 4) Cancerous satellite nodules (late sign)
5) Cancer en cuirasse5) Cancer en cuirasse
The massThe mass the axillathe axilla The armThe arm
2- palpation2- palpation palpate breasts with both the flat of your palpate breasts with both the flat of your
hand and fingers hand and fingers with flat fingers compress breast tissue with flat fingers compress breast tissue follow systematically in a circular follow systematically in a circular
pattern around the nipple or along the pattern around the nipple or along the radial lines (simulate a clock) or vertical radial lines (simulate a clock) or vertical segments and feel the entire breast segments and feel the entire breast including the tail near the axillaincluding the tail near the axilla
Examine criteria of the mass site size shape consistency
Examine axillary lymph nodes
American Joint Committee on Cancer TNM Staging System for Breast American Joint Committee on Cancer TNM Staging System for Breast Cancer Cancer
Primary Tumor (T)Primary Tumor (T) TX Primary tumor cannot be assessedTX Primary tumor cannot be assessed T0 No evidence of primary tumorT0 No evidence of primary tumor Tis Carcinoma Tis Carcinoma in situin situ
Note Pagets disease associated with a tumor is classified according Note Pagets disease associated with a tumor is classified according to the size of the tumor to the size of the tumor
T1 Tumor 2 cm or less in greatest dimensionT1 Tumor 2 cm or less in greatest dimension
T1mic Microinvasion 01 cm or less in greatest dimensionT1mic Microinvasion 01 cm or less in greatest dimension
T1a Tumor more than 01 cm but not more than 05 cm in greatest T1a Tumor more than 01 cm but not more than 05 cm in greatest dimension dimension
T1b Tumor more than 05 cm but not more than 1 cm in greatest T1b Tumor more than 05 cm but not more than 1 cm in greatest dimension dimension
T1c Tumor more than 1 cm but not more than 2 cm in greatest T1c Tumor more than 1 cm but not more than 2 cm in greatest dimensiondimension
T2 Tumor more than 2 cm but not more than 5 cm in greatest T2 Tumor more than 2 cm but not more than 5 cm in greatest dimensiondimension
T3 Tumor more than 5 cm in greatest dimensionT3 Tumor more than 5 cm in greatest dimension T4a Extension to chest wall not including pectoralis muscleT4a Extension to chest wall not including pectoralis muscle
T4b Edema (including peau dorange) or ulceration of the skin of the T4b Edema (including peau dorange) or ulceration of the skin of the breast or satellite skin nodules confined to the same breast breast or satellite skin nodules confined to the same breast
T4c Both T4a and T4bT4c Both T4a and T4b
T4d Inflammatory carcinomaT4d Inflammatory carcinoma
Regional Lymph Nodes (N) Regional Lymph Nodes (N) NX Regional lymph nodes cannot be assessed (eg NX Regional lymph nodes cannot be assessed (eg
previously removed) previously removed) N0 No regional lymph node metastasisN0 No regional lymph node metastasis N1 Metastasis to movable ipsilateral axillary lymph N1 Metastasis to movable ipsilateral axillary lymph
node(s)node(s) N2 N2
N2a Metastases in ipsilateral axillary lymph nodes N2a Metastases in ipsilateral axillary lymph nodes fixed to one another (matted) or to other structures fixed to one another (matted) or to other structures
N2b Metastasis only in N2b Metastasis only in clinically apparentclinically apparent ipsilateral ipsilateral internal mammary nodes and in theinternal mammary nodes and in the absence absence of of clinically evident axillary lymph node metastasis clinically evident axillary lymph node metastasis
N3N3
N3a Metastasis in ipsilateral infraclavicular lymph N3a Metastasis in ipsilateral infraclavicular lymph node(s)node(s)
N3b Metastasis in ipsilateral internal mammary N3b Metastasis in ipsilateral internal mammary lymph node(s) and axillary lymph node(s) lymph node(s) and axillary lymph node(s)
N3c Metastasis in ipsilateral supraclavicular lymph N3c Metastasis in ipsilateral supraclavicular lymph node(s)node(s)
M ( METASTASIS)M ( METASTASIS)
MX metastasis can no be assessedMX metastasis can no be assessed
M0 no metastasisM0 no metastasis
M1 metastasisM1 metastasis
American Cancer SocietyAmerican Cancer SocietyScreening RecommendationsScreening Recommendations
Annual mammogramsAnnual mammograms starting at starting at age 40age 40
Clinical breast examsClinical breast examsndash every year starting at age 40every year starting at age 40ndash every 3 years for women age every 3 years for women age 20-3920-39
Self-breast examsSelf-breast exams monthly starting monthly starting at age 20at age 20
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 11 Begin by looking at your breasts in the mirror Begin by looking at your breasts in the mirror
with your shoulders straight and yourwith your shoulders straight and your
arms on your hipsarms on your hips Heres what you should look forHeres what you should look for
Breasts that are their usual size shape and colorBreasts that are their usual size shape and color
--Breasts that are evenly shaped without visible --Breasts that are evenly shaped without visible distortion or swellingdistortion or swelling
If you see any of the following changes bring If you see any of the following changes bring them to your doctors attentionthem to your doctors attention
--Dimpling puckering or bulging of the skin--Dimpling puckering or bulging of the skin
--A nipple that has changed position or become --A nipple that has changed position or become inverted (pushed inward instead ofinverted (pushed inward instead of
sticking out)sticking out) --Redness soreness rash or swelling--Redness soreness rash or swelling
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 22
Raise your arms and look for the Raise your arms and look for the
samesame
changeschanges
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 33 Feel your breasts while lying down using Feel your breasts while lying down using
your right hand to feel your left breast and your right hand to feel your left breast and then your left hand to feel your right breast then your left hand to feel your right breast Use a firm smooth touch with the first few Use a firm smooth touch with the first few fingers of your hand keeping the fingersfingers of your hand keeping the fingers
flat and togetherflat and together
Cover the entire breast from top to Cover the entire breast from top to bottom side to sidemdashfrom your bottom side to sidemdashfrom your collarbone to the top of your abdomen collarbone to the top of your abdomen and from your armpit to your cleavageand from your armpit to your cleavage
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 44
Finally feel your breasts while you are Finally feel your breasts while you are standing or sitting Many women find standing or sitting Many women find that the easiest way to feel their breasts that the easiest way to feel their breasts is when their skin is wet and slippery is when their skin is wet and slippery so they like to do this step in the so they like to do this step in the shower Cover your entire breast using shower Cover your entire breast using the same hand movements described in the same hand movements described in Step 3Step 3
InvestigationsInvestigations
Mammography (conrsquot)Mammography (conrsquot) 1048698 1048698 Standard mammography Standard mammography depends on depends on
density of the tissue and its ability to stop density of the tissue and its ability to stop xrayxray
beam from exposing film placed on the other beam from exposing film placed on the other side of the breastside of the breast
Digital mammography Digital mammography works on the same works on the same principle but there is also some ability to principle but there is also some ability to manipulate the image by computer Main manipulate the image by computer Main advantage is storage of the filmsadvantage is storage of the films
UltrasoundUltrasound
Since solid tissue andSince solid tissue and collections of fluid look thecollections of fluid look the same on mammographysame on mammography ultrasound is very useful in ultrasound is very useful in telling whether a mass istelling whether a mass is solid or fluid and if solid ifsolid or fluid and if solid if characteristics arecharacteristics are suspicioussuspicious CystCyst
MRIMRI MRI relies on completely different type of MRI relies on completely different type of
wavewave
energy a strong magnet that affects the energy a strong magnet that affects the charge incharge in
the nuclei As magnetic force is applied and the nuclei As magnetic force is applied and thenthen
released different types of tissue send back released different types of tissue send back different types of radio wavesdifferent types of radio waves
MRI can be extremely useful in very denseMRI can be extremely useful in very dense
breasts hereditary casesbreasts hereditary cases
Fine needle aspiration of a palpable mass
1048698 Fine needle aspiration takes individual cells out ofmass Can be done for palpable or non-palpablemasses Does not show architecture especially wallof duct so best used to confirm strong suspicions
Fine Needle Aspiration
C0 No epithelial cellsC1 InadequateC2 BenignC3 AtypiaC4 SuspiciousC5 Malignant
1048698 Core biopsy can also bedone on palpable and non palpableabnormalities and on microcalcifications
Core Biopsy
B1 Normal tissue unsatisfactoryB2 BenignB3 Lesion uncertain malignant potentialB4 Suspicion of malignancyB5a In situ malignancyB5b Invasive malignancy
Investigations for Investigations for metastasismetastasis
1- abdominal ultrasound1- abdominal ultrasound
2- chest x ray or CT2- chest x ray or CT
3- bone survey or bone scan3- bone survey or bone scan
Established prognostic Established prognostic factorsfactors
bull Nodal status Nodal status bull Tumor size Tumor size bull Lymph node Lymph node bull Grade Grade bull ERPR StatusERPR Statusbull Age Age bull Lymphatic invasionLymphatic invasionbull Histological tumor typeHistological tumor type bull Perinodular infiltrationPerinodular infiltration
TREATMENT OPTIONS FOR PRIMARY OPERABLE BREAST CANCER Objective Options
Local control Lumpectomy Lumpectomy with breast irradiation Mastectomy
Regional control Axillary lymph node dissection Regional irradiation
Control of occult Chemotherapymicrometastatic disease Hormone therapy
Improved function and cosmesis Breast-conserving therapy Reconstruction (immediate or delayed)
Localized breast cancer Surgery is mainstay Halsted 1882 radical mastectomy
John Hopkins
Metastatic breast cancer Systemic treatment
Radical mastectomy A Entire breast and a
chest wall muscle is removed
LNs in the level 1 (B) and level 2 (C ) and even sometimes more distant lymph node groups (D E and F) were also removed
Modified radical mastectomy (MRM)
A Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed called an axillary lymph node dissection
MRM = simple mastectomy + ALND
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
Clinical pictureClinical picture Symptoms Symptoms
A- AsymptomaticA- Asymptomatic- - discovered discovered accidentally during screening programs accidentally during screening programs
B- SymptomaticB- Symptomatic- -
1 Mass 1 Mass ((commonest presentationcommonest presentation) )
2 Pain2 Pain ( (Very Rare 10Very Rare 10))
3 Nipple discharge 3 Nipple discharge - Bloody discharge - Bloody discharge in duct carcinoma in duct carcinoma
4 Skin amp nipple manifestations4 Skin amp nipple manifestations
5 Manifestations of metastasis- 5 Manifestations of metastasis-
Signs Signs
A) General examinationsA) General examinations
1 Chest signs of pleural effusion or 1 Chest signs of pleural effusion or mediastinal LNmediastinal LN
2 Abdominal examination2 Abdominal examination
- Hepatomegaly - Ascites- Hepatomegaly - Ascites
3 PR or PV nodules in the 3 PR or PV nodules in the Douglasrsquo pouch or Krukenbergrsquos Douglasrsquo pouch or Krukenbergrsquos tumortumor
4 Bone for tenderness swelling amp 4 Bone for tenderness swelling amp pathological fracturepathological fracture
B) Local examinationB) Local examination
1- inspection1- inspection
BreastBreast compared to healthy side compared to healthy side
Nipple amp areola Nipple amp areola may showmay show
the skinthe skin
1) Skin dimpling Tethering amp Puckering1) Skin dimpling Tethering amp Puckering
2) ulceration amp fungation 2) ulceration amp fungation
3) Peau drsquoorange (Pitted edema) 3) Peau drsquoorange (Pitted edema)
4) Cancerous satellite nodules (late sign) 4) Cancerous satellite nodules (late sign)
5) Cancer en cuirasse5) Cancer en cuirasse
The massThe mass the axillathe axilla The armThe arm
2- palpation2- palpation palpate breasts with both the flat of your palpate breasts with both the flat of your
hand and fingers hand and fingers with flat fingers compress breast tissue with flat fingers compress breast tissue follow systematically in a circular follow systematically in a circular
pattern around the nipple or along the pattern around the nipple or along the radial lines (simulate a clock) or vertical radial lines (simulate a clock) or vertical segments and feel the entire breast segments and feel the entire breast including the tail near the axillaincluding the tail near the axilla
Examine criteria of the mass site size shape consistency
Examine axillary lymph nodes
American Joint Committee on Cancer TNM Staging System for Breast American Joint Committee on Cancer TNM Staging System for Breast Cancer Cancer
Primary Tumor (T)Primary Tumor (T) TX Primary tumor cannot be assessedTX Primary tumor cannot be assessed T0 No evidence of primary tumorT0 No evidence of primary tumor Tis Carcinoma Tis Carcinoma in situin situ
Note Pagets disease associated with a tumor is classified according Note Pagets disease associated with a tumor is classified according to the size of the tumor to the size of the tumor
T1 Tumor 2 cm or less in greatest dimensionT1 Tumor 2 cm or less in greatest dimension
T1mic Microinvasion 01 cm or less in greatest dimensionT1mic Microinvasion 01 cm or less in greatest dimension
T1a Tumor more than 01 cm but not more than 05 cm in greatest T1a Tumor more than 01 cm but not more than 05 cm in greatest dimension dimension
T1b Tumor more than 05 cm but not more than 1 cm in greatest T1b Tumor more than 05 cm but not more than 1 cm in greatest dimension dimension
T1c Tumor more than 1 cm but not more than 2 cm in greatest T1c Tumor more than 1 cm but not more than 2 cm in greatest dimensiondimension
T2 Tumor more than 2 cm but not more than 5 cm in greatest T2 Tumor more than 2 cm but not more than 5 cm in greatest dimensiondimension
T3 Tumor more than 5 cm in greatest dimensionT3 Tumor more than 5 cm in greatest dimension T4a Extension to chest wall not including pectoralis muscleT4a Extension to chest wall not including pectoralis muscle
T4b Edema (including peau dorange) or ulceration of the skin of the T4b Edema (including peau dorange) or ulceration of the skin of the breast or satellite skin nodules confined to the same breast breast or satellite skin nodules confined to the same breast
T4c Both T4a and T4bT4c Both T4a and T4b
T4d Inflammatory carcinomaT4d Inflammatory carcinoma
Regional Lymph Nodes (N) Regional Lymph Nodes (N) NX Regional lymph nodes cannot be assessed (eg NX Regional lymph nodes cannot be assessed (eg
previously removed) previously removed) N0 No regional lymph node metastasisN0 No regional lymph node metastasis N1 Metastasis to movable ipsilateral axillary lymph N1 Metastasis to movable ipsilateral axillary lymph
node(s)node(s) N2 N2
N2a Metastases in ipsilateral axillary lymph nodes N2a Metastases in ipsilateral axillary lymph nodes fixed to one another (matted) or to other structures fixed to one another (matted) or to other structures
N2b Metastasis only in N2b Metastasis only in clinically apparentclinically apparent ipsilateral ipsilateral internal mammary nodes and in theinternal mammary nodes and in the absence absence of of clinically evident axillary lymph node metastasis clinically evident axillary lymph node metastasis
N3N3
N3a Metastasis in ipsilateral infraclavicular lymph N3a Metastasis in ipsilateral infraclavicular lymph node(s)node(s)
N3b Metastasis in ipsilateral internal mammary N3b Metastasis in ipsilateral internal mammary lymph node(s) and axillary lymph node(s) lymph node(s) and axillary lymph node(s)
N3c Metastasis in ipsilateral supraclavicular lymph N3c Metastasis in ipsilateral supraclavicular lymph node(s)node(s)
M ( METASTASIS)M ( METASTASIS)
MX metastasis can no be assessedMX metastasis can no be assessed
M0 no metastasisM0 no metastasis
M1 metastasisM1 metastasis
American Cancer SocietyAmerican Cancer SocietyScreening RecommendationsScreening Recommendations
Annual mammogramsAnnual mammograms starting at starting at age 40age 40
Clinical breast examsClinical breast examsndash every year starting at age 40every year starting at age 40ndash every 3 years for women age every 3 years for women age 20-3920-39
Self-breast examsSelf-breast exams monthly starting monthly starting at age 20at age 20
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 11 Begin by looking at your breasts in the mirror Begin by looking at your breasts in the mirror
with your shoulders straight and yourwith your shoulders straight and your
arms on your hipsarms on your hips Heres what you should look forHeres what you should look for
Breasts that are their usual size shape and colorBreasts that are their usual size shape and color
--Breasts that are evenly shaped without visible --Breasts that are evenly shaped without visible distortion or swellingdistortion or swelling
If you see any of the following changes bring If you see any of the following changes bring them to your doctors attentionthem to your doctors attention
--Dimpling puckering or bulging of the skin--Dimpling puckering or bulging of the skin
--A nipple that has changed position or become --A nipple that has changed position or become inverted (pushed inward instead ofinverted (pushed inward instead of
sticking out)sticking out) --Redness soreness rash or swelling--Redness soreness rash or swelling
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 22
Raise your arms and look for the Raise your arms and look for the
samesame
changeschanges
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 33 Feel your breasts while lying down using Feel your breasts while lying down using
your right hand to feel your left breast and your right hand to feel your left breast and then your left hand to feel your right breast then your left hand to feel your right breast Use a firm smooth touch with the first few Use a firm smooth touch with the first few fingers of your hand keeping the fingersfingers of your hand keeping the fingers
flat and togetherflat and together
Cover the entire breast from top to Cover the entire breast from top to bottom side to sidemdashfrom your bottom side to sidemdashfrom your collarbone to the top of your abdomen collarbone to the top of your abdomen and from your armpit to your cleavageand from your armpit to your cleavage
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 44
Finally feel your breasts while you are Finally feel your breasts while you are standing or sitting Many women find standing or sitting Many women find that the easiest way to feel their breasts that the easiest way to feel their breasts is when their skin is wet and slippery is when their skin is wet and slippery so they like to do this step in the so they like to do this step in the shower Cover your entire breast using shower Cover your entire breast using the same hand movements described in the same hand movements described in Step 3Step 3
InvestigationsInvestigations
Mammography (conrsquot)Mammography (conrsquot) 1048698 1048698 Standard mammography Standard mammography depends on depends on
density of the tissue and its ability to stop density of the tissue and its ability to stop xrayxray
beam from exposing film placed on the other beam from exposing film placed on the other side of the breastside of the breast
Digital mammography Digital mammography works on the same works on the same principle but there is also some ability to principle but there is also some ability to manipulate the image by computer Main manipulate the image by computer Main advantage is storage of the filmsadvantage is storage of the films
UltrasoundUltrasound
Since solid tissue andSince solid tissue and collections of fluid look thecollections of fluid look the same on mammographysame on mammography ultrasound is very useful in ultrasound is very useful in telling whether a mass istelling whether a mass is solid or fluid and if solid ifsolid or fluid and if solid if characteristics arecharacteristics are suspicioussuspicious CystCyst
MRIMRI MRI relies on completely different type of MRI relies on completely different type of
wavewave
energy a strong magnet that affects the energy a strong magnet that affects the charge incharge in
the nuclei As magnetic force is applied and the nuclei As magnetic force is applied and thenthen
released different types of tissue send back released different types of tissue send back different types of radio wavesdifferent types of radio waves
MRI can be extremely useful in very denseMRI can be extremely useful in very dense
breasts hereditary casesbreasts hereditary cases
Fine needle aspiration of a palpable mass
1048698 Fine needle aspiration takes individual cells out ofmass Can be done for palpable or non-palpablemasses Does not show architecture especially wallof duct so best used to confirm strong suspicions
Fine Needle Aspiration
C0 No epithelial cellsC1 InadequateC2 BenignC3 AtypiaC4 SuspiciousC5 Malignant
1048698 Core biopsy can also bedone on palpable and non palpableabnormalities and on microcalcifications
Core Biopsy
B1 Normal tissue unsatisfactoryB2 BenignB3 Lesion uncertain malignant potentialB4 Suspicion of malignancyB5a In situ malignancyB5b Invasive malignancy
Investigations for Investigations for metastasismetastasis
1- abdominal ultrasound1- abdominal ultrasound
2- chest x ray or CT2- chest x ray or CT
3- bone survey or bone scan3- bone survey or bone scan
Established prognostic Established prognostic factorsfactors
bull Nodal status Nodal status bull Tumor size Tumor size bull Lymph node Lymph node bull Grade Grade bull ERPR StatusERPR Statusbull Age Age bull Lymphatic invasionLymphatic invasionbull Histological tumor typeHistological tumor type bull Perinodular infiltrationPerinodular infiltration
TREATMENT OPTIONS FOR PRIMARY OPERABLE BREAST CANCER Objective Options
Local control Lumpectomy Lumpectomy with breast irradiation Mastectomy
Regional control Axillary lymph node dissection Regional irradiation
Control of occult Chemotherapymicrometastatic disease Hormone therapy
Improved function and cosmesis Breast-conserving therapy Reconstruction (immediate or delayed)
Localized breast cancer Surgery is mainstay Halsted 1882 radical mastectomy
John Hopkins
Metastatic breast cancer Systemic treatment
Radical mastectomy A Entire breast and a
chest wall muscle is removed
LNs in the level 1 (B) and level 2 (C ) and even sometimes more distant lymph node groups (D E and F) were also removed
Modified radical mastectomy (MRM)
A Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed called an axillary lymph node dissection
MRM = simple mastectomy + ALND
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
Signs Signs
A) General examinationsA) General examinations
1 Chest signs of pleural effusion or 1 Chest signs of pleural effusion or mediastinal LNmediastinal LN
2 Abdominal examination2 Abdominal examination
- Hepatomegaly - Ascites- Hepatomegaly - Ascites
3 PR or PV nodules in the 3 PR or PV nodules in the Douglasrsquo pouch or Krukenbergrsquos Douglasrsquo pouch or Krukenbergrsquos tumortumor
4 Bone for tenderness swelling amp 4 Bone for tenderness swelling amp pathological fracturepathological fracture
B) Local examinationB) Local examination
1- inspection1- inspection
BreastBreast compared to healthy side compared to healthy side
Nipple amp areola Nipple amp areola may showmay show
the skinthe skin
1) Skin dimpling Tethering amp Puckering1) Skin dimpling Tethering amp Puckering
2) ulceration amp fungation 2) ulceration amp fungation
3) Peau drsquoorange (Pitted edema) 3) Peau drsquoorange (Pitted edema)
4) Cancerous satellite nodules (late sign) 4) Cancerous satellite nodules (late sign)
5) Cancer en cuirasse5) Cancer en cuirasse
The massThe mass the axillathe axilla The armThe arm
2- palpation2- palpation palpate breasts with both the flat of your palpate breasts with both the flat of your
hand and fingers hand and fingers with flat fingers compress breast tissue with flat fingers compress breast tissue follow systematically in a circular follow systematically in a circular
pattern around the nipple or along the pattern around the nipple or along the radial lines (simulate a clock) or vertical radial lines (simulate a clock) or vertical segments and feel the entire breast segments and feel the entire breast including the tail near the axillaincluding the tail near the axilla
Examine criteria of the mass site size shape consistency
Examine axillary lymph nodes
American Joint Committee on Cancer TNM Staging System for Breast American Joint Committee on Cancer TNM Staging System for Breast Cancer Cancer
Primary Tumor (T)Primary Tumor (T) TX Primary tumor cannot be assessedTX Primary tumor cannot be assessed T0 No evidence of primary tumorT0 No evidence of primary tumor Tis Carcinoma Tis Carcinoma in situin situ
Note Pagets disease associated with a tumor is classified according Note Pagets disease associated with a tumor is classified according to the size of the tumor to the size of the tumor
T1 Tumor 2 cm or less in greatest dimensionT1 Tumor 2 cm or less in greatest dimension
T1mic Microinvasion 01 cm or less in greatest dimensionT1mic Microinvasion 01 cm or less in greatest dimension
T1a Tumor more than 01 cm but not more than 05 cm in greatest T1a Tumor more than 01 cm but not more than 05 cm in greatest dimension dimension
T1b Tumor more than 05 cm but not more than 1 cm in greatest T1b Tumor more than 05 cm but not more than 1 cm in greatest dimension dimension
T1c Tumor more than 1 cm but not more than 2 cm in greatest T1c Tumor more than 1 cm but not more than 2 cm in greatest dimensiondimension
T2 Tumor more than 2 cm but not more than 5 cm in greatest T2 Tumor more than 2 cm but not more than 5 cm in greatest dimensiondimension
T3 Tumor more than 5 cm in greatest dimensionT3 Tumor more than 5 cm in greatest dimension T4a Extension to chest wall not including pectoralis muscleT4a Extension to chest wall not including pectoralis muscle
T4b Edema (including peau dorange) or ulceration of the skin of the T4b Edema (including peau dorange) or ulceration of the skin of the breast or satellite skin nodules confined to the same breast breast or satellite skin nodules confined to the same breast
T4c Both T4a and T4bT4c Both T4a and T4b
T4d Inflammatory carcinomaT4d Inflammatory carcinoma
Regional Lymph Nodes (N) Regional Lymph Nodes (N) NX Regional lymph nodes cannot be assessed (eg NX Regional lymph nodes cannot be assessed (eg
previously removed) previously removed) N0 No regional lymph node metastasisN0 No regional lymph node metastasis N1 Metastasis to movable ipsilateral axillary lymph N1 Metastasis to movable ipsilateral axillary lymph
node(s)node(s) N2 N2
N2a Metastases in ipsilateral axillary lymph nodes N2a Metastases in ipsilateral axillary lymph nodes fixed to one another (matted) or to other structures fixed to one another (matted) or to other structures
N2b Metastasis only in N2b Metastasis only in clinically apparentclinically apparent ipsilateral ipsilateral internal mammary nodes and in theinternal mammary nodes and in the absence absence of of clinically evident axillary lymph node metastasis clinically evident axillary lymph node metastasis
N3N3
N3a Metastasis in ipsilateral infraclavicular lymph N3a Metastasis in ipsilateral infraclavicular lymph node(s)node(s)
N3b Metastasis in ipsilateral internal mammary N3b Metastasis in ipsilateral internal mammary lymph node(s) and axillary lymph node(s) lymph node(s) and axillary lymph node(s)
N3c Metastasis in ipsilateral supraclavicular lymph N3c Metastasis in ipsilateral supraclavicular lymph node(s)node(s)
M ( METASTASIS)M ( METASTASIS)
MX metastasis can no be assessedMX metastasis can no be assessed
M0 no metastasisM0 no metastasis
M1 metastasisM1 metastasis
American Cancer SocietyAmerican Cancer SocietyScreening RecommendationsScreening Recommendations
Annual mammogramsAnnual mammograms starting at starting at age 40age 40
Clinical breast examsClinical breast examsndash every year starting at age 40every year starting at age 40ndash every 3 years for women age every 3 years for women age 20-3920-39
Self-breast examsSelf-breast exams monthly starting monthly starting at age 20at age 20
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 11 Begin by looking at your breasts in the mirror Begin by looking at your breasts in the mirror
with your shoulders straight and yourwith your shoulders straight and your
arms on your hipsarms on your hips Heres what you should look forHeres what you should look for
Breasts that are their usual size shape and colorBreasts that are their usual size shape and color
--Breasts that are evenly shaped without visible --Breasts that are evenly shaped without visible distortion or swellingdistortion or swelling
If you see any of the following changes bring If you see any of the following changes bring them to your doctors attentionthem to your doctors attention
--Dimpling puckering or bulging of the skin--Dimpling puckering or bulging of the skin
--A nipple that has changed position or become --A nipple that has changed position or become inverted (pushed inward instead ofinverted (pushed inward instead of
sticking out)sticking out) --Redness soreness rash or swelling--Redness soreness rash or swelling
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 22
Raise your arms and look for the Raise your arms and look for the
samesame
changeschanges
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 33 Feel your breasts while lying down using Feel your breasts while lying down using
your right hand to feel your left breast and your right hand to feel your left breast and then your left hand to feel your right breast then your left hand to feel your right breast Use a firm smooth touch with the first few Use a firm smooth touch with the first few fingers of your hand keeping the fingersfingers of your hand keeping the fingers
flat and togetherflat and together
Cover the entire breast from top to Cover the entire breast from top to bottom side to sidemdashfrom your bottom side to sidemdashfrom your collarbone to the top of your abdomen collarbone to the top of your abdomen and from your armpit to your cleavageand from your armpit to your cleavage
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 44
Finally feel your breasts while you are Finally feel your breasts while you are standing or sitting Many women find standing or sitting Many women find that the easiest way to feel their breasts that the easiest way to feel their breasts is when their skin is wet and slippery is when their skin is wet and slippery so they like to do this step in the so they like to do this step in the shower Cover your entire breast using shower Cover your entire breast using the same hand movements described in the same hand movements described in Step 3Step 3
InvestigationsInvestigations
Mammography (conrsquot)Mammography (conrsquot) 1048698 1048698 Standard mammography Standard mammography depends on depends on
density of the tissue and its ability to stop density of the tissue and its ability to stop xrayxray
beam from exposing film placed on the other beam from exposing film placed on the other side of the breastside of the breast
Digital mammography Digital mammography works on the same works on the same principle but there is also some ability to principle but there is also some ability to manipulate the image by computer Main manipulate the image by computer Main advantage is storage of the filmsadvantage is storage of the films
UltrasoundUltrasound
Since solid tissue andSince solid tissue and collections of fluid look thecollections of fluid look the same on mammographysame on mammography ultrasound is very useful in ultrasound is very useful in telling whether a mass istelling whether a mass is solid or fluid and if solid ifsolid or fluid and if solid if characteristics arecharacteristics are suspicioussuspicious CystCyst
MRIMRI MRI relies on completely different type of MRI relies on completely different type of
wavewave
energy a strong magnet that affects the energy a strong magnet that affects the charge incharge in
the nuclei As magnetic force is applied and the nuclei As magnetic force is applied and thenthen
released different types of tissue send back released different types of tissue send back different types of radio wavesdifferent types of radio waves
MRI can be extremely useful in very denseMRI can be extremely useful in very dense
breasts hereditary casesbreasts hereditary cases
Fine needle aspiration of a palpable mass
1048698 Fine needle aspiration takes individual cells out ofmass Can be done for palpable or non-palpablemasses Does not show architecture especially wallof duct so best used to confirm strong suspicions
Fine Needle Aspiration
C0 No epithelial cellsC1 InadequateC2 BenignC3 AtypiaC4 SuspiciousC5 Malignant
1048698 Core biopsy can also bedone on palpable and non palpableabnormalities and on microcalcifications
Core Biopsy
B1 Normal tissue unsatisfactoryB2 BenignB3 Lesion uncertain malignant potentialB4 Suspicion of malignancyB5a In situ malignancyB5b Invasive malignancy
Investigations for Investigations for metastasismetastasis
1- abdominal ultrasound1- abdominal ultrasound
2- chest x ray or CT2- chest x ray or CT
3- bone survey or bone scan3- bone survey or bone scan
Established prognostic Established prognostic factorsfactors
bull Nodal status Nodal status bull Tumor size Tumor size bull Lymph node Lymph node bull Grade Grade bull ERPR StatusERPR Statusbull Age Age bull Lymphatic invasionLymphatic invasionbull Histological tumor typeHistological tumor type bull Perinodular infiltrationPerinodular infiltration
TREATMENT OPTIONS FOR PRIMARY OPERABLE BREAST CANCER Objective Options
Local control Lumpectomy Lumpectomy with breast irradiation Mastectomy
Regional control Axillary lymph node dissection Regional irradiation
Control of occult Chemotherapymicrometastatic disease Hormone therapy
Improved function and cosmesis Breast-conserving therapy Reconstruction (immediate or delayed)
Localized breast cancer Surgery is mainstay Halsted 1882 radical mastectomy
John Hopkins
Metastatic breast cancer Systemic treatment
Radical mastectomy A Entire breast and a
chest wall muscle is removed
LNs in the level 1 (B) and level 2 (C ) and even sometimes more distant lymph node groups (D E and F) were also removed
Modified radical mastectomy (MRM)
A Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed called an axillary lymph node dissection
MRM = simple mastectomy + ALND
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
B) Local examinationB) Local examination
1- inspection1- inspection
BreastBreast compared to healthy side compared to healthy side
Nipple amp areola Nipple amp areola may showmay show
the skinthe skin
1) Skin dimpling Tethering amp Puckering1) Skin dimpling Tethering amp Puckering
2) ulceration amp fungation 2) ulceration amp fungation
3) Peau drsquoorange (Pitted edema) 3) Peau drsquoorange (Pitted edema)
4) Cancerous satellite nodules (late sign) 4) Cancerous satellite nodules (late sign)
5) Cancer en cuirasse5) Cancer en cuirasse
The massThe mass the axillathe axilla The armThe arm
2- palpation2- palpation palpate breasts with both the flat of your palpate breasts with both the flat of your
hand and fingers hand and fingers with flat fingers compress breast tissue with flat fingers compress breast tissue follow systematically in a circular follow systematically in a circular
pattern around the nipple or along the pattern around the nipple or along the radial lines (simulate a clock) or vertical radial lines (simulate a clock) or vertical segments and feel the entire breast segments and feel the entire breast including the tail near the axillaincluding the tail near the axilla
Examine criteria of the mass site size shape consistency
Examine axillary lymph nodes
American Joint Committee on Cancer TNM Staging System for Breast American Joint Committee on Cancer TNM Staging System for Breast Cancer Cancer
Primary Tumor (T)Primary Tumor (T) TX Primary tumor cannot be assessedTX Primary tumor cannot be assessed T0 No evidence of primary tumorT0 No evidence of primary tumor Tis Carcinoma Tis Carcinoma in situin situ
Note Pagets disease associated with a tumor is classified according Note Pagets disease associated with a tumor is classified according to the size of the tumor to the size of the tumor
T1 Tumor 2 cm or less in greatest dimensionT1 Tumor 2 cm or less in greatest dimension
T1mic Microinvasion 01 cm or less in greatest dimensionT1mic Microinvasion 01 cm or less in greatest dimension
T1a Tumor more than 01 cm but not more than 05 cm in greatest T1a Tumor more than 01 cm but not more than 05 cm in greatest dimension dimension
T1b Tumor more than 05 cm but not more than 1 cm in greatest T1b Tumor more than 05 cm but not more than 1 cm in greatest dimension dimension
T1c Tumor more than 1 cm but not more than 2 cm in greatest T1c Tumor more than 1 cm but not more than 2 cm in greatest dimensiondimension
T2 Tumor more than 2 cm but not more than 5 cm in greatest T2 Tumor more than 2 cm but not more than 5 cm in greatest dimensiondimension
T3 Tumor more than 5 cm in greatest dimensionT3 Tumor more than 5 cm in greatest dimension T4a Extension to chest wall not including pectoralis muscleT4a Extension to chest wall not including pectoralis muscle
T4b Edema (including peau dorange) or ulceration of the skin of the T4b Edema (including peau dorange) or ulceration of the skin of the breast or satellite skin nodules confined to the same breast breast or satellite skin nodules confined to the same breast
T4c Both T4a and T4bT4c Both T4a and T4b
T4d Inflammatory carcinomaT4d Inflammatory carcinoma
Regional Lymph Nodes (N) Regional Lymph Nodes (N) NX Regional lymph nodes cannot be assessed (eg NX Regional lymph nodes cannot be assessed (eg
previously removed) previously removed) N0 No regional lymph node metastasisN0 No regional lymph node metastasis N1 Metastasis to movable ipsilateral axillary lymph N1 Metastasis to movable ipsilateral axillary lymph
node(s)node(s) N2 N2
N2a Metastases in ipsilateral axillary lymph nodes N2a Metastases in ipsilateral axillary lymph nodes fixed to one another (matted) or to other structures fixed to one another (matted) or to other structures
N2b Metastasis only in N2b Metastasis only in clinically apparentclinically apparent ipsilateral ipsilateral internal mammary nodes and in theinternal mammary nodes and in the absence absence of of clinically evident axillary lymph node metastasis clinically evident axillary lymph node metastasis
N3N3
N3a Metastasis in ipsilateral infraclavicular lymph N3a Metastasis in ipsilateral infraclavicular lymph node(s)node(s)
N3b Metastasis in ipsilateral internal mammary N3b Metastasis in ipsilateral internal mammary lymph node(s) and axillary lymph node(s) lymph node(s) and axillary lymph node(s)
N3c Metastasis in ipsilateral supraclavicular lymph N3c Metastasis in ipsilateral supraclavicular lymph node(s)node(s)
M ( METASTASIS)M ( METASTASIS)
MX metastasis can no be assessedMX metastasis can no be assessed
M0 no metastasisM0 no metastasis
M1 metastasisM1 metastasis
American Cancer SocietyAmerican Cancer SocietyScreening RecommendationsScreening Recommendations
Annual mammogramsAnnual mammograms starting at starting at age 40age 40
Clinical breast examsClinical breast examsndash every year starting at age 40every year starting at age 40ndash every 3 years for women age every 3 years for women age 20-3920-39
Self-breast examsSelf-breast exams monthly starting monthly starting at age 20at age 20
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 11 Begin by looking at your breasts in the mirror Begin by looking at your breasts in the mirror
with your shoulders straight and yourwith your shoulders straight and your
arms on your hipsarms on your hips Heres what you should look forHeres what you should look for
Breasts that are their usual size shape and colorBreasts that are their usual size shape and color
--Breasts that are evenly shaped without visible --Breasts that are evenly shaped without visible distortion or swellingdistortion or swelling
If you see any of the following changes bring If you see any of the following changes bring them to your doctors attentionthem to your doctors attention
--Dimpling puckering or bulging of the skin--Dimpling puckering or bulging of the skin
--A nipple that has changed position or become --A nipple that has changed position or become inverted (pushed inward instead ofinverted (pushed inward instead of
sticking out)sticking out) --Redness soreness rash or swelling--Redness soreness rash or swelling
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 22
Raise your arms and look for the Raise your arms and look for the
samesame
changeschanges
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 33 Feel your breasts while lying down using Feel your breasts while lying down using
your right hand to feel your left breast and your right hand to feel your left breast and then your left hand to feel your right breast then your left hand to feel your right breast Use a firm smooth touch with the first few Use a firm smooth touch with the first few fingers of your hand keeping the fingersfingers of your hand keeping the fingers
flat and togetherflat and together
Cover the entire breast from top to Cover the entire breast from top to bottom side to sidemdashfrom your bottom side to sidemdashfrom your collarbone to the top of your abdomen collarbone to the top of your abdomen and from your armpit to your cleavageand from your armpit to your cleavage
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 44
Finally feel your breasts while you are Finally feel your breasts while you are standing or sitting Many women find standing or sitting Many women find that the easiest way to feel their breasts that the easiest way to feel their breasts is when their skin is wet and slippery is when their skin is wet and slippery so they like to do this step in the so they like to do this step in the shower Cover your entire breast using shower Cover your entire breast using the same hand movements described in the same hand movements described in Step 3Step 3
InvestigationsInvestigations
Mammography (conrsquot)Mammography (conrsquot) 1048698 1048698 Standard mammography Standard mammography depends on depends on
density of the tissue and its ability to stop density of the tissue and its ability to stop xrayxray
beam from exposing film placed on the other beam from exposing film placed on the other side of the breastside of the breast
Digital mammography Digital mammography works on the same works on the same principle but there is also some ability to principle but there is also some ability to manipulate the image by computer Main manipulate the image by computer Main advantage is storage of the filmsadvantage is storage of the films
UltrasoundUltrasound
Since solid tissue andSince solid tissue and collections of fluid look thecollections of fluid look the same on mammographysame on mammography ultrasound is very useful in ultrasound is very useful in telling whether a mass istelling whether a mass is solid or fluid and if solid ifsolid or fluid and if solid if characteristics arecharacteristics are suspicioussuspicious CystCyst
MRIMRI MRI relies on completely different type of MRI relies on completely different type of
wavewave
energy a strong magnet that affects the energy a strong magnet that affects the charge incharge in
the nuclei As magnetic force is applied and the nuclei As magnetic force is applied and thenthen
released different types of tissue send back released different types of tissue send back different types of radio wavesdifferent types of radio waves
MRI can be extremely useful in very denseMRI can be extremely useful in very dense
breasts hereditary casesbreasts hereditary cases
Fine needle aspiration of a palpable mass
1048698 Fine needle aspiration takes individual cells out ofmass Can be done for palpable or non-palpablemasses Does not show architecture especially wallof duct so best used to confirm strong suspicions
Fine Needle Aspiration
C0 No epithelial cellsC1 InadequateC2 BenignC3 AtypiaC4 SuspiciousC5 Malignant
1048698 Core biopsy can also bedone on palpable and non palpableabnormalities and on microcalcifications
Core Biopsy
B1 Normal tissue unsatisfactoryB2 BenignB3 Lesion uncertain malignant potentialB4 Suspicion of malignancyB5a In situ malignancyB5b Invasive malignancy
Investigations for Investigations for metastasismetastasis
1- abdominal ultrasound1- abdominal ultrasound
2- chest x ray or CT2- chest x ray or CT
3- bone survey or bone scan3- bone survey or bone scan
Established prognostic Established prognostic factorsfactors
bull Nodal status Nodal status bull Tumor size Tumor size bull Lymph node Lymph node bull Grade Grade bull ERPR StatusERPR Statusbull Age Age bull Lymphatic invasionLymphatic invasionbull Histological tumor typeHistological tumor type bull Perinodular infiltrationPerinodular infiltration
TREATMENT OPTIONS FOR PRIMARY OPERABLE BREAST CANCER Objective Options
Local control Lumpectomy Lumpectomy with breast irradiation Mastectomy
Regional control Axillary lymph node dissection Regional irradiation
Control of occult Chemotherapymicrometastatic disease Hormone therapy
Improved function and cosmesis Breast-conserving therapy Reconstruction (immediate or delayed)
Localized breast cancer Surgery is mainstay Halsted 1882 radical mastectomy
John Hopkins
Metastatic breast cancer Systemic treatment
Radical mastectomy A Entire breast and a
chest wall muscle is removed
LNs in the level 1 (B) and level 2 (C ) and even sometimes more distant lymph node groups (D E and F) were also removed
Modified radical mastectomy (MRM)
A Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed called an axillary lymph node dissection
MRM = simple mastectomy + ALND
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
2- palpation2- palpation palpate breasts with both the flat of your palpate breasts with both the flat of your
hand and fingers hand and fingers with flat fingers compress breast tissue with flat fingers compress breast tissue follow systematically in a circular follow systematically in a circular
pattern around the nipple or along the pattern around the nipple or along the radial lines (simulate a clock) or vertical radial lines (simulate a clock) or vertical segments and feel the entire breast segments and feel the entire breast including the tail near the axillaincluding the tail near the axilla
Examine criteria of the mass site size shape consistency
Examine axillary lymph nodes
American Joint Committee on Cancer TNM Staging System for Breast American Joint Committee on Cancer TNM Staging System for Breast Cancer Cancer
Primary Tumor (T)Primary Tumor (T) TX Primary tumor cannot be assessedTX Primary tumor cannot be assessed T0 No evidence of primary tumorT0 No evidence of primary tumor Tis Carcinoma Tis Carcinoma in situin situ
Note Pagets disease associated with a tumor is classified according Note Pagets disease associated with a tumor is classified according to the size of the tumor to the size of the tumor
T1 Tumor 2 cm or less in greatest dimensionT1 Tumor 2 cm or less in greatest dimension
T1mic Microinvasion 01 cm or less in greatest dimensionT1mic Microinvasion 01 cm or less in greatest dimension
T1a Tumor more than 01 cm but not more than 05 cm in greatest T1a Tumor more than 01 cm but not more than 05 cm in greatest dimension dimension
T1b Tumor more than 05 cm but not more than 1 cm in greatest T1b Tumor more than 05 cm but not more than 1 cm in greatest dimension dimension
T1c Tumor more than 1 cm but not more than 2 cm in greatest T1c Tumor more than 1 cm but not more than 2 cm in greatest dimensiondimension
T2 Tumor more than 2 cm but not more than 5 cm in greatest T2 Tumor more than 2 cm but not more than 5 cm in greatest dimensiondimension
T3 Tumor more than 5 cm in greatest dimensionT3 Tumor more than 5 cm in greatest dimension T4a Extension to chest wall not including pectoralis muscleT4a Extension to chest wall not including pectoralis muscle
T4b Edema (including peau dorange) or ulceration of the skin of the T4b Edema (including peau dorange) or ulceration of the skin of the breast or satellite skin nodules confined to the same breast breast or satellite skin nodules confined to the same breast
T4c Both T4a and T4bT4c Both T4a and T4b
T4d Inflammatory carcinomaT4d Inflammatory carcinoma
Regional Lymph Nodes (N) Regional Lymph Nodes (N) NX Regional lymph nodes cannot be assessed (eg NX Regional lymph nodes cannot be assessed (eg
previously removed) previously removed) N0 No regional lymph node metastasisN0 No regional lymph node metastasis N1 Metastasis to movable ipsilateral axillary lymph N1 Metastasis to movable ipsilateral axillary lymph
node(s)node(s) N2 N2
N2a Metastases in ipsilateral axillary lymph nodes N2a Metastases in ipsilateral axillary lymph nodes fixed to one another (matted) or to other structures fixed to one another (matted) or to other structures
N2b Metastasis only in N2b Metastasis only in clinically apparentclinically apparent ipsilateral ipsilateral internal mammary nodes and in theinternal mammary nodes and in the absence absence of of clinically evident axillary lymph node metastasis clinically evident axillary lymph node metastasis
N3N3
N3a Metastasis in ipsilateral infraclavicular lymph N3a Metastasis in ipsilateral infraclavicular lymph node(s)node(s)
N3b Metastasis in ipsilateral internal mammary N3b Metastasis in ipsilateral internal mammary lymph node(s) and axillary lymph node(s) lymph node(s) and axillary lymph node(s)
N3c Metastasis in ipsilateral supraclavicular lymph N3c Metastasis in ipsilateral supraclavicular lymph node(s)node(s)
M ( METASTASIS)M ( METASTASIS)
MX metastasis can no be assessedMX metastasis can no be assessed
M0 no metastasisM0 no metastasis
M1 metastasisM1 metastasis
American Cancer SocietyAmerican Cancer SocietyScreening RecommendationsScreening Recommendations
Annual mammogramsAnnual mammograms starting at starting at age 40age 40
Clinical breast examsClinical breast examsndash every year starting at age 40every year starting at age 40ndash every 3 years for women age every 3 years for women age 20-3920-39
Self-breast examsSelf-breast exams monthly starting monthly starting at age 20at age 20
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 11 Begin by looking at your breasts in the mirror Begin by looking at your breasts in the mirror
with your shoulders straight and yourwith your shoulders straight and your
arms on your hipsarms on your hips Heres what you should look forHeres what you should look for
Breasts that are their usual size shape and colorBreasts that are their usual size shape and color
--Breasts that are evenly shaped without visible --Breasts that are evenly shaped without visible distortion or swellingdistortion or swelling
If you see any of the following changes bring If you see any of the following changes bring them to your doctors attentionthem to your doctors attention
--Dimpling puckering or bulging of the skin--Dimpling puckering or bulging of the skin
--A nipple that has changed position or become --A nipple that has changed position or become inverted (pushed inward instead ofinverted (pushed inward instead of
sticking out)sticking out) --Redness soreness rash or swelling--Redness soreness rash or swelling
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 22
Raise your arms and look for the Raise your arms and look for the
samesame
changeschanges
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 33 Feel your breasts while lying down using Feel your breasts while lying down using
your right hand to feel your left breast and your right hand to feel your left breast and then your left hand to feel your right breast then your left hand to feel your right breast Use a firm smooth touch with the first few Use a firm smooth touch with the first few fingers of your hand keeping the fingersfingers of your hand keeping the fingers
flat and togetherflat and together
Cover the entire breast from top to Cover the entire breast from top to bottom side to sidemdashfrom your bottom side to sidemdashfrom your collarbone to the top of your abdomen collarbone to the top of your abdomen and from your armpit to your cleavageand from your armpit to your cleavage
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 44
Finally feel your breasts while you are Finally feel your breasts while you are standing or sitting Many women find standing or sitting Many women find that the easiest way to feel their breasts that the easiest way to feel their breasts is when their skin is wet and slippery is when their skin is wet and slippery so they like to do this step in the so they like to do this step in the shower Cover your entire breast using shower Cover your entire breast using the same hand movements described in the same hand movements described in Step 3Step 3
InvestigationsInvestigations
Mammography (conrsquot)Mammography (conrsquot) 1048698 1048698 Standard mammography Standard mammography depends on depends on
density of the tissue and its ability to stop density of the tissue and its ability to stop xrayxray
beam from exposing film placed on the other beam from exposing film placed on the other side of the breastside of the breast
Digital mammography Digital mammography works on the same works on the same principle but there is also some ability to principle but there is also some ability to manipulate the image by computer Main manipulate the image by computer Main advantage is storage of the filmsadvantage is storage of the films
UltrasoundUltrasound
Since solid tissue andSince solid tissue and collections of fluid look thecollections of fluid look the same on mammographysame on mammography ultrasound is very useful in ultrasound is very useful in telling whether a mass istelling whether a mass is solid or fluid and if solid ifsolid or fluid and if solid if characteristics arecharacteristics are suspicioussuspicious CystCyst
MRIMRI MRI relies on completely different type of MRI relies on completely different type of
wavewave
energy a strong magnet that affects the energy a strong magnet that affects the charge incharge in
the nuclei As magnetic force is applied and the nuclei As magnetic force is applied and thenthen
released different types of tissue send back released different types of tissue send back different types of radio wavesdifferent types of radio waves
MRI can be extremely useful in very denseMRI can be extremely useful in very dense
breasts hereditary casesbreasts hereditary cases
Fine needle aspiration of a palpable mass
1048698 Fine needle aspiration takes individual cells out ofmass Can be done for palpable or non-palpablemasses Does not show architecture especially wallof duct so best used to confirm strong suspicions
Fine Needle Aspiration
C0 No epithelial cellsC1 InadequateC2 BenignC3 AtypiaC4 SuspiciousC5 Malignant
1048698 Core biopsy can also bedone on palpable and non palpableabnormalities and on microcalcifications
Core Biopsy
B1 Normal tissue unsatisfactoryB2 BenignB3 Lesion uncertain malignant potentialB4 Suspicion of malignancyB5a In situ malignancyB5b Invasive malignancy
Investigations for Investigations for metastasismetastasis
1- abdominal ultrasound1- abdominal ultrasound
2- chest x ray or CT2- chest x ray or CT
3- bone survey or bone scan3- bone survey or bone scan
Established prognostic Established prognostic factorsfactors
bull Nodal status Nodal status bull Tumor size Tumor size bull Lymph node Lymph node bull Grade Grade bull ERPR StatusERPR Statusbull Age Age bull Lymphatic invasionLymphatic invasionbull Histological tumor typeHistological tumor type bull Perinodular infiltrationPerinodular infiltration
TREATMENT OPTIONS FOR PRIMARY OPERABLE BREAST CANCER Objective Options
Local control Lumpectomy Lumpectomy with breast irradiation Mastectomy
Regional control Axillary lymph node dissection Regional irradiation
Control of occult Chemotherapymicrometastatic disease Hormone therapy
Improved function and cosmesis Breast-conserving therapy Reconstruction (immediate or delayed)
Localized breast cancer Surgery is mainstay Halsted 1882 radical mastectomy
John Hopkins
Metastatic breast cancer Systemic treatment
Radical mastectomy A Entire breast and a
chest wall muscle is removed
LNs in the level 1 (B) and level 2 (C ) and even sometimes more distant lymph node groups (D E and F) were also removed
Modified radical mastectomy (MRM)
A Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed called an axillary lymph node dissection
MRM = simple mastectomy + ALND
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
American Joint Committee on Cancer TNM Staging System for Breast American Joint Committee on Cancer TNM Staging System for Breast Cancer Cancer
Primary Tumor (T)Primary Tumor (T) TX Primary tumor cannot be assessedTX Primary tumor cannot be assessed T0 No evidence of primary tumorT0 No evidence of primary tumor Tis Carcinoma Tis Carcinoma in situin situ
Note Pagets disease associated with a tumor is classified according Note Pagets disease associated with a tumor is classified according to the size of the tumor to the size of the tumor
T1 Tumor 2 cm or less in greatest dimensionT1 Tumor 2 cm or less in greatest dimension
T1mic Microinvasion 01 cm or less in greatest dimensionT1mic Microinvasion 01 cm or less in greatest dimension
T1a Tumor more than 01 cm but not more than 05 cm in greatest T1a Tumor more than 01 cm but not more than 05 cm in greatest dimension dimension
T1b Tumor more than 05 cm but not more than 1 cm in greatest T1b Tumor more than 05 cm but not more than 1 cm in greatest dimension dimension
T1c Tumor more than 1 cm but not more than 2 cm in greatest T1c Tumor more than 1 cm but not more than 2 cm in greatest dimensiondimension
T2 Tumor more than 2 cm but not more than 5 cm in greatest T2 Tumor more than 2 cm but not more than 5 cm in greatest dimensiondimension
T3 Tumor more than 5 cm in greatest dimensionT3 Tumor more than 5 cm in greatest dimension T4a Extension to chest wall not including pectoralis muscleT4a Extension to chest wall not including pectoralis muscle
T4b Edema (including peau dorange) or ulceration of the skin of the T4b Edema (including peau dorange) or ulceration of the skin of the breast or satellite skin nodules confined to the same breast breast or satellite skin nodules confined to the same breast
T4c Both T4a and T4bT4c Both T4a and T4b
T4d Inflammatory carcinomaT4d Inflammatory carcinoma
Regional Lymph Nodes (N) Regional Lymph Nodes (N) NX Regional lymph nodes cannot be assessed (eg NX Regional lymph nodes cannot be assessed (eg
previously removed) previously removed) N0 No regional lymph node metastasisN0 No regional lymph node metastasis N1 Metastasis to movable ipsilateral axillary lymph N1 Metastasis to movable ipsilateral axillary lymph
node(s)node(s) N2 N2
N2a Metastases in ipsilateral axillary lymph nodes N2a Metastases in ipsilateral axillary lymph nodes fixed to one another (matted) or to other structures fixed to one another (matted) or to other structures
N2b Metastasis only in N2b Metastasis only in clinically apparentclinically apparent ipsilateral ipsilateral internal mammary nodes and in theinternal mammary nodes and in the absence absence of of clinically evident axillary lymph node metastasis clinically evident axillary lymph node metastasis
N3N3
N3a Metastasis in ipsilateral infraclavicular lymph N3a Metastasis in ipsilateral infraclavicular lymph node(s)node(s)
N3b Metastasis in ipsilateral internal mammary N3b Metastasis in ipsilateral internal mammary lymph node(s) and axillary lymph node(s) lymph node(s) and axillary lymph node(s)
N3c Metastasis in ipsilateral supraclavicular lymph N3c Metastasis in ipsilateral supraclavicular lymph node(s)node(s)
M ( METASTASIS)M ( METASTASIS)
MX metastasis can no be assessedMX metastasis can no be assessed
M0 no metastasisM0 no metastasis
M1 metastasisM1 metastasis
American Cancer SocietyAmerican Cancer SocietyScreening RecommendationsScreening Recommendations
Annual mammogramsAnnual mammograms starting at starting at age 40age 40
Clinical breast examsClinical breast examsndash every year starting at age 40every year starting at age 40ndash every 3 years for women age every 3 years for women age 20-3920-39
Self-breast examsSelf-breast exams monthly starting monthly starting at age 20at age 20
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 11 Begin by looking at your breasts in the mirror Begin by looking at your breasts in the mirror
with your shoulders straight and yourwith your shoulders straight and your
arms on your hipsarms on your hips Heres what you should look forHeres what you should look for
Breasts that are their usual size shape and colorBreasts that are their usual size shape and color
--Breasts that are evenly shaped without visible --Breasts that are evenly shaped without visible distortion or swellingdistortion or swelling
If you see any of the following changes bring If you see any of the following changes bring them to your doctors attentionthem to your doctors attention
--Dimpling puckering or bulging of the skin--Dimpling puckering or bulging of the skin
--A nipple that has changed position or become --A nipple that has changed position or become inverted (pushed inward instead ofinverted (pushed inward instead of
sticking out)sticking out) --Redness soreness rash or swelling--Redness soreness rash or swelling
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 22
Raise your arms and look for the Raise your arms and look for the
samesame
changeschanges
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 33 Feel your breasts while lying down using Feel your breasts while lying down using
your right hand to feel your left breast and your right hand to feel your left breast and then your left hand to feel your right breast then your left hand to feel your right breast Use a firm smooth touch with the first few Use a firm smooth touch with the first few fingers of your hand keeping the fingersfingers of your hand keeping the fingers
flat and togetherflat and together
Cover the entire breast from top to Cover the entire breast from top to bottom side to sidemdashfrom your bottom side to sidemdashfrom your collarbone to the top of your abdomen collarbone to the top of your abdomen and from your armpit to your cleavageand from your armpit to your cleavage
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 44
Finally feel your breasts while you are Finally feel your breasts while you are standing or sitting Many women find standing or sitting Many women find that the easiest way to feel their breasts that the easiest way to feel their breasts is when their skin is wet and slippery is when their skin is wet and slippery so they like to do this step in the so they like to do this step in the shower Cover your entire breast using shower Cover your entire breast using the same hand movements described in the same hand movements described in Step 3Step 3
InvestigationsInvestigations
Mammography (conrsquot)Mammography (conrsquot) 1048698 1048698 Standard mammography Standard mammography depends on depends on
density of the tissue and its ability to stop density of the tissue and its ability to stop xrayxray
beam from exposing film placed on the other beam from exposing film placed on the other side of the breastside of the breast
Digital mammography Digital mammography works on the same works on the same principle but there is also some ability to principle but there is also some ability to manipulate the image by computer Main manipulate the image by computer Main advantage is storage of the filmsadvantage is storage of the films
UltrasoundUltrasound
Since solid tissue andSince solid tissue and collections of fluid look thecollections of fluid look the same on mammographysame on mammography ultrasound is very useful in ultrasound is very useful in telling whether a mass istelling whether a mass is solid or fluid and if solid ifsolid or fluid and if solid if characteristics arecharacteristics are suspicioussuspicious CystCyst
MRIMRI MRI relies on completely different type of MRI relies on completely different type of
wavewave
energy a strong magnet that affects the energy a strong magnet that affects the charge incharge in
the nuclei As magnetic force is applied and the nuclei As magnetic force is applied and thenthen
released different types of tissue send back released different types of tissue send back different types of radio wavesdifferent types of radio waves
MRI can be extremely useful in very denseMRI can be extremely useful in very dense
breasts hereditary casesbreasts hereditary cases
Fine needle aspiration of a palpable mass
1048698 Fine needle aspiration takes individual cells out ofmass Can be done for palpable or non-palpablemasses Does not show architecture especially wallof duct so best used to confirm strong suspicions
Fine Needle Aspiration
C0 No epithelial cellsC1 InadequateC2 BenignC3 AtypiaC4 SuspiciousC5 Malignant
1048698 Core biopsy can also bedone on palpable and non palpableabnormalities and on microcalcifications
Core Biopsy
B1 Normal tissue unsatisfactoryB2 BenignB3 Lesion uncertain malignant potentialB4 Suspicion of malignancyB5a In situ malignancyB5b Invasive malignancy
Investigations for Investigations for metastasismetastasis
1- abdominal ultrasound1- abdominal ultrasound
2- chest x ray or CT2- chest x ray or CT
3- bone survey or bone scan3- bone survey or bone scan
Established prognostic Established prognostic factorsfactors
bull Nodal status Nodal status bull Tumor size Tumor size bull Lymph node Lymph node bull Grade Grade bull ERPR StatusERPR Statusbull Age Age bull Lymphatic invasionLymphatic invasionbull Histological tumor typeHistological tumor type bull Perinodular infiltrationPerinodular infiltration
TREATMENT OPTIONS FOR PRIMARY OPERABLE BREAST CANCER Objective Options
Local control Lumpectomy Lumpectomy with breast irradiation Mastectomy
Regional control Axillary lymph node dissection Regional irradiation
Control of occult Chemotherapymicrometastatic disease Hormone therapy
Improved function and cosmesis Breast-conserving therapy Reconstruction (immediate or delayed)
Localized breast cancer Surgery is mainstay Halsted 1882 radical mastectomy
John Hopkins
Metastatic breast cancer Systemic treatment
Radical mastectomy A Entire breast and a
chest wall muscle is removed
LNs in the level 1 (B) and level 2 (C ) and even sometimes more distant lymph node groups (D E and F) were also removed
Modified radical mastectomy (MRM)
A Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed called an axillary lymph node dissection
MRM = simple mastectomy + ALND
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
Regional Lymph Nodes (N) Regional Lymph Nodes (N) NX Regional lymph nodes cannot be assessed (eg NX Regional lymph nodes cannot be assessed (eg
previously removed) previously removed) N0 No regional lymph node metastasisN0 No regional lymph node metastasis N1 Metastasis to movable ipsilateral axillary lymph N1 Metastasis to movable ipsilateral axillary lymph
node(s)node(s) N2 N2
N2a Metastases in ipsilateral axillary lymph nodes N2a Metastases in ipsilateral axillary lymph nodes fixed to one another (matted) or to other structures fixed to one another (matted) or to other structures
N2b Metastasis only in N2b Metastasis only in clinically apparentclinically apparent ipsilateral ipsilateral internal mammary nodes and in theinternal mammary nodes and in the absence absence of of clinically evident axillary lymph node metastasis clinically evident axillary lymph node metastasis
N3N3
N3a Metastasis in ipsilateral infraclavicular lymph N3a Metastasis in ipsilateral infraclavicular lymph node(s)node(s)
N3b Metastasis in ipsilateral internal mammary N3b Metastasis in ipsilateral internal mammary lymph node(s) and axillary lymph node(s) lymph node(s) and axillary lymph node(s)
N3c Metastasis in ipsilateral supraclavicular lymph N3c Metastasis in ipsilateral supraclavicular lymph node(s)node(s)
M ( METASTASIS)M ( METASTASIS)
MX metastasis can no be assessedMX metastasis can no be assessed
M0 no metastasisM0 no metastasis
M1 metastasisM1 metastasis
American Cancer SocietyAmerican Cancer SocietyScreening RecommendationsScreening Recommendations
Annual mammogramsAnnual mammograms starting at starting at age 40age 40
Clinical breast examsClinical breast examsndash every year starting at age 40every year starting at age 40ndash every 3 years for women age every 3 years for women age 20-3920-39
Self-breast examsSelf-breast exams monthly starting monthly starting at age 20at age 20
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 11 Begin by looking at your breasts in the mirror Begin by looking at your breasts in the mirror
with your shoulders straight and yourwith your shoulders straight and your
arms on your hipsarms on your hips Heres what you should look forHeres what you should look for
Breasts that are their usual size shape and colorBreasts that are their usual size shape and color
--Breasts that are evenly shaped without visible --Breasts that are evenly shaped without visible distortion or swellingdistortion or swelling
If you see any of the following changes bring If you see any of the following changes bring them to your doctors attentionthem to your doctors attention
--Dimpling puckering or bulging of the skin--Dimpling puckering or bulging of the skin
--A nipple that has changed position or become --A nipple that has changed position or become inverted (pushed inward instead ofinverted (pushed inward instead of
sticking out)sticking out) --Redness soreness rash or swelling--Redness soreness rash or swelling
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 22
Raise your arms and look for the Raise your arms and look for the
samesame
changeschanges
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 33 Feel your breasts while lying down using Feel your breasts while lying down using
your right hand to feel your left breast and your right hand to feel your left breast and then your left hand to feel your right breast then your left hand to feel your right breast Use a firm smooth touch with the first few Use a firm smooth touch with the first few fingers of your hand keeping the fingersfingers of your hand keeping the fingers
flat and togetherflat and together
Cover the entire breast from top to Cover the entire breast from top to bottom side to sidemdashfrom your bottom side to sidemdashfrom your collarbone to the top of your abdomen collarbone to the top of your abdomen and from your armpit to your cleavageand from your armpit to your cleavage
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 44
Finally feel your breasts while you are Finally feel your breasts while you are standing or sitting Many women find standing or sitting Many women find that the easiest way to feel their breasts that the easiest way to feel their breasts is when their skin is wet and slippery is when their skin is wet and slippery so they like to do this step in the so they like to do this step in the shower Cover your entire breast using shower Cover your entire breast using the same hand movements described in the same hand movements described in Step 3Step 3
InvestigationsInvestigations
Mammography (conrsquot)Mammography (conrsquot) 1048698 1048698 Standard mammography Standard mammography depends on depends on
density of the tissue and its ability to stop density of the tissue and its ability to stop xrayxray
beam from exposing film placed on the other beam from exposing film placed on the other side of the breastside of the breast
Digital mammography Digital mammography works on the same works on the same principle but there is also some ability to principle but there is also some ability to manipulate the image by computer Main manipulate the image by computer Main advantage is storage of the filmsadvantage is storage of the films
UltrasoundUltrasound
Since solid tissue andSince solid tissue and collections of fluid look thecollections of fluid look the same on mammographysame on mammography ultrasound is very useful in ultrasound is very useful in telling whether a mass istelling whether a mass is solid or fluid and if solid ifsolid or fluid and if solid if characteristics arecharacteristics are suspicioussuspicious CystCyst
MRIMRI MRI relies on completely different type of MRI relies on completely different type of
wavewave
energy a strong magnet that affects the energy a strong magnet that affects the charge incharge in
the nuclei As magnetic force is applied and the nuclei As magnetic force is applied and thenthen
released different types of tissue send back released different types of tissue send back different types of radio wavesdifferent types of radio waves
MRI can be extremely useful in very denseMRI can be extremely useful in very dense
breasts hereditary casesbreasts hereditary cases
Fine needle aspiration of a palpable mass
1048698 Fine needle aspiration takes individual cells out ofmass Can be done for palpable or non-palpablemasses Does not show architecture especially wallof duct so best used to confirm strong suspicions
Fine Needle Aspiration
C0 No epithelial cellsC1 InadequateC2 BenignC3 AtypiaC4 SuspiciousC5 Malignant
1048698 Core biopsy can also bedone on palpable and non palpableabnormalities and on microcalcifications
Core Biopsy
B1 Normal tissue unsatisfactoryB2 BenignB3 Lesion uncertain malignant potentialB4 Suspicion of malignancyB5a In situ malignancyB5b Invasive malignancy
Investigations for Investigations for metastasismetastasis
1- abdominal ultrasound1- abdominal ultrasound
2- chest x ray or CT2- chest x ray or CT
3- bone survey or bone scan3- bone survey or bone scan
Established prognostic Established prognostic factorsfactors
bull Nodal status Nodal status bull Tumor size Tumor size bull Lymph node Lymph node bull Grade Grade bull ERPR StatusERPR Statusbull Age Age bull Lymphatic invasionLymphatic invasionbull Histological tumor typeHistological tumor type bull Perinodular infiltrationPerinodular infiltration
TREATMENT OPTIONS FOR PRIMARY OPERABLE BREAST CANCER Objective Options
Local control Lumpectomy Lumpectomy with breast irradiation Mastectomy
Regional control Axillary lymph node dissection Regional irradiation
Control of occult Chemotherapymicrometastatic disease Hormone therapy
Improved function and cosmesis Breast-conserving therapy Reconstruction (immediate or delayed)
Localized breast cancer Surgery is mainstay Halsted 1882 radical mastectomy
John Hopkins
Metastatic breast cancer Systemic treatment
Radical mastectomy A Entire breast and a
chest wall muscle is removed
LNs in the level 1 (B) and level 2 (C ) and even sometimes more distant lymph node groups (D E and F) were also removed
Modified radical mastectomy (MRM)
A Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed called an axillary lymph node dissection
MRM = simple mastectomy + ALND
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
M ( METASTASIS)M ( METASTASIS)
MX metastasis can no be assessedMX metastasis can no be assessed
M0 no metastasisM0 no metastasis
M1 metastasisM1 metastasis
American Cancer SocietyAmerican Cancer SocietyScreening RecommendationsScreening Recommendations
Annual mammogramsAnnual mammograms starting at starting at age 40age 40
Clinical breast examsClinical breast examsndash every year starting at age 40every year starting at age 40ndash every 3 years for women age every 3 years for women age 20-3920-39
Self-breast examsSelf-breast exams monthly starting monthly starting at age 20at age 20
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 11 Begin by looking at your breasts in the mirror Begin by looking at your breasts in the mirror
with your shoulders straight and yourwith your shoulders straight and your
arms on your hipsarms on your hips Heres what you should look forHeres what you should look for
Breasts that are their usual size shape and colorBreasts that are their usual size shape and color
--Breasts that are evenly shaped without visible --Breasts that are evenly shaped without visible distortion or swellingdistortion or swelling
If you see any of the following changes bring If you see any of the following changes bring them to your doctors attentionthem to your doctors attention
--Dimpling puckering or bulging of the skin--Dimpling puckering or bulging of the skin
--A nipple that has changed position or become --A nipple that has changed position or become inverted (pushed inward instead ofinverted (pushed inward instead of
sticking out)sticking out) --Redness soreness rash or swelling--Redness soreness rash or swelling
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 22
Raise your arms and look for the Raise your arms and look for the
samesame
changeschanges
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 33 Feel your breasts while lying down using Feel your breasts while lying down using
your right hand to feel your left breast and your right hand to feel your left breast and then your left hand to feel your right breast then your left hand to feel your right breast Use a firm smooth touch with the first few Use a firm smooth touch with the first few fingers of your hand keeping the fingersfingers of your hand keeping the fingers
flat and togetherflat and together
Cover the entire breast from top to Cover the entire breast from top to bottom side to sidemdashfrom your bottom side to sidemdashfrom your collarbone to the top of your abdomen collarbone to the top of your abdomen and from your armpit to your cleavageand from your armpit to your cleavage
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 44
Finally feel your breasts while you are Finally feel your breasts while you are standing or sitting Many women find standing or sitting Many women find that the easiest way to feel their breasts that the easiest way to feel their breasts is when their skin is wet and slippery is when their skin is wet and slippery so they like to do this step in the so they like to do this step in the shower Cover your entire breast using shower Cover your entire breast using the same hand movements described in the same hand movements described in Step 3Step 3
InvestigationsInvestigations
Mammography (conrsquot)Mammography (conrsquot) 1048698 1048698 Standard mammography Standard mammography depends on depends on
density of the tissue and its ability to stop density of the tissue and its ability to stop xrayxray
beam from exposing film placed on the other beam from exposing film placed on the other side of the breastside of the breast
Digital mammography Digital mammography works on the same works on the same principle but there is also some ability to principle but there is also some ability to manipulate the image by computer Main manipulate the image by computer Main advantage is storage of the filmsadvantage is storage of the films
UltrasoundUltrasound
Since solid tissue andSince solid tissue and collections of fluid look thecollections of fluid look the same on mammographysame on mammography ultrasound is very useful in ultrasound is very useful in telling whether a mass istelling whether a mass is solid or fluid and if solid ifsolid or fluid and if solid if characteristics arecharacteristics are suspicioussuspicious CystCyst
MRIMRI MRI relies on completely different type of MRI relies on completely different type of
wavewave
energy a strong magnet that affects the energy a strong magnet that affects the charge incharge in
the nuclei As magnetic force is applied and the nuclei As magnetic force is applied and thenthen
released different types of tissue send back released different types of tissue send back different types of radio wavesdifferent types of radio waves
MRI can be extremely useful in very denseMRI can be extremely useful in very dense
breasts hereditary casesbreasts hereditary cases
Fine needle aspiration of a palpable mass
1048698 Fine needle aspiration takes individual cells out ofmass Can be done for palpable or non-palpablemasses Does not show architecture especially wallof duct so best used to confirm strong suspicions
Fine Needle Aspiration
C0 No epithelial cellsC1 InadequateC2 BenignC3 AtypiaC4 SuspiciousC5 Malignant
1048698 Core biopsy can also bedone on palpable and non palpableabnormalities and on microcalcifications
Core Biopsy
B1 Normal tissue unsatisfactoryB2 BenignB3 Lesion uncertain malignant potentialB4 Suspicion of malignancyB5a In situ malignancyB5b Invasive malignancy
Investigations for Investigations for metastasismetastasis
1- abdominal ultrasound1- abdominal ultrasound
2- chest x ray or CT2- chest x ray or CT
3- bone survey or bone scan3- bone survey or bone scan
Established prognostic Established prognostic factorsfactors
bull Nodal status Nodal status bull Tumor size Tumor size bull Lymph node Lymph node bull Grade Grade bull ERPR StatusERPR Statusbull Age Age bull Lymphatic invasionLymphatic invasionbull Histological tumor typeHistological tumor type bull Perinodular infiltrationPerinodular infiltration
TREATMENT OPTIONS FOR PRIMARY OPERABLE BREAST CANCER Objective Options
Local control Lumpectomy Lumpectomy with breast irradiation Mastectomy
Regional control Axillary lymph node dissection Regional irradiation
Control of occult Chemotherapymicrometastatic disease Hormone therapy
Improved function and cosmesis Breast-conserving therapy Reconstruction (immediate or delayed)
Localized breast cancer Surgery is mainstay Halsted 1882 radical mastectomy
John Hopkins
Metastatic breast cancer Systemic treatment
Radical mastectomy A Entire breast and a
chest wall muscle is removed
LNs in the level 1 (B) and level 2 (C ) and even sometimes more distant lymph node groups (D E and F) were also removed
Modified radical mastectomy (MRM)
A Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed called an axillary lymph node dissection
MRM = simple mastectomy + ALND
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
American Cancer SocietyAmerican Cancer SocietyScreening RecommendationsScreening Recommendations
Annual mammogramsAnnual mammograms starting at starting at age 40age 40
Clinical breast examsClinical breast examsndash every year starting at age 40every year starting at age 40ndash every 3 years for women age every 3 years for women age 20-3920-39
Self-breast examsSelf-breast exams monthly starting monthly starting at age 20at age 20
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 11 Begin by looking at your breasts in the mirror Begin by looking at your breasts in the mirror
with your shoulders straight and yourwith your shoulders straight and your
arms on your hipsarms on your hips Heres what you should look forHeres what you should look for
Breasts that are their usual size shape and colorBreasts that are their usual size shape and color
--Breasts that are evenly shaped without visible --Breasts that are evenly shaped without visible distortion or swellingdistortion or swelling
If you see any of the following changes bring If you see any of the following changes bring them to your doctors attentionthem to your doctors attention
--Dimpling puckering or bulging of the skin--Dimpling puckering or bulging of the skin
--A nipple that has changed position or become --A nipple that has changed position or become inverted (pushed inward instead ofinverted (pushed inward instead of
sticking out)sticking out) --Redness soreness rash or swelling--Redness soreness rash or swelling
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 22
Raise your arms and look for the Raise your arms and look for the
samesame
changeschanges
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 33 Feel your breasts while lying down using Feel your breasts while lying down using
your right hand to feel your left breast and your right hand to feel your left breast and then your left hand to feel your right breast then your left hand to feel your right breast Use a firm smooth touch with the first few Use a firm smooth touch with the first few fingers of your hand keeping the fingersfingers of your hand keeping the fingers
flat and togetherflat and together
Cover the entire breast from top to Cover the entire breast from top to bottom side to sidemdashfrom your bottom side to sidemdashfrom your collarbone to the top of your abdomen collarbone to the top of your abdomen and from your armpit to your cleavageand from your armpit to your cleavage
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 44
Finally feel your breasts while you are Finally feel your breasts while you are standing or sitting Many women find standing or sitting Many women find that the easiest way to feel their breasts that the easiest way to feel their breasts is when their skin is wet and slippery is when their skin is wet and slippery so they like to do this step in the so they like to do this step in the shower Cover your entire breast using shower Cover your entire breast using the same hand movements described in the same hand movements described in Step 3Step 3
InvestigationsInvestigations
Mammography (conrsquot)Mammography (conrsquot) 1048698 1048698 Standard mammography Standard mammography depends on depends on
density of the tissue and its ability to stop density of the tissue and its ability to stop xrayxray
beam from exposing film placed on the other beam from exposing film placed on the other side of the breastside of the breast
Digital mammography Digital mammography works on the same works on the same principle but there is also some ability to principle but there is also some ability to manipulate the image by computer Main manipulate the image by computer Main advantage is storage of the filmsadvantage is storage of the films
UltrasoundUltrasound
Since solid tissue andSince solid tissue and collections of fluid look thecollections of fluid look the same on mammographysame on mammography ultrasound is very useful in ultrasound is very useful in telling whether a mass istelling whether a mass is solid or fluid and if solid ifsolid or fluid and if solid if characteristics arecharacteristics are suspicioussuspicious CystCyst
MRIMRI MRI relies on completely different type of MRI relies on completely different type of
wavewave
energy a strong magnet that affects the energy a strong magnet that affects the charge incharge in
the nuclei As magnetic force is applied and the nuclei As magnetic force is applied and thenthen
released different types of tissue send back released different types of tissue send back different types of radio wavesdifferent types of radio waves
MRI can be extremely useful in very denseMRI can be extremely useful in very dense
breasts hereditary casesbreasts hereditary cases
Fine needle aspiration of a palpable mass
1048698 Fine needle aspiration takes individual cells out ofmass Can be done for palpable or non-palpablemasses Does not show architecture especially wallof duct so best used to confirm strong suspicions
Fine Needle Aspiration
C0 No epithelial cellsC1 InadequateC2 BenignC3 AtypiaC4 SuspiciousC5 Malignant
1048698 Core biopsy can also bedone on palpable and non palpableabnormalities and on microcalcifications
Core Biopsy
B1 Normal tissue unsatisfactoryB2 BenignB3 Lesion uncertain malignant potentialB4 Suspicion of malignancyB5a In situ malignancyB5b Invasive malignancy
Investigations for Investigations for metastasismetastasis
1- abdominal ultrasound1- abdominal ultrasound
2- chest x ray or CT2- chest x ray or CT
3- bone survey or bone scan3- bone survey or bone scan
Established prognostic Established prognostic factorsfactors
bull Nodal status Nodal status bull Tumor size Tumor size bull Lymph node Lymph node bull Grade Grade bull ERPR StatusERPR Statusbull Age Age bull Lymphatic invasionLymphatic invasionbull Histological tumor typeHistological tumor type bull Perinodular infiltrationPerinodular infiltration
TREATMENT OPTIONS FOR PRIMARY OPERABLE BREAST CANCER Objective Options
Local control Lumpectomy Lumpectomy with breast irradiation Mastectomy
Regional control Axillary lymph node dissection Regional irradiation
Control of occult Chemotherapymicrometastatic disease Hormone therapy
Improved function and cosmesis Breast-conserving therapy Reconstruction (immediate or delayed)
Localized breast cancer Surgery is mainstay Halsted 1882 radical mastectomy
John Hopkins
Metastatic breast cancer Systemic treatment
Radical mastectomy A Entire breast and a
chest wall muscle is removed
LNs in the level 1 (B) and level 2 (C ) and even sometimes more distant lymph node groups (D E and F) were also removed
Modified radical mastectomy (MRM)
A Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed called an axillary lymph node dissection
MRM = simple mastectomy + ALND
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 11 Begin by looking at your breasts in the mirror Begin by looking at your breasts in the mirror
with your shoulders straight and yourwith your shoulders straight and your
arms on your hipsarms on your hips Heres what you should look forHeres what you should look for
Breasts that are their usual size shape and colorBreasts that are their usual size shape and color
--Breasts that are evenly shaped without visible --Breasts that are evenly shaped without visible distortion or swellingdistortion or swelling
If you see any of the following changes bring If you see any of the following changes bring them to your doctors attentionthem to your doctors attention
--Dimpling puckering or bulging of the skin--Dimpling puckering or bulging of the skin
--A nipple that has changed position or become --A nipple that has changed position or become inverted (pushed inward instead ofinverted (pushed inward instead of
sticking out)sticking out) --Redness soreness rash or swelling--Redness soreness rash or swelling
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 22
Raise your arms and look for the Raise your arms and look for the
samesame
changeschanges
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 33 Feel your breasts while lying down using Feel your breasts while lying down using
your right hand to feel your left breast and your right hand to feel your left breast and then your left hand to feel your right breast then your left hand to feel your right breast Use a firm smooth touch with the first few Use a firm smooth touch with the first few fingers of your hand keeping the fingersfingers of your hand keeping the fingers
flat and togetherflat and together
Cover the entire breast from top to Cover the entire breast from top to bottom side to sidemdashfrom your bottom side to sidemdashfrom your collarbone to the top of your abdomen collarbone to the top of your abdomen and from your armpit to your cleavageand from your armpit to your cleavage
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 44
Finally feel your breasts while you are Finally feel your breasts while you are standing or sitting Many women find standing or sitting Many women find that the easiest way to feel their breasts that the easiest way to feel their breasts is when their skin is wet and slippery is when their skin is wet and slippery so they like to do this step in the so they like to do this step in the shower Cover your entire breast using shower Cover your entire breast using the same hand movements described in the same hand movements described in Step 3Step 3
InvestigationsInvestigations
Mammography (conrsquot)Mammography (conrsquot) 1048698 1048698 Standard mammography Standard mammography depends on depends on
density of the tissue and its ability to stop density of the tissue and its ability to stop xrayxray
beam from exposing film placed on the other beam from exposing film placed on the other side of the breastside of the breast
Digital mammography Digital mammography works on the same works on the same principle but there is also some ability to principle but there is also some ability to manipulate the image by computer Main manipulate the image by computer Main advantage is storage of the filmsadvantage is storage of the films
UltrasoundUltrasound
Since solid tissue andSince solid tissue and collections of fluid look thecollections of fluid look the same on mammographysame on mammography ultrasound is very useful in ultrasound is very useful in telling whether a mass istelling whether a mass is solid or fluid and if solid ifsolid or fluid and if solid if characteristics arecharacteristics are suspicioussuspicious CystCyst
MRIMRI MRI relies on completely different type of MRI relies on completely different type of
wavewave
energy a strong magnet that affects the energy a strong magnet that affects the charge incharge in
the nuclei As magnetic force is applied and the nuclei As magnetic force is applied and thenthen
released different types of tissue send back released different types of tissue send back different types of radio wavesdifferent types of radio waves
MRI can be extremely useful in very denseMRI can be extremely useful in very dense
breasts hereditary casesbreasts hereditary cases
Fine needle aspiration of a palpable mass
1048698 Fine needle aspiration takes individual cells out ofmass Can be done for palpable or non-palpablemasses Does not show architecture especially wallof duct so best used to confirm strong suspicions
Fine Needle Aspiration
C0 No epithelial cellsC1 InadequateC2 BenignC3 AtypiaC4 SuspiciousC5 Malignant
1048698 Core biopsy can also bedone on palpable and non palpableabnormalities and on microcalcifications
Core Biopsy
B1 Normal tissue unsatisfactoryB2 BenignB3 Lesion uncertain malignant potentialB4 Suspicion of malignancyB5a In situ malignancyB5b Invasive malignancy
Investigations for Investigations for metastasismetastasis
1- abdominal ultrasound1- abdominal ultrasound
2- chest x ray or CT2- chest x ray or CT
3- bone survey or bone scan3- bone survey or bone scan
Established prognostic Established prognostic factorsfactors
bull Nodal status Nodal status bull Tumor size Tumor size bull Lymph node Lymph node bull Grade Grade bull ERPR StatusERPR Statusbull Age Age bull Lymphatic invasionLymphatic invasionbull Histological tumor typeHistological tumor type bull Perinodular infiltrationPerinodular infiltration
TREATMENT OPTIONS FOR PRIMARY OPERABLE BREAST CANCER Objective Options
Local control Lumpectomy Lumpectomy with breast irradiation Mastectomy
Regional control Axillary lymph node dissection Regional irradiation
Control of occult Chemotherapymicrometastatic disease Hormone therapy
Improved function and cosmesis Breast-conserving therapy Reconstruction (immediate or delayed)
Localized breast cancer Surgery is mainstay Halsted 1882 radical mastectomy
John Hopkins
Metastatic breast cancer Systemic treatment
Radical mastectomy A Entire breast and a
chest wall muscle is removed
LNs in the level 1 (B) and level 2 (C ) and even sometimes more distant lymph node groups (D E and F) were also removed
Modified radical mastectomy (MRM)
A Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed called an axillary lymph node dissection
MRM = simple mastectomy + ALND
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 22
Raise your arms and look for the Raise your arms and look for the
samesame
changeschanges
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 33 Feel your breasts while lying down using Feel your breasts while lying down using
your right hand to feel your left breast and your right hand to feel your left breast and then your left hand to feel your right breast then your left hand to feel your right breast Use a firm smooth touch with the first few Use a firm smooth touch with the first few fingers of your hand keeping the fingersfingers of your hand keeping the fingers
flat and togetherflat and together
Cover the entire breast from top to Cover the entire breast from top to bottom side to sidemdashfrom your bottom side to sidemdashfrom your collarbone to the top of your abdomen collarbone to the top of your abdomen and from your armpit to your cleavageand from your armpit to your cleavage
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 44
Finally feel your breasts while you are Finally feel your breasts while you are standing or sitting Many women find standing or sitting Many women find that the easiest way to feel their breasts that the easiest way to feel their breasts is when their skin is wet and slippery is when their skin is wet and slippery so they like to do this step in the so they like to do this step in the shower Cover your entire breast using shower Cover your entire breast using the same hand movements described in the same hand movements described in Step 3Step 3
InvestigationsInvestigations
Mammography (conrsquot)Mammography (conrsquot) 1048698 1048698 Standard mammography Standard mammography depends on depends on
density of the tissue and its ability to stop density of the tissue and its ability to stop xrayxray
beam from exposing film placed on the other beam from exposing film placed on the other side of the breastside of the breast
Digital mammography Digital mammography works on the same works on the same principle but there is also some ability to principle but there is also some ability to manipulate the image by computer Main manipulate the image by computer Main advantage is storage of the filmsadvantage is storage of the films
UltrasoundUltrasound
Since solid tissue andSince solid tissue and collections of fluid look thecollections of fluid look the same on mammographysame on mammography ultrasound is very useful in ultrasound is very useful in telling whether a mass istelling whether a mass is solid or fluid and if solid ifsolid or fluid and if solid if characteristics arecharacteristics are suspicioussuspicious CystCyst
MRIMRI MRI relies on completely different type of MRI relies on completely different type of
wavewave
energy a strong magnet that affects the energy a strong magnet that affects the charge incharge in
the nuclei As magnetic force is applied and the nuclei As magnetic force is applied and thenthen
released different types of tissue send back released different types of tissue send back different types of radio wavesdifferent types of radio waves
MRI can be extremely useful in very denseMRI can be extremely useful in very dense
breasts hereditary casesbreasts hereditary cases
Fine needle aspiration of a palpable mass
1048698 Fine needle aspiration takes individual cells out ofmass Can be done for palpable or non-palpablemasses Does not show architecture especially wallof duct so best used to confirm strong suspicions
Fine Needle Aspiration
C0 No epithelial cellsC1 InadequateC2 BenignC3 AtypiaC4 SuspiciousC5 Malignant
1048698 Core biopsy can also bedone on palpable and non palpableabnormalities and on microcalcifications
Core Biopsy
B1 Normal tissue unsatisfactoryB2 BenignB3 Lesion uncertain malignant potentialB4 Suspicion of malignancyB5a In situ malignancyB5b Invasive malignancy
Investigations for Investigations for metastasismetastasis
1- abdominal ultrasound1- abdominal ultrasound
2- chest x ray or CT2- chest x ray or CT
3- bone survey or bone scan3- bone survey or bone scan
Established prognostic Established prognostic factorsfactors
bull Nodal status Nodal status bull Tumor size Tumor size bull Lymph node Lymph node bull Grade Grade bull ERPR StatusERPR Statusbull Age Age bull Lymphatic invasionLymphatic invasionbull Histological tumor typeHistological tumor type bull Perinodular infiltrationPerinodular infiltration
TREATMENT OPTIONS FOR PRIMARY OPERABLE BREAST CANCER Objective Options
Local control Lumpectomy Lumpectomy with breast irradiation Mastectomy
Regional control Axillary lymph node dissection Regional irradiation
Control of occult Chemotherapymicrometastatic disease Hormone therapy
Improved function and cosmesis Breast-conserving therapy Reconstruction (immediate or delayed)
Localized breast cancer Surgery is mainstay Halsted 1882 radical mastectomy
John Hopkins
Metastatic breast cancer Systemic treatment
Radical mastectomy A Entire breast and a
chest wall muscle is removed
LNs in the level 1 (B) and level 2 (C ) and even sometimes more distant lymph node groups (D E and F) were also removed
Modified radical mastectomy (MRM)
A Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed called an axillary lymph node dissection
MRM = simple mastectomy + ALND
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 33 Feel your breasts while lying down using Feel your breasts while lying down using
your right hand to feel your left breast and your right hand to feel your left breast and then your left hand to feel your right breast then your left hand to feel your right breast Use a firm smooth touch with the first few Use a firm smooth touch with the first few fingers of your hand keeping the fingersfingers of your hand keeping the fingers
flat and togetherflat and together
Cover the entire breast from top to Cover the entire breast from top to bottom side to sidemdashfrom your bottom side to sidemdashfrom your collarbone to the top of your abdomen collarbone to the top of your abdomen and from your armpit to your cleavageand from your armpit to your cleavage
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 44
Finally feel your breasts while you are Finally feel your breasts while you are standing or sitting Many women find standing or sitting Many women find that the easiest way to feel their breasts that the easiest way to feel their breasts is when their skin is wet and slippery is when their skin is wet and slippery so they like to do this step in the so they like to do this step in the shower Cover your entire breast using shower Cover your entire breast using the same hand movements described in the same hand movements described in Step 3Step 3
InvestigationsInvestigations
Mammography (conrsquot)Mammography (conrsquot) 1048698 1048698 Standard mammography Standard mammography depends on depends on
density of the tissue and its ability to stop density of the tissue and its ability to stop xrayxray
beam from exposing film placed on the other beam from exposing film placed on the other side of the breastside of the breast
Digital mammography Digital mammography works on the same works on the same principle but there is also some ability to principle but there is also some ability to manipulate the image by computer Main manipulate the image by computer Main advantage is storage of the filmsadvantage is storage of the films
UltrasoundUltrasound
Since solid tissue andSince solid tissue and collections of fluid look thecollections of fluid look the same on mammographysame on mammography ultrasound is very useful in ultrasound is very useful in telling whether a mass istelling whether a mass is solid or fluid and if solid ifsolid or fluid and if solid if characteristics arecharacteristics are suspicioussuspicious CystCyst
MRIMRI MRI relies on completely different type of MRI relies on completely different type of
wavewave
energy a strong magnet that affects the energy a strong magnet that affects the charge incharge in
the nuclei As magnetic force is applied and the nuclei As magnetic force is applied and thenthen
released different types of tissue send back released different types of tissue send back different types of radio wavesdifferent types of radio waves
MRI can be extremely useful in very denseMRI can be extremely useful in very dense
breasts hereditary casesbreasts hereditary cases
Fine needle aspiration of a palpable mass
1048698 Fine needle aspiration takes individual cells out ofmass Can be done for palpable or non-palpablemasses Does not show architecture especially wallof duct so best used to confirm strong suspicions
Fine Needle Aspiration
C0 No epithelial cellsC1 InadequateC2 BenignC3 AtypiaC4 SuspiciousC5 Malignant
1048698 Core biopsy can also bedone on palpable and non palpableabnormalities and on microcalcifications
Core Biopsy
B1 Normal tissue unsatisfactoryB2 BenignB3 Lesion uncertain malignant potentialB4 Suspicion of malignancyB5a In situ malignancyB5b Invasive malignancy
Investigations for Investigations for metastasismetastasis
1- abdominal ultrasound1- abdominal ultrasound
2- chest x ray or CT2- chest x ray or CT
3- bone survey or bone scan3- bone survey or bone scan
Established prognostic Established prognostic factorsfactors
bull Nodal status Nodal status bull Tumor size Tumor size bull Lymph node Lymph node bull Grade Grade bull ERPR StatusERPR Statusbull Age Age bull Lymphatic invasionLymphatic invasionbull Histological tumor typeHistological tumor type bull Perinodular infiltrationPerinodular infiltration
TREATMENT OPTIONS FOR PRIMARY OPERABLE BREAST CANCER Objective Options
Local control Lumpectomy Lumpectomy with breast irradiation Mastectomy
Regional control Axillary lymph node dissection Regional irradiation
Control of occult Chemotherapymicrometastatic disease Hormone therapy
Improved function and cosmesis Breast-conserving therapy Reconstruction (immediate or delayed)
Localized breast cancer Surgery is mainstay Halsted 1882 radical mastectomy
John Hopkins
Metastatic breast cancer Systemic treatment
Radical mastectomy A Entire breast and a
chest wall muscle is removed
LNs in the level 1 (B) and level 2 (C ) and even sometimes more distant lymph node groups (D E and F) were also removed
Modified radical mastectomy (MRM)
A Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed called an axillary lymph node dissection
MRM = simple mastectomy + ALND
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
Breast Self-Exam ndash Step Breast Self-Exam ndash Step 44
Finally feel your breasts while you are Finally feel your breasts while you are standing or sitting Many women find standing or sitting Many women find that the easiest way to feel their breasts that the easiest way to feel their breasts is when their skin is wet and slippery is when their skin is wet and slippery so they like to do this step in the so they like to do this step in the shower Cover your entire breast using shower Cover your entire breast using the same hand movements described in the same hand movements described in Step 3Step 3
InvestigationsInvestigations
Mammography (conrsquot)Mammography (conrsquot) 1048698 1048698 Standard mammography Standard mammography depends on depends on
density of the tissue and its ability to stop density of the tissue and its ability to stop xrayxray
beam from exposing film placed on the other beam from exposing film placed on the other side of the breastside of the breast
Digital mammography Digital mammography works on the same works on the same principle but there is also some ability to principle but there is also some ability to manipulate the image by computer Main manipulate the image by computer Main advantage is storage of the filmsadvantage is storage of the films
UltrasoundUltrasound
Since solid tissue andSince solid tissue and collections of fluid look thecollections of fluid look the same on mammographysame on mammography ultrasound is very useful in ultrasound is very useful in telling whether a mass istelling whether a mass is solid or fluid and if solid ifsolid or fluid and if solid if characteristics arecharacteristics are suspicioussuspicious CystCyst
MRIMRI MRI relies on completely different type of MRI relies on completely different type of
wavewave
energy a strong magnet that affects the energy a strong magnet that affects the charge incharge in
the nuclei As magnetic force is applied and the nuclei As magnetic force is applied and thenthen
released different types of tissue send back released different types of tissue send back different types of radio wavesdifferent types of radio waves
MRI can be extremely useful in very denseMRI can be extremely useful in very dense
breasts hereditary casesbreasts hereditary cases
Fine needle aspiration of a palpable mass
1048698 Fine needle aspiration takes individual cells out ofmass Can be done for palpable or non-palpablemasses Does not show architecture especially wallof duct so best used to confirm strong suspicions
Fine Needle Aspiration
C0 No epithelial cellsC1 InadequateC2 BenignC3 AtypiaC4 SuspiciousC5 Malignant
1048698 Core biopsy can also bedone on palpable and non palpableabnormalities and on microcalcifications
Core Biopsy
B1 Normal tissue unsatisfactoryB2 BenignB3 Lesion uncertain malignant potentialB4 Suspicion of malignancyB5a In situ malignancyB5b Invasive malignancy
Investigations for Investigations for metastasismetastasis
1- abdominal ultrasound1- abdominal ultrasound
2- chest x ray or CT2- chest x ray or CT
3- bone survey or bone scan3- bone survey or bone scan
Established prognostic Established prognostic factorsfactors
bull Nodal status Nodal status bull Tumor size Tumor size bull Lymph node Lymph node bull Grade Grade bull ERPR StatusERPR Statusbull Age Age bull Lymphatic invasionLymphatic invasionbull Histological tumor typeHistological tumor type bull Perinodular infiltrationPerinodular infiltration
TREATMENT OPTIONS FOR PRIMARY OPERABLE BREAST CANCER Objective Options
Local control Lumpectomy Lumpectomy with breast irradiation Mastectomy
Regional control Axillary lymph node dissection Regional irradiation
Control of occult Chemotherapymicrometastatic disease Hormone therapy
Improved function and cosmesis Breast-conserving therapy Reconstruction (immediate or delayed)
Localized breast cancer Surgery is mainstay Halsted 1882 radical mastectomy
John Hopkins
Metastatic breast cancer Systemic treatment
Radical mastectomy A Entire breast and a
chest wall muscle is removed
LNs in the level 1 (B) and level 2 (C ) and even sometimes more distant lymph node groups (D E and F) were also removed
Modified radical mastectomy (MRM)
A Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed called an axillary lymph node dissection
MRM = simple mastectomy + ALND
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
InvestigationsInvestigations
Mammography (conrsquot)Mammography (conrsquot) 1048698 1048698 Standard mammography Standard mammography depends on depends on
density of the tissue and its ability to stop density of the tissue and its ability to stop xrayxray
beam from exposing film placed on the other beam from exposing film placed on the other side of the breastside of the breast
Digital mammography Digital mammography works on the same works on the same principle but there is also some ability to principle but there is also some ability to manipulate the image by computer Main manipulate the image by computer Main advantage is storage of the filmsadvantage is storage of the films
UltrasoundUltrasound
Since solid tissue andSince solid tissue and collections of fluid look thecollections of fluid look the same on mammographysame on mammography ultrasound is very useful in ultrasound is very useful in telling whether a mass istelling whether a mass is solid or fluid and if solid ifsolid or fluid and if solid if characteristics arecharacteristics are suspicioussuspicious CystCyst
MRIMRI MRI relies on completely different type of MRI relies on completely different type of
wavewave
energy a strong magnet that affects the energy a strong magnet that affects the charge incharge in
the nuclei As magnetic force is applied and the nuclei As magnetic force is applied and thenthen
released different types of tissue send back released different types of tissue send back different types of radio wavesdifferent types of radio waves
MRI can be extremely useful in very denseMRI can be extremely useful in very dense
breasts hereditary casesbreasts hereditary cases
Fine needle aspiration of a palpable mass
1048698 Fine needle aspiration takes individual cells out ofmass Can be done for palpable or non-palpablemasses Does not show architecture especially wallof duct so best used to confirm strong suspicions
Fine Needle Aspiration
C0 No epithelial cellsC1 InadequateC2 BenignC3 AtypiaC4 SuspiciousC5 Malignant
1048698 Core biopsy can also bedone on palpable and non palpableabnormalities and on microcalcifications
Core Biopsy
B1 Normal tissue unsatisfactoryB2 BenignB3 Lesion uncertain malignant potentialB4 Suspicion of malignancyB5a In situ malignancyB5b Invasive malignancy
Investigations for Investigations for metastasismetastasis
1- abdominal ultrasound1- abdominal ultrasound
2- chest x ray or CT2- chest x ray or CT
3- bone survey or bone scan3- bone survey or bone scan
Established prognostic Established prognostic factorsfactors
bull Nodal status Nodal status bull Tumor size Tumor size bull Lymph node Lymph node bull Grade Grade bull ERPR StatusERPR Statusbull Age Age bull Lymphatic invasionLymphatic invasionbull Histological tumor typeHistological tumor type bull Perinodular infiltrationPerinodular infiltration
TREATMENT OPTIONS FOR PRIMARY OPERABLE BREAST CANCER Objective Options
Local control Lumpectomy Lumpectomy with breast irradiation Mastectomy
Regional control Axillary lymph node dissection Regional irradiation
Control of occult Chemotherapymicrometastatic disease Hormone therapy
Improved function and cosmesis Breast-conserving therapy Reconstruction (immediate or delayed)
Localized breast cancer Surgery is mainstay Halsted 1882 radical mastectomy
John Hopkins
Metastatic breast cancer Systemic treatment
Radical mastectomy A Entire breast and a
chest wall muscle is removed
LNs in the level 1 (B) and level 2 (C ) and even sometimes more distant lymph node groups (D E and F) were also removed
Modified radical mastectomy (MRM)
A Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed called an axillary lymph node dissection
MRM = simple mastectomy + ALND
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
UltrasoundUltrasound
Since solid tissue andSince solid tissue and collections of fluid look thecollections of fluid look the same on mammographysame on mammography ultrasound is very useful in ultrasound is very useful in telling whether a mass istelling whether a mass is solid or fluid and if solid ifsolid or fluid and if solid if characteristics arecharacteristics are suspicioussuspicious CystCyst
MRIMRI MRI relies on completely different type of MRI relies on completely different type of
wavewave
energy a strong magnet that affects the energy a strong magnet that affects the charge incharge in
the nuclei As magnetic force is applied and the nuclei As magnetic force is applied and thenthen
released different types of tissue send back released different types of tissue send back different types of radio wavesdifferent types of radio waves
MRI can be extremely useful in very denseMRI can be extremely useful in very dense
breasts hereditary casesbreasts hereditary cases
Fine needle aspiration of a palpable mass
1048698 Fine needle aspiration takes individual cells out ofmass Can be done for palpable or non-palpablemasses Does not show architecture especially wallof duct so best used to confirm strong suspicions
Fine Needle Aspiration
C0 No epithelial cellsC1 InadequateC2 BenignC3 AtypiaC4 SuspiciousC5 Malignant
1048698 Core biopsy can also bedone on palpable and non palpableabnormalities and on microcalcifications
Core Biopsy
B1 Normal tissue unsatisfactoryB2 BenignB3 Lesion uncertain malignant potentialB4 Suspicion of malignancyB5a In situ malignancyB5b Invasive malignancy
Investigations for Investigations for metastasismetastasis
1- abdominal ultrasound1- abdominal ultrasound
2- chest x ray or CT2- chest x ray or CT
3- bone survey or bone scan3- bone survey or bone scan
Established prognostic Established prognostic factorsfactors
bull Nodal status Nodal status bull Tumor size Tumor size bull Lymph node Lymph node bull Grade Grade bull ERPR StatusERPR Statusbull Age Age bull Lymphatic invasionLymphatic invasionbull Histological tumor typeHistological tumor type bull Perinodular infiltrationPerinodular infiltration
TREATMENT OPTIONS FOR PRIMARY OPERABLE BREAST CANCER Objective Options
Local control Lumpectomy Lumpectomy with breast irradiation Mastectomy
Regional control Axillary lymph node dissection Regional irradiation
Control of occult Chemotherapymicrometastatic disease Hormone therapy
Improved function and cosmesis Breast-conserving therapy Reconstruction (immediate or delayed)
Localized breast cancer Surgery is mainstay Halsted 1882 radical mastectomy
John Hopkins
Metastatic breast cancer Systemic treatment
Radical mastectomy A Entire breast and a
chest wall muscle is removed
LNs in the level 1 (B) and level 2 (C ) and even sometimes more distant lymph node groups (D E and F) were also removed
Modified radical mastectomy (MRM)
A Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed called an axillary lymph node dissection
MRM = simple mastectomy + ALND
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
MRIMRI MRI relies on completely different type of MRI relies on completely different type of
wavewave
energy a strong magnet that affects the energy a strong magnet that affects the charge incharge in
the nuclei As magnetic force is applied and the nuclei As magnetic force is applied and thenthen
released different types of tissue send back released different types of tissue send back different types of radio wavesdifferent types of radio waves
MRI can be extremely useful in very denseMRI can be extremely useful in very dense
breasts hereditary casesbreasts hereditary cases
Fine needle aspiration of a palpable mass
1048698 Fine needle aspiration takes individual cells out ofmass Can be done for palpable or non-palpablemasses Does not show architecture especially wallof duct so best used to confirm strong suspicions
Fine Needle Aspiration
C0 No epithelial cellsC1 InadequateC2 BenignC3 AtypiaC4 SuspiciousC5 Malignant
1048698 Core biopsy can also bedone on palpable and non palpableabnormalities and on microcalcifications
Core Biopsy
B1 Normal tissue unsatisfactoryB2 BenignB3 Lesion uncertain malignant potentialB4 Suspicion of malignancyB5a In situ malignancyB5b Invasive malignancy
Investigations for Investigations for metastasismetastasis
1- abdominal ultrasound1- abdominal ultrasound
2- chest x ray or CT2- chest x ray or CT
3- bone survey or bone scan3- bone survey or bone scan
Established prognostic Established prognostic factorsfactors
bull Nodal status Nodal status bull Tumor size Tumor size bull Lymph node Lymph node bull Grade Grade bull ERPR StatusERPR Statusbull Age Age bull Lymphatic invasionLymphatic invasionbull Histological tumor typeHistological tumor type bull Perinodular infiltrationPerinodular infiltration
TREATMENT OPTIONS FOR PRIMARY OPERABLE BREAST CANCER Objective Options
Local control Lumpectomy Lumpectomy with breast irradiation Mastectomy
Regional control Axillary lymph node dissection Regional irradiation
Control of occult Chemotherapymicrometastatic disease Hormone therapy
Improved function and cosmesis Breast-conserving therapy Reconstruction (immediate or delayed)
Localized breast cancer Surgery is mainstay Halsted 1882 radical mastectomy
John Hopkins
Metastatic breast cancer Systemic treatment
Radical mastectomy A Entire breast and a
chest wall muscle is removed
LNs in the level 1 (B) and level 2 (C ) and even sometimes more distant lymph node groups (D E and F) were also removed
Modified radical mastectomy (MRM)
A Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed called an axillary lymph node dissection
MRM = simple mastectomy + ALND
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
Fine needle aspiration of a palpable mass
1048698 Fine needle aspiration takes individual cells out ofmass Can be done for palpable or non-palpablemasses Does not show architecture especially wallof duct so best used to confirm strong suspicions
Fine Needle Aspiration
C0 No epithelial cellsC1 InadequateC2 BenignC3 AtypiaC4 SuspiciousC5 Malignant
1048698 Core biopsy can also bedone on palpable and non palpableabnormalities and on microcalcifications
Core Biopsy
B1 Normal tissue unsatisfactoryB2 BenignB3 Lesion uncertain malignant potentialB4 Suspicion of malignancyB5a In situ malignancyB5b Invasive malignancy
Investigations for Investigations for metastasismetastasis
1- abdominal ultrasound1- abdominal ultrasound
2- chest x ray or CT2- chest x ray or CT
3- bone survey or bone scan3- bone survey or bone scan
Established prognostic Established prognostic factorsfactors
bull Nodal status Nodal status bull Tumor size Tumor size bull Lymph node Lymph node bull Grade Grade bull ERPR StatusERPR Statusbull Age Age bull Lymphatic invasionLymphatic invasionbull Histological tumor typeHistological tumor type bull Perinodular infiltrationPerinodular infiltration
TREATMENT OPTIONS FOR PRIMARY OPERABLE BREAST CANCER Objective Options
Local control Lumpectomy Lumpectomy with breast irradiation Mastectomy
Regional control Axillary lymph node dissection Regional irradiation
Control of occult Chemotherapymicrometastatic disease Hormone therapy
Improved function and cosmesis Breast-conserving therapy Reconstruction (immediate or delayed)
Localized breast cancer Surgery is mainstay Halsted 1882 radical mastectomy
John Hopkins
Metastatic breast cancer Systemic treatment
Radical mastectomy A Entire breast and a
chest wall muscle is removed
LNs in the level 1 (B) and level 2 (C ) and even sometimes more distant lymph node groups (D E and F) were also removed
Modified radical mastectomy (MRM)
A Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed called an axillary lymph node dissection
MRM = simple mastectomy + ALND
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
1048698 Core biopsy can also bedone on palpable and non palpableabnormalities and on microcalcifications
Core Biopsy
B1 Normal tissue unsatisfactoryB2 BenignB3 Lesion uncertain malignant potentialB4 Suspicion of malignancyB5a In situ malignancyB5b Invasive malignancy
Investigations for Investigations for metastasismetastasis
1- abdominal ultrasound1- abdominal ultrasound
2- chest x ray or CT2- chest x ray or CT
3- bone survey or bone scan3- bone survey or bone scan
Established prognostic Established prognostic factorsfactors
bull Nodal status Nodal status bull Tumor size Tumor size bull Lymph node Lymph node bull Grade Grade bull ERPR StatusERPR Statusbull Age Age bull Lymphatic invasionLymphatic invasionbull Histological tumor typeHistological tumor type bull Perinodular infiltrationPerinodular infiltration
TREATMENT OPTIONS FOR PRIMARY OPERABLE BREAST CANCER Objective Options
Local control Lumpectomy Lumpectomy with breast irradiation Mastectomy
Regional control Axillary lymph node dissection Regional irradiation
Control of occult Chemotherapymicrometastatic disease Hormone therapy
Improved function and cosmesis Breast-conserving therapy Reconstruction (immediate or delayed)
Localized breast cancer Surgery is mainstay Halsted 1882 radical mastectomy
John Hopkins
Metastatic breast cancer Systemic treatment
Radical mastectomy A Entire breast and a
chest wall muscle is removed
LNs in the level 1 (B) and level 2 (C ) and even sometimes more distant lymph node groups (D E and F) were also removed
Modified radical mastectomy (MRM)
A Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed called an axillary lymph node dissection
MRM = simple mastectomy + ALND
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
Investigations for Investigations for metastasismetastasis
1- abdominal ultrasound1- abdominal ultrasound
2- chest x ray or CT2- chest x ray or CT
3- bone survey or bone scan3- bone survey or bone scan
Established prognostic Established prognostic factorsfactors
bull Nodal status Nodal status bull Tumor size Tumor size bull Lymph node Lymph node bull Grade Grade bull ERPR StatusERPR Statusbull Age Age bull Lymphatic invasionLymphatic invasionbull Histological tumor typeHistological tumor type bull Perinodular infiltrationPerinodular infiltration
TREATMENT OPTIONS FOR PRIMARY OPERABLE BREAST CANCER Objective Options
Local control Lumpectomy Lumpectomy with breast irradiation Mastectomy
Regional control Axillary lymph node dissection Regional irradiation
Control of occult Chemotherapymicrometastatic disease Hormone therapy
Improved function and cosmesis Breast-conserving therapy Reconstruction (immediate or delayed)
Localized breast cancer Surgery is mainstay Halsted 1882 radical mastectomy
John Hopkins
Metastatic breast cancer Systemic treatment
Radical mastectomy A Entire breast and a
chest wall muscle is removed
LNs in the level 1 (B) and level 2 (C ) and even sometimes more distant lymph node groups (D E and F) were also removed
Modified radical mastectomy (MRM)
A Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed called an axillary lymph node dissection
MRM = simple mastectomy + ALND
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
Established prognostic Established prognostic factorsfactors
bull Nodal status Nodal status bull Tumor size Tumor size bull Lymph node Lymph node bull Grade Grade bull ERPR StatusERPR Statusbull Age Age bull Lymphatic invasionLymphatic invasionbull Histological tumor typeHistological tumor type bull Perinodular infiltrationPerinodular infiltration
TREATMENT OPTIONS FOR PRIMARY OPERABLE BREAST CANCER Objective Options
Local control Lumpectomy Lumpectomy with breast irradiation Mastectomy
Regional control Axillary lymph node dissection Regional irradiation
Control of occult Chemotherapymicrometastatic disease Hormone therapy
Improved function and cosmesis Breast-conserving therapy Reconstruction (immediate or delayed)
Localized breast cancer Surgery is mainstay Halsted 1882 radical mastectomy
John Hopkins
Metastatic breast cancer Systemic treatment
Radical mastectomy A Entire breast and a
chest wall muscle is removed
LNs in the level 1 (B) and level 2 (C ) and even sometimes more distant lymph node groups (D E and F) were also removed
Modified radical mastectomy (MRM)
A Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed called an axillary lymph node dissection
MRM = simple mastectomy + ALND
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
TREATMENT OPTIONS FOR PRIMARY OPERABLE BREAST CANCER Objective Options
Local control Lumpectomy Lumpectomy with breast irradiation Mastectomy
Regional control Axillary lymph node dissection Regional irradiation
Control of occult Chemotherapymicrometastatic disease Hormone therapy
Improved function and cosmesis Breast-conserving therapy Reconstruction (immediate or delayed)
Localized breast cancer Surgery is mainstay Halsted 1882 radical mastectomy
John Hopkins
Metastatic breast cancer Systemic treatment
Radical mastectomy A Entire breast and a
chest wall muscle is removed
LNs in the level 1 (B) and level 2 (C ) and even sometimes more distant lymph node groups (D E and F) were also removed
Modified radical mastectomy (MRM)
A Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed called an axillary lymph node dissection
MRM = simple mastectomy + ALND
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
Localized breast cancer Surgery is mainstay Halsted 1882 radical mastectomy
John Hopkins
Metastatic breast cancer Systemic treatment
Radical mastectomy A Entire breast and a
chest wall muscle is removed
LNs in the level 1 (B) and level 2 (C ) and even sometimes more distant lymph node groups (D E and F) were also removed
Modified radical mastectomy (MRM)
A Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed called an axillary lymph node dissection
MRM = simple mastectomy + ALND
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
Radical mastectomy A Entire breast and a
chest wall muscle is removed
LNs in the level 1 (B) and level 2 (C ) and even sometimes more distant lymph node groups (D E and F) were also removed
Modified radical mastectomy (MRM)
A Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed called an axillary lymph node dissection
MRM = simple mastectomy + ALND
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
Modified radical mastectomy (MRM)
A Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed called an axillary lymph node dissection
MRM = simple mastectomy + ALND
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
Breast conserving surgery
Also called lumpectomy with safety margin with axillary clearance or sentinel lymph node biopsy
RT should be followed
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
Adjuvant systemic treatment
Hypothesis Eradicate micrometastasis From effective treatment for overt
(macro) metastasis
Chemotherapy Hormone therapy
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
Adjuvant chemotherapy
CMF first generation 1970s Cyclophosphamide Methotrexate 5-FU
Benefit in Distant recurrence Survival
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
Adjuvant chemotherapy
CAF or CEF 2nd generation 1980s Cyclophophamide Adramycin(or Epirubicin) 5-FU
More toxic than CMF CAF better than CMF in high-risk group
Axilla LN+ LN- but tumor large or other risk factor
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
Adjuvant chemotherapy
Incorporate Taxane TAC 3rd generation mid-1990s
Taxotere Adriamycin Cyclophosphamide
More toxic than CAF Better than CAF in high-risk group
Need more time to observe
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
Adjuvant Herceptin(HER-2 (Human Epidermal growth factor Receptor 2) also
known as proto-oncogene Neu Over expression of this gene is correlated with higher aggressiveness in breast cancer
HER2 is a cell membrane surface-bound receptor tyrosine kinase and is normally involved in the signal transduction pathways leading to cell growth and differentiation)
Effective in Her2+ pts ICH3+ FISH+
Herceptin + adjuvant chemotherapy Optimal role to be defined
Concurrent or sequential Maintenance Duration
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
Adjuvant hormone therapy
In premenopausal woman Oophorectomy could control metastatic
disease
Tamoxifen Selective estrogen receptor antagonist Effective in pre- and post-menopausal Effective in adjuvant setting
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
Adjuvant hormone therapy
Aromatase inhibitor Effective in post-menopausal state Aromatase in fat tissue
Convert androgen to estrogen Main estrogen source in post-menopausal
Exemestane Aromasin Letrozole Femara Anastrozole Arimidex
More effective than Tamoxifen
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
Adjuvant ovarian suppression
Effective in pre-menopausal state Type
Surgical ablation RT ablation GnRH analogue Goserelin Leupride
Exact role to be defined Combination with chemotherapy Combination with AI or TAM
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
Radiation therapy Radiation kills the cancer cells left after surgery Radiation therapy doesnt make you radio active Radiation is painless when itrsquos delivered but it will
become more painful over time Treatments will be given up to 5-7 weeks 5 days a week Treatments only take frac12 hour so you can keep your
routine Your hair wonrsquot fall out unless you are also taking
chemotherapy Your skin in the area may become red and easily irritated You may feel tired even after its over Radiation after surgery reduces the chances of the cancer
reoccurring
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery
Treatment of metastatic dz
Usual sites bone lung liver brain Incurable
Goal live with dz for longest time
Systemic treatment is mainstay Chemotherapy Hormone therapy
Palliative local therapy Radiotherapy Palliative surgery